2012 Pre-Survey Documentation
Below is a list of documentation that must be provided for the surveyor two weeks prior to the onsite visit. This information must be uploaded through the SAR menu under the, ‘Survey Documentation’ link.
- Cancer committee/leadership body minutes from 2009, 2010, and 2011
- Include only those attachments that apply to the compliance of standards. (Attachments can be included with the minutes or uploaded as a separate document as long as the document is appropriately titled with the corresponding minutes.)
- Certificate of accreditation or letter from the accrediting body (Std 1.1)
- Section of bylaws related to the cancer committee (Std 2.1)
- Policy and procedure on cancer conference/tumor board criteria (Stds 2.6, 2.7, 2.8)
- Cancer conference/tumor board grid from 2009, 2010, and 2011 (Std 2.9)
- QC Review Plan or policy (Std 2.10)
- Outcomes analysis studies completed in 2009, 2010, and 2011 (Std 2.11)
- If an annual report was published, upload copy of report from 2009, 2010, and 2011
- Follow-up reports from day of survey (Stds 3.4, 3.5)
- Written process for monitoring staging, prognostic factors, and national treatment guidelines (Std 4.3)
- Documentation of educational activities for 2009, 2010, and 2011. This should include; posting/announcement, agenda, objectives, and attendance sheets (Std 7.1)
- Quality studies completed in 2009, 2010, and 2011 (Std 8.1)
- Accession lists from 2009 and 2011 (2nd, 3rd, and 4th quarters)
- Lists to include accession number, site, class of case, and procedure. Patient names are to be excluded.
- NEW programs will confirm year of review with Karen Stachon, Cancer Program Advisor, when they are released for initial survey
- Final agenda (as agreed upon between surveyor and facility)
The surveyor will review additional information as appropriate at the facility on the day of survey. Paper documents will NOT be accepted for surveys, appeals, or deficiency resolutions.
HIPAA and Protected Health Information
In concordance with the HIPAA guidelines, the Commission on Cancer cannot accept documentation that includes patient identifying information (protected health information [PHI]). Receipt of PHI violates the Business Associate Agreement between the American College of Surgeons and the CoC-accredited cancer program.
This applies to documentation submitted for survey, appeals, and/or deficiency resolutions. Documents that may include PHI, but are not limited to: accession lists, suspense reports, pathology reports, collected data for studies. Special care should be taken to ensure that all PHI is removed before documentation is uploaded to the SAR.
In compliance with the American College of Surgeons HIPAA Privacy and Security Policy, appropriate supervisory and managerial staff of the American College of Surgeons will be notified when documentation that includes PHI has been received. The American College of Surgeons Privacy Official will make a determination about a notification to the CoC-accredited cancer program and disposition of the documentation that includes PHI.
Programs will be required to remove or block the patient information and resubmit the documentation as soon as possible after receiving notification from the American College of Surgeons Privacy Official.
Online February 2, 2012