American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Accreditation Committee Modifies Standard 1.3; New Manual Version Released

January 27, 2014

Late in 2013, the Accreditation Committee approved important changes to Standard 1.3 that will affect all CoC-accredited programs and new programs working toward accreditation. This communication outlines several changes to this standard.

A new CoC Standards manual (Version 1.2.1) is now available for download through the CoC website. Replacement pages for version 1.2 can also be downloaded from the same page.

All changes were effective January 1, 2014; therefore, we encourage you to read this communication, the new standard‘s definition and requirements, and the ratings in Version 1.2.1 so that the changes can be addressed at your first quarter cancer committee meeting in 2014.

If the cancer committee at your program has already held a meeting in the first quarter this year, then please address the changes during the second quarter meeting and document this in the cancer committee minutes to ensure compliance with the new standard.

Because these requirements were released after the first of the year, all cancer programs surveyed in 2014 will receive a default rating of 1 (compliance) for this standard.

What has changed and how is my cancer program affected?

Standard 1.3 (Version 1.2.1): “Each required member or the designated alternate attends at least 75 percent of the cancer committee meetings held during any given year.”

First, one appointed member and a designated alternate member can be identified for each required physician and nonphysician member of the cancer committee. The alternate must be from the same specialty or have the same credential as the appointed member, e.g.

  • a surgeon is the designated alternate for the surgeon member
  • a pathologist is the designated alternate for the pathology member
  • a nurse is the designated alternate for the nursing member

The appointment of the member and identification of a designated alternate must take place at the beginning of the year when cancer committee membership is confirmed. This information must be documented in the cancer committee minutes. The designated alternate should also be identified on the cancer committee roster. The Survey Application Record (SAR) fields used to identify cancer committee members have been expanded so that the appointed member and a designated alternate can be recorded in the same field.

To Note: If a member of the specialty or credential is not available, then a designated alternate is not allowed. A different designated alternate is required for each cancer committee role.

The second change increases the annual attendance by each required member to 75 percent of the meetings held each year. The Accreditation Committee decided that allowing a designated alternate justified increasing the attendance requirement for each required member.

Because of this change, attendance to meet the standard can be calculated on the required role that is filled by the member and the designated alternate, for example, surgeon, medical oncologist, radiation oncologist, and so forth. This means that if Dr. Jones is the cancer committee member for general surgery and attends two meetings, and Dr. Smith, the designated alternate for general surgery, attends 2 meetings then the attendance rate for general surgery is 4 of 4 quarterly meetings or 100 percent.

Record the appointed member and the designated alternate in the same field in the SAR (as described above) so that attendance can be shown by specialty.

Note: The attendance requirement is based on the cancer committee’s meeting schedule. If the committee meets monthly, then attendance at 9 meetings is required to meet the standard. If the committee meets every other month, then attendance at 5 meetings is required.

Note: This change does not allow substitutions as needed or by whomever is available. The designated alternate is identified at the beginning of the year and cannot be changed during the year that they are identified for this role unless the designated alternate leaves the facility permanently. If a departure takes place then, a new designated alternate can be identified, but only once during the calendar year.

The final change

Data for the 2013 surveys showed that more than 25 percent of programs received a deficiency for this standard and a similar percentage of programs earned commendation for this standard. This is far below the Accreditation Committee’s expectation of performance and as a result, the Accreditation Committee eliminated the commendation for this standard in preference for increasing the overall attendance requirement.

Beginning in 2014, only ratings of 1 (compliance) and 5 (noncompliance) will be used to rate Standard 1.3. Now, seven standards are eligible for commendation, instead of 8, and will be used to determine the Outstanding Achievement Award (OAA) recipients. The commendation standards can be found on page 27 of Version 1.2.1. All seven commendations are required to earn commendation at the Gold level and comprise the OAA criteria.

Cancer Programs Surveyed in 2013

Survey results for all programs surveyed in 2013 will be reviewed and adjusted to show compliance with this standard. An updated Performance Report will be issued to each program and new complimentary certificates will be available if the accreditation status is upgraded or the commendation level changes. Programs will receive an accreditation notification by email when the updated Performance Report is posted to CoC Datalinks.

The Accreditation and Standards team expects to complete this review by mid-February. The 2013 OAA recipients will be identified as soon as this review is completed.

Questions about the new standard should be submitted to the CAnswer Forum so that everyone can benefit from the response. Questions about this communication should be submitted to accreditation@facs.org. Please include “standard 1.3 Special Source” in the subject line.