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

Accreditation Committee Clarifications for Standards 3.1 Patient Navigation Process and 3.2 Psychosocial Distress Screening

This is the first in a series of two communications that address clarifications made by the CoC Accreditation Committee for the phase in standards in Chapter 3 of Cancer Program Standards, 2012: Ensuring Patient-Centered Care, v. 1.2.1.  This communication addresses standards 3.1 Patient Navigation Process and 3.2 Psychosocial Distress Screening.  The second communication will address standard 3.3 Survivorship Care Plan and will be released the week of September 8th.

In late summer of 2013, the CoC Member Organizations conducted a readiness survey that asked CoC-accredited programs to report their implementation activities for Standards 3.1 Patient Navigation Process, 3.2 Distress Screening, and 3.3 Survivorship Care Plan.  Information in the Standards Manual states that all standards in Chapter 3 are to be implemented by January 1, 2015.

3.1 Patient Navigation Process

Survey results indicated that 51 percent of programs are completely confident that they will be able to implement standard 3.1 by the January 1, 2015 phase-in date.  Another 40 percent were somewhat confident that implementation can be accomplished by that time.

Scans of questions submitted to the CAnswer Forum show that programs are requesting specific direction for the community needs assessment and clarification of the requirement to identify and address new barriers.  Finding the right mix of actions to address a barrier could take extended time and effort on the part of the cancer program.

The Accreditation Committee offers the following clarifications for standard 3.1 to guide implementation of this standard:

  1. The community needs assessment must be done every three years, as currently codified in the Standards Manual.  The cancer committee defines the scope of the community needs assessment and is encouraged to link with the outreach and or marketing department or community-based organizations outside of the facility to accomplish this task.  The cancer committee needs to be involved in the design of the assessment and the evaluation of results.  The cancer committee's activities are documented in cancer committee minutes.
  2. The intent of the Standard is to identify and address a new barrier each year; however, programs are allowed to address the same barrier or disparity for more than one year as long as the following criteria are fulfilled:
    1. The cancer committee determines that addressing the barrier is the most important concern for their patients.
    2. The cancer committee documents in their minutes that they have put forth significant activity over the year, but that there is an ongoing need to continue addressing the barrier (i.e., significant progress to address the barrier is still needed).
    3. The current progress to address the barrier is reported to the cancer committee annually.
    4. The cancer committee decides to continue work to address the barrier until the issue is resolved, for a period not to exceed the 3 years between CoC program surveys.

Standard 3.2 Psychosocial Distress Screening

The readiness assessment indicated that 58 percent of programs are completely confident in their ability to implement this standard by January 1, 2015.  In addition, 35 percent responded that they are somewhat confident about implementation by the deadline.

A scan of CAnswer Forum questions shows that programs are seeking more information about tools and guidance on when and how distress screening should occur.

The Accreditation Committee offers the following clarifications for standard 3.2 to guide implementation of this standard:

  1. The Cancer Committee defines one or more medical visits that are part of a pivotal time for distress screening.
  2. The process developed by the cancer committee should address screening at the CoC-accredited facility and/or with the designated provider (such as offices of physicians) who are part of the program (e. g. medical oncologists and/or radiation oncologists).
  3. The screening for distress must be discussed at a medical visit.
  4. Questionnaires or forms that are distributed or returned by mail and/or phone interviews without discussion at a pivotal medical visit do not meet the intent of the standard because this method does not allow for immediate attention for extreme distress or suicidal ideation if patient reported. 
  5. For those programs utilizing an electronic patient portal, patients may complete the distress screening tool through the patient portal, but the screening results must be reviewed and discussed with patients face-to-face at a pivotal visit.
  6. The process developed by the cancer committee includes treatment or referral for treatment for distress identified by the screening.

Both Standard 3.1 Patient Navigation Process and Standard 3.2 Psychosocial Distress Screening are to be fully implemented on January 1, 2015 as planned.

Questions about these and other standards are to be submitted to the CAnswer Forum at http://cancerbulletin.facs.org/forums/

Linda W. Ferris, PhD
Chair, Accreditation Committee

Danny Takanishi, MD, FACS
Vice Chair, Accreditation Committee