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

How Are Cancer Programs Accredited?

Cancer program surveys are a comprehensive evaluation of the entire scope, organization, and activity of a cancer program. A survey is performed every three years by a physician surveyor who is specially trained to evaluate compliance with the 34 standards that are required for accreditation.

Program standards are outlined in the Cancer Program Standards 2012, v1.2.1. Standards for data collection are presented in Facility Oncology Registry Data Standards (FORDS).

Each program being surveyed must complete the Web-enabled Survey Application Record (SAR). The SAR provides background on the structure of the program and activity since the last survey. It also includes the evaluation standards and allows the program and surveyor to rate compliance with each standard.

An independent review of a program's application and supporting documentation is performed by a Cancer Program Specialist team member in the Accreditation and Standards section of Cancer Programs. Program-related activity and standard ratings may also be reviewed by the multidisciplinary Program Review Subcommittee before an accreditation award is assigned.

Accreditation Awards

Accreditation awards are based on compliance with the 34 standards. Programs with a deficiency in any standard are allowed 12 months to document changes for administrative review in order to receive full accreditation.

The accreditation awards are as follows:

Three-Year with
Commendation
Three-Year
Accreditation
Three-Year with Contingency Non
accreditation
Provisional
Complies with all standards at the time of survey and receives a commendation rating for 1 or more standards

Gold: 7 commendations
Silver: 4–6 commendations
Bronze: 1–3 commendations
Complies with all standards at the time of survey but does not receive a commendation rating for any standard.

Or, is awarded when all deficiencies are resolved regardless of the number of commendations awarded at survey.
1–7 deficiencies

8 or more
deficiencies

Programs undergoing initial accreditation: 3 or more deficiencies

Program undergoing initial accreditation; 1 or 2 deficiencies in any standard

Three-Year with Commendation is given to programs, either new or established, that comply with all standards and receive a commendation rating for one or more standard. A Bronze, Silver, or Gold designation is applied depending on the number of commendations awarded.A certificate of accreditation is issued and these programs are surveyed at a three-year interval from the date of the survey.

Three-Year Accreditation is given to programs, either new or established, that comply with all standards but do not receive a commendation rating for any standards. This award also applies to programs that received and resolved a deficiency for 1 or more standards regardless of the number of commendations received at the time of survey. A certificate of accreditation is issued and these programs are surveyed at a three-year interval from the date of the survey.

Three-Year Accreditation with Contingency is given when 1–7 standards are rated deficient. The contingency status is resolved by the submission of documentation of compliance within 12 months. Three-Year Accreditation is granted following submission of documentation. A certificate of accreditation is issued after resolution of deficiencies and these programs are surveyed at a three-year interval from the date of the survey.

Nonaccreditation is given when 8 or more standards are rated deficient or for a new program undergoing initial accreditation and found to be deficient in 3 or more standards. Programs are encouraged to improve their performance and may reapply.

Provisional Accreditation is given when a new program is rated deficient in 1 or 2 standards at the initial survey. The provisional status is resolved by the submission of documentation of compliance within 12 months. Documentation required to resolve the deficiency for each standard is available on the Cancer Programs page of the ACS website. Three-Year with Commendation or Three-Year Accreditation is granted following submission of documentation without resurvey. A certificate of accreditation is issued after resolution of deficiencies and these programs are surveyed at a three-year interval from the date of the submission of documentation. Programs that do not resolve this status at the end of the 12-month period must reapply for survey.