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

Guidelines for Merged Cancer Programs

If your facility has merged, or plans to merge in the near future, the Commission on Cancer (CoC) requests that you first review the Guidelines for Merged Cancer Programs. After reviewing the guidelines, please complete the Merger Notification Form and submit it to Carol Woody. In addition, please direct all questions regarding the Guidelines for Merged Programs to Carol Woody.

The following topics are addressed within these guidelines:

  • Merger Checklist
  • Merger Notification Form
  • Demographic Information
  • Definition
  • Cancer Program Identification
  • Cancer Program Activity
  • Cancer Liaison Physician (CLP)
  • Cancer Registry Operations and Database Management
  • CoC Datalinks
  • Facility and Staff Contact Information
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Facility Information Profile System (FIPS)
  • National Cancer Data Base (NCDB) Data Transmission
  • NCDB Statistics
  • Survey Application Record (SAR)

Merger Checklist

We have provided the following checklist to ensure a successful merger and smooth transition between your facility and the CoC.

  • Confirm single The Joint Commission or other accreditation standing for the merged facilities.
  • Download, complete, and submit the Merger Notification Form.
  • Identify your CLP(s) and indicate on the Merger Notification Form.
  • Receive confirmation from the CoC (Facility Identification Number [FIN], reference date, category, accreditation award).
  • Share a copy of the completed Merger Notification Form and CoC confirmation with appropriate cancer program staff.
  • Access CoC Datalinks with your user ID and password to review applications under the new FIN:
    • Review and sign a new HIPAA Business Associate and Data Use Agreement (BAA/DUA).
    • Update facility and staff contact information.
    • View other applications reflecting the merger:
      • National Cancer Data Base (NCDB) data transmission, including history and edits of data submitted to the database
      • NCDB statistics
      • Survey Application Record (SAR)

Demographic Information

The following information is required and should be included on the Merger Notification Form:

  1. Complete name, street address, city, state, zip code, phone number, and website address of merged facility
  2. Complete name, street address, city, state, zip code, and FIN of each campus
  3. Contact information (name, credentials, title, street address, city, state, zip code, phone number, fax number, and e-mail address) for the following individuals:
    • Chief executive officer, president, administrator
    • Cancer program director/administrator
    • Cancer committee chair
    • Cancer liaison physician
    • Cancer registrar(s)
      (The selection of these contacts is left to the discretion of the merged facility.)

Definition

  • A merged facility is composed of two or more campuses with a single accreditation standing from The Joint Commission, the American Osteopathic Association (AOA), or a health facility licensor organization (usually located within a state health department).
  • Effective with the date of the merger, the merged facility will have one cancer program. All cancer program activities of the campuses in the merger must begin to become coordinated even if the medical staff have not yet merged and activities have not yet been consolidated.
  • The difference between a CoC network cancer program and CoC merged cancer program are:
    • Merged: One hospital now owns another hospital. The merged hospital may have multiple campuses that are operated and accredited as one facility under one FIN.
    • Network: Each hospital is individually operated and accredited, but all are owned by the same parent company.

Forming a cancer program network is an option for programs, whereas becoming a merged facility is not optional, but a mandatory CoC process resulting from two or more facilities’ decision to consolidate their services.

Please refer to the Guidelines for Network Cancer Programs for additional requirements for network programs.

Cancer Program Identification

Following receipt of the Merger Notification Form, CoC staff will provide the cancer registrar with an e-mail confirming the new FIN, reference date, cancer program category, and accreditation award designation for the merged facility.

The assignment of the reference date will take into consideration the following:

  • Current CoC guidelines on reference dates
  • Current status (accredited or not accredited) of the individual campuses
  • The earliest reference date of the individual campuses

One category of accreditation will be assigned to the merged facility by the CoC. The category assignment will take into consideration the following:

  • The categories of the individual campuses
  • The scope of services provided at all campuses
  • The number of annual analytic accessions at all campuses

One accreditation award will be assigned to the merged facility by the CoC. The award assignment will take into consideration the following:

  • The current status (accredited or not accredited) of the individual campuses (campuses not accredited prior to the merger become accredited upon merging)
  • The outstanding deficiencies, if any exist, for the individual campuses

Cancer Program Activity

A single coordinated cancer program is to be established that involves all campuses of the merged facility. This must be in place by the time of the next CoC cancer program survey, except where noted. This includes the following:

  • A coordinated approach to the provision of clinical services involving all campuses of the merged facility
  • A single cancer committee representing the cancer activities and medical staff at all campuses (campus-based subcommittees may be established as long as the subcommittee activity is reported to the cancer committee)
  • A single program of cancer conferences representing the case mix of the merged facility
  • A single system of studies of quality and improvements in cancer patient care addressing issues at all campuses of the merged facility
  • An overall program for clinical research at the merged facility, if applicable
  • One system for supportive services and community outreach through screening and early detection programs coordinated among all campuses of the merged facility
  • An overall program for professional education and staff support within the merged facility

Cancer Liaison Physician

A single cancer liaison physician (CLP) should be appointed to serve the merged facility. In most cases, a CLP currently in place at one of the campuses will be selected to fill this role. Upon selection of a CLP, all remaining CLP appointments will be terminated.

Another option would be to select an entirely new CLP. The instructions to appoint, reappoint, or remove a CLP can be found on the Cancer Liaison Physician Information Board or contact Carolyn Jones at cjones@facs.org.

If the merged facility believes that it is necessary to appoint more than one CLP (most likely if facilities are separated geographically), please contact Carolyn Jones. The merged facility must submit rationale in writing in order to receive permission to maintain more than one CLP.

Cancer Registry Operations and Database Management

Mergers affect registry operations and registry case identification data items in different ways. CoC observes that many merged programs continue to use separate registry databases at each campus after merging, at least in the short term, while others combine all cases into a single registry database with new accession numbers assigned. When the registry data from multiple sources are being combined, the legacy (historic) FINs (NAACCR # 540) for the pre-existing registry data should be copied into the Archive FIN (NAACCR # 3100) area of the new combined registry so that the primary source of information is retained. The combined registry should have the assigned FIN for the merged program stored in the FIN (NAACCR item # 450) area.

  • When the registry data for the merged program have been merged into a single combined registry with newly-assigned accession numbers, please contact Jerri Linn Phillips at jphillips@facs.org to arrange to resubmit all merged data from 1985 diagnoses forward using the new identification numbers. NCDB will need to remove the previously submitted data for all affected programs from its database prior to this resubmission.
  • As long as the merged campuses continue to maintain separate registries for each campus with separately numbered accession numbers, it is essential to continue to use the legacy (historic) individual FINs rather than the merger FIN for both the FIN and Archive FIN data items for all cases. Do not use the merger FIN when the campuses maintain separate registries with separate accession number numbering. NCDB processing will identify the legacy FINs as belonging to the merger FIN and will handle the cases appropriately.

Program access to CoC Datalinks and the NCDB data submission history or SAR standards 3.6, 3.7, and 3.8 histories will be accommodated through the new merger FIN once the merger has been approved. Prior to approval of the merger, access will be available only through the legacy FINs.

Previously accredited programs are required to submit NCDB data from the time of the merger reference date, in accord with the Calls for Data. Facilities (or campuses) that were not previously accredited are required to submit NCDB data from the date of the merger forward, but earlier cases may be submitted at the program’s discretion.

CoC Datalinks

CoC Datalinks is a central repository for maintaining CoC-accredited cancer program data and information. This password-protected portion of the CoC website enables programs to access, provide, and utilize facility-specific information. For purposes of the merger, the following CoC Datalinks portal applications are described in detail below. This list does not reflect all selections found within the application. Therefore, you are encouraged to access CoC Datalinks to view all selections.

  • HIPAA business associate agreement (BAA)
  • Facility and staff contact information
  • Federal Information Processing Standards (FIPS)
  • National Cancer Data Base (NCDB)
  • Survey Application Record (SAR)

Once facilities merge and notify the CoC of the newly selected chief executive officer/president/administrator, cancer program administrator, cancer committee chair, cancer liaison physician (CLP), and cancer registrar, these contacts will be entered in the CoC's system under a newly assigned facility identification number (FIN). All previously assigned FINs will be deactivated and CoC Datalinks applications for the individual facilities will no longer be accessible. The merged facility will be responsible for submitting new facility and staff contact information, completing a new SAR and FIPS application, signing the HIPAA BAA, and submitting data to the NCDB as described above.

The designated cancer registrar, cancer committee chair, CLP, and cancer program administrator are automatically granted access to CoC Datalinks. If any of these staff had user IDs and passwords prior to the merger, their user IDs and passwords will remain the same and can be used to access the merged facility's CoC Datalinks applications. Those who were not identified as designated staff by the merged facility and were previously granted access to CoC Datalinks through the old FIN will no longer be authorized users.

If the merged facility assigns a new cancer registrar, cancer committee chair, CLP, or cancer program administrator who does not already have a CoC user ID and password, that individual will be assigned a unique user ID and password via e-mail to access CoC Datalinks. For security purposes and to protect facility data, user IDs and passwords are not to be shared. The CoC is not responsible for the unauthorized release or sharing of log-in information and data by any CoC Datalinks user.

A facility may request CoC Datalinks access for additional members of the cancer program and/or medical staff online through CoC Datalinks. Please use the Staff Management web page for information on adding/removing roles, editing contact information and removing users. It is at the discretion of the merged facility to designate additional users.

Facility and Staff Contact Information

Upon CoC accreditation of the merged program, the cancer registrar or designee must access the facility and staff contact information in CoC Datalinks and enter information for the facility and cancer program staff.

Health Insurance Portability and Accountability Act (HIPAA)

Under the HIPAA regulations, the American College of Surgeons serves as a "business associate" to assist you with accreditation and quality improvement efforts of your cancer program. To accomplish these tasks, the College must enter into BAAs with all CoC-accredited cancer programs. Before any cancer program can schedule a survey, and before data can be accepted by the NCDB, a signed BAA must be in place. The merged facility can access the BAA to provide its electronic signature through the CoC Datalinks activity menu of the password-protected CoC Datalinks portal. Information describing the BAA is accessible through the HIPAA link.

The BAA specifically addresses the following issues:

  • Data confidentiality
  • Systems in place to safeguard protected health information reported to the CoC's NCDB
  • The survey process and surveyors associated with the accreditation program
  • Insurance and alternate reporting dates when state law requires a shorter time frame

A BAA has been individually signed by each CoC-accredited facility involved in the merger. Facilities that are part of the merger but are not currently accredited by the CoC are not business associates of the College and have not signed a BAA. The merger will not be officially recognized by the CoC until this initial step is complete. The BAA currently in effect prior to the merger will remain in effect until a BAA for the merged facility is signed.

National Cancer Data Base (NCDB) Data Transmission

After the BAA/DUA has been signed and the merged program accredited, it is possible for the registrar to submit data to NCDB representing the merged program and to track the progress of NCDB data submissions under the new merger FIN through the “History and Edits of Patient-Level Data Submission to the NCDB” in the CoC Datalinks. Contact NCDB staff at ncdb@facs.org if you have questions.

NCDB Statistics

Newly merged programs will have access to the Survival Reports for the merged program once the merger is approved. However, the Hospital Comparison Benchmark Reports and Cancer Program Practice Profile Reports are updated annually and will become available for the merged program only after the next annual update, which takes place in the fall and is based on all data submitted through the preceding Call for Data submission period. Programs that anticipate needing the information from these tools in the interim should secure screen shots or images of the relevant information prior to approval of the merger. Extensive documentation for these tools is available within each application. Read an overview of the NCDB statistical tools.

Survey Application Record

Cancer programs participating in the CoC Accreditation Program are asked to complete the Survey Application Record (SAR) in preparation for the survey. The SAR details the cancer program's activity as it relates to compliance with the CoC’s standards as outlined in Cancer Program Standards 2012 Version 1.2.1: Ensuring Patient Centered Care.

The SAR is available throughout the three-year accreditation period for use as a record-keeping tool to document program activity. Access to the SAR is provided to the cancer registrar, cancer committee chair, cancer program administrator, and cancer liaison physician. Additional users can be identified by the program.

Password-protected access to the SAR is provided through CoC Datalinks. CoC Datalinks is a password-protected portal accessed through the CoC's website.

To facilitate a thorough and accurate evaluation of the cancer program during the survey, the facility completes or updates the SAR at least 14 days before the scheduled on-site visit. The cancer program surveyor reviews the facility’s online SAR before the on-site visit to assess compliance with the standards, to become familiar with the resources and services offered at the facility and the cancer program activity.

The cancer registrar is notified by e-mail when the SAR is available for completion in preparation for the survey. Completion of the SAR should be a team effort of members of the cancer committee with one individual chosen to coordinate the activity and record the information in the SAR.

Each year, the facility is notified of the areas of the SAR requiring annual updates. The eligibility requirements must be updated on the annual schedule. If the SAR is not updated on the annual schedule, then all information must be provided before the survey.

Prior to merging, individual facilities accredited by the CoC are listed separately in separate SARs. Following the merger, a single SAR will appear that includes historical information from one or a combination of the original facilities. The merged program is responsible for updating and completing the SAR as requested at the time of the survey or during the annual update period.

For questions regarding the SAR, e-mail SAR@facs.org.