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) requires that you first review these Guidelines for Merged Cancer Programs. After reviewing the guidelines, please complete the Merger Notification Form and submit it to Carol Woody.

What Is a Merged Cancer Program?

  • A CoC-merged program is composed of two or more campuses with a single accreditation standing from The Joint Commission, DNV Healthcare, the American Osteopathic Association (AOA), or a health facility licensor organization (usually located within a state health department).  Essentially, one hospital may have two or more physical locations. The merged hospital operates and is accredited as one facility under the accrediting body.
  • 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 has not yet merged and activities have not yet been consolidated.

Important notes to consider when merging:

  • A legal document showing that a single accreditation or license exists for the merged facilities must be submitted along with this form (for example, copy of certificate/license, official letter).
  • Programs with a cancer program survey due date within six months of submitting a notification form cannot be merged until after the survey takes place.
  • Programs currently on a Three-year with Contingency (3/C) accreditation status cannot be merged by the CoC until all deficiencies have been resolved and full accreditation status is restored.
  • Merging two or more CoC-accredited facilities could result in a change in the cancer program category, accreditation award, and/or reference date.
  • Programs actively submitting data to the National Cancer Data Base (NCDB) cannot be merged in the month of December or during an open Call for Data submission period (January 1–April 1), unless they have completed their NCDB Call for Data submission.

The cancer program administrator and cancer registrar will have access to CoC Datalinks under the new, merged program Facility Identification Number (FIN). The facility is responsible for adding additional staff contacts into CoC Datalinks. The following topics are addressed within these guidelines:

  • Merger Checklist
  • Merger Notification Form
  • Demographic Information
  • Cancer Program Identification
  • Cancer Program Activity
  • Cancer Liaison Physician
  • 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)
  • 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. All steps MUST be completed.

  • Complete the checklist to confirm single The Joint Commission or other accreditation standing for the merged facilities.
  • Download, complete, and submit the Merger Notification Form.
  • Receive confirmation from the CoC (FIN, reference date, category, accreditation award).
  • Contact the current NCDB Manager of Information and Data Standards in writing for instructions on how to address the FINs currently in your cancer registry database(s) and implementation of your new FIN.
  • 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) at baa@facs.org.
    • Update facility and staff contact information.
    • View other applications reflecting the merger:
      • 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 (the location that will represent the merged program)
  2. Complete name, street address, city, state, ZIP code,  FIN, and accreditation status of each campus
  3. Contact information (name, credentials, title, street address, city, state, ZIP code, phone number,  and e-mail address) for the following individuals:
    • Cancer program director/administrator
    • Cancer registrar

The cancer program administrator and lead cancer registrar will have access to CoC Datalinks under the new, merged program FIN. The facility is responsible for adding additional staff contacts into CoC Datalinks.

  • The differences between a CoC network cancer program and CoC merged cancer program are:
    • Merged: One hospital may now have two or more physical locations which are operated and accredited as a single facility under one FIN.
    • Network: An organization that owns, operates, leases, or is part of a joint venture with multiple facilities having multiple FINs providing integrated cancer care and comprehensive services. At least one facility in the category is a hospital and all facilities that are part of the network are CoC-accredited cancer programs.

Forming a CoC cancer program network is optional for programs, whereas becoming a CoC merged facility is 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)
  • Any outstanding deficiencies for the individual campuses

The new FIN assigned to the merged facility will be used to identify the facility, and data submitted by the merged program will be displayed in aggregate on CoC Datalinks.

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
  • Appropriately accessioned cases in the cancer registry database(s)
  • 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 CLP Information Board or contact the Cancer Liaison Program at CLP@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

Due to the heavy reliance on the FIN and accession number by the NCDB to identify individual records, mergers can affect registry operations and registry case identification data items in different ways. The CoC observes that some merged programs continue to use separate registry databases at each campus after merging, while others combine all cases into a single registry database with new accession numbers assigned. As a result, it is essential that every newly merged program contact the current NCDB Manager of Information and Data Standards in writing for instructions on how to address the FINs currently in your cancer registry database(s) and implementation of your new FIN.

It is preferable that the original FINs from the individual facilities for the preexisting registry data be used for both the FIN (NAACCR #540) and the Archive FIN (NAACCR # 3100) so subsequent reports for the same case can be tracked by NCDB. New cases can be assigned the legacy FIN for the individual campus. However, how cases are accessioned is also important.

  • If the registry data for the merged program will be combined into a single registry database, all cases (regardless of diagnosis date) must be reaccessioned at the time of the database merge. Your facility must contact Kathleen Thoburn to arrange for resubmission of all cases from the registry database from the program’s reference date forward. NCDB will need to remove the previously submitted data for all affected programs from its database prior to this resubmission, so it is very important that the submission for data be at the scheduled time.
  • If the merged campuses continue to maintain separate registry databases for each campus with separately numbered accession numbers, it is essential to continue to use the original FINs from the individual facilities within the separate databases. Do not use the new FIN assigned to the merged program when the campuses maintain separate registries and accessioning of cases. The NCDB data processing system will identify the original FINs as belonging to the merger FIN and will aggregate the cases appropriately.

Please note that because mergers can be carried out differently, the FIN included in the registry database(s) may differ from the FIN under which your registry staff will access CoC Datalinks. Program access to CoC Datalinks, NCDB data submission history, SAR Standards 5.5 and 5.6 histories will be accommodated via the newly assigned FIN once the merger has been approved. Prior to approval of the merger, access will be available only through the original FINs.

Previously accredited programs are required to submit data to the NCDB for cases diagnosed from the time of the merger reference date, in accordance with the calls for data. Facilities (or campuses) that were not previously accredited are required to submit data to the NCDB for cases diagnosed from the date of the merger forward, and 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 section of the CoC website enables programs to access, provide, and utilize facility-specific information and data. 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:

  • Facility and staff contact information
  • Federal Information Processing Standards (FIPS)
  • NCDB
  • SAR and Program Activity Record

Once facilities merge, the cancer registrar or cancer program administrator must add the newly selected chief executive officer, president, or administrator; cancer program administrator; cancer committee chair; CLP, and cancer registrar(s) to the Manage Staff Contacts section in CoC Datalinks under a newly assigned FIN.  Access to CoC Datalinks via all previously assigned FINs will be deactivated, and CoC Datalinks applications and data for the individual facilities will no longer be accessible. The merged facility will be responsible for submitting new facility and staff contact information, completing new SAR and FIPS applications, signing the HIPAA BAA, and submitting data to the NCDB as described above.

The designated cancer registrar 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, those individuals 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 or medical staff through CoC Datalinks. Please review How to Manage Staff Contacts 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

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, up-to-date 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 from the HIPAA page.

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.

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 for the merged program via the NCDB: Data Submission History and Edits link located in the NCDB Data Transmission section of 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.