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

Standard 4.3

Cancer Liaison Physician Responsibilities

A Cancer Liaison Physician (CLP) serves in a leadership role within the cancer program and is responsible for evaluating, interpreting, and reporting the cancer program’s performance using data from the National Cancer Data Base (NCDB). The CLP, or an equivalent designee, reports the results of this analysis to the cancer committee at least four times each calendar year.

Definition and Requirements

A CLP is a physician responsible for providing leadership and direction to monitor and improve quality within the cancer program.

CLP Selection Criteria

The CLP position is a required role in Commission on Cancer (CoC)-accredited cancer programs. The CLP serves a three-year term with eligibility to serve an unlimited number of terms based on performance as assessed by the CoC and the cancer committee. A CLP may be replaced at any time during the three-year term. The new CLP’s term will be effective on the first of that month and will extend three years.

CLP Education Requirements

The CLP is required to complete CLP orientation within three months of initial appointment and on reappointment every three years. The CLP will view all Web-based CLP education programs provided by the CoC each year. This is a recommendation and is not required. These programs are specific to continuously informing and enhancing the role of the CLP. All the CLP education is located in the Cancer Liaison Program section of the CoC Website.

Primary CLP Responsibilities

The primary responsibility of the CLP is to monitor, interpret, and provide update reports of the program’s performance using NCDB data to evaluate and improve the quality of care. At least four times each calendar year, the CLP reports and discusses the facility’s performance and response related to the accountability and quality improvement measures in the Cancer Program Practice Profile Reports, and on data from additional NCDB reporting tools such as the Cancer Quality Improvement Program, the Rapid Quality Reporting System, Hospital Comparison Benchmark Reports, or Survival Reports. A quality-related audit is initiated for any of the accountability and quality improvement measures that fall below required levels of compliance.

Secondary Responsibilities

  • The CLP reports on CoC activities, initiatives, and priorities to the cancer committee.
  • The CLP serves as liaison between the cancer program, the CoC, and the American Cancer Society.
  • The CLP attends the CoC accreditation on-site survey and meets with the surveyor to discuss the NCDB Quality Reporting Tools and CLP responsibilities.