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

Post Site Visit

Accreditation status notifications are distributed via e-mail within approximately 45 days, or as soon as practical thereafter, following the completed site visit. The Cancer Program Administrator, Cancer Committee Chair, Cancer Liaison Physician, and Hospital Registrar each receive an email when the completed Accreditation Report is posted electronically. 

The Accreditation Report provides the following:

  • A comprehensive summary of the site visit outcome and accreditation award
  • The cancer program’s compliance rating for each standard
  • A narrative description of deficiencies that require corrective action
  • Suggestions to improve or enhance the program

If accredited without contingency, information to order the complimentary Certificate of Accreditation is provided to the Cancer Program Administrator following posting of the Accreditation Report. The program may appeal a finding for any standard or the accreditation award within 30 days of the date the Accreditation Report is posted. Information about the appeals process is in the cancer program’s password-protected portal. 

Ratings for each standard are assigned based on consensus by the cancer program’s site visit reviewer and Commission on Cancer staff. When required, the applicable executive review group will also contribute to the standard rating decision as a final adjudicator.

A Compliant, Noncompliant, or Not Applicable rating is assigned for each standard. Any standard with a Noncompliant rating is deficient.

A program receives one of the following Accreditation Awards following the site visit process:

Three-Year Accreditation

Three-Year Accreditation with Contingency

Non-Accreditation

Complies with all standards or is awarded when all deficiencies are resolved.

1–7 deficiencies for established programs.

1–2 deficiencies for new programs.

8 or more deficiencies for established programs.

3 or more deficiencies for new programs.

 

Post Site Visit Evaluation

The Post Site Visit Evaluation (PSE) is an important component of the cancer program site visit. The PSE captures feedback from the facility, which enables the CoC to evaluate and improve the site visit process, site visit reviewer performance, and to develop educational materials and training programs for site visit reviewers and participating programs. 

All responses are confidential and do not influence the cancer program evaluation or accreditation award. Responses on the evaluation form should represent a consensus opinion of the cancer committee. The PSE should be completed within 14 calendar days of the site visit.

Marketing Your Accreditation

The CoC encourages accredited programs to access a wide array of resources that are made available to promote accreditation to employees, patients, and the community. These resources are accessible from the cancer program’s password-protected portal for use by the public relations or marketing departments and include the CoC accreditation certificate, accreditation logo, sample press release, a poster and banner stand, and patient information brochure. New resources are added regularly.