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

Site Visit Preparation

Pre-Review Questionnaire

The Pre-Review Questionnaire (PRQ) is an online reporting tool that is available and utilized during the year of the accreditation site visit to demonstrate and document compliance with the Commission on Cancer (CoC) Standards. Once the site visit has taken place, the PRQ will close permanently. Access to the PRQ is provided to the Hospital Registrar, Cancer Committee Chair, Cancer Program Administrator, and Cancer Liaison Physician. Additional users can be identified by the cancer program and added through the Manage Staff Contacts link located in the cancer program’s password-protected portal.

To facilitate a thorough and accurate evaluation of the cancer program during the site visit, the program completes the PRQ at least 30 calendar days before the scheduled on-site visit. All required fields must be completed, including all required templates. Completion of the PRQ should be a team effort of members of the cancer committee. The PRQ will close 14 calendar days before the on-site visit. The cancer program’s site visit reviewer will evaluate the PRQ before the site visit to assess compliance with the standards and to become familiar with the resources and services offered and the cancer program activity.

CoC-accredited cancer programs document their activities using multiple sources, including policies, procedures, manuals, tables and grids; however, cancer committee minutes are the primary source for documentation of cancer program activity. All meeting minutes should contain enough detail to accurately reflect the activities of the cancer committee and demonstrate compliance with CoC Standards. Consent agendas are permitted if each item that is reviewed before the committee meeting is on the formal agenda and is documented in the minutes with the approval or discussion.

The documentation required for each standard is included in the specifications for the standard.

Select standards require a medical record review to ensure compliance. Compliance with these components of the standard will be evaluated during the on-site visit. The cancer program will submit the required patient list in the PRQ at least 30 days before the site visit.

The patient list uploaded in the PRQ or any other electronic communication with the CoC and/or the site visit reviewer cannot contain any Protected Health Information (PHI). However, the medical records reviewed on site do not need to be de-identified. Review of PHI on site is covered by the Business Associate Agreement that the program signs with the American College of Surgeons at the time of application for accreditation.

Site Visit Agenda

A member of the cancer committee confirms the agenda for the survey with the site visit reviewer(s) at least 14 days before the on-site visit. The site visit reviewer’s role is to define the standards and verify that the cancer program is in compliance.

To accomplish this task on the day of site visit, the site visit reviewer(s) will:

  • Meet and provide education to key members of facility administrative leadership on the value of CoC accreditation and how to market this achievement.
  • Meet the cancer committee to discuss the activities and responsibilities of the cancer committee in relationship to the cancer program and to verify the accuracy of the data recorded in the PRQ.
  • Attend a cancer conference to observe the program’s multidisciplinary patient management and discussions.
  • Meet with the Cancer Liaison Physician to discuss the his or her role and responsibilities, including opportunities to use National Cancer Database data.
  • Meet with the Cancer Program Administrator and cancer registry representatives to discuss cancer registry functions and cancer committee operations.
  • Review medical records to determine relevant standard compliance.

Attendance is important, and it is highly encouraged that all members of the cancer committee attend and participate in the site visit. At a minimum, the site visit reviewer(s) must meet with the following staff:

  • Chief Executive Officer and/or other chief leadership administrators
  • Cancer Liaison Physician
  • Cancer Committee Chair