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

Accreditation Survey Process

Cancer program surveys are a comprehensive evaluation of the entire scope, organization, and activity of a cancer program. A survey is performed every three years by a Commission on Cancer (CoC) surveyor who is trained to evaluate compliance with the CoC eligibility requirements and standards that are required for accreditation.

Program standards are outlined in the Cancer Program Standards (2016 Edition). Standards for data collection are presented in Facility Oncology Registry Data Standards (FORDS).

Each program being surveyed must complete the Web-enabled Survey Application Record (SAR). The SAR an online reporting tool that is available and utilized during the year of the accreditation survey to demonstrate and document compliance of CoC Eligibility Requirements and Standards.

An independent quality assurance review of a program's SAR and supporting documentation is performed by an Accreditation Technical Specialist in the Accreditation and Standards division of the CoC. If required, program-related activity and standard ratings may also be reviewed by the multidisciplinary Program Review Subcommittee before an accreditation award is assigned.

Accreditation Awards

Currently, accreditation awards are based on compliance with the 34 standards.

The accreditation awards are as follows:

Three-Year with
Commendation

Three-Year
Accreditation

Three-Year with Contingency

Non-
Accreditation

Complies with all standards at the time of survey and receives a commendation rating for one or more standards.

Gold: 7 commendations
Silver: 4–6 commendations
Bronze: 1–3 commendations

Complies with all standards at the time of survey but does not receive a commendation rating for any standard.

Or, is awarded when all deficiencies are resolved regardless of the number of commendations awarded at survey.

1–7 deficiencies at the time of survey for established programs.

1–2deficiencies at the time of survey for new programs.

8 or more deficiencies at the time of survey for established programs.

3 or more deficiencies at the time of survey for new programs.

Three-Year with Commendation is conferred to programs that comply with all standards at the time of survey and receive a commendation rating for one or more standards. A program receiving commendation for one to three standards earns “Three-Year with Commendation” Bronze level. Commendation ratings for four to six standards earns “Three-Year with Commendation” Silver level. Commendation ratings for all seven standards earns “Three-Year with Commendation” Gold level. These levels are subject to change based on commendation standards. A certificate of accreditation is issued, and these programs are surveyed at three-year intervals.

Three-Year Accreditation is conferred to programs that comply with all standards at the time of survey but do not receive a commendation rating for any standards. This award is also applied to programs that received and resolved a deficiency for one or more standards, regardless of the number of commendations received at the time of survey. A certificate of accreditation is issued and these programs are surveyed at three-year intervals.

Three-Year Accreditation with Contingency is conferred to an established program when one to seven standards are rated deficient or to new programs when one or two standards are rated deficient at the time of survey. The contingency status must be resolved within 12 months from survey results. Programs follow the guidelines for deficiency resolution. Programs submit proper documentation to resolve the contingency status directly through the SAR. “Three-Year Accreditation” status is granted following submission and evaluation of resolution documentation. A certificate of accreditation is issued after resolution of deficiencies, and these programs are surveyed at three-year interval.

Non-accreditation is conferred to an established program when eight or more standards are rated deficient or when a new program undergoing initial survey is deficient in three or more standards. CoC staff will work directly with these programs to assist them with deficiency resolution to reinstate accreditation. Programs can also choose to withdrawal, improve their performance, and then reapply for accreditation.