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

CoC Cancer Liaison Physician

Role

The Commission on Cancer (CoC) Cancer Liaison Physician (CLP) is an integral and required member of a CoC-accredited cancer program’s cancer committee.

The CLP:

  • Is selected and appointed by the cancer committee.
  • Can be a physician of any specialty who is an active member of the medical staff.
  • Fulfills the role of physician quality leader of the cancer committee.
  • Serves as the alternate for the cancer committee chair and oversees cancer committee meetings if the chair is not in attendance.
  • When choosing a CLP, the selection of women, minorities, and those of diverse backgrounds are encouraged.

It is permissible for the CLP to also serve as the cancer committee chair, but it is encouraged that the CLP role and the chair role be filled by two individuals.

Responsibilities

According to the CoC Optimal Resources for Cancer Care (2020 Standards), the CLP is identified as the physician quality leader of the cancer committee and is expected to fulfill the responsibilities within each of the following Standards:

2.2 Cancer Liaison Physician

The cancer program fulfills all the compliance criteria:

  • The CLP or the CLP’s alternate identifies, analyzes, and presents NCDB data specific to the cancer program, with preference for areas of concern and/or where benchmarks are not met, to the cancer committee at a minimum of two meetings each calendar year.
  • The CLP is present during the CoC site visit and meets with the site visit reviewer to discuss CLP activities and responsibilities.

National Cancer Database Tools 2021

CoC Cancer Liaison Physician Education Series: Utilizing the National Cancer Database Tools

7.1 Accountability and Quality Improvement Measures

The CLP is expected to:

  • Be familiar with CoC Standard which requires the cancer committee to monitor the program’s expected Estimated Performance Rates (EPRs) for accountability and quality improvement measures selected by the CoC.
  • Regularly review the cancer program’s performance against the selected measures in the Rapid Cancer Reporting System and reference in your presentation to the cancer committee (Standard 2.2) and discuss recommendations for improvement where measures fall below expected EPRs.

7.3 Quality Improvement Initiative

Under the guidance of the Cancer Liaison Physician (CLP), the Quality Improvement Coordinator, and the cancer committee, the cancer program must measure, evaluate, and improve its performance through at least one cancer-specific quality improvement initiative each year:

  • One quality improvement initiative based on an identified quality-related problem is initiated each year. The QI initiative documentation includes how it measured, evaluated, and improved performance through implementation of a recognized, standardized performance improvement tool.
  • Status updates are provided to the cancer committee two times. Reports are documented in the cancer committee minutes.

Overview of the CLP Role: CoC Standards 2.2, 7.1, and 7.3

Additional Duties

CLP Access to the NCDB

Upon appointment, CLPs are provided access to CoC Datalinks, the password-protected portal that contains information about their CoC-accredited cancer program. CLPs are encouraged to review descriptions of each of the Quality Cancer Tools and log in to CoC Datalinks to access and review their facility’s data. In the event you forget your password, please visit the Member Login page to use the Forgot User Name or Password feature to reset your password. The Quality Cancer Tools include: 

  • NCDB Hospital Comparison Benchmark Reports (HCBR)
  • NCDB Survival Reports
  • NCDB Rapid Cancer Reporting System
  • Cancer Quality Improvement Program
  • NCDB Completeness Reports
  • Site by Stage Distribution Reports
  • Participant User Files (PUF)

Additional CLP Resources

The following are additional resources to support CLPs in their role. 

CLP Meetings

Tuesday, April 20, 2021

During this meeting an overview of the implementation of operative standards and an update from the American Cancer Society was provided. A new return to screening QI project was covered, a clinical study opportunity was announced, and site reviewers shared tips and best practices.

Thursday, October 22, 2020

This meeting overviewed resources and best practices to support Cancer Liaison Physicians in their role within their CoC-accredited cancer program. 

Communications from CoC State Chairs

The following are general communications from CoC State Chairs and are not inclusive of every communication you might receive from your CoC State Chair.