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

Steps Toward Achieving Accreditation

The Commission on Cancer (CoC) has defined the following high-level steps to help guide your cancer program toward CoC accreditation. We encourage you to use these steps in conjunction with the most current standards manual. Download a complimentary copy of the current Cancer Program Standards Manual.

Form a cancer committee, establish a meeting schedule, and appoint a chair and a member responsible for developing the agenda, recording minutes, and other deliberations.

Appoint a cancer liaison physician to act as physician champion, providing leadership and direction to establish, maintain, and support the facility’s cancer program. The appointment process is outlined on our website.

Develop a checklist to review the 12 eligibility requirements and required documentation to track compliance of standards applicable to programs seeking initial accreditation.

Establish a cancer registry and abstract one (1) year of data as well as one (1) year of successful patient follow-up using CoC standards and current coding instructions to describe all reportable cases.

Complete the new program application. Submit your completed application and application fee, currently $1,000.

Sign the American College of Surgeons Business Associate Agreement (BAA). This BAA covers all American College of Surgeons Quality Programs. An electronic signing process may be initiated our website.

Once both previous steps are complete, the Eligibility Requirements (ER) and Program Activity Record (PAR) will become available.

  • Complete key information required for survey including contact staff and supporting documentation.
  • Complete all ERs.
  • Utilize the PAR to demonstrate compliance with the standards.

Submit a letter from the cancer committee chair indicating the ER and PAR are complete and your program is ready to be surveyed.

The CoC will assign a physician surveyor. The physician surveyor will contact your cancer program to negotiate a date for survey and plan the visit.

Your program will be invoiced approximately 60 days prior to the scheduled survey date and will have 30 days to remit payment to the CoC.

Following the survey visit, the surveyor will submit the findings to the CoC. CoC staff will perform a second evaluation and prepare a performance report of survey results that is available through CoC Datalinks approximately six weeks following the survey.

Submit to NCDB as part of the next annual Call for Data. Submit all analytic cases in January for any diagnosis years beginning with your Reference Date.

Resources

Visit the CoC website for tools, resources, and best practices designed to assist your program in compliance with the standards.

  • Cancer Forum is a virtual bulletin board for CoC constituents to ask questions, search topics, and connect with the latest CoC activities.
  • The Standards Resource Library contains tools and examples designed to help cancer programs meet the standards.

For more information on the benefits of CoC accreditation or how to become accredited, visit our website or contact Karen Stachon, Accreditation Technical Specialist, at Accreditation@facs.org.