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Cancer Programs

Timeline and Compliance Information

Compliance Requirements and Site Visit Process for the CoC Operative Standards 

Year

Standards 5.3, 5.4, 5.5, and 5.6

Standards 5.7 and 5.8

2021

Programs begin developing plans for how they will meet the requirements of Standards 5.3–5.6.

Standards 5.7 and 5.8 take effect starting January 1. Programs must achieve at least 70 percent compliance in 2021.

2022

Programs document their final plans and work on getting up to compliance.

Programs must achieve at least 80 percent compliance in 2022. Site visits assess pathology reports from 2021 for 70 percent compliance.

2023

Standards 5.3, 5.4, 5.5, and 5.6 take effect starting January 1. Programs must achieve at least 70 percent compliance in 2023.

Programs must achieve at least 80 percent compliance in 2023. Site visits assess pathology reports from 2021-2022 for 80 percent compliance.

2024


Programs must achieve at least 80 percent compliance in 2024. Site visits assess operative reports from 2023 for 70 percent compliance.

Programs must achieve at least 80 percent compliance in 2024. Site visits assess pathology reports from 2021-2023 for 80 percent compliance.

2025

Programs must achieve at least 80 percent compliance in 2025. Site visits assess operative reports from 2023-2024 for 80 percent compliance.

Programs must achieve at least 80 percent compliance in 2025. Site visits assess pathology reports from 2022-2024 for 80 percent compliance.

Requirements for Compliance with CoC Standards 5.7 and 5.8

  • Standards 5.7 and 5.8 require pathology reports to include specific elements in synoptic format (also required by the College of American Pathologists (CAP)). Standards 5.7 and 5.8 took effect on January 1, 2021, and 70 percent compliance for that year is expected.
    • Pathology reports will be assessed for compliance with these standards starting with site visits taking place in 2022.
  • 2022 site visits will evaluate charts from 2021 to determine whether 70 percent of pathology reports within the scope of the standards meet the requirements for Standards 5.7 and 5.8 (5 out of 7 pathology reports reviewed must meet standard requirements).
    • The compliance rate will increase to 80 percent (6 out of 7 pathology reports reviewed must meet standard requirements) for 2023 site visits. 2023 site visits will review pathology reports from 2021 and 2022 for 80 percent compliance.
    • 2024 site visits will review pathology reports from 2021, 2022, and 2023 for 80 percent compliance.
  • The Scope of Standard and Measure of Compliance are defined for each standard in the Optimal Resources for Cancer Care (2020 Standards).

Requirements for Compliance with CoC Standards 5.3–5.6

  • Standards 5.3, 5.4, 5.5 and 5.6 require operative reports to include specific elements and responses in synoptic format. These standards will be implemented in a phased approach and will take full effect on January 1, 2023.
    • Programs must achieve 70 percent compliance starting January 1, 2023.
    • Operative reports will be assessed for compliance with these standards starting with site visits taking place in 2024.
  • In 2021, CoC-accredited programs should be working on their plans for how they will meet the requirements of Standards 5.3, 5.4, 5.5 and 5.6 starting on January 1, 2023.
    • We recommend that the cancer committee review the CoC Operative Standards, their intent, and the requirements. We also recommend that the cancer committee begin educating and training their surgeons, pathologists, and registrars about these standards. CoC-accredited programs are encouraged to utilize the educational resources in the Operative Standards Toolkit.
  • In 2022, CoC-accredited programs should be working on getting up to 70 percent compliance. Programs will need to document their final plan for how they will meet the requirements of Standards 5.3, 5.4, 5.5 and 5.6 beginning on January 1, 2023.
    • Formal plans must be documented in 2022. Documentation of final plans will be reviewed at site visits in 2023, 2024, and 2025.
  • Standards 5.3, 5.4, 5.5, and 5.6 take effect on January 1, 2023, and sites must achieve 70 percent compliance for these standards in 2023.
    • 2024 site visits will evaluate charts from 2023 to determine whether 70 percent of operative reports within the scope of the standards meets the requirements for Standards 5.3, 5.4, 5.5, and 5.6 (5 out of 7 operative reports reviewed must meet standard requirements).
    • The compliance rate will increase to 80 percent (6 out of 7 operative reports reviewed must meet standard requirements) on January 1, 2024. 2025 site visits will review operative reports from 2023 and 2024 for 80 percent compliance.
    • 2026 site visits will review operative reports from 2023, 2024, and 2025 for 80 percent compliance.
  • The Scope of Standard and Measure of Compliance are defined for each standard in the Optimal Resources for Cancer Care (2020 Standards).

Site Visit Process

  • Once all standards are being rated during site visits, site reviewers will review 7 charts for each operative standard (42 total).
    • If a program has fewer than 7 charts within the scope of a specific standard, then all charts within the scope of the standard from the applicable timeframe will be reviewed by the site reviewer If a program has no charts within the scope of a specific standard, they are exempt from that standard.
    • If a program has no charts within the scope of a specific standard, they are exempt from that standard.
  • Once all standards are being rated during site visits, each hospital in an Integrated Network Cancer Program (INCP) will have 7 charts assessed per standard. The INCP will then be rated cumulatively.
    • For example, an INCP with 10 hospitals would have 70 charts reviewed per standard (7 charts × 10 hospitals). 49 of the 70 charts assessed would need to meet all requirements to achieve 70 percent compliance for that standard, or 56 of the 70 charts to achieve 80 percent compliance. Compliance levels depend on the standard being assessed and the year of the site visit.
  • The site reviewer may choose to include a portion of the 14 charts reviewed for Standards 5.7 and 5.8 in the sample to determine compliance with Standard 5.1: CAP Synoptic Reporting.
  • A non-compliant rating will be given to a program that does not meet the required percentage during the medical record review. However, during 2024 site visits, an internal audit of compliance with Standards 5.3, 5.4, 5.5, and/or 5.6 and an action plan that addresses compliance issues may be considered by Site Reviewers when rating the standard.
    • The internal audit and resulting action plan must be documented in cancer committee minutes from a 2023 or 2024 meeting and must be from before the Site Reviewer selects the cases to be reviewed during the site visit. The internal audit must outline the specific issue(s) affecting compliance and the interventions that will be implemented to achieve compliance. An action plan must be documented for each potentially non-compliant standard. During the site visit, the medical record review will be conducted. If the expected compliance percentage is not met, the site reviewer will evaluate the results of the site’s internal audit and action plan as documented in the cancer committee minutes. A “deficient but resolved” rating may then be given.
      • This is a temporary alternative pathway for compliance with Standards 5.3-5.6. At this time, it has only been approved for 2024 site visits. A site taking advantage of this alternative compliance pathway is expected to be fully compliant with Standards 5.3-5.6 at its next site visit. This option is not available for Standard 5.7 or 5.8 compliance.
    • If the program does not meet the compliance threshold for Standards 5.7 or 5.8 and is deemed non-compliant, the program must complete a random sample review of 10 reports eligible for the noncompliant standard to determine whether the synoptic elements and responses were met.
      • The audit of the reports must be documented in the cancer committee minutes. The cancer committee should designate who should conduct the audit. The number of reports reviewed and the number of reports that were compliant must also be documented. If a program has less than 10 cases in this time period, the audit should include all applicable cases. The reports reviewed must be from procedures occurring after the period reviewed during the site visit. The outcome must meet the original threshold of compliance to resolve the standard. Additional information can be found on the Timeline and Compliance Information webpage.

Best Practices for CoC-Accredited Programs

  • All surgeons, pathologists, registrars, cancer committee members, and anyone else involved in the operations within the scope of these standards should be fully aware of these standards and their requirements. We also suggest bringing this topic to tumor boards, surgeon staff meetings, and/or pathologist staff meetings.
  • It is recommended that CoC-accredited programs perform an internal audit for these standards. While not required for compliance, this will allow programs to identify the gaps/opportunities for improvement specific to their institution.