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

Chapter 1: Program Management

About the Standards in Chapter 1

Physician credentials are addressed in Standard 1.1. Physicians treating or providing diagnostic services to cancer patients must be board certified in their specialty or be in the process of becoming board certified.

Standard 1.2 defines cancer committee membership. Cancer committee has the authority for program leadership and is responsible for goal setting, planning, development, initiation, evaluation, and improvement of all cancer-related activities.

Cancer committee attendance is covered by Standard 1.3, which requires that each member attend at least 50% of the cancer committee meetings each calendar year.

Cancer Program Goals are addressed in Standard 1.5. Each calendar year the cancer committee must develop, implement, monitor, evaluate, and document at least one clinical and one programmatic goal.

Monitoring Cancer Conference Activity is covered in Standard 1.7. The coordinator for cancer conference is responsible for monitoring these conferences, evaluating the activity and reporting to cancer committee at least once per year.

Standard 1.8 addresses the responsibilities and activities of the community outreach coordinator.

Standard 1.9, Clinical Trials Accrual, is a phase-in Standard for 2015 as the required participation rates have been increased for most accreditation categories. Cancer programs will be required to accrue a specified percentage of patients to cancer-related clinical trials yearly, based on category.

Standard 1.10 specifies that cancer committee must offer at least one cancer-related educational activity each year.

Standard 1.11 requires that all members of the cancer registry staff participate in at least one cancer-related educational activity each year.

Standard 1.12 is different from other standards in that it is fulfilled for commendation only. In other words: it is optional. A cancer program can fulfill this standard by developing and publishing or distributing a report on patient or program outcomes to the public.