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

ACS Cancer Programs Provides Update on Accreditation Site Reviews and Resources

The leadership and staff of the American College of Surgeons Commission on Cancer (CoC), National Accreditation Program for Breast Centers (NAPBC), and National Accreditation Program for Rectal Cancer (NAPRC) are committed to the health and safety of our participating accredited program staff, health care professionals, physicians, and patients as we continue dealing with ramifications of the COVID-19 pandemic. We would like to provide an update on our plans to begin resuming site visits and to share new resources that will become available to our participating programs later this month.

Accreditation Site Visits

In early March we made the decision to postpone 2020 accreditation site visits for eight months and to further postpone 2021 site visits to 2022. Beginning this month, the CoC and NAPBC site reviewers will begin contacting those programs due for a site visit in 2020 to start the rescheduling process. As our site reviewers contact these programs, it is our intention that they will work to establish a mutually agreeable date for the site visit beginning this fall and extending through June 2021. We hope that by that time we will be able to complete the remaining site visits that were postponed beginning in March. Please give your site reviewer time to contact you over the next month.

Because there may continue to be concerns about traveling and holding gatherings of large groups, we have developed a virtual site visit plan that we will offer as an alternative to the in-person visit. We will pilot test the plan with a few CoC and NAPBC programs in July and August and will subsequently evaluate the results, refine the plans, train our site reviewers, and communicate this option to our programs. The NAPRC is also in the preliminary stages of investigating a virtual site visit option, and site reviewers will begin contacting programs with postponed site visits to discuss rescheduling. We feel that the virtual plans we have developed will retain the key components of the in-person visit and offer the same level of quality to assess compliance with the accreditation standards, provide education and consultation, and offer strategies to help programs enhance the quality of their cancer care delivery. More information about this option is forthcoming. In the meantime, please work with your site reviewer to reschedule your site visit, which can always be switched to a virtual visit later.

New Resources to Support Accreditation

Later this month, we plan to release the following resources to support standards compliance:

COVID-19 Accreditation Tracker – This resource will assist programs with documenting the impact of COVID-19 on compliance with the CoC accreditation standards. Cancer programs have requested additional detail on compliance expectations for the individual standards, and this resource will build on our previous communication regarding accommodations for disruptions to normal program operations due to the pandemic. Please note that programs will not be penalized for standards that could not be met due to the impacts of the pandemic. Similar trackers are in development to support the NAPBC and NAPRC standards.

Cancer Program Activity Templates – The new CoC Program Review Questionnaire (PRQ), currently in development to support the 2020 standards, is on schedule to be released this fall. The PRQ will replace the current Survey Application Record (SAR). Major components of program activity will now be tracked using templates that will be uploaded into the new PRQ. We are completing development of 11 templates for programs to use to track a variety of program activities (for example, cancer committee meetings, cancer program goal, and so on). The NAPBC is also developing new templates, and both the NAPBC and NAPRC PRQs will be released later this summer.

Folder Structure Resource – Because preparing for CoC accreditation is a multidisciplinary, cross-program initiative, an effective file and folder structure is essential for organizing accreditation documents. This resource will provide tips and techniques for organizing your content in an ongoing fashion to make site visit preparation easier and less burdensome. Folder structure resources to support the NAPBC and NAPRC programs will be released later in June.

Standards Resource Library – CoC program staff can access the new Standards Resource Library from CoC Datalinks, and the library will include a variety of resources to support compliance with the 2020 standards.

New Education and Training

Due to the COVID-19 pandemic, we have canceled in-person workshops on the CoC and NAPBC standards and accreditation processes. In order to fill this void, the CoC and NAPBC will each be hosting a webinar series over the next several months to support compliance with the accreditation standards. The CoC schedule was included in the most recent issue of Cancer Programs News and can be found on our website. The webinars are free, but registration is required. Later this month we will be releasing information on the NAPBC education series, which will also be free. We look forward to your participation in these programs.

We encourage you to regularly visit the accreditation program websites for program updates and resources. We value your continued participation in our accreditation programs and welcome your feedback, questions, and concerns. Please contact us anytime at acscancerprograms@facs.org.