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

Commission on Cancer-Accredited Cancer Program Requirements for 2021

Dear Cancer Program Colleagues,

The following communication outlines specific standards required for implementation in 2021 as outlined in the Optimal Resources for Cancer Care (2020 Standards). Programs scheduled for a site visit in 2022 will be reviewed on 2020 and 2021 program activity.

The following resources are available to assist your program with implementation:

Oncology Nursing Credentials – Standard 4.2

Programs will be expected to comply with Standard 4.2 beginning January 1, 2021. Resources to support implementation include:

  • Oncology Nursing Certification Corporation (ONCC) website for information on certification and continuing education (CE). The ONCC also provides an updated list of available free CE options.
  • Oncology Nursing Society also provides information on continuing education for nurses, including free options.
  • Oncology Nursing Credentials Frequently Asked Questions resource answers questions submitted by programs regarding all aspects of the standard.
  • The Oncology Nursing Credentials Template, located in CoC Datalinks, is a useful tool to track compliance throughout the accreditation cycle and can be used to demonstrate compliance with the standard. The template must be uploaded into the Pre-Review Questionnaire at least 30 days before the site visit.

Survivorship Program – Standard 4.8

Programs will be expected to comply with Standard 4.8 beginning January 1, 2021. A Frequently Asked Questions document and a resource that provides compliance examples for a variety of programs are available in the Standards Resource Library.

Total Mesorectal Excision – Standard 5.7
Pulmonary Resection – Standard 5.8

These standards require pathology reports to include specific elements (also required by the College of American Pathologists (CAP)). For site visits conducted in 2022, site reviewers will evaluate 2021 documentation to determine whether 70% of pathology reports for eligible patients meet the requirements for Standards 5.7 and 5.8. The compliance rate will increase to 80% beginning with 2023 site visits (which will review 2021 and 2022 pathology reports). Site reviewers will review 7 charts for each standard (14 total). If a program has less than 7 patients that meet the patient criteria for a specific standard, then all patient charts meeting the criteria will be reviewed by the site reviewer. The site reviewer may choose to include a portion of the 14 patients reviewed for Standards 5.7 and 5.8 in the sample to determine compliance with Standard 5.1: CAP Synoptic Reporting.

Note: Standards 5.3 Breast Sentinel Node Biopsy, 5.4 Breast Axillary Dissection, 5.5 Primary Cutaneous Melanoma, and 5.6 Colon Resection require operative reports to include specific elements in synoptic format. These will be implemented in a phased in approach over 3 years beginning in 2022. In 2021 we recommend that the cancer committee review the operative standards, their intent and the requirements and begin planning for implementation. As mentioned in previous communications, tools and resources are in development to assist programs with compliance and will be shared with CoC-accredited cancer programs as soon as they are available.

The full implementation plan for Standards 5.3-5.8 may be found on the Commission on Cancer 2020 Operative Standards website.

Data Submission – Standard 6.2

This standard will be retired beginning in 2021 as complete data for all requested analytic cases will be submitted to the National Cancer Database (NCDB) in accordance with the requirements for use of the new Rapid Cancer Reporting System (RCRS).

Data Accuracy – Standard 6.3

This standard will be retired beginning in 2021 as the NCDB works to develop new methods to measure data accuracy using the Rapid Cancer Reporting System (RCRS).

Rapid Quality Reporting System (RQRS) Participation – Standard 6.4

This standard will be renamed Rapid Cancer Reporting System (RCRS) Data Submission with the following requirements:

  • All new and updated cancer cases are submitted at least once each calendar month.
  • Submit all complete analytic cases for all disease sites via RCRS as specified by the annual Call for Data.
  • Rapid Cancer Reporting System data and required quality measure performance rates are reviewed by the cancer committee at least twice each calendar year and documented in the cancer committee minute.

The Standards Manual will be updated later this year to reflect the changes outlined for Standards 6.2, 6.3, and 6.4.

Accountability and Quality Improvement Measures – Standard 7.1

This standard requires programs to treat cancer patients according to nationally accepted accountability and quality improvement measures indicated by the CoC and included in the Rapid Cancer Reporting System (RCRS) tool.

  • Each calendar year, the expected performance rate is met for each of the selected accountability and quality improvement measures as defined by the CoC, and the cancer committee of each accredited program monitors the selected accountability measures.
  • For 2020 and 2021, the program’s performance rate for this standard is expected to be equal to or greater than the expected rate specified by the CoC for the nine (9) selected measures. If the performance rate is not in compliance, the upper limit of the confidence interval computed by the NCDB, which is used to adjust for patient count, may be used to judge performance. These performance rates will be reviewed during site visits beginning in 2022.

Pre-Review Questionnaire (PRQ)

A Pre-Review Questionnaire (PRQ), which replaces the Survey Application Record (SAR) and supports the 2020 standards, will be released in October in CoC Datalinks. A PDF of the PRQ will be also be available. As mentioned in a previous communication, much of the documentation to support compliance with the standards is now required using a series of templates that are accessible in CoC Datalinks. Programs must complete and submit these templates with the PRQ at least 30 days before the confirmed site visit date. The templates are also a useful tool to track compliance throughout the accreditation cycle.

Accreditation Fee

The 2021 Accreditation Fee Chart has been added to the homepage of CoC Datalinks under “Resources.”

We appreciate your continued participation in the CoC Accreditation Program. Please submit your questions to coc@facs.org.

Thank you,

CoC Leadership and Staff