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

Important Communication for Programs Preparing for their Re-Scheduled 2020 Site Visit

Dear Cancer Program Colleagues,

As you prepare for your re-scheduled 2020 site visit to assess your cancer program’s compliance with the Commission on Cancer (CoC) accreditation standards for 2017, 2018, and 2019, we are requesting that you add the following task to your site visit preparations to support Standards 4.4 and 4.5 Accountability and Quality Improvement Measures.

  • Standard 4.4 states that each calendar year, the expected performance rate is met for each accountability measure as defined by the CoC.
  • Standard 4.5 states that each calendar year, the expected performance rate is met for each quality improvement measure as defined by the CoC.

The program’s performance rate for these Standards is expected to be equal to or greater than the expected rate specified by the CoC. The nine measures assessed under Standards 4.4 and 4.5 and the expected performance rates are outlined here.

Although these standards indicate that the measure compliance can be assessed using the Cancer Program Practice Profile Reports (CP3R), this tool was recently discontinued, and the measures are now included in the new Rapid Cancer Reporting System (RCRS) tool.

To assist the site reviewer in assessing compliance with these two standards for the nine defined measures, we are requesting programs due for a site visit to export the CoC Accreditation Measures for Surveyor table that displays the EPRs for the years of program performance being assessed (2015, 2016, and 2017 cases) in the RCRS Dashboard. This table should be exported as a PDF at least 30 days prior to the site visit and posted in the Other section of the Survey Application Record (SAR) menu. The site reviewer will be responsible for reviewing the PDF to assess compliance with the two standards and will include the table in their presentation to the cancer committee during the site visit.

Instructions to export the Quality Measures table in the RCRS Dashboard

  • Log in to the Rapid Cancer Reporting System.
  • A sample of the CoC Accreditation Measures for Surveyor table that should appear in your Dashboard when you are logged in is below:

Dashboard

  • Click on the arrows in the upper right corner of the table to expand the table.
  • Right click in the white space on the screen and select Export and Visualized to PDF
  • This What to export box will appear next to the table. Make sure all boxes displayed below are checked:

Dashboard

  • Click the blue Export button in the bottom right hand corner of the screen.
  • A display will open at the bottom of your screen that will allow you to Save the PDF to your computer.
  • Log in to the Survey Application Record in CoC Datalinks and upload the PDF file to the Other section of the Survey Application Record (SAR) menu and save the page.

Please direct any questions about this new process to coc@facs.org.

Thank you,
CoC Staff