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

ACS Cancer Programs Postponement FAQ

When was the communication sent to ACS Cancer Programs accredited programs regarding the postponement of accreditation site visits for 2020 and beyond?

Monday, March 24, 2020

When did the postponement of accreditation site visits take effect?

In early March 2020 we began communicating with programs due for a site visit in March and April 2020 to determine their ability to move forward with their scheduled site visit.  Site visit postponements started around March 12th and continued to increase.  COVID-19 has caused postponements across all of the ACS accreditation and verification programs. 

When did the ACS decision to postpone accreditation site visits take effect?

Site visits scheduled from March 12th forward are included in the ACS accreditation/verification program postponement decision.

If my program is due for an accreditation site visit in 2020, what does the postponement mean for my program?

Once the COVID-19 pandemic as subsided, site reviewers assigned to CoC, NAPBC, and/or NAPRC programs scheduled for an accreditation site visit in 2020 will begin contacting you to reschedule for a date that works best for your program and the site reviewer.  Site visits should not resume until late fall through June 30, 2021. If you already have a site visit scheduled in October, November or December, you can work with your site reviewer to determine if you want to retain that date. This means, we will not be automatically re-assigning you a new site visit due date 6-months from your original date.  Instead we will allow you to work directly with your site reviewer to reschedule a mutually agreeable date.

If my program is due for an accreditation site visit in 2020 and is postponed, when will I receive more information about how to re-schedule?

The ACS Cancer Programs Staff will be contacting you and the site reviewers once the COVID-19 pandemic has subsided to begin the rescheduling process

Will I have the same site reviewer that was initially assigned to conduct my accreditation site visit?

We are working to retain your originally assigned site reviewer to conduct your program site visit.  Some site reviewers may have conflicts with rescheduling and if we need to assign your program a new site reviewer, you will be notified by ACS Cancer Programs Staff.  

If my program is due for an accreditation site visit in 2020 that gets rescheduled later this year and in to 2021, what years of program activity will my program be evaluated on?

All programs originally due for an accreditation site visit in 2020 will be evaluated on 2017, 2018, and 2019 program activity.

How does the postponement impact my program visit if my next accreditation due date was in 2021, 2022, and 2023? 

Programs due for an accreditation site visit in 2021, 2022, and 2023 will be extended one full year from their original site visit due date.  For example, if you are due for an accreditation site visit in February 2021, you will be rescheduled for an accreditation site visit due in February 2022.

Previous Site Visit Year

Original Accreditation Site Visit  Year

New Accreditation Site Visit Date/Year

2017

2020

Extended 6 months – site visits occurring between September 2020 thru June 2021 – see chart below

2018

2021

2022

2019

2022

2023

2020

2023

2024

Will my program lose its accreditation status due to these postponements?

No. The accreditation status of all programs will be maintained through the next scheduled accreditation site visit. 

If my program was due for an accreditation site visit in 2021 and my accreditation site visit is now scheduled for 2022, what years of program activity will I be responsible for?

For CoC programs, 2022 accreditation site visits will include a review of program activity for 2020 and 2021.
For NAPBC programs, 2022 accreditation site visits will include a review of program activity for 2019, 2020, and 2021 activity (we will not be reviewing 2018 activity). NAPRC reaccreditation site visits now occurring in 2022 will review 2019, 2020, and 2021 activity.

What if my program received a deficiency/deficiencies as a result of our last accreditation site visit (in the last three years through March 12th site visits?

Programs that are currently working to resolve deficiencies will receive a 6-month extension to their original deficiency resolution due date.  ACS Cancer Programs staff are contacting each program to confirm this extension. 

Our program has submitted an application for accreditation.  How soon can I have an initial accreditation site visit?

If your program has a confirmed initial accreditation site visit date this year, you will be contacted by your site reviewer to reschedule before June 30, 2021. If your program is ready to schedule an initial accreditation site visit, please contact us so we can schedule your site visit beginning in October 2020 and later. Accreditation site  visits scheduled for new Commission on Cancer (CoC) programs between October 2020 and June 2021 will be reviewed on one year of program activity (2019) from the CoC’s Cancer Program Standards: Ensuring Patient-Centered Care (2016 Edition).  New programs applying for National Accreditation Program for Breast Centers (NAPBC) and National Accreditation Program for Rectal Cancer (NAPRC) accreditation that are ready to proceed with a site visit will be reviewed on a rolling 12 months of program activity. We will decide later this year on what years will be reviewed for any new programs that choose to apply for accreditation during this year. 

How should my program document our inability to maintain standard program operations and compliance with the standards during the COVID-19 pandemic?

We understand normal program operations have been disrupted and the utmost flexibility will be granted.  Programs will not be penalized for standards that cannot be met at this time. Disruptions may include cancellations of meetings of the cancer committee or breast program leadership, tumor boards, screening events, etc. to name a few impacted activities.  Whether or not to move forward with these activities is left to the discretion of the program.  We encourage programs to document the impact of COVID-19 on accreditation-related activities so that it can be referenced by the site reviewer at the next accreditation site visit.   The Survey Application Records (SAR) for programs due in 2020 will remain open this year to upload program information but there is no mandatory requirement to do so until 30 days prior to the rescheduled accreditation site visit date.

If cancer patient treatment is delayed, how will that be highlighted in future CP3R’s?
If a patient is diagnosed with lung cancer, and after review of the many treatment choices, the patient opts for radiation treatment vs the optimal surgical treatment during this COVID-19 pandemic – how will that be profiled in the future? 
In general, how will the CoC’s future cancer care data reflect this COVID-19 pandemic?

The CoC continues to monitor the effects of COVID-19 on our hospitals, clinicians and patients. We have received several inquiries regarding potential delays in treatment or alterations of treatment choices by patients in the current environment. Registrars should continue to follow the STORE rules and instructions to abstract/code cases. We are working with our clinical leadership across the country to maintain the highest standards of patient care while determining how adjustments to compliance with accreditation benchmark quality measure performance rates should be considered. Further details on how compliance will be best measured will be communicated with programs in the coming months.

Is ACS Cancer Programs offering virtual accreditation site visits in lieu of in-person accreditation site visits?

Virtual accreditation site visits are not being offered at this time. We will contact all programs if and when a virtual accreditation site visit option becomes available.

Are the new survivorship and nursing standards included in the Commission on Cancer Resources for Optimal Cancer Care (2020 Standards) still being implemented beginning in 2021?

Yes

When are the new operative standards for cancer surgery included in the Commission on Cancer Resources for Optimal Cancer Care (2020 Standards) being implemented?

A date has not yet been set for implementation of the new operative standards. 

Is the Commission on Cancer going to extend the May 31, 2020 deadline for National Cancer Database (NCDB) Call for Data for 2018 cancer cases?

The 2020 NCDB Call for Data was originally scheduled to be conducted from January 1 through May 31, 2020.  We understand many hospital registrars may be experiencing work disruptions due to the COVID-19 pandemic and related adjustments being made by hospitals across the country.   Due to the many issues registrars are experiencing, the 2020 Call For Data window will be extended to August 31, 2020 (11:59 pm CST) for submissions and corrections to allow programs to successfully meet the CoC Standards 5.5 and 5.6 requirements.

Published 4/6/2020