With the latest Commission on Cancer (CoC) standards taking effect in January 2015, cancer centers across the United States are in various stages of compliance. Altogether, the commission has accredited approximately 1500 cancer programs and more than 70% of patients with cancer are being treated at a CoC-accredited program.1
In an effort to provide you with the latest information on these standards, the Journal of Oncology Navigation & Survivorship (JONS) has dedicated this issue of the journal to the CoC and its standards. In this article, we had the opportunity to discuss key opportunities and issues facing cancer centers seeking accreditation with members of the CoC governance, and learn more about the commission.
The CoC was founded in 1922 under the authority of the American College of Surgeons and is led by volunteer leaders that are nominated and elected for the positions of leadership. With the new standards, the commission is seeking to improve quality of life and survival for patients with cancer.
“Several years ago, we looked at our standards,” Daniel P. McKellar, MD, FACS, Chair of the CoC, told JONS. “We also looked at some important documents, like the Institute of Medicine reports on cancer care, as well as healthcare in this country. They made a very strong argument that healthcare in this country really isn’t patient-centered, like it should be.”
In particular, the report, provided strong support for survivorship care, patient navigation, palliative care, and psychosocial distress management. To address these gaps of care, members of the commission, completely revised the standards and included 3 new patient-centered standards, which became effective in January 2012. The new standards included establishing a patient navigation process (3.1), screening patients for psychosocial distress (3.2), and creating a survivorship care plan (3.3).2
The CoC allowed for a phase-in period for these standards and requested that cancer programs show how they are working to meet the standards during a 3-year span from 2012 to 2015, at which point the standards would take effect.
“The programs have done pretty well,” according to Dr McKellar. “I think their standards have done a lot to generate a lot of activity in the United States around areas like patient navigation, survivorship, and management of psychosocial distress.”
Providing, Advocating for Quality of Care
Over the years, the commission has evolved its accreditation standards to match the current state of cancer care, according to Lawrence Shulman, MD, Chair of the Quality Integration Committee. For example, the committee manages the National Cancer Database (NCD) —a compilation of registry data from all other CoC-accredited hospitals.
In addition, the Committee consists of several subcommittees that develop new quality measures that can be evaluated from the NCD database, and provide reports to each CoC-accredited hospital with their data and data from the overall CoC database to help hospitals better understand how they are performing in many of the quality metrics. Another subcommittee oversees research programs performed through the CoC and the NCD.
The CoC also has a reach in Washington, and is currently involved in several major initiatives, according to James J. Hamilton, Jr, MD, FACS, Chair of the Advocacy Committee. Because one of the CoC standards includes enrolling patients in clinical trials, the commission is also lobbying to increase National Institutes of Health funding.
“What the CoC brings to the table, for congress or for anyone, is that we have all 1500 programs that are organized in ways that can participate in research and that are encouraged because of our standards to do so,” Dr Hamilton explained. “The value to the government is that when you have that system in place, it doesn’t really cost them a dime that can facilitate this research.”
On the state level, the commission has also been very active in cancer control programs. Specifically, members of the commission are promoting the importance of survivorship issues, navigation in the cancer process, and helping the stress reduction in patients in accordance with the CoC standards.
CoC accreditation comes with a wide range of benefits, including national recognition as having established performance measures for the provision of high-quality of cancer care.3 Accredited institutions also have the benefit of quality improvement measures such as participating in the NCD and access to Comparison Benchmark Reports. There is also the benefit of organized care, data analysis, and public awareness.
For centers considering accreditation, the CoC offers a wide range of resources to get the process started. “We have a unique opportunity to effect change in those cancer programs,” Dr McKellar explained. “We have to also be sensitive to resource availability, and we know that in most hospitals around the country, resources really are dwindling. That’s why we provide a lot of support to our cancer programs to help them meet the standard.” The CoC website also provides a series of best practices, including tools for cancer programs as well as examples of how other cancer programs are meeting those standards. Webinars and face-to-face webinars are also available (see, eo2.commpartners.com/users/acsnew/search.php).
In addition, the Academy of Oncology Nurse & Patient Navigators Fifth Annual Conference will be offering several sessions focusing on the standards, including “Commission on Cancer Updates” (Friday, September 19, at 8 am) and “Navigation and Survivorship Standards – Are You Ready for Your Commission on Cancer Accreditation?” (Saturday, September 20, 2014 , at 10 am).
There is also a wealth of information available on YouTube, including videos on “CoC Distress Screening Quality Care Standard” (see, http://youtube/yulicgrxKnY) and “Accreditations for Cancer Care More Than Just CoC” (see, http://youtube/UB2SEvjWi8Q).
Overall, the CoC has a team of approximately 50 surveyors, which is overseen by the Field Staff Subcommittee. “The role of the surveyor is very, very important,” Dr McKellar emphasized. “The American College of Surgeons has many quality programs and part of our philosophy is that we want to provide meaningful standards, we want to collect rigorous data, and we want to verify that cancer programs are truly meeting the standards.” To that end, the surveyors go out onsite, and every 3 years, they visit each cancer program.
A surveyor visit is a full-day meeting, where they review the standards with the cancer programs. “We like to think of our surveyors more as consultants,” Dr McKellar explained. “They are really going out and looking deeply into the cancer programs trying to identify opportunities for improvements.” During their visit, the surveyors also bring ideas from previous cancer centers they surveyed, as well as share best practices and various tools.
Onsite visits are key to verifying compliance with the standards. In addition, as part of the accreditation process, all CoC-accredited programs have to submit comprehensive data on every patient treated in their program for the NCD. These data are used to ensure quality improvement, and cancer programs have to show compliance within a threshold for each specific measure set by the CoC.
The process is transparent, and the surveyors have an open communication with the centers to identify deficiencies or opportunities for improvement. “When I, as a surveyor, go and visit a program,” Dr McKellar said. “If I see that they’re not meeting certain standards in my summation I will tell the cancer program, ‘You’re not meeting this standard. Here’s what I recommend.’”
The CoC has a system of deficiency resolutions in place to resolve all areas needing improvement within 1 year, at which point cancer centers need to submit documentation showing that they are resolved. A program can have up to 7 deficiencies of approximately 34 standards, and still maintain their accreditation until they are resolved, according to Dr McKellar. If a program has more than 7 deficiencies, they receive nonaccreditation and have to restart the process.
“The programs truly have to be showing compliance,” Dr McKellar stated. “If they’re not in compliance with more than 7 standards, we consider them nonaccreditation, and we encourage them to have a consultant come in and assist their program.” The CoC works with a team of CoC-trained consultants, who are independent and not employed by the commission. These services may be especially useful for new centers just starting out. Although these consultants are not mandated by the commission, they are a great resource for cancer centers working toward becoming accredited.
Joining the Team of Surveyors
Both physicians and nonphysicians can become a surveyor. To become a surveyor, candidates should be actively practicing medicine for a CoC-accredited cancer program or recently retired.4 Retired physicians may be considered if their retirement began less than 1 year before the application date. Nonphysicians should have recognized experience and service in oncology administration for a CoC-accredited cancer program as well as significant operational knowledge regarding Tumor Registry.
Once an application is submitted, the candidate undergoes an interview with the Field Staff Subcommittee chair. Selected candidates are trained and undergo a 1-day orientation in August, followed by a 2-day surveyor training in November. Upon completion, the surveyor receives their survey assignments, which begins in January of the following year. The new surveyor is also required to go on an observation with an experienced surveyor, Dr McKellar explained, and is assigned a mentor. The mentor helps train them, answer their questions, and goes with the new surveyor when they perform their first survey.
Barriers to Accreditation
Cancer centers that are working on integrating the standards are facing several key barriers, including understanding the standards, finding the best ways to implement them, as well as finding the budget to do so.
The CoC standards do not provide a step-by-step guide on how to implement a navigation program or psychosocial stress test. They leave room for creativity on the part of the cancer center. Stephen B. Edge, MD, FACS, Chair of the Nominating Committee, explained that at his center, which includes a 14-hospital network with 6 cancer center buildings, 5500 new analytics cases annually, and 25 to 30 medical oncologists who are distributed over a 250- mile radius, it is not feasible to include a genetic counselor in every center. However, to meet this challenge, they are looking to implement video consultation for genetics, which has been shown to be equally effective with in-person counseling. “There is plenty of room for creativity with quality standards,” he added. “As any time, you have a creative process going on, it doesn’t always work out the way you expect. You recognize it and you try something different.”
According to the LIVESTRONG survey results he continued, the navigation standards were best understood, followed by the distress assessment, then survivorship standards. “How to functionally implement a distress assessment tool and deal with the results of it is not a trivial activity for any center,” Dr Shulman explained. “The larger you are, the more complex it is.” Once the standard is implemented, it needs to be evaluated, and centers need to be able to manage patients who have a high level of distress. “Not every program is currently staffed to manage that.” The survivorship standard is currently being reevaluated and it is possible that the time and the components of that standard will change before they become effective in January.
The survivorship standard is more vague in terms of the appropriate patient population that it applies to, whether everyone needs a survivorship care plan or just patient treated with curative intent; is it patients with all diseases or just the common diseases; what data components should be in the treatment summary and survivorship care plan. “There is no consensus on that,” according to Dr Shulman.
Other concerns raised by these standards are the costs associated with accreditation. Specifically, the application fee is $1000; annual maintainance, $1500; the survey, $7500; and survey cancellation is $1000.5 These fees do not include the cost of hiring staff to meet each of the standards.
If you are lucky enough to have just gone through this process, you may not be in the hot seat until 2016 or 2017, but putting these standards on the back burner, will not be beneficial for your patients or your center. If, however, you are looking to get the process started, keep in mind that you are not alone and there are resources available to you.
When learning about the standards, consider asking the following questions: what do the standards really mean; what does it really mean when you operationalize it; does it get measured one time or do you have to incorporate it into every visit; what do we mean by the survivorship care plan standards; and how are we going to support the implementation of survivorship care plans around hospitals?
In the end, centers owe it to themselves and their patients to meet these standards, Dr Edge told JONS. “The important point is that people are not implementing these standards, simply to assure that they remain accredited. People are implementing the standards, because they will improve the patient experience and the outcome of cancer care.”
1. American College of Surgeons. About the CoC Accreditation. www.facs.org/quality-programs/cancer/accredited/about. Accessed September 2, 2014.
2. American College of Surgeons. Cancer Program Standards 2012. www.facs.org/quality%20programs/cancer/coc/standards. Accessed August 28, 2014.
3. Benefits of Being a CoC-Accredited Program. www.facs.org/quality-programs/cancer/accredited/benefitscoc. Accessed September 2, 2014.
4. The American College of Surgeons. January 2013 Introducing the CoC Source. www.facs.org/publications/newsletters/coc-source/2013/jan- 2013-introsource. Accessed August 28, 2014.
5. American College of Surgeons. Fees. www.facs.org/quality-programs/cancer/accredited/benefitscoc/fees. Accessed September 2, 2014.