The American College of Surgeons’ Commission on Cancer (CoC) is a consortium of professional organizations working to improve survival and quality of life for cancer patients. Through the CoC Accreditation Program, cancer programs achieve benefits for themselves and for the patients they serve. To help our readers determine if accreditation is right for them, the Journal of Multidisciplinary Cancer Care recently spoke with Robert Flanigan, MD, FACS, vice chair of the accreditation committee and chair of the recruitment and retention subcommittee of the CoC, about the steps involved in the accreditation process.

At present, approximately 72% of newly diagnosed cancer patients are treated in CoC-accredited centers, and the number of accredited centers is just short of 1500 throughout the United States and Puerto Rico, which represents between 25% and 30% of hospital facilities. “I think we accumulated this expanse of attachment to these newly diagnosed cancer patients because many of our facilities are dominant in their areas in their communities, not speaking of the National Cancer Institute facilities and the academic medical institutions that are accredited,” Flanigan said. “We accredit institutions that attract medical oncologists, radiation oncologists, and other specialists, and they bring their cancer patients to these facilities, perhaps from other institutions or other outlying areas.”

In short, CoC-accredited institutions have something to offer. “The CoC’s goal is to provide the best quality of care to the patients, which begins with a comprehensive multidisciplinary team approach to their care.” As Flanigan explained: “Some cancers can be dealt with by one board-certified individual. For example, a stage I melanoma does not require evaluation by a medical oncologist or radiation oncologist, any reasonably trained general surgeon can handle that particular case. However, the vast majority of cancers (lung, colon, breast, etc) require a multidisciplinary approach. The CoC has a diverse membership; it represents 47 organizations. Those disciplines address every potential facet of cancer care that a patient could require.”

There are five key elements to the success of a CoC-accredited cancer program¹:

1. The clinical services provide state-of- the-art pretreatment evaluation, staging, treatment, and clinical follow-up for cancer patients seen at the facility for primary, secondary, tertiary, or quaternary care.

2. The cancer committee leads the program through setting goals, monitoring activity, evaluating patient outcomes, and improving care.

3. The cancer conferences provide a forum for patient consultation and contribute to physician education.

4. The quality-improvement program is the mechanism for evaluating and improving patient outcomes.

5. The cancer registry and database is the basis for monitoring the quality of care.

“For a physician to want a program with these attributes, he/she needs to be dedicated to the thought of providing the best possible care for that patient. And for a program to succeed, it needs a number of individuals with a passion for doing that and for wanting to follow through with the effort,” Flanigan explained. “It is a teamwork phenomenon, it cannot be just one individual, that individual needs to seek others that want to be involved likewise and proceed with this effort.”

Designing a program

There is no one design model for CoC-accredited institutions. Each center develops its own approach to compliance with the CoC’s 36 standards. The standards provide a framework for developing a program up to the point of accreditation. They cover all the basics from the leadership model needed to the necessary diagnostics, therapeutics, support services, quality studies, activities, and registry management, according to Flanigan.

“The path to accreditation is never exactly the same,” he said. Many programs that express an interest in becoming accredited already have a number of the required elements. It may be just a matter of making sure all the clinical services are available, and then coordinating the interested surgical specialists as well as medical and radiation oncologists. A center does not necessarily need to provide all the clinical services on its campus; these services can be provided by referral, according to Flanigan. “For instance, I just surveyed a hospital and the radiation facility was privately owned and located across the street. That setup is fine. As long as the services are available to the patients in that community, that is an acceptable approach.”

In addition, most cancer programs already have a cancer committee or a group of individuals who are concerned about the delivery of cancer care to patients at that institution. According to Flanigan, “this is a major start point, as this is the leadership group who will develop the program and begin to address the 36 standards.”

Developing a cancer conference is usually not a complicated issue, nor is developing a quality-improvement program, Flanigan said. Most hospitals already have a manager to address quality- improvement concerns.

Developing a cancer registry, however, is “probably one of the major hurdles when developing a program with the goal of accreditation because, though every state requires reporting of cancer incidence data, having a dedicated registry is a little bit different from having an individual in the medical records department assigned to accumulate that information.” Registry activity must be supervised by a certified tumor registrar, and certified individuals are limited. However, according to Flanigan, centers can enlist a consulting service that provides registrar services by contract.

For accreditation, the CoC also requires programs to have a certain stream of reliable data from their established registry that has been reported to the National Cancer Database (NCDB) before a program can be surveyed and accredited. Another important step is for the programs to be evaluated by a consultant, with a mock survey performed. This will give the programs a sense of whether they are in compliance with the 36 standards, Flanigan explained. “For new programs, the pass/fail bar is very high, with the CoC expecting them to be compliant on all 36 standards. They are given only one standard for noncompliance. Other wise, they have to go back and start again.”

Help is available, however. If a program is making progress but needs help with some remaining challenges, it can request a visit by a CoC ambassador. “This no-charge to the facility visit by a surveyor or state liaison chair consists of a site visit to meet with the cancer committee and administration. The ambassador first reviews the benefits of being an accredited program and then functions like a consultant, discussing some of the issues and problems that the center may be having in moving forward,” said Flanigan. The ambassador tries to provide the center help in reaching the point of accreditation.

The timetable

Developing a program requires leadership from within the facility, and it takes a number of physicians who have a passion to proceed with accreditation and who believe accreditation will benefit the patients, the community, and the institution. Depending on a center’s current operating procedures, the accreditation process may take 2 to 3 years, according to Flanigan.

After a center has been cleared for a survey by a consultant, it is just a matter of getting the survey scheduled. As Flanigan described, “the survey process must include the surveyor attending a cancer conference as well as meeting with the cancer committee, having a tour of the facility, and reviewing some cases via medical records case reviews. The surveyors also meet separately with the administration.” Therefore, the survey process takes between 6 and 7 hours. Then, the turnaround time for receiving the performance report can be as short as 2 weeks.

Benefits of accreditation

This year the CoC is refocusing on one of the major benefits of accreditation. “I think everybody in the country is certainly aware of the fact that we need to be upfront with the quality of work that we are doing,” Flanigan said. “In particular, payers and the federal government are very concerned aboutthe quality of care that we are giving.”

Accredited institutions have access to the NCDB. The database, a joint project of the CoC and the American Cancer Society developed in 1989, is currently the largest cancer database in the world. It contains nearly 25 million records from hospital cancer registries across the United States and Puerto Rico. With their web-based, password-protected access, accredited cancer programs can use the database to access almost 8.3 million case reports of patients diagnosed between 2000 and 2007. The institution can generate reports showing data reported to the NCDB from the user’s cancer registry; aggregated data by hospital system, state, or region or at the national level; or a comparison of the cases submitted to the NCDB by the user’s cancer program and all the other programs identified by the user in the comparative group.²

Survival data are available on 51 cancer sites; supportive care; and detection, prevention, and risk reduction interventions. “Institutions can run their survival data and compare it with other institutions in the same accrediting category (there are 12 categories), so they can get an apples-to-apples comparison of their survival data,” explained Flanigan.

Benchmarking is also available through the NCDB; again it is webbased, password-protected, and accessible only by accredited programs. Flanigan, a former breast surgeon, described how this feature can be used: “A breast surgeon can look at the stage of disease for his/her breast cancer patients at diagnosis. One interesting phenomenon is the ability to look at stage 0, which is in situ disease that is only detectable mammographically, and to compare the percentage of his/her stage 0 patients against other community hospital or teaching institutions. That percentage against peers will give the surgeon an idea as to whether he/she is screening for breast cancer well in the community or not. This is a great example of how members can use NCDB data at a keystroke to demonstrate how effective they are in their community at screening for breast cancer.” In addition, “in a matter of seconds, surgeons can look at the percentage of surgical procedures and the types of surgical procedures performed for their breast cancer patients and see what percentage are having breast conservation surgery versus mastectomy. This can then be compared with outcomes at other institutions in the same category,” Flanigan continued.

Another use of the NCDB deals with treatment guidelines. National Comprehensive Cancer Network (NCCN) clinical practice guidelines correlate with the 51 cancer sites and interventions in the NCDB, which allows accredited programs to determine whether they are in compliance. According to Flanigan, the NCDB currently offers three breast measures and three colorectal measures, with the additional cancer measures being developed soon. “With the federal government and payers believing that guideline compliance is a better measure for quality of care than survival data alone, an institution can easily look at estimated performance rates in terms of how well it is following NCCN guidelines and get feedback on this quality of care measure and, just as importantly, the quality of the data coming out of its cancer registry,” Flanigan said.

In addition to the NCDB, the CoC’s relationship with the American Cancer Society provides members a marketing boost. Flanigan provided this example: “On the American Cancer Society website, if a patient navigates through the web site looking for a treatment center, the site links these inquiries for cancer treatment centers to the CoC, which allow the patient to search in his/her zip code. The treatment center identified will be a CoC-accredited cancer program.”

So, is accreditation right for you?

Each cancer program must make this decision for itself. For programs dedicated to the best patient care and a multidisciplinary approach, CoC-accreditation may be a good fit. Start by assessing where your program is in compliance with the CoC’s five elements to success. Follow that with developing an action plan to fulfill any currently unmet criteria. If you are willing to proceed with accreditation, accreditation can benefit your patients, your community, and your institution.

References

1. Commission on Cancer. Cancer program accreditation. October 12, 2009. www.facs.org/cancer/coc/whatis.html. Accessed March 15, 2010.

2. Commission on Cancer. National Cancer Data Base (NCDB). December 18, 2009. www.facs.org/cancer/ncdb/index.html. Accessed March 15, 2010.