by Joseph Halperin, M.D., and Patsy Long, R.N.

In 1996 the American College of Surgeons' Commission on Cancer revised its Cancer Program Standards to ensure standardized reporting procedures.¹ In addition, the Commission made a number of important updates to its requirements for approval. The new standards are broader and address documentation of quality and outcomes, such as survival, patient satisfaction, and resource utilization, in the face of shrinking economic resources. One of the most controversial of the Commission's new standards involves the 1998 requirement to collect data on patients who are diagnosed and treated exclusively in the physician's office. Another problematic Commission requirement involves physician staging. Documentation of extent of disease by the managing physician at the time of treatment planning is fundamental to good care. Although this requirement is certainly not new, it remains the most difficult to enforce.²

These changes were a reaction to a number of forces in today's health care arena: a shift from inpatient to outpatient evaluation and treatment, the advent of freestanding cancer and surgical centers, a new focus on multisite oncology practices, and the acquisition/merger of oncology practices.

The result, unfortunately, is additional demands on oncology program directors to manage an increasingly complicated ACoS program approval process. Some cancer programs are reacting to the new demands by bringing excessive resources four to six months prior to the survey. This crisis management approach may become more common because of a lack of systems to index and address ongoing program documentation requirements.

Today's cancer programs are challenged with keeping program and survey elements catalogued for dynamic, regular review, action, and documentation. Staff at the Moses Cone Health System in Greensboro, N.C., met the challenge by developing an easy-to-use system that achieves real-time survey readiness. Central to success of the system are:

• a clear definition of cancer center, cancer committee, and registry management responsibility and accountability
• weekly to twice-monthly registry staff meetings
• clear communication, participation, written documentation, and reporting of all program elements to the cancer committee chairman and members
• creation of a timeline survey requirements checklist
• assignment of registry staff to coordinate and document the elements in the checklist on a quarterly basis.

Without a checklist and timeline of elements, meeting the numerous obligatory standards would be difficult. Some ACoS requirements are structural and require initiation and annual review, such as those defined in Section 1 of the Standards of the Commission on Cancer "Institutional and Programmatic Resources" and Section 2, "Program Management and Administration." Other requirements demand ongoing monitoring, such as Standard 3.4.0 ("The majority of cases presented at cancer conference are prospective.") or the new Standard 6.2.0 ("The required percentage of cancer patients entering clinical trials has to be tabulated regularly."). Finally, many ACoS standards require that program elements be evaluated and presented at prescribed intervals to or by the Cancer Committee, such as patient care evaluation studies (PCEs), involving a process of project identification, review, and regular follow-up of developed action plans.

The task timeline (Table 1), along with a regular review of the Cancer Program Standards and a physician-friendly PCE/guideline process, makes the process manageable. What's more, it can vitalize the cancer program survey process and structure continuous readiness.

¹Standards of the Commission on Cancer, Vol. I: Cancer Program Standards, 1996. Published by the American College of Surgeons.

²Phillips K. The expanding role of cancer registries. Oncology Issues, 12(3): 23-25, May/June 1997.