New CoC Compliance Option: Operative Standards (5.3-5.6) during Initial Site Visits

Starting with 2024 site visits, a site undergoing its first accreditation visit may meet CoC Standard 5.3-5.6 through an alternative compliance pathway.

To do so, the site must perform an internal audit of its compliance with Standards 5.3-5.6. If compliance does not meet expected technical and/or documentation requirements, an action plan must be developed. The corrective action plan must outline the specific issue(s) affecting compliance and the interventions that will be implemented to achieve compliance. The results of the internal audit and the action plan must be documented in the cancer committee minutes. If there are issues with more than one standard, an action plan must be developed for each potentially noncompliant standard.

During the site visit, the medical record review will be conducted. If the expected compliance percentage is not met, the site reviewer will evaluate the results of the site’s internal audit and action plan as documented in the cancer committee minutes. A “deficient but resolved” rating may then be given. This rating acknowledges the non-compliant status of the standard but does not require that corrective action be submitted. It is considered the same as a “compliant” rating when determining the accreditation award.

A site taking advantage of this option is expected to be fully compliant with Standards 5.3-5.6 at its first reaccreditation visit.

New Integrated Network Cancer Programs and NCI Networks: This option does not apply to a currently accredited program undergoing an initial network site visit. However, a currently unaccredited individual hospital joining an existing or new network may use the internal audit and action plan option to meet the standard during its first site visit.

Please post any questions to the CAnswer Forum.