Two important changes have been approved that impact review of the CoC Operative Standards during site visits, effective immediately.
Required Compliance Percentage for Sites with Less than Seven Applicable Cases
The percentages required for compliance for Standards 5.3-5.8 have been modified.
Previously, 100% compliance was required if the accredited site had fewer than seven applicable pathology or operative reports for a select standard.
Effective immediately, if a site has fewer than seven applicable cases for Standards 5.3-5.8, then the standard’s applicable percentage for that year will be applied. In other words, for site reviews conducted in 2024, 70% compliance will be required for Standards 5.3-5.6, regardless of the number of cases to be reviewed. Additionally, 80% compliance will be required for Standards 5.7 and 5.8, regardless of the number of cases to be reviewed.
Alternative Compliance Pathway for Standards 5.3-5.6
During 2024 site visits, an internal audit of compliance with Standards 5.3, 5.4, 5.5, and/or 5.6 and an action plan that addresses compliance issues may be considered by Site Reviewers when rating the standard.
The internal audit and resulting action plan must be documented in cancer committee minutes from a 2023 or 2024 meeting and must be from before the Site Reviewer selects the cases to be reviewed during the site visit. The internal audit must outline the specific issue(s) affecting compliance and the interventions that will be implemented to achieve compliance. An action plan must be documented for each potentially non-compliant standard.
If the expected compliance percentage is not met in the medical record review during the site visit, 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 is a temporary alternative pathway for compliance with Standards 5.3-5.6. At this time, it has only been approved for 2024 site visits. A site taking advantage of this alternative compliance pathway is expected to be fully compliant with Standards 5.3-5.6 at its next site visit.
This alternative compliance pathway option does not apply to Standard 5.7 or Standard 5.8.
Sites that already Underwent a Site Visit in 2024
Programs that have already undergone a site visit in 2024 but feel the above adjustments would change their rating of Standards 5.3-5.8 should email CoC@facs.org. In the email, please include your site’s Company ID, the standard you would like reconsidered, and a description of the reason for review.
