Alternative Compliance Pathway for Standards 5.3-5.6 Extended to 2025 and 2026 Site Visits

In March 2024, an important change for demonstrating compliance was announced as an alternative compliance pathway for the review of the CoC Operative Standards during 2024 site visits.

The Alternative Compliance Pathway has been approved to be continued for 2025 and 2026 site visits. During 2025 and 2026 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 meeting during the year before or the year of the site visit and must be from before the Site Reviewer selects the cases to be reviewed during the site visit. For example, if the site visit is in 2026, then the internal audit/action plan must be documented in the minutes from a 2025 or 2026 cancer committee meeting.

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 for 2024, 2025, and 2026 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.