Provided here for you is a just-the-facts list of changes to the CoC Accreditation Survey process resulting from COVID-19. Keep in mind that the nThrive Cancer and Clinical Registry team provides CoC Program accreditation support. 100% of health care organizations that engage our accreditation support – 10 to 15 a year – attain full accreditation status.

  • Virtual Surveys are being offered in addition to onsite surveys.
  • Onsite surveys have been on hold since March 2020.
  • Hospitals are rescheduling the surveys either to be conducted virtually now or onsite in 2021.
  • Your medical organization can host an onsite visit in 2020 or 2021 if the surveyor and hospital both agree to it.
  • Hospitals opting to be surveyed in 2020 will be measured on the past three years – 2017, 2018 and 2019. The visits are being pushed back by six months.
  • Hospitals scheduled to be surveyed in 2021, 2022 and 2023 will be rescheduled for their survey one year later. This means that programs scheduled for 2021 will be surveyed in 2022 in the same month and will be evaluated on cancer program activity of 2020 and 2021.
  • A six-month extension is granted to health care organizations that received a deficiency from their last survey to provide documentation that resolves the deficiency. For example, if a survey was conducted in September 2019 and the hospital received a deficiency, they would normally have until September of 2020 to submit the documentation. With this extension, the hospital now has an additional six months, meaning their documentation is due March 2021.
  • Part of survey requirements mandate onsite cancer conferences to present each cancer case. A lot of conferences have been cancelled due to COVID-19, although that could potentially be a risk to patient care.
  • There are now packaged offerings to conduct the conferences online. Hospitals are looking at these applications to conduct virtual conferencing.
  • Developed COVID-19 Accreditation Trackers have been developed for each program to assist with documenting the impact of COVID-19 on compliance with the CoC, NAPBC, and NAPRC accreditation standards.

Preparations for Cancer Registry Virtual Surveys

If you elect to undergo a cancer registry virtual survey, a unique preparation process is involved. Listed here are tips to ensure a smooth survey:

Preparation for virtual survey:

  • Allow extra time – at least two hours, according to one surveyor.
  • Select electronic platform – e.g. Zoom, Webex, etc.
  • Conduct a technology practice run between surveyor and the CTR. Ensure the electronic platform is working.
  • Set agenda (similar to onsite visit)
  • Prior to survey event, prepare a visual presentation tour (PowerPoint or video) of the facility to be shown at the survey event.
  • Also prior to survey event, de-identify path reports (remove all patient PHI) in the College of American Pathologists review process (CAP review). This is CAP protocol.
  • Engage the use of Dropbox during the survey for large presentations to be provided to the C-Suite and the CC committee. Each departmental area and/or the surveyor requires a location to house their large presentation files.

Survey day:

  • Zoom meeting
  • Call in from home or office – usually, a limited number of staff are onsite. The CTR runs the meeting.
  • Ask remote participants to join the meeting with their cameras on to encourage dialogue and engagement
  • During the survey, there will be one-on-one conversations between the surveyor and the cancer liaison physician (the point of contact physician between the organization and the CoC) and Pathology (CAP Review) (CLP is required to prepare/share reports quarterly or semi-annually
  • Connection can be tough for the staff who are calling in. Be sure to test the electronic meeting platform and on-camera participant presence to facilitate a smoother event.
  • Be willing to converse with the surveyor prior to getting down to work. Generally, surveyors try to connect with the participants to better understand them and to establish trust between the parties. This can prove to be more of a challenge when conducted virtually.

More about nThrive Cancer and Clinical Registry Services

nThrive Cancer and Clinical Registry abstracts more than 130,000 cases annually. The team provides additional registry services for:

  • COVID-19
  • Bariatrics
  • Bone Marrow
  • Cardiac
  • Stroke

If you'd like more information, visit our Cancer and Clinical Registry Services website. Questions? Scroll down the page and fill out the Contact Us form. We'll get back to you soon!