Statement of Work.pdf

Statement of Work

American College of Surgeons (ACS) accreditation for Veterans Affairs Medical Center Washington, D.C.

American College of Surgeons (ACS) Executive Summary

The Commission on Cancer (CoC) is a consortium of professional organizations dedicated to improving survival and quality of life for patients with cancer by setting and raising standards. The CoC promote cancer prevention, research, education, and monitoring of comprehensive quality care.

There are approximately 1,500 CoC-accredited cancer programs in the U.S. and Puerto Rico. CoC accreditation encourages hospitals, treatment centers, and other facilities to improve their quality of care through various cancer-related programs and activities.

These programs are concerned with the full continuum of cancer from prevention to survivorship and end-of-life care while addressing both survival and quality of life. CoC accreditation is granted to facilities that are committed to providing the best in cancer care and demonstrate compliance with the CoC standards. Each cancer program must undergo a rigorous evaluation and review of its performance and compliance with the CoC standards. To maintain accreditation, cancer programs must undergo an on-site review every three years. The standards facilitate each cancer program seeking accreditation to provide all patients with a full range of diagnostic, treatment, and supportive services either on-site at the facility or by referral to another location, including community-based resources.

Benefits of CoC Accreditation

Access to the Rapid Cancer Reporting System and other Reporting Tools

Facilitated by programs’ monthly submissions to the Rapid Cancer Reporting System (RCRS), CoC-accredited programs are provided with access to web-based tools to support quality improvement, community assessment, and cancer program administration. The tools can be used to:

• Evaluate and compare the cancer care delivered to patients diagnosed and/or treated at your facility with other CoC-accredited facilities at the state, regional, and national levels.

• Identify areas for quality improvement to ensure that patients receive the right treatment at the right time.

• Compare quality-related performance measures with aggregated CoC-accredited programs, including accountability, quality improvement, and surveillance measures.

• Assess performance across multiple disease sites.

• Run benchmark reports to drive quality improvement and quality assurance activities.

• Track and analyze data on all types of cancer to:

• Explore trends in cancer care.

• Review regional and state benchmarks for CoC-accredited facilities.

• Serve as the basis for quality improvement.

• Access participant user files so that investigators can advance the quality of care delivered to patients with cancer.

RCRS reporting tools assist CoC-accredited programs addressing quality issues, identifying patient care challenges, and focusing their performance improvement efforts in a way that benefits the patient.

American College of Surgeons (ACS) Quality Plan

The American College of Surgeons (ACS) has developed a Quality Plan that provide oversight of the effectiveness of the program by periodically conducting inspections and maintaining accreditation certification.

Obligations of American College of Surgeons (ACS)

1. Assistance in establishing a cancer program structure.

2. Assistance in establishing services is essential for cancer care.

3. External assessment of the program.

4. Data with which to assess quality performance against National Cancer Database (NCDB) benchmarks.

5. A framework to guide program development, and in this activity, most constructively work with hospital administrators.

6. Provided “accredited” status when the facility has completed a site visit and demonstrated full compliance with all applicable standards and has provided all required documentation to support compliance.

7. ACS shall bill Hospital for the Services in accordance with all applicable laws, rules and regulations, and will properly disclose the nature and manner of ACS Services on cost reports or where otherwise required.

8. When and if a site visit and evaluation is scheduled by ACS, the contractor shall be provided notice at least 30-days in advance.

Obligations of Hospital

1. Case abstracting shall be performed by a Certified Tumor Registrar (CTR). All cancer registry staff who abstract cases at a CoC accredited program must either hold a current Certified Tumor Registrar (CTR) credential or perform case abstracting under the supervision of a CTR.

2. CTRs will enter patient data to demonstrate the overall maintenance of cancer patient care across the continuum of services from diagnosis to treatment and survivorship.

3. Each Hospital member that is required to access and enter patient information (non-identifiable data) within the ACS database will maintain all requirements outlined by the ACS that ensures access is always granted.

4. Each Hospital member shall adhere to the outlined ACS standards to ensure a high level of patient quality of care. Each member must be aware that access may be revoked if ACS requirements are not adhered.

5. When ACS are required to be onsite for any inspection the Hospital shall provide an adequate and safe space sufficient for the performance of their inspection.

6. The space used for performance of the Services shall be equipped with all utilities including, but not limited to, water, electricity, heating/air conditioning, emergency backup power in case of power outage and telephone lines for voice and data transmission. Further, this space shall have the same level of facilities support as all other areas of the Hospital (e.g., janitorial and maintenance services, communications support, emergency response system, etc.).

Operating Hours and Response Time

1. When site visits are scheduled by ACS the contractor will provide an advance notice of any site visit and evaluation.