Most Common Commission on Cancer (CoC) Standard Deficiencies for Survey Years 2014 and 2015


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  1. 4.7 Studies of Quality
  2. 1.8 Monitoring Community Outreach
  3. 4.3 Cancer Liaison Physician Responsibilities
  4. 4.8 Quality Improvements
  5. 5.5 and 5.6 NCDB Data Submission and Accuracy of Data



  1. 1.3/1.4 Cancer Committee Attendance and/or Meeting Requirements
  2. 1.8 Monitoring Community Outreach
  3. 4.7 Studies of Quality
  4. 4.8 Quality Improvements
  5. 4.3 Cancer Liaison Physician Responsibilities

Once reviewing the above list of common deficiencies over the past two survey years, you begin to see a pattern of repeat problematic standards for cancer programs to ensure compliance. Those that are repeat offenders are 1.8, 4.7, 4.3, 4.8 the other standards 5.5, 5.6, 1.3 and 1.4 seem to be more intermittent.

Here are some brief tips on ensuring that you continuing to comply with some of these more challenging standards:


1.3 and 1.4:

  • Schedule quarterly meetings for the entire year, use the middle month of the quarter in case there is a need to reschedule a meeting i.e.; February, May, August, November.
  • Select an appropriate designated alternate for each required member at the first meeting of each calendar year.


  • The Community Outreach Coordinator must:
    • Monitor the effectiveness of the prevention, screening and outreach activities annually (this requires documentation in the annual summary report and inclusion in the cancer committee minutes and presented each year to the cancer committee


  • Meet the required number of studies (based on their category) each year.
  • Programs are required to analyze all studies completed and evidence of cancer committee review of analysis must also be documented in the minutes.
  • Capture the date the quality study is reviewed and include the methodology, summary, analysis, recommendations and follow-up for EACH study completed.
  • Focus must be on a suspected problematic quality-related issue relevant to the program and local patient population. Have key physicians and clinicians brainstorm on areas that they notice might need to be studies, what do they hear from peers, patients that might cause concerns.
  • Studies are designed to involve physicians and allied health professionals.
  • Do not use another cancer program standard requirement as a study of quality.
  • Begin and end your study of quality within the same calendar year.


  • Implement at least 2 patient care improvements each year.
  • One improvement must be directly based on the result of a 4.7 Quality Study and the other can be identified from another cancer related source or another quality study.
  • The patient care improvement must be reviewed by the cancer committee as documented in the minutes.
  • Patient care improvement implementation documentation must be shared with the medical staff and administration.

If your cancer program struggles any of the above mentioned standards, or those not mentioned as the top 5 each year, Registry Partners CoC-trained consultants can assist in resolving identified deficiencies, evaluation of standards compliance at any time, review of your Program Activity Record (PAR) or Survey Application Record (SAR) for optimal documentation requirements. We are here to help.