CancerCare Center | Accreditation

Trinity CancerCare Center:


Trinity Health’s cancer care program has maintained its “Accreditation with Commendation” from the American College of Surgeons’ Commission on Cancer. The Trinity CancerCare Center was re-surveyed in April 2015, and once again received full accreditation with no areas of deficiency as well as commendation in five of the possible specific seven standards, explained Shane Jordan, BSRT (R)(T), CMD, Director of the CancerCare Center.

The history of the Commission on Cancer and standards for cancer care begins with the American College of Surgeons (ACoS). From its creation in 1913, the ACoS has focused on improving the care of the surgical patient through the advancement of surgical skills and physician education. The initial work was focused on establishing “cancer clinics” within hospitals where patients could expect to receive consistent diagnostic and cancer treatment services. By 1933, 140 clinics had gained accreditation. Since accreditation of this initial group, the number of Accredited Programs has slowly and steadily increased to encompass more than 1,500 hospitals, freestanding cancer centers, and cancer program networks nationwide. Commission on Cancer-accredited programs represent 30 percent of the general medical-surgical hospitals in the United States and Puerto Rico and provide care to close to 70 percent of patients who are newly diagnosed with cancer each year.

A three-year with commendation accreditation is given to programs, either new or established, that comply with all standards at the time of survey and receive a commendation rating for one or more standards. A program receiving commendation for up to three standards earns Three-Year with Commendation Bronze level. Commendation for four to six standards earns Three-Year with Commendation Silver level. Commendation for seven or eight standards earns Three-Year with Commendation Gold level. A certificate of accreditation is issued, and these programs are surveyed at three-year intervals from the date of the survey. Trinity has been accredited for many years, with a level of commendation. Accreditation with Commendation is awarded when a program complies with all standards and additionally demonstrates a high level of compliance with one or more of the six standards that comprise the full scope of cancer service.

Accredited as a Comprehensive Community Cancer Program, the classification of a facility that sees more than 500 newly diagnosed cancer cases each year was new this year, Jordan said. “In 2012, we were surveyed as a Community Cancer Program due to our number of diagnosed cases each year being less than 500,” Jordan said. “We are seeing more patients come to our center now and the ability to provide top notch care is very rewarding and a benefit to the community of Minot and the region at large.”

Jordan noted that this accreditation is not just for the Trinity CancerCare Center, but for Trinity Health as an institution. “It is truly a multi-disciplinary approach in order to reach this level of accreditation,” Jordan said. “There is a great deal of work and dedication by members of our Cancer Committee.”

The Cancer Committee is represented by various departments within Trinity Health, including Administration, Radiology, Pathology, General Surgery, Home Health/Hospice, Marketing, Clinical Excellence and Patient Safety (CEPS), Pharmacy, Pastoral Care, and Staff Development, as well as representatives from departments within Trinity CancerCare Center, such as Patient Navigation, Social Work, Survivorship, Tumor Registry, Cancer Research, and Nursing.

The purpose of the Cancer Committee is to insure that the Trinity CancerCare Center follows the standards set by the Commission on Cancer. The committee has quarterly meetings, at which time each member has an opportunity to share information regarding issues being completed within their departments. “If there are any opportunities for improvement that need to take place, they are discussed and moved on with a majority recommendation by this committee,” Jordan said.

The Trinity CancerCare Center has excelled in these five levels: clinical trial accrual, cancer registrar education, pathology report protocols, rapid quality reporting system participation, and submission and accuracy of data.

The actual survey is a three year process in which “we submit information to the Survey Application Record,” Jordan said. The Survey Application Record, or SAR, is used as a record-keeping tool to record program activity and document compliance with the set standards.”

“The survey itself is a one-day survey in which a representative from the ACoS Commission on Cancer comes on site and reviews the Survey Application Record with representatives of the Cancer Committee.” A final accreditation decision is made after the information is reviewed by the ACoS Commission on Cancer staff.

“We are very excited to have received commendation of five of the seven possible specific standards,” Jordan added. “We are putting processes in place to obtain the final two levels prior to recertification in 2018.”

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