Opportunity Knocks: New ACoS Standard Requires Navigation Process in Place by 2015


Facilities seeking Commission on Cancer accreditation now need to have a patient navigation process in place by 2015.

One recent development on the minds of NCONN 2012 attendees is the new patient navigation standard announced in March by the American College of Surgeons Commission on Cancer (CoC). Facilities seeking CoC accreditation now need to have a patient navigation process in place by 2015.

Mary Lou Woodford, RN, BSN, MBA, CCM, care coordination program director for the Massachusetts Department of Health, offered practical guidance to the group on how to use the CoC standard to help their institutions design programs that break down barriers and ensure equal access to care in the communities they serve.

“My Hospital Is CoC-Accredited: What Do I Need to Do to Comply?”

When Woodford hears this question, and she often does, she explains that under Standard 3.1: Patient Navigation, facilities will need to demonstrate that they have a process in place that removes barriers to care. This does not mean that facilities have to employ patient navigators; however, Woodford emphasized these key elements:

  • Perform a community “needs assessment” to documents disparities and barriers to care for patients in the community
  • Identify resources—either on-site or through referral—to address these disparities / barriers
  • Present patient navigation process to cancer committee annually for formal evaluation
  • Modify or enhance patient navigation process to address results and recommendations from the committee evaluation

“To do a thorough needs assessment, and to do it well, can take 12 months,” noted Woodford. “Look at your own state’s comprehensive cancer plan. Every state health department has one. They can help you get the data you need for the assessment.”

She emphasizes that CoC is looking for measurable data on what prevents some people from accessing care at a facility and cites community interviews and focus groups as examples of ways to secure the required data. “Bringing in other units, such as cardiovascular or chronic disease specialists, to work with you on the needs assessment may also be an approach that will work for your facility,” Woodford added.

The purpose of the assessment, Woodford explained, is to identify: (1) the needs of the population a facility serves, (2) health disparities in the community, and (3) resources to prevent barriers and improve access to care. Armed with this information, facilities can create building blocks for program development, implementation, and evaluation.

“The assessment is broader than just who comes to your facility,” said Woodford. “You need to get into the community and find out why some people don’t access care.”

Woodford pointed out that it would be hard for one individual, such as a navigator, to set up this process alone, and suggested engaging a multidisciplinary group at each facility to work on the project. Members of the multidisciplinary team might include evaluation research, quality improvement, discharge planning, medical records, and community resources.

When Should We Start?

Despite the extended 2015 deadline, Woodford strongly advised facilities to get started no matter where they happen to be in their own CoC 3-year survey cycle for accreditation. “[The CoC] wants facilities to succeed. If you start working on implementation before the survey staff visit, it will be a great opportunity to get their guidance. We all know what the standard is, and survey evaluators will be looking at your progress.”

“The ultimate goal is to serve the whole community,” concluded Woodford.

For more information on the standards, visit www.facs.org/cancer


View more from the 2012 NCONN Conference

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