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Ms. Hulbert may indeed be a certified tumor registrar (CTR), but I very much doubt she has ever been a CTR at a program under survey (Preparing for Your AcoS Survey, April 2009).
Having been through multiple American College of Surgeons/Commission on Cancer (ACoS/CoC) surveys, the first tip-off was her presumption that a registrar waits until the official letter arrives before starting preparations. Wrong.
Any CTR worth her/his salt will tell you we're always gathering information and preparing for the next survey. The reason for all those regularly scheduled (and mandated) cancer committee meetings is to have discussion about the progress on each of the 36 Standards.
Before the first committee meeting of the year, we develop a Cancer Committee Goals and Objectives, a formalized list of what needs to be done and who is to do it; by the final committee meeting of the year, every entry must be accounted for.
At any given time, the CTR should know exactly where the facility stands in regard to each and every one of those Standards. There's no need to develop a separate three-ring binder; keep all the material with the minutes at which it was discussed. Then, when the survey letter does arrive, plug information for the past 3 years into the SAR and send required hard copies to the CoC surveyor and ACoS.
And on the day of survey, there's much more to being a CTR for a CoC accredited cancer program than reserving conference rooms and arranging refreshments. True, those are responsibilities we handle, but we also make certain all players have their schedules and know their scripts, all departments are ready for the visit with relevant documentation at hand, that our abstracting data is ready to be scrutinized, and that numerous ancillary statistical reports are ready and waiting.
Nancy Story, BS, CTR
Via e-mail
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