Pathway to accreditation


Accreditation process

    1.  Introduction
      Cancer Care Commission’s (CCC) business is to support partner organisations’ ambition to deliver high quality cancer care by:
      Providing a multidisciplinary framework, integrating the necessary medical specialties, cancer care pathways and treatment guidelines
      Offering continuing medical education and training for client staff using a variety of linked methods (face to face in Oxford; on line CME; access to published material eg. oxford Textbook of Oncology)
      Accrediting the quality of client organisations’ cancer care using a unique tool which captures both process and clinical outcomes and permits benchmarking with internationally acclaimed cancer hospitals and Providing second opinions on patients, with referrals to Oxford Clinical Faculty in UK-Establishing and supporting clinical research.
    2.  Accreditation
      One of Cancer Care Commission’s key activities (above) is Accreditation of Cancer Care Services.
      Accreditation is the formal recognition that an organisation is competent to perform specific processes, activities, or tasks in a reliable credible and accurate manner. In the healthcare environment,  accreditation provides reassurance to patients, commissioners, health and social care providers, that the service provided has been independently evaluated against recognised standards. Accreditation underpins  quality and confidence in health care, providing consistency in the delivery of healthcare services to patients and commissioners. It seeks to validate and recognise success, as well as drive up the quality and consistency of service by aspiring towards excellence and the sharing of good practice with quality patient outcomes at its core.
      Accreditation which is objective, transparent and effective, is recognised as a desirable asset. In Cancer Care Commission (CCC), the accreditation process is performed by highly professional  assessors and technical experts that are reliable, ethical and competent in both accreditation processes and the relevant clinical environments.
      From a commercial perspective, accreditation delivers a Competitive Advantage, it provides independent assurance that your staff is competent and you provide a quality service. It establishes differentiation from the competition, and identifies your organisation as being progressive, forward thinking and keen to drive quality improvement in service provision and patient care. It can highlight gaps in capability, thereby providing the opportunity for improved organisational efficiency and outputs.
      Accreditation also expands market access, it is increasingly specified and recognised by a growing number of public and private sector organisations, and a knowledgeable, informed general public.

      • Internal Assessment
    3. Cancer Care Commission has a framework of 5 broad questions, when completing assessments for organisations . Are the services; 1) Safe, 2) Effective, 3) Caring, 4) Responsive to patient needs, and are they 5) Well led? These questions are answered following a detailed assessment of resources, clinical treatment and patient outcomes in the following areas:
      • Cancer Service Line Assessment
      • Breast/Colorectal/Lung/Prostate programme assessments
      • Palliative Care Assessment Tool
      • Psychosocial Care Assessment Tool

      The self – assessment framework is constructed around a 30 page box filling, document, which is straight forward and easy to complete. CCC is acutely aware that any assessment process should not be cumbersome, bureaucratic or time consuming.

      Once the self – assessment is complete, it is sent to Oxford for analysis and External Validation.


      • External Validation

      The External Validation team, which will include a senior Clinician (NHS Consultant level) will review the feedback and produce an Assessment Visit plan, in association with the host organisation. The feedback will provide the CCC team with an initial overview of the organisation and determine the areas for assessment, during the visit.


      • External Assessment Visit (EAV)

      The Assessment will be conducted by a Lead Assessor supported, as necessary, by technical assessors with the expertise to cover your scope of application.  The length of the visit will depend upon the scope of application requested (generally 3 or 4 days). In advance of the visit, the organisation will receive a visit confirmation followed by a visit plan, which provides a proposed timetable for the work to be assessed, which may include:

      • An opening meeting will take place to confirm the process.
      • The assessment will involve a detailed review of pertinent documentation.
      • Interviews with staff, managers, patients, as well as witnessing of key activities.
      • A de-brief of the visit and an outline of initial findings will be discussed at a closing meeting.
      • CCC will provide a full report following the assessment visit.


      During the EAV , if the Assessment Team identifies any working practices which present an extreme risk to particular aspects of patient care, they will be highlighted in the Risk Matrix below.



      Final Report

      When compiling the report, CCC will be benchmarking against documented standards and determining the compliance rate against those standards, whilst having a Total Quality Improvement overview in the areas noted below:

      • An emphasis on being clinically led
      • A focus on improvement
      • A focus on system and services within and across the organisation, to ensure coordination of patient care
      • A focus on coordination of patient pathways
      • Patient and carer involvement.
      • Greater focus on continued self – assessments and internal quality assurance
      • Better use of resources and greater emphasis on patient outcomes

      The report will include findings, recommendations and identify actions that need to be taken within agreed timescales, building on the strengths identified and addressing any aspects in need of improvement. It is important to recognise that approval and follow up of agreed actions is primarily the function of clinical and corporate governance systems of the organisation, and not a continuing function of CCC. Actions should be included in strategic development plans and the relevant team’s/service’s work programme, to ensure continuing improvement.



    4. Feedback analysis of External Assessment Visit (EAV) and awarding of Accreditation levelOnce the final report has determined the level of compliance against standards, if the organisation meets the required standards, it will be awarded an appropriate level of accreditation. The compliance benchmark against standards will be a transparent process which will be included as an annex to the final report. The report will be signed off by the Clinical Lead (Accreditation) 

      The Cancer Care Commission will present a certificate and an inscribed commemorative plaque at one of the following levels:


      Associate : Not yet fulfilling criteria to achieve bronze level Accreditation, however, adheres to continuous quality improvement principles in health care.

      Bronze : Safe service delivery and clinical practices. Good foundation and base for development.

      Silver: Enhanced service delivery with good clinical outcomes. Developed Improvement Plan for targeted areas.

      Gold: Professional (clinical) service excellence with outstanding personal service. Continually striving for quality improvement , including exceptional patient satisfaction, in all areas.

      Platinum: Exemplary and distinguished service at all levels. World leaders in Oncology.


      Continued accreditation will be confirmed on an annual basis by monitoring visits, with a full re-assessment every fourth year ( an organisation can request a full re-assessment after 24months of the initial assessment/accreditation). The first surveillance visit takes place 6 months after the Grant of Accreditation.