Cancer Program Guidelines
Chapter 1: Institutional and Programmatic Resources
Section 1: Program Leadership
Administrative structure is in place to ensure efficient, appropriate, and effective management of the cancer program and services.
The administrative leadership is responsible for maintaining high standards of patient care through the use of human, fiscal, and material resources. The administrative leadership must demonstrate commitment to excellence in cancer care, development and growth of multidisciplinary staff, and provision of comprehensive programs and services. The administrative leadership must be accountable for the development of resources to both sustain and increase the program and its capability to meet the needs of the community that it serves.
- The administrative leadership is appointed by the governing body, hospital, and/or parent organization, and is responsible for the development, implementation, and evaluation of the cancer program.
- The administrative leadership, qualified by education and experience, appropriately fulfills designated responsibilities. The administrator should have at least a bachelor’s degree in a healthcare profession, business, economics, or related area, and 4-6 years of experience in health care management. Master’s level degree and training in a health care field are preferred.
- The administrative leadership creates an environment of trust and respect, balancing financial concerns with patient care needs.
- The administrative leadership ensures compliance with applicable laws, regulations, and professional accreditation standards.
- The administrative leadership:
- Creates and facilitates the multidisciplinary team for development of the program’s strategic plan throughout the continuum of care
- Implements a management structure to develop program goals and objectives, to maintain accountability for outcomes, and to perform cost analysis for cost-effective use of resources
- Creates access to financial, human, and material resources necessary for comprehensive service and program planning, implementation, and evaluation.
- The administrative leadership gathers and assimilates program-related data from appropriate sources and disseminates same in a timely manner to the leadership team and cancer committee for evaluation, review, and revision of goals and objectives annually and as needed.
- The administrative leadership assumes accountability for the financial viability of the cancer program; establishes and implements program budget, monitors financial data, and assumes accountability for budget and variances; coordinates effective billing and reimbursement procedures to ensure maximum appropriate reimbursement for services; and secures adequate supplemental funding.
- The administrative leadership ensures sound partnership with health care providers/professionals by sharing accountability for the overall quality of care and financial viability of the cancer program.
- The administrative leadership ensures adequate multidisciplinary staffing to meet the needs of cancer patients and their families.
Section 2: Medical Leadership
The program has a designated medical director on a part-time or full-time basis.
A medical director, with experience in multidisciplinary cancer care, provides medical leadership as well as clinical expertise and administrative competencies for optimal program outcomes.
The background of the medical director should include the following:
- Documented training, experience, and competence in cancer care, such as board certification in a recognized oncology specialty
- Experience in multidisciplinary cancer care and support of same throughout program
- Demonstrated administrative ability and leadership skills. The medical director assumes appropriate level of authority and accountability for program outcomes.
The authority of the medical director is defined and documented by the sponsoring organization of the program.
The medical director must have a documented job description and/or contract that defines lines of authority and responsibility.
The organization has defined the authority of the medical director in the following suggested areas:
- Program definition, vision, mission, goals, planning, implementation, and objectives
- Recruitment, appointment, evaluation, and promotion of relevant personnel within the scope of the program
- Reporting structure/requirements
- Space allocation
- Interaction with other departments, organizations, and the public
- Budgetary and administrative responsibility appropriate to the structure of the organization
- Medical, scientific, research, and other program component decisions
- Performance improvement and clinical pathways development
- Monitoring of quality of care.
The medical director is subject to a minimum of annual performance review.
Timely evaluation of the medical director’s overall performance is the responsibility of the organization’s administrative leadership and medical staff and/or review group as defined in the job description.
The evaluation measures how well the medical director has achieved the following goals:
- Assurance that appropriate programs are in place and operating according to standards to standards
- Ongoing program planning and implementation
- Well-developed and managed relationships with other organizational components, physicians, external organizations, patients, their families, and the public
- Establishment, maintenance, and documentation of medical, scientific, and ethical standards
- Quality of care
- Securing and/or maintaining appropriate certifications, accreditations, and memberships
- Cost-effective operations
- Efficient and effective management of budget and personnel
- Annual, or more frequent, reporting.
Compensation should be considered commensurate with expected time commitment.