American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

CoC Quality Measure Development

The Quality Integration Committee (QIC) of the Commission on Cancer (CoC) partners with internal and external clinical experts to develop quality measures. The development and approval of quality measures encompassing multiple primary sites relies on the specialized expertise of members of the QIC and CoC Member Organizations. The currently reported gynecologic measures were developed in the conjunction with the Society of Gynecologic Oncology (SGO). Additionally, the QIC is collaborating with experts from the Society of Surgical Oncology (SSO) and the Society of Urologic Oncology (SUO)/ American Urologic Association (AUA) on quality measures.

Types of Quality

There are several types of measures approved by the CoC. Evidence-based measures or accountability measures promote improvements in care delivery and are the highest standard for measurement. These measures demonstrate provider accountability, influence payment for services, and promote transparency. The quality improvement measure function is to monitor the need for quality improvement or remediation. Generally, these measures are for individual program use. Surveillance measures are used to identify the status quo, generate information for decision making, and/or to monitor patterns and trends of care. The following table summarizes the purposes and use of these measures:

Measure Type

Measure definition and use

Accountability

High level of evidence supports the measure, including multiple randomized control trials. These measures can be used for such purposes as public reporting, payment incentive programs, and the selection of providers by consumers, health plans, or purchasers.

Quality Improvement

Evidence from experimental studies, not randomized control trials supports the measure. These are intended for internal monitoring of performance within an organization.  

Surveillance

Limited evidence exist that supports the measure or the measure is used for informative purposes to accredited programs. These measures can be used for to identify the status quo as well as monitor patterns and trends of care in order to guide decision-making and resource allocation.

For questions related to the release of these quality measures, please contact the NCDB at ncdb@facs.org.

Current Reporting Activities

The Cancer Program Practice Profile Reports (CP3R) were first released in January 2005, and since then have been updated annually. This reporting tool has demonstrated that improvements in data quality can demonstrate the quality of patient care when the entire cancer committee supports system-level enhancements to ensure complete and precise documentation.

The Rapid Quality Reporting System (RQRS) was developed to assist CoC-accredited cancer programs in promoting evidence-based cancer care at the local level. It is a Web-based, systematic data collection and reporting system that advances evidence-based treatment through a prospective alert system for anticipated care that supports care coordination required for breast and colorectal cancer patients at participating cancer programs. 

CoC Standards 4.4 and 4.5 Implementation

Expected Estimated Performance Rates (EPR) for accountability and quality measures assessed with Commission on Cancer (CoC) Standards 4.4 and 4.5 are established based on the year of survey. These standards require performance levels be met annually according to the specified accountability and quality improvement measures defined by the CoC. Please review the information below for currently assessed quality measures.

2017 Surveys

2016 Surveys

2015 Surveys

For questions related to the release of these quality measures, please contact the NCDB at ncdb@facs.org.