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

From the Director’s Desk

Surveys: The Foundation for Continuous Improvement within the Cancer Programs

Heidi Nelson, MD, FACS

Heidi Nelson, MD, FACS
Medical Director, ACS Cancer Programs

Why so many surveys? In the March 18, 2021, issue of Cancer Programs News, we shared with you what we learned from our equity, diversity, and inclusion survey. In that survey, we learned that we have a welcoming and respectful culture, we are open to the expression of ideas and beliefs, and people feel valued. We also learned that we have room to improve when it comes to supporting diversity among members and leaders, and we need to improve on equal access and transparency on access to leadership positions. We are working on finalizing a process for such improvements and will share it soon. Several months ago, we sent a survey to the registrars to learn more about the effort required to conduct life-time follow-up of cancer patients. We are using the data to estimate the burden of follow-up and to evaluate whether the value and quality of the data justify the burden. We expect to share these learnings this month, including any decisions about the duration of follow-up that may result from the survey.

By now you are noticing that our surveys keep coming. We are aware that you may view these surveys as extra work, and, truthfully, they are one more "to do" on your long list of daily activities. For us they are the best option for obtaining the feedback we need to improve our customer service. To increase our yield and keep your burden to a minimum, we aim to keep our surveys short and simple; most are 10 or fewer questions, requiring little more than five to 10 minutes to complete. We also aim to provide feedback on the results and the changes we may implement as a result of what we learn. There are many forums and opportunities for us to learn about your likes and dislikes, but so far, the surveys represent the only way for us to quantitate your perspectives and preferences on a given topic. We appreciate your willingness to help us with our version of continuous improvement. Thank you!

Next Steps on Return to Cancer Screening PDSA Quality Improvement Project and Clinical Study

We have heard great interest in the Return to Screening Plan/Do/Study/Act (PDSA) Quality Improvement Project and Clinical Study that was covered in last week's issue of Cancer Programs News. The Project and Clinical Study details are posted online. By early next week, we will post an FAQ document to the program portals—Commission on Cancer (CoC) Datalinks and National Accreditation Program for Breast Centers (Qport)—which we will update on a weekly basis. Please submit all questions to CAnswer Forum. Here are some of the early questions we received regarding this initiative.

If participants do not reach the pre-pandemic screening rates or the goal of a 10 percent increase, will they still get credit for the standards?
The compliance credit for all standards will apply to 2021 even if activity extends into 2022. We will consider extensions into 2022. Further, the Accreditation Committee will consider how credit for CoC Standards 7.3, 8.3, and 9.1 might be managed if goals are not achieved by the timeline outlined.

Is data collection for step 1e only for the months of September 2019 and January 2020, or is it September through January?
It is not September through January. It is data from September AND January. We need just two months of data from screening activities pre-pandemic (9/2019 and 1/2020) and two months of data during the pandemic (9/2020 and 1/2021). The average of the two months (September and January) will help set the baseline for closing the gap in screening that has occurred due to the pandemic.

By completing the PDSA, can sites get credit for BOTH CoC Standard 8.3 and 7.3 for the same work? We know that usually sites can only get credit in one standard area for a project.
We are giving double credit just this year for this project. Programs will get credit for both CoC Standards 7.3 and 8.3 if they complete the PDSA. We are still in a pandemic, and we know health care practices are not entirely back to normal. In these unusual times we considered it prudent to ask folks to focus on what really matters right now—keeping cancer cases from accelerating in volume.

Does an "event" have to occur to get credit for CoC Standard 8.3, as stated in the standard description? The variety of interventions listed are mostly not event related, so I wanted to be clear that an event is not necessary to get credit.
An event does not have to take place to get credit. We expect programs to use at least one of the interventions listed as an alternative to events. Most "events" were in person, and that has not been a safe or even permissible option, so we wanted to help programs find alternatives and then support them by giving them credit. Doing something is better than doing nothing. It does not need to be a traditional event.

Our program is planning to participate in the elective PDSA project. Our program is also in the process of addressing barriers to care for screening disparities (for breast cancer) in AA women ages 40 to 50. Can we use this elective project to address the disparities to care barrier (Standard 8.1) if we also collect screening information on race?
This project does not apply to CoC Standard 8.1.

I just received information regarding an Elective Quality Improvement Project and Clinical Study open to all CoC/NAPBC sites. According to the information I received from our American Cancer Society contact, our participation in the project can be used to meet several standards. I have been under the impression the CoC does not allow a project to cover more than one standard. Per the information sheet that was sent my way, it says we can use this to fulfill CoC Standards 8.3, 7.3, and 9.1. Can we use this project to meet requirements for all three standards, or are we supposed to decide on only one of the standards to use it for?
If you complete the screening interventions, the quality improvement project, and the clinical study you will be eligible to use them for compliance with all three CoC standards for 2021 and for this project only.

My facility is a very small community hospital. We do, however, have a passion for reaching the underserved and uninsured in our community through a free screening mammogram program that has been impacted by COVID restrictions. Can we still participate and receive credit if we limit the screening program (breast) used for the "post-pandemic return to screening" to the target population of underserved and uninsured versus the general public?
You can target any population you choose as long as you follow the instructions and guidelines as outlined in the project.

Deadline Fast Approaching; Submit Your Abstracts for the Quality and Safety Conference Today

Share your important surgical quality improvement initiatives with your colleagues by submitting an abstract to the American College of Surgeons (ACS) Quality and Safety Conference Call for Abstracts. The deadline for this call is April 30.

The abstract should relate to the development, implementation, or validation of best practices. We are also interested in operational best practices relating to workflows around collecting data and reporting. Abstracts should utilize data from one or more of the ACS Quality Programs.

Review the Call for Abstracts for more information or submit your abstract.