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

NAPBC Standards

2014 NAPBC Standards Manual (effective January 1, 2014–March 31, 2018)

2018 NAPBC Standards Manual (effective April 1, 2018)

NAPBC Standards Clarifications and Changes

The NAPBC Standards Manual has been reformatted for the 2018 version. Each standard is now comprised of five sections:

  • Definition and Requirements—Standard and requirements are defined
  • Process Requirements—Responsibilities of the center, leadership, and breast care team
  • Documentation—Required documentation to meet compliance
  • Evaluation—Surveyor responsibility/actions during the site visit
  • Rating Compliance—Criteria for the compliance/noncompliance rating

References and Resources are additional sections that are added when applicable.

2018 Changes Summary

  • Accreditation process information updated
  • Addition of a glossary
  • Standardized language applied to all content
  • Text trimmed and edited for clarity
  • New Breast Program Director (BPD), Breast Program Leadership Committee (BPLC), and Breast Care Team (BCT) definitions incorporated into all standards
  • Class of Case defined as applicable to each standard
  • Standard 6.2 deleted; Performance measures have been incorporated into standards as applicable

NAPBC Standards Change Log 2018

If a standard is not listed below, formatting has been the only change. See above for information on the new formatting.

Standard

Standard Name

2018 Changes

1.1

Level of Responsibility and Accountability

New Definitions and Requirements for:

  • Breast Program Director (BPD)
  • Breast Program Leadership Committee (BPLC)
  • Breast Care Team (BCT)

BPLC required to meet quarterly (at minimum)

Annual audit list moved to Process Requirements in each applicable standard

1.2

Multidisciplinary Breast Care Conference

Attendance thresholds set (see table in standard)

2.1

Multidisciplinary Patient Management

Title of standard changed to Multidisciplinary Breast Care Conference

“Breast Cancer” changed to “Breast Disease”

2.2

Patient Navigation

Changed “non-professional” to “Lay Navigator”

Added navigator training to compliance criteria

2.3

Breast Conservation

Performance Measure from 6.2 added to standard and compliance criteria

2.4

Sentinel Node Biopsy

Class of Case 10–14

2.5

Breast Cancer Surveillance

Surveillance plans must be modeled after evidence-based guidelines (for example, ASCO, NCCN)

2.6

Breast Cancer Staging

BPLC designs a staging policy defining where stage is recorded, and when staging is performed

2.7

Pathology

Title of standard changed to Pathology

Clarified that outside pathology slides must be reviewed

2.8

Breast Imaging

Standard rewritten:

  • Title of standard changed to Breast Imaging
  • New standard requirements:
    • BPLC adopts nationally recognized mammography screening guidelines and advises/educates the medical community affiliated with the breast center
    • MRI accreditation

2.10

Ultrasonography

Certification/accreditation required at the time of initial site visit

2.11

Stereotactic Core Needle Biopsy

Certification/accreditation required at the time of initial site visit

2.12

Radiation Oncology

Certification/accreditation required at the time of initial site visit

Performance Measure from 6.2 added to standard and compliance criteria

Updated documentation and process requirements for locally developed quality assurance (QA) program

2.13

Medical Oncology

Performance Measure from 6.2 added to standard and compliance criteria

2.14

Nursing

Removed nursing assessment and intervention process

Added AOCN to list of compliant certifications for nurses

2.16

Genetic Evaluation and Management

List of compliant genetic counseling credentials updated

Clarification of genetics education requirement

2.17

Educational Resources

Updated required resources now include information on metastatic disease (Stage IV) and fertility options

2.19

Evaluation and Management of Non-Malignant Breast Disease

“Benign” changed to “Non-Malignant”

“Breast Cancer” changed to “Breast Disease”

2.20

Breast Cancer Survivorship Care

Survivorship Care Plans (SCP) must, at minimum, include ASCO’s SCP data elements

Who can deliver the SCP defined

Updated compliance percentages

3.2

Clinical Trial Accrual

Track accrual by categories listed in the standard

5.1

Breast Care Team Continuing Education

Title of standard changed to Breast Care Team Continuing Education

Edited for clarity; no new requirements

6.1

Quality and Outcomes

Standard requirements updated to three (3) center studies OR two (2) center studies and one (1) physician quality improvement program