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

Standard 1.1: Level of Responsibility and Accountability

The organizational structure of the breast center gives the Breast Program Director (BPD) and Breast Program Leadership Committee (BPLC) responsibility and accountability for provided services.

Definition and Requirements

Breast Program Director  

There must be a single Breast Program Director with authority and accountability for the operation of the breast center.

Breast Program Leadership Committee

The Breast Program Leadership Committee (BPLC) is the governing body of the breast center and is chaired by the BPD. There must be a core group of health care professionals from different disciplines who contribute to the policies and procedures of the center. BPLC member disciplines include, but are not limited to, pathology, radiology, surgery, medical oncology, radiation oncology, reconstruction, research, nursing, social work, hospital administration, and other members when probable and as deemed necessary by the BPD. To ensure all decisions of the BPLC include the voice of the patients we serve, it is recommended that a community representative and/or a patient representative be a full member of the BPLC.

Requirements for BPLC membership:

  • The physician committee members have current specialty board certification in their area of specialty or be in the process of obtaining board certification as applicable
  • The physician committee members possess current medical licensure and appropriate active medical staff appointment 
  • The non-physician committee members have appropriate qualifications/certifications in their field and hold appropriate breast program relationships and accountability as outlined in the applicable standards
  • The committee members establish and maintain an environment of professional development and scholarship
  • The committee members regularly participate in organized clinical discussions, journal clubs, and conferences 

The BPD and the BPLC are responsible for goal setting, as well as planning, initiating, implementing, evaluating, and improving all breast-related activities in the center.

Breast Care Team

The breast center must have a designated Breast Care Team (BCT). The BCT includes health care professionals who contribute to the active assessment, treatment, and/or dissemination of information to a breast center patient, including pathologists, radiologists, surgeons, medical oncologists, radiation oncologists, cancer registrars, physician assistants, radiology technologists, registered nurses, licensed practical nurses, nurse practitioners, genetic counselors, patient navigators, social workers, and other members deemed necessary by the BPLC.

Requirements for BCT membership:

  • Have appropriate qualifications/certifications/registrations in their field
  • Collaborate and develop a treatment plan that will lead to the best possible quality outcome for the breast disease patient
  • Provide patient care in accordance with institutional policies and in compliance with National Accreditation Program for Breast Centers (NAPBC) Standards
  • Attend the multidisciplinary conference as appropriate
  • Participate in annual continuing education sessions in compliance with NAPBC requirements

All professionally credentialed members of the BCT must have appropriate certification.

All physician team members are required to be board certified or in the process of obtaining board certification.

Other Program Personnel

The program must ensure the availability of all necessary administrative personnel for the effective administration of the program. Some examples include, but are not limited to:

  • Chief executive office/dean
  • Center/hospital administration
  • Marketing director
  • Administrative assistants
  • Data analysts

Process Requirements

Breast center or medical staff office process requirements

The breast center or medical staff formally establishes the responsibility, accountability, and multidisciplinary membership required for the BPLC to fulfill its role.

The center documents the BPD’s and the BPLC’s responsibility and accountability using a method appropriate to the center’s organizational structure.

Examples include, but are not limited to:

  • The center bylaws designate the BPLC as a subcommittee of the cancer committee within a larger institution with authority defined
  • The medical staff bylaws designate the BPLC to be a standing committee with authority defined
  • Policies and procedures for the center define authority of the BPD and the BPLC
  • Policies and procedures for the medical staff define the authority of the BPD and the BPLC

The breast center must have a defined multidisciplinary Breast Care Team with a minimum of one appointed physician member from each of the following specialties: surgery, pathology, radiology, medical oncology, and radiation oncology.

BPD process requirements

  • Be familiar with and comply with NAPBC site visit policies and procedures as outlined in the NAPBC Standards Manual
  • Designate an individual to prepare and submit all information required and requested by the NAPBC (including program changes/requests), and ensure that the information submitted is accurate and complete. This information includes, but is not limited to:
    • Program application forms
    • Annual program updates
    • Center name updates/changes
    • Satellite site information
    • Change of Breast Program Director
    • Voluntary withdrawal
    • Deficiency resolution
    • Appeals
  • Oversee and monitor compliance with the NAPBC Standards, including all participating satellite centers
  • Ensure the medical staff bylaws, policies, and regulations designate and define the BPLC authority and reporting accountability
  • Approve the selection of BCT members as appropriate, and confirm that all professionally credentialed members of the BCT have specialty certification
  • Define the policies and procedures for the BCT and other breast program personnel
  • Distribute policies and procedures to the BPLC and BCT

BPLC process requirements

  • Meet a minimum of four times per year
  • In conjunction with the BPD, plan, develop, implement, and evaluate all activities of the breast center
  • Oversee and monitor compliance with the NAPBC Standards, including all participating satellite centers
  • Review all center data annually

Documentation

Complete all required standard fields in the Survey Application Record (SAR).

Upload/describe the organizational structure of the breast center.

Complete and upload the Breast Care Team Worksheet.

Upload BPLC meeting minutes for the last three years.

Upload bylaws or policy and procedures, or other center-approved methods, used to document the level of responsibility and accountability designated to the BPD.

Complete and upload the BPLC annual audit template.

Evaluation

The surveyor will discuss the organizational structure of the center and review and discuss all required documentation during the site visit.

Rating Compliance

Compliance

The organizational structure of the breast center gives the BPD and BPLC responsibility and accountability for provided breast center services.

Noncompliance

The center does not fulfill one or more of the compliance criteria.

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