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

Standard 1.3: Evaluation and Management Guidelines

The Breast Program Leadership Committee (BPLC) adopts evidence-based breast disease patient management and treatment guidelines. The guidelines are referenced by the Breast Care Team (BCT) during the multidisciplinary breast cancer conference (MBCC). These guidelines are used in patient care.

Definition and Requirements

Patient management and treatment guidelines promote an organized approach to providing care. National organizations that have developed breast care guidelines include, but are not limited to:

  • American Society of Clinical Oncology (ASCO)
  • American Society for Radiation Oncology (ASTRO)
  • National Comprehensive Cancer Network (NCCN)
  • Can develop individual breast center guidelines

Examples of referencing the guidelines include having web access, a PowerPoint presentation, or handouts available during the MBCC.

Process Requirements

The BPLC will implement breast disease management and treatment guidelines developed by national organizations appropriate to the patients who are diagnosed and treated by the center. Guidelines adopted by the BPLC are reviewed and documented in the BPLC meeting minutes annually.

Documentation

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

Evaluation

The surveyor will review patient medical records during the medical records review portion of the site visit to evaluate compliance with the patient management and treatment guidelines that have been identified by the BPLC, and ensure that these guidelines are referenced during the MBCC at the site visit.

Rating Compliance

Compliance

  1. The BPLC adopts evidence-based breast disease patient management and treatment guidelines.
  2. The guidelines are referenced by the BCT during the multidisciplinary MBCC.

Noncompliance

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