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

Standard 2.12: Radiation Oncology

Radiation oncology treatment services are provided by or referred to radiation oncologists who are board certified or in the process of board certification by the American Board of Radiology (ABR). The center can be accredited by the American College of Radiology Radiation Oncology Practice Accreditation (ACR-ROPA), the American Society for Radiation Oncology Accreditation Program for Excellence (ASTRO-APEx), the American College of Radiation Oncology (ACRO), or has a self-administered quality assurance program in place.

Definition and Requirements

Radiation therapy is a primary component of multimodality treatment, and it is administered by board-certified physicians or physicians in the process of board certification in radiation oncology from the ABR. Board certification from the ABR should be in therapeutic radiology or radiation oncology.

Quality assurance practices with respect to radiation treatment are followed, as demonstrated by one of the following:

  • Accreditation by one of the following is preferred:
    • ACR-ROPA
    • ASTRO-APEx
    • ACRO
  • A quality assurance program is in place, and a Radiation Quality Assurance report confirms adherence to the following minimal quality assurance practices:
    • Patient identity is verified by two independent methods prior to each encounter
    • Daily, monthly, and annual radiation treatment machine quality assurance (QA) procedures are performed that comply with the American Association of Physicist in Medicine (AAPM) guidelines (machine-specific QA)
    • There is an independent check of dose calculation for every new or changed treatment prior to starting treatment
    • Patient-specific QA is done prior to initiation of Intensity-Modulated Radiation Therapy (IMRT)

Performance Measures

The NAPBC requires the Breast Program Leadership Committee (BPLC) to review the quality of patient care using the NAPBC-identified performance measures appropriate to the patients who are treated by the center each year.

Performance Measures

Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.

Radiation therapy is considered or administered within one year (365 days) of diagnosis for women undergoing mastectomy for breast cancer with four or more positive regional lymph nodes.

Process Requirements

Accession List and Data Review Requirements for the Site Visit

The center is required to provide a de-identified accession (case) list of breast cancer cases diagnosed and/or treated at the center (class of case 10–22) prior to the site visit date. Class of case is defined in the Facility Oncology Registry Data Standards (FORDS) manual.

If radiation oncologists are in the process of board certification by the ABR at the time of the site visit, certification should be obtained as applicable. The center must send documentation confirming board certification to the NAPBC administrative office.

If the center has a locally developed quality assurance program in place, a Radiation Quality Assurance report must be submitted no later than thirty (30) days prior to the site visit, confirming adherence to the minimal quality assurance practices listed above.

Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.

Radiation therapy is considered or administered within one year (365 days) of diagnosis for women undergoing mastectomy for breast cancer with four or more positive regional lymph nodes.

Compliance is reviewed annually by the BPLC.

Documentation

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

Provide documentation of board certification for all radiation oncologists on the Breast Care Team (BCT).

Provide documentation of radiation oncology department/facility accreditation by one of the organizations/programs listed above, or the Radiation Quality Assurance report for a locally developed quality assurance program.

Document the annual audit by the BPLC, including the review of the performance measures listed above, in the meeting minutes.

Evaluation

The surveyor will confirm board certification and accreditation by one of the organizations/programs listed above, or will review the Radiation Quality Assurance report, during the site visit.

The surveyor will review patient medical records during the medical records review portion of the site visit, to evaluate compliance with the performance measures listed above.

Rating Compliance

Compliance

  1. Radiation oncology treatment services are provided by or referred to board-certified radiation oncologists.
  2. The radiation oncology department/facility has been accredited by ACR-ROPA, ASTRO-APEx, or ACRO, or a self-administered quality assurance program is in place and the breast cancer quality measure is endorsed by the NQF for radiation.
    1. If the center has a locally developed quality assurance program in place, a Radiation Quality Assurance report is submitted no later than thirty (30) days prior to the site visit, confirming adherence to the minimal quality assurance practices listed above.
  3. Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.
  4. Radiation therapy is considered or administered within one year (365 days) of diagnosis for women undergoing mastectomy for breast cancer with four or more positive regional lymph nodes.
  5. Compliance is reviewed annually by the BPLC and documented in the meeting minutes.

Noncompliance

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

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