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

Standard 6.1: Quality and Outcomes

Each year the breast center conducts or participates in three (3) or more center-specific studies that measure quality and/or outcomes, or two (2) or more center-specific studies and one (1) or more of the physician members participate in their specialty-specific quality improvement program. The findings are communicated and discussed with the members of the multidisciplinary Breast Care Team (BCT) and other breast center staff.

Definition and Requirements

The annual evaluation of services and care provide specific information to measure quality and an opportunity to correct deficiencies and enhance patient outcomes. These studies of quality may include structure, process, and patient outcome variables, and are selected by the Breast Program Leadership Committee (BPLC).

Study topics must be selected based on a problematic quality-related issue relevant to the breast center and local patient population, and used as a means to identify a potential issue or understand why a problem is occurring. Quality studies can evaluate various spectrums of patient care, including diagnosis, treatment access, and supportive care; within that spectrum they can be issues related to structure, process, and outcomes.

Each quality study is required, at a minimum, to have the following components:

  • Must indicate the study topic that identifies a problematic quality-related issue within the breast center
  • Define study methodology and the criteria for evaluation, including data needed to evaluate the study topic or answer the quality-related question
  • Conduct the study according to the identified measures and methodology
  • Prepare a summary of the study findings
  • Design a corrective action plan based on evaluation of the data (if needed)
  • Establish follow-up steps to monitor the actions implemented (if needed)

Process Requirements

Each year the breast center conducts or participates in three (3) or more center-specific studies that measure quality and/or outcomes, or two (2) or more center-specific studies and one (1) or more of the physician members participate in their specialty-specific quality improvement program.

For physician specialty-specific quality improvement programs, a summary of the data over the past year or time of study is presented to the BPLC.

A summary of the analysis of data and outcome of each study is discussed with the members of the BCT and other breast center staff.

The BPLC sets specific quality improvement goals for the center based on the quality studies. The goals and processes to implement changes in program activities are documented and discussed with the BCT.

Compliance is reviewed annually by the BPLC and documented in the meeting minutes.

Standard Specifications

  • The BPLC is required to conduct the annual audit within the 12 month date range. It is not required that studies be completed within the 12 month period, but they must be reviewed.
  • Quality studies that duplicate topics or studies from year-to-year do not fulfill this standard.
  • Quality improvement study designs and research cannot be counted/allocated to subsequent triennial accreditation cycles.
  • Review of data presented in the NCDB data reports or tools (including measure compliance) do not fulfill the requirement for this standard.

Documentation

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

Complete the template documenting the types of studies conducted and the methods utilized to communicate the study results, goals, and processes to implement changes in program activities with the BCT.

Provide documentation of physician and/or center participation in a national quality improvement initiative related to breast care, and the methods utilized to communicate the study results, goals, and processes to implement changes in program activities, with the BPLC and the BCT.

Document the annual audit by the BPLC in the meeting minutes.

Evaluation

The surveyor will review and discuss the quality studies and required documentation during the site visit.

Rating Compliance

Compliance

  1. Each year the breast center conducts or participates in three (3) or more center-specific studies that measure quality and/or outcomes, or two (2) or more center-specific studies and one (1) or more of your physician members participate in their specialty-specific quality improvement program.
  2. For physician specialty-specific quality improvement programs, a summary of the data over the past year or time of study is presented to the BPLC.
  3. A summary of the analysis of data and outcome of each study is discussed with the members of the BCT and other breast center staff.
  4. The BPLC sets specific quality improvement goals for the center based on the quality studies. The goals and processes to implement changes in program activities are documented and discussed with the BCT.

Noncompliance

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

Resources

Specialty-specific quality improvement programs: