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

Accreditation Information

Ratings for each standard are assigned based on a consensus by the NAPBC Surveyor and an NAPBC Technical Reviewer. When required, the applicable review subcommittee will also contribute to the standard rating decision, as a final adjudicator.

Critical Standards

Three (3) standards are considered critical standards. The breast center must be in compliance with the following standards at the time of the site visit in order to receive NAPBC Accreditation:

  • Standard 1.1: Level of Responsibility and Accountability
  • Standard 1.2: Multidisciplinary Breast Cancer Conference
  • Standard 2.1: Multidisciplinary Patient Management

Accreditation Awards and Rating System

Based on the rating criteria specified for each standard a “Compliant,” or “Noncompliant,” rating is assigned. Any standard with a “Noncompliant” rating is a “deficiency.”

Accreditation awards are determined by the number of noncompliant ratings the breast center receives. Following the site visit, a center receives one of the three Accreditation Awards.

Three-Year Accreditation is conferred to a center that receives a “Compliant” rating for all standards at the time of the site visit. A certificate of accreditation is issued.

Three-Year Accreditation with Deficiency is conferred to a center when one (1) to three (3) of the standards are rated “Noncompliant” at the time of the site visit. Deficiency resolution documentation must be submitted within 12 months of the date of the site visit. A certificate of accreditation is issued.

Three-Year Contingency Accreditation is conferred to a center when four (4) to eight (8) standards are rated “Noncompliant” at the time of the site visit. Deficiency resolution documentation must be submitted within 12 months of the date of the site visit. A center that does not resolve its deficiencies within the allotted timeframe is at risk of having its accreditation status discontinued. A certificate of accreditation is only issued after resolution of all deficiencies.

Accreditation Deferred is conferred to a center when one (1) or more of the critical standards is rated “Noncompliant.” Accreditation Deferred is also conferred to a center that receives a “Noncompliant” rating for nine (9) or more standards. When applicable, NAPBC staff will work directly with the center to assist with deficiency resolution, so accreditation may be reinstated. The deferred status is resolved by submission of documentation for compliance and/or an additional site visit within 12 months. Centers can also choose to withdraw, improve their performance, and then reapply for accreditation as a new center. Note, new center application fees will apply when reapplying for accreditation.