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

Accreditation Process

Accreditation Cycle
Annual Accreditation Fee
Accreditation Resources for Centers
Initial Accreditation
Required Documentation
Site Visit
Medical Records Review

Post-Survey Evaluation
Notification of Site Visit Results
Appeals
Deficiency Resolution
Certificates, Marketing, and Visibility
Site Visit Postponement and Cancelations

Accreditation Cycle

The initial site visit date establishes the accreditation cycle. After initial accreditation, the re-accreditation site visit occurs once every three (3) years.

Initial Accreditation

All centers seeking accreditation for the first time must submit an application through the NAPBC Center Portal. Within 30 days of submission of the application, or as soon as practical thereafter, the primary contact listed will be notified of approval or if additional information is required.

After approval of the application and completion of all required agreements, the breast center must complete the Center Profile in the NAPBC Center Portal.

One component of determining whether NAPBC accreditation will be awarded to a breast center is the site visit. The initial NAPBC site visit occurs after the applying center attests that the NAPBC standards have been in place and complied with in the center for 12 months.

In preparation for accreditation, the center must:

  1. Assess and demonstrate compliance with the requirements for all standards outlined in National Accreditation Program for Breast Centers Standards Manual
  2. Submit payment for the annual accreditation fee
  3. Confirm the site visit date with the assigned surveyor
  4. Complete and upload required documentation to the Survey Application Record (SAR)

Centers are notified of their assigned NAPBC surveyors by e-mail.

Note: The site visit does not count as one of the required Breast Program Leadership Committee (BPLC) meetings.

Required Documentation

All documentation demonstrating compliance with the NAPBC standards, excluding patient medical records, must be uploaded and completed in the SAR.

Site Visit

In preparation for the site visit, the SAR must be submitted no later than 30 calendar days before the site visit.

The surveyor’s role is to verify whether the breast center is in compliance with the NAPBC standards. On the day of the site visit, the surveyor will:

  • Present information to key members of the center’s leadership on the NAPBC
  • Meet with the BPLC to discuss the activities and responsibilities of its members and to verify the accuracy of the data and documentation submitted
  • Attend a Breast Conference to observe the center’s multidisciplinary patient management and discussions
  • Meet with the Breast Program Director to discuss the Director’s roles and responsibilities
  • Conduct a medical records review as outlined in the standards
  • Tour the center
  • Conduct a summation to provide initial impressions on the breast center’s strengths, areas in need of improvement, and provide a chance for the Breast Care Team (BCT) and BPLC members to ask and respond to any additional questions

It is recommended that all members of the BPLC attend and participate in the site visit. At a minimum, the surveyor must meet with the following people:

  • Administrators with fiduciary and administrative oversight of the center
  • Key clinician leaders
  • Breast Program Director

Medical Records Review

Many NAPBC standards require a medical records review to ensure compliance with rating criteria. Compliance with these components of the rating criteria will be evaluated during the site visit, through the surveyor’s medical records review of 20 patient medical records from the provided accession list. The percentage of medical records that meet the rating criteria will determine whether the breast center is in compliance with that aspect of the standard.

The breast center will provide the surveyor with an accession list of eligible cancer patients for the medical records review. No later than 14 calendar days before the site visit, the surveyor will inform the center of the selected, applicable medical records that will be reviewed.

In addition, the breast center will make available five (5) medical records, of their selection, of patients with non-malignant breast disorders, and five (5) additional medical records, of their selection, of patients with high risk lesions.

The medical records reviewed are not required to be deidentified. Review of the patient health information (PHI) is covered by the Business Associate Agreement (BAA) that the center signs at the time of application for accreditation.

Post-Survey Evaluation

The Post-Survey Evaluation (PSE) is a required component of the NAPBC site visit. The PSE captures feedback from the breast center, which enables the NAPBC to evaluate and improve the site visit process. Feedback from the PSE also assists development of educational materials and training programs for both surveyors and participating centers.

All PSE responses are confidential and do not influence the NAPBC site visit results. Only one PSE is collected per center, therefore, responses on the evaluation form must represent a consensus opinion of the BPLC. The PSE must be completed within 14 calendars days of the site visit.

Notification of Site Visit Results

A performance report, detailing the results of the breast center’s site visit, will be available within 45 days of the site visit date, or as soon as practical thereafter. The Breast Program Director will receive an e-mail when the completed performance report is available.

The performance report provides the following:

  • A summary of the site visit outcome and accreditation award
  • The breast center’s rating for each standard
  • A narrative description for noncompliant standards
  • Suggestions to improve or enhance the breast center

Appeals

Centers may appeal a finding for any standard within 45 calendar days of the performance report notification. The appeals process is outlined in the Accreditation Decision Appeal Form on the NAPBC website.

Deficiency Resolution

A breast center that received one (1) to eight (8) deficiencies is required to complete the deficiency resolution process. The deficiency resolution process begins on the site visit date and ends 12 months after the site visit date. A program that fails to resolve deficiencies within the allotted time are at risk of having accreditation withdrawn.

Certificates, Marketing, and Visibility

Centers that are awarded Three Year Full accreditation and Three Year accreditation with deficiency, can order one (1) complimentary Certificate of Accreditation. Additional copies are available for purchase. Certificate information is on the marketing resources webpage. The link is provided in the performance report cover letter.

In addition to displaying the Certificate of Accreditation, the NAPBC encourages breast centers to use the marketing tools provided on the marketing resources webpage, to promote the value of NAPBC accreditation to patients, families, and the community. The marketing tools include an NAPBC-accredited center logo, patient brochures, event posters (for example, Breast Cancer Awareness), and more. A link to the marketing resources webpage will be provided to the breast center in the performance report cover letter, if the center achieves full accreditation.

Centers that are awarded full accreditation are listed on the NAPBC-accredited center locator. The locator is an online search engine for patients to find an accredited center. Listings on the locator include the center name, location, website, description, and an image of the breast center. Breast center profiles can be edited in the General Center Information section of the NAPBC Center Portal.

Site Visit Postponement and Cancelations

When extenuating circumstances affect center activity, a site visit postponement may be appropriate. Postponements are granted on a case-by-case basis, with a maximum postponement being six (6) months.

Valid extenuating circumstances that may warrant a site visit postponement include, but are not limited to:

  • Natural disasters (for example, hurricane, earthquake, tornado, flood) that directly affect the center
  • Anthropogenic hazards (for example, fire, industrial accidents) that directly affect the center

Examples of circumstances that do not warrant a site visit postponement include, but are not limited to:

  • Software conversion or IT issues
  • Staff absences, turnovers, or resignations
  • Delayed abstracting or missing data
  • Standard deficiencies

The Breast Program Director must submit a formal request for a postponement via e-mail to NAPBC@facs.org. The request must include specifics regarding the rationale for the request, a proposed plan, and a timeline to resolve the issues necessitating the postponement request. The center will be notified of the postponementrequest decision as soon as practical, following receipt of the written request.

Centers are discouraged from canceling the scheduled site visit. However, if site visit cancelation becomes necessary after the site visit date is confirmed, the breast center must submit a written notification to NAPBC@facs.org. The center will be invoiced for a cancelation fee and any non-refundable travel expenses incurred by the surveyor.