Cancer Research Program

In order to help hospitals and healthcare facilities manage multiple accreditation programs, ACS Quality Programs restructured the standards and procedures to fit into the newly created “Nine Domains” (see Figure 1). Leaders of the National Accreditation Program for Breast Centers (NAPBC) saw this as an opportunity to rewrite the standards focusing on the patients’ perspectives—an approach that previously had not been considered. 

“Standards and guidelines were developed to improve patient outcomes, and were written by physicians, for physicians. While standards do improve patient care, individual patient concerns and goals may not be addressed by physician-focused standards,” said Scott H. Kurtzman, MD, FACS, NAPBC Chair.* “We want each NAPBC center to think about the multidisciplinary care their team provides through the lens of the breast cancer patient rather than focusing only on the treatment from each provider’s perspective.”

Jill R. Dietz, MD, MHCM, FACS, Chair of the Standards and Accreditation (SA) Committee and lead author of the new standards explains, “‘Chapter 5, Patient Care: Expectations and Protocols’ has been restructured to focus on the patient journey: diagnosis, evaluation and decision-making, treatment, and post-treatment survivorship and surveillance. Our goal was to remove tedious, check-the-box standards, and instead, emphasize each center’s focus on patient-centric care. Some of the standards are unchanged and relocated to the appropriate chapters in the new Nine Domains format. We also developed additional standards that specifically focus on patient experience.”

The standards rewrite team was composed of multidisciplinary members of the SA Committee, patient advocates, site reviewers, members of the Education and Quality committees, NAPBC leadership, and ACS staff. The rewrite was approached by gathering patient experience data and surveying what centers value from their accreditation status. 

This team of multidisciplinary experts met weekly to lay out an ideal patient journey, supplying many examples of exemplary patient care. The group and leadership chose the critical metrics that would be achievable by most accredited sites. The standards went through a public comment period from February 14 through March 7, 2022, and then a revision process, taking into consideration feedback from the accredited centers. The new standards were approved by NAPBC leadership and the board.  

By setting standards that were achievable by all centers regardless of center size or resources, the NAPBC standards have successfully raised the bar for care. Early on, the use of image-guided biopsy, case presentation at multidisciplinary tumor boards, and even the use of breast-conserving procedures was inconsistent. Through standard setting, significant progress has been made in multidisciplinary cancer care. 

The 2018 Standards are now met by the majority of accredited sites and are no longer serving the original purpose of “raising the bar.” NAPBC leadership felt that it was time to change direction and focus on the patient journey and value-based care, and the improvement aims of the Institute of Medicine Crossing the Quality Chasm report.^† The 2018 standards addressing surgical care are excellent examples of the shift to more contemporary patient-centered measures. Previous surgical standards focused on procedures and thresholds such as percentage of breast conservation versus mastectomy and sentinel node biopsy rates. Recent data have shown high compliance rates with these threshold standards, which suggests mastery of the concepts, making the need to keep those standards outdated. 

The surgical section in the new standards asks centers to ensure that patients are involved in the decision-making process and have the education to make the best decisions for their situation. 

Additionally, the new surgical standards suggest surgeons should assess preoperative or postoperative patient and environmental factors that could lead to functional or complicating issues that may require intervention such as lymphedema or mobility concerns. To improve recovery and lessen the chance of patients getting addicted to opioids, the new surgical standards encourage surgeons to use enhanced recovery after surgery (ERAS) protocols and prehabilitation as well as consider alternatives to narcotics for postoperative pain management. 

Dr. Kurtzman suggests, “It is easier for centers and site reviewers to have objective, threshold metrics to check off; however, while these metrics previously were useful, many of them do little to improve care today. Implementation of the new standards will require a shift in philosophy. Are programs embracing the spirit of the standard or just checking a box to pass accreditation?” 

Randy E. Stevens, MD, a radiation oncologist and NAPBC lead site reviewer explains, “Using this new approach and philosophy rather than being the ‘breast center police,’ the standards and site reviewers have the shared purpose of helping each center provide the best possible care for their patients. Both centers and site reviewers will need education, bidirectional interaction and feedback, and a prolonged rollout phase to ensure the successful implementation of the new standards.”

ACS senior leadership has supported the development and rollout of the new standards because the approach aligns with many other value-based programs initiated through the College. The new standards were released November 7 but NAPBC centers will not be required to follow them until 2024. Change is difficult, so hopefully centers that embrace the new standards will be at the forefront and ready to transition to value-based reimbursement models. Most importantly, the patient’s journey will be improved. 

*Miller M, Bleicher R, Kaufman C, et al. Impact of Breast Center Accreditation on Compliance with Breast Quality Performance Measures at Commission on Cancer-Accredited Centers. Ann Surg Oncol. 2019;26(5):1202-1211.

†Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. 

Dr. Jill Dietz is a breast surgeon in Cleveland, OH. She is also Vice-Chair of the NAPBC and board chair of the American Society of Breast Surgeons.