Journal of Surgical Oncology 2014;110:611–615
The Role of the American College of Surgeons’ Cancer Program Accreditation in Influencing Oncologic Outcomes ALLISON C. KNUTSON, CCRP,1 ERICA J. MCNAMARA, MPH, MM,1 DANIEL P. MCKELLAR, MD, FACS,2 CARY S. KAUFMAN, MD, FACS,3 AND DAVID P. WINCHESTER, MD, FACS1* 1
3
American College of Surgeons, Commission on Cancer, Chicago, Illinois 2 Wayne Healthcare, Greenville, Ohio University of Washington, Bellingham Regional Breast Center, Bellingham, Washington
The multidisciplinary Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC), administered by the American College of Surgeons (ACoS), defines evidence and consensus‐based standards, require an operational infrastructure, collect high quality cancer data, and validate compliance with standards through external peer review. A survey of our constituents confirms a high level of agreement that accreditation is regarded as important in improving oncologic outcomes through compliance with standards that include continuous quality improvement.
J. Surg. Oncol. 2014;110:611–615. ß 2014 Wiley Periodicals, Inc.
KEY WORDS: accreditation; oncology; outcomes
INTRODUCTION The American College of Surgeons (ACoS) has a long and distinguished history of developing and implementing programs to benefit cancer patients. Founded in 1913, the ACoS soon moved into the cancer field, forming a Committee on the Treatment of Malignant Diseases with Radium and X‐Ray in 1922 [1]. This was the forerunner of today’s Commission on Cancer (CoC). The CoC is a consortium of over 50 professional, multidisciplinary organizations dedicated to improving survival and quality of life for cancer patients through standard‐setting, prevention, research, education, and the monitoring of comprehensive quality care. In 1930, at the request of The American Cancer Society (ACS), the ACoS developed standards of care for cancer clinics in the United States and instituted surveys to assess compliance, laying the foundation for the modern CoC and most recently, the National Accreditation for Breast Programs (NAPBC) accreditation. NAPBC is a consortium of national, professional organizations specifically focused on breast health and accrediting breast cancer programs. Both, the NAPBC and CoC develop standards to improve patient care and outcomes in conjunction with expert panels utilizing evidence‐based practices [2,3].
Definition of Oncologic Outcomes in Relation to Accreditation Oncologic outcomes follow the structure and processes established by the principles of accreditation. The definition of oncologic outcomes is not simply survival rates. It includes demonstrated compliance and improvement of evidence‐based standards, quality measure improvement, patient and family engagement, and a wide variety of patient‐centered programs within accredited centers. In essence, oncologic outcomes encompass the entire spectrum of cancer patient diagnosis including survivorship and palliation and hospice. Survivorship is a vital component of cancer care and a measurable outcome. In 2012, there were an estimated 13.7 million Americans alive with a history of cancer; by 2022 this is expected to grow to 18 million cancer survivors [4]. In addition, palliative and end‐of‐life care is important to ensure patients receive care consistent with their needs, values, and preferences. In 2014, over a half million Americans are expected to die of cancer; these patients deserve well‐conceived palliative services. Each of these important components of cancer care
ß 2014 Wiley Periodicals, Inc.
are addressed in the CoC and NAPBC accreditation standards and accredited programs are required to provide on‐site or by referral survivorship care plans and palliative care for patients.
Relationship Between Quality Improvement Measures and Accreditation One aspect of CoC and NAPBC accreditation is collecting standardized data from accredited healthcare organizations to measure cancer care quality. This data is used to monitor treatment patterns and outcomes, enhance cancer control and clinical surveillance activities, and to improve cancer prevention, early detection, delivery of care, and outcomes. High quality cancer data is an essential requisite for cancer program accreditation. Without this, oncologic outcomes cannot be assessed. Cancer registries collect information on all types of cancer in CoC‐accredited centers and submit annually to the National Cancer Database (NCDB).
The NCDB and Quality Improvement Measures The NCDB, established in 1989, is an oncology outcomes database capturing approximately 70% of newly diagnosed cancer cases in the United States from all CoC‐accredited cancer programs each year, which currently contains over 30 million records captured from hospital cancer registries [5,6]. Cancer registry data that is captured is reported back to cancer programs via the NCDB’s Data Quality Reporting Tools,
Disclosure: The author(s) of this publication have a direct interest to the subject matter being reported and are affiliated with the accreditation programs mentioned; including employment by the American College of Surgeons. *Correspondence to: David P. Winchester, MD, FACS, American College of Surgeons, Commission on Cancer, 633 N. Saint Clair Street, Chicago, IL 60611. Fax: þ1‐312‐202‐5009. E‐mail: [email protected] Received 12 March 2014; Accepted 2 May 2014 DOI 10.1002/jso.23680 Published online 8 July 2014 in Wiley Online Library (wileyonlinelibrary.com).
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including the Cancer Practice Program Profile Report (CP3R) and the Rapid Quality Reporting System (RQRS) based on data supplied through the cancer registry. With access to their own and comparative data, accredited cancer programs are able to determine areas for quality improvement and assess changes in the quality of their care over time. Responding to a call from the National Quality Forum (NQF), the NCDB submitted measures to the NQF. Five breast and colon measures were originally endorsed in 2007 (Table I).
Value of CoC and NAPBC Accreditation Accreditation encompasses the principle that adherence to evidence‐ based standards will translate to higher quality healthcare services, and improve patient care and outcomes. CoC‐accredited programs are required to meet 34 standards (27 standards for NAPBC) that encompass the full continuum of cancer care from prevention to survivorship to palliative care [2,3]. Standards help to establish a framework for organizing patient‐centered cancer care that address the full continuum of care and needs identified by Institute of Medicine reports [7]. Standards set a bar of internal and external monitoring in order to improve quality, care coordination and ensuring compliance with national treatment guidelines. CoC‐accredited cancer programs also commit to improvements in quality by both analyzing data from the NCDB to improve outcomes for patients and implementing at least two patient care improvements annually. Studies may assess patterns of care and identify cancer disparities. This is a mechanism of accreditation targeted at evaluating and improving patient outcomes. Improvements can be developed throughout the continuum of care and are based on a need within each individual cancer program [2,3]. Benefits that CoC and NAPBC accredited programs gain include access to the NCDB to monitor and report outcomes, determine patterns of care, identify cancer disparities and focus on areas for quality improvement initiatives. This provides extensive data on patients treated within the facility to use for internal quality improvement, administration and research. Administrative uses and benefits include cancer program growth, resource allocation, in/out migration of cancer patients, patterns of care, and utilization of technology.
Constituents’ Views on the Value of Accreditation With a disjointed health system, in which a patient can move among different providers, employers, and payers, challenges arise in aligning
the financial incentives for improving the quality of care [8]. Accredited organizations demonstrate their commitment to quality patient care to patients, providers, payers, and policymakers. Cancer programs are dedicating time, staff, and resources to provide or refer the healthcare services that are required to earn accreditation, as well as quality treatment and support to cancer patients. These services include, but are not limited to, risk assessment and genetic counseling, cancer screening and prevention programs, palliative care, clinical trial accrual, and community outreach. Accreditation has a strong impact on the results that are put forth from the organizations’ self‐assessment, availability and delivery of health care services, and areas in need of improvement.
Study Aims The aims of this article are to explore members of CoC and NAPBC accredited facilities’ beliefs and perceptions regarding the importance of accreditation, and to evaluate possible correlations between standard compliance and improved patient care and oncologic outcomes. It also assesses how utilizing the NCDB data to report compliance with cancer quality metrics have impacted adherence to NQF endorsed process measures to improve patient care. By evaluating the perceptions of accredited programs and data submitted to the NCDB, we are able to address both the value of accreditation at the local level and global improvements in accredited cancer programs’ quality of care.
MATERIALS AND METHODS CoC/NAPBC Accreditation Questionnaires Two 15‐item questionnaires (CoC and NAPBC specific) were constructed using the Internet design software, SurveyMonkey (SurveyMonkey, Portland, OR). Questions were designed to assess views and perceptions about the importance and impact of accreditation, and how it may correlate with patient and cancer program improvements and outcomes. The questionnaires were sent to various staff and cancer program members from all currently accredited CoC programs (N ¼ 1,513) and/or NAPBC programs (N ¼ 525). Because of their unique position to assess impacts on patient care the questionnaire was targeted to members of accredited facilities who designated themselves in a specific leadership role, such as Cancer Committee Chair and Cancer Program Administrator. Participants were identified through the CoC and NAPBC’s database, which houses
TABLE I. Reported Annual Compliance With National Quality Forum Endorsed Cancer Measures Over Time Quality measure Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III hormone receptor negative breast cancer At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer
2005 % (CI)
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2009 % (CI)
91.0 (90.8, 91.2)
2011 % (CI)
92.2 (92.0, 92.4)
85.0 (84.7, 85.3)
87.3 (87.0, 87.6)
72.2 (71.9, 72.5)
81.3 (81.0, 81.6)
87.8 (87.6, 88.0)
90.1 (89.9, 90.3)
84.5 (83.9, 85.1)
88.2 (87.7, 88.7)
90.7 (90.2, 91.2)
92.6 (92.2, 93.0)
61.9 (61.4, 62.4)
78.2 (77.8, 78.6)
84.9 (84.5, 85.3)
87.8 (87.5, 88.1)
86.6 (86.0, 87.2)
89.6 (89.1, 90.1)
91.8 (91.3, 92.3)
90.6 (90.0, 91.2)
CI, confidence interval. Significant increase in reported compliance to prior reported diagnosis year.
2007 % (CI)
The Role of the American College of Surgeons’ Cancer Program contact information for accredited facilities, including facility affiliation, email address, credentials, and roles at the accredited facility. An electronic link to the questionnaire and explanation of the survey were emailed to these individuals. The questionnaire was open for 2 weeks and included close‐ended questions (varying between binomial, Likert‐ scale and multiple choices). Frequency distributions were reported for all items. Respondents completed the survey online once and anonymously. The titles of the services and standards listed within questions were pulled directly from the CoC and NAPBC Standards manuals.
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outcomes.” For the analysis of level of agreement, the response options were on a four‐point Likert scale from “Strongly Agree” to “Strongly Disagree.” 600 of 664 (90%) of the participants who answered the question responded with “Strongly Agree” or “Agree” (N ¼ 125 skipped the question). The same question was asked in the NAPBC survey: “NAPBC‐ Accreditation correlates with the improvement of patient care and outcomes.” 200 of 219 (91%) of the participants who answered the question responded with “Strongly Agree” or “Agree” (N ¼ 20 skipped the question).
Tracking Compliance With Cancer Quality Measures Data from the Cancer Practice Program Profile Report (CP3R) was used to assess changes in compliance with NQF endorsed cancer quality measures (Table I). Accredited programs are able to view aggregate compliance rates for multiple diagnosis years of data within this application and edit case information as follow‐up treatment information becomes available. Case information for patients diagnosed between 2005 through 2011 was used for this study. To ensure the most accurate information aggregate annual compliance was calculated based on the latest date for which the diagnose year was available in CP3R, allowing cancer registries ample time to update, and find accurate adjuvant therapy information for all cases. Aggregate annual compliance with the measures was calculated for all programs, which were CoC accredited at the time of data capture. An alpha of 0.05 was used to determine significance.
RESULTS A total of 790 individuals responded to the CoC questionnaire and 239 to the NAPBC questionnaire. Job titles and CoC or NAPBC‐ designated roles (based on standard compliance for cancer committee membership) of the participants are listed in Table II. Participants could select multiple roles if applicable. Approximately, 59% of survey respondents were members of cancer programs that had been CoC accredited for 11 or more years. Of the 239 responders to the NAPBC survey, 210 (87%) stated that their facility was also CoC accredited. Both surveyed groups were queried about why their facilities decided to seek accreditation. Seventy‐seven percent of CoC and nearly ninety percent of NAPBC respondents stated that “validation of the cancer program quality” as the top reason for becoming accredited (Table III).
Respondents’ Perceptions on Importance and Direct Impact of Selected Healthcare Services We asked each group to rate the importance of various healthcare services and programs (that accredited programs are required to have on‐site or by referral to be in compliance with standards) have on improving patient care and outcomes. From the CoC questionnaire, all eight healthcare services had an average importance rating of 3.12 or higher (Likert scale rating of 1—“Not at All Important” to 4—“Very Important”). The following question asked the respondents’ whether the selected services and programs had a direct impact on improving patient care and outcomes. Six of the eight healthcare services surveyed had average direct impact ratings of 4.0 or higher (Likert scale rating of 1—“Not at All” to 5—“Definitely”), with palliative care as the highest score at 4.49 (Fig. 1). From the NAPBC questionnaire, all eight selected healthcare services had an average importance rating of 3.46 and above, with medical oncology consultation/treatment having the highest rating at 3.87 (Likert scale rating of 1—“Not at All Important” to 4—“Very Important”). Of the selected NAPBC required services, all eight that were surveyed had average direct impact ratings of 4.25 or higher (Likert scale rating of 1—“Not at All” to 5—“Definitely”) (Fig. 2).
Respondents’ Perceptions on CoC Quality Improvement Standards and Outcomes Participants were asked to rate the level of correlation between selected CoC quality improvement standards and improved patient care and outcomes. For all nine standards surveyed, responses showed an average correlational rating between 3.88 and 4.31 on the five‐point rating scale from 1 being “Not At All” correlated to “Definitely” being correlated (Fig. 3).
Respondents’ Perceptions on CoC/NAPBC Accreditation and Outcomes
Respondents’ Perceptions on Accredited Program Improvement
We attempted to determine respondents’ overall perceptions of the correlation between accreditation and improved patient care and outcomes by classifying their level of agreement with the statement: “CoC‐Accreditation correlates with the improvement of patient care and
Both surveyed groups were asked if CoC or NAPBC accreditation encouraged the improvement for selected areas of their cancer (breast) program’s activity. These areas are all required standards to earn
TABLE II. Cancer Program Role of Respondents Within CoC or NAPBC Accredited Facilities
TABLE III. Respondents’ Reasons for Why Their Facilities Decided to Initial Seek or Maintain Accreditation
Cancer (breast) program roles
CoC N (%)
NAPBC N (%)
Reasons for seeking or maintaining accreditation
Chief Executive Officer Cancer Program Administrator Breast Program Leader Physician Leadership Role CoC‐Designated Role NAPBC‐Designated Role Cancer Registrar Member of more than one cancer program Other
20 (2.6) 274 (35) NA 258 (33) 287 (36.8) NA 74 (9.5) 41 (5.2) 69 (8.8)
NA NA 122 (61.9) 27 (13.7) NA 65 (33) 11 (5.6) NA 51 (35.9)
Respondents were asked to check all that apply in response to this question.
Journal of Surgical Oncology
Executive Leadership decision Pay‐for‐performance Marketing decision Wanted access to the National Cancer Data Base and tools Validation of the cancer [breast cancer] program quality
CoC N (%) 419 75 245 274
(54.6) (9.8) (31.9) (35.7)
588 (76.7)
Respondents were asked to check all that apply.
NAPBC N (%) 128 14 77 39
(55.2) (6.0) (33.2) (16.8)
208 (89.7)
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Fig. 1. Average direct impact rating of respondents for selected, Commission on Cancer‐required healthcare services and programs on improving patient care and outcomes.
Fig. 3. Average rating of respondents’ perceptions of the correlation between the selected Commission on Cancer Quality Improvement Standards and improved patient care and outcomes.
DISCUSSION accreditation. The majority of respondents for both questionnaires indicated that across various aspects of program activity, that accreditation did result in improvements. The highest rated activities in the CoC questionnaire were Cancer Program goals and Cancer Registry and Quality Control Plans, with 85% of respondents stating that these areas of activity were improved (Fig. 4). Public Reporting of Patient/Cancer Care Outcomes had a 71% “improved” response rate, with 11% of respondents being “Unsure” (Fig. 4). The NAPBC questionnaire responses regarding the quality improvements and outcomes (the focus of this study), showed that 86% of respondents believe that quality improvement and outcomes improved due to NAPBC accreditation.
Since NQF first assessment of endorsed measure compliance in 2005, the CoC has shown that by developing quality measures and reporting adherence compliance increases significantly over time (Table I). Table I displays the average annual compliance to breast and colon measures available in CP3R. Between 2005 and 2011, the average compliance to the measure “removal of at least 12 regional lymph nodes for resected colon cancer” increased by 41.8%. Significant increases in compliance were noted in the other measures as well. Reported compliance with “receipt of hormone therapy for hormone receptor positive women” increased from 72.2% in 2005 to 90.1% in 2011.
This study confirms the value physicians and administrators place on CoC and NAPBC accreditation and the willingness of facilities to commit significant, recurring resources for maintaining their programs. Over 90% of survey respondents stated that accreditation improves patient care and outcomes. The results of this survey corroborate recent events depicting the importance of CoC and NABPC accreditation in advancing the quality of patient care. Recently, state governments and popular organizations have touted the importance of accreditation and standards. In 2013, the Cancer Center of Excellence Award was created by the Florida state legislature. One of the requirements for this award is that cancer programs seek and maintain CoC accreditation [9]. The Lizzie B. Byrd Act in Ohio requires surgeons treating breast patients to follow the NABPC standards regarding referrals of care [10]. In addition, the Woman’s Choice Award recognizing America’s best breast centers required programs be NAPBC‐accredited to be eligible for their award [11]. NCDB represents a vital need for improved systems for clinical information storage and retrieval, with the ability to use the data for internal and external monitoring of clinical measures and other facility information [12]. Publications suggest that both government and private payers have a strong interest in the rapid maturation of the technology platforms and standards, as well as the organizational frameworks that have a better chance of placing information and decision support for cancer care [8]. This serves as a concrete benefit for which to gauge the value of accreditation.
Fig. 2. Average direct impact rating of respondents for selected, National Accreditation Program for Breast Centers‐required healthcare services and programs on improving patient care and outcomes.
Fig. 4. Respondents views on if Commission on Cancer accreditation improves select areas of cancer program activity.
Compliance With Cancer Quality Measures
Journal of Surgical Oncology
The Role of the American College of Surgeons’ Cancer Program The IOM notes that developing clinical practice guidelines is not enough; the guidelines must be translated into practice, measured, and systems should monitor and assess performance [13]. CoC‐accredited cancer programs may publically report compliance with the NQF endorsed measures. This has been initiated formally through the Centers for Medicare and Medicaid Services (CMS) with 11 Prospective Payment System Exempt (PPS‐exempt) hospitals in accordance with Section 3005 of the Patient Protection and Affordable Care Act. These programs utilize the CoC’s RQRS application to track and assess compliance with three accountability measures to publically report compliance [14]. The Pennsylvania Health Care Quality Alliance and the ACS CoC recently collaborated to allow for programs in the state to publically report their compliance with measures through the CP3R application [15]. Public reporting of outcomes is an important avenue to inform patients, providers and payers about the quality of care delivered at CoC‐accredited cancer programs. The CoC assumes the position that increasing the number of clinical quality measures increases the benefits of accreditation for constituents. Since the CoC has reported adherence to NQF clinical quality measures, CoC‐accredited cancer program compliance has increased significantly with these measures, underscoring the importance to improvements in patient care. Observed increases include enhancements in the completeness of adjuvant therapy information found in the cancer registry, as well as improvements in adherence to the standard of care. To assess true changes in care, this study assessed compliance rates after CoC‐ accredited cancer programs had time to review and update patient treatment information but it is possible that a portion of the observed improvements were due to incomplete data. However, the significant improvements in compliance with the removal of twelve regional lymph nodes for resected colon cancer from 62% in 2005 to 88% in 2011, signifies an important change in practice. Regardless of the nature of the observed increases in compliance with these measures, accredited facilities are able to document improvement and high quality adherence to clinical quality measures. The NAPBC recently gained access to the breast file of the NCDB. It is expected that their facilities will soon be able to show similar improvements in compliance with NAPBC’s approved breast measures. Some limitations need to be considered with the administration of the questionnaires. It is difficult to know the response rate based on the large amount of recipients that were emailed the survey based on email addresses that were no longer functioning or entered incorrectly into the CoC and NAPBC contact database. There may be a bias to the level of importance and value of accreditation from surveying only individuals
Fig. 5. Respondents views on if National Accreditation Program for Breast Centers accreditation improves select areas of cancer program activity.
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that were part of accredited programs, however, these individuals are the most familiar with the requirements and standards of CoC and/or NAPBC accreditation. Respondents were also allowed to skip questions on the questionnaires preventing opinions being obtained for selected questions. To be generalized, our results may need to be compared to broader sample of clinicians and health care providers of cancer programs that are not currently accredited. In conclusion, this study adds evidence to the existing literature that accreditation supports internal monitoring and program improvement allows organizations to focus on outcomes measurements to allow them to benchmark their cancer programs with other healthcare facilities [16]. CoC and NAPBC accreditation standards continuously evolve to propelling accredited centers to assess and improve patient care. This high level of agreement is evidence (Figs. 4 and 5) that CoC and NAPBC accreditation is regarded as important in improving oncologic outcomes through compliance with standards that include continuous quality improvement.
REFERENCES 1. Stephenson GW: American College of Surgeons at 75. Chicago: American College of Surgeons; 1990. 2. Commission on Cancer. Cancer program standards 2012: Ensuring patient‐centered care V1.2.1. Chicago, IL: American College of Surgeons; 2014. 3. National Accreditation Program for Breast Centers. Breast Center Standards Manual. Chicago, IL: American College of Surgeons; 2013. 4. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press; 2001. 5. American Cancer Society. Cancer facts & figures 2014. Atlanta: American Cancer Society; 2014. 6. Bilimoria KY, Stewart AK, Winchester DP, et al.: The National Cancer Data Base: A powerful initiative to improve cancer care in the United States. Ann Surg Oncol 2008;15:683–690. 7. American College of Surgeons [Internet]. About the National Cancer Data Base [updated 12 Feb 2013 cited 10 March 2014] Available from: http://www.facs.org/cancer/ncdb/index.html. 8. National Research Council. Delivering high‐quality cancer care: Charting a new course for a system in crisis. Washington, DC: The National Academies Press; 2013. 9. American College of Surgeons [Internet]. PPS‐Exempt Hospitals Quality Reporting Program (PCHRQ). [updated 2014 Feb 21 cited 01 Mar 2014]. Available from: http://www.facs.org/cancer/ncdb/ pchrqp.html. 10. American College of Surgeons. Pennsylvania Cancer Centers’ Outcomes Data Is Publicly Released through New Partnership between the ACoS Commission on Cancer and Pennsylvania Health Care Quality Alliance. News from the American College of Surgeons. [updated 9 Dec. 2013 cited 01 Mar. 2014]. Available from: http://www.facs.org/news/2013/coc‐phcqa1213.html. 11. Leatherman S, Berwick D, Iles D, et al.: The business case for quality: Case studies and an analysis. Health Affairs 22:17–30. 12. Florida Department of Health. Florida Health. Cancer Center of Excellence Award. [updated 2013 cited 01 Mar. 2014]. Available from http://www.floridahealth.gov/provider‐and‐partner‐resources/ research/cancer‐center‐of‐excellence‐award.html. 13. Lizzie B, Byrd Act: Breast cancer surgery and referrals‐standards. Ohio HB 147. 130th General Assembly. (4 Dec 2013). 14. Long Susan. The Women’s Choice Award Recognizes America’s Best Breast Centers. PRWeb. [updated 19 Feb. 2014. cited 10 Mar. 2014]. Available from: http://www.prweb.com/releases/americasbestbreastcenters/WomensChoiceAward/prweb11595749.html. 15. Raval MV, Bilimoria KY, Stewart AK, et al.: Using the NCDB for cancer care improvement: An introduction to available quality assessment tools. J Surg Oncol 2009;99:488–490. 16. Nicklin W, Dickinson S: The value and impact of accreditation in health care: A review of the literature. Ottawa: Accreditation Canada; 2009.
The Role of the American College of Surgeons’ Cancer Program Accreditation in Influencing Oncologic Outcomes ALLISON C. KNUTSON, CCRP,1 ERICA J. MCNAMARA, MPH, MM,1 DANIEL P. MCKELLAR, MD, FACS,2 CARY S. KAUFMAN, MD, FACS,3 AND DAVID P. WINCHESTER, MD, FACS1* 1
3
American College of Surgeons, Commission on Cancer, Chicago, Illinois 2 Wayne Healthcare, Greenville, Ohio University of Washington, Bellingham Regional Breast Center, Bellingham, Washington
The multidisciplinary Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC), administered by the American College of Surgeons (ACoS), defines evidence and consensus‐based standards, require an operational infrastructure, collect high quality cancer data, and validate compliance with standards through external peer review. A survey of our constituents confirms a high level of agreement that accreditation is regarded as important in improving oncologic outcomes through compliance with standards that include continuous quality improvement.
J. Surg. Oncol. 2014;110:611–615. ß 2014 Wiley Periodicals, Inc.
KEY WORDS: accreditation; oncology; outcomes
INTRODUCTION The American College of Surgeons (ACoS) has a long and distinguished history of developing and implementing programs to benefit cancer patients. Founded in 1913, the ACoS soon moved into the cancer field, forming a Committee on the Treatment of Malignant Diseases with Radium and X‐Ray in 1922 [1]. This was the forerunner of today’s Commission on Cancer (CoC). The CoC is a consortium of over 50 professional, multidisciplinary organizations dedicated to improving survival and quality of life for cancer patients through standard‐setting, prevention, research, education, and the monitoring of comprehensive quality care. In 1930, at the request of The American Cancer Society (ACS), the ACoS developed standards of care for cancer clinics in the United States and instituted surveys to assess compliance, laying the foundation for the modern CoC and most recently, the National Accreditation for Breast Programs (NAPBC) accreditation. NAPBC is a consortium of national, professional organizations specifically focused on breast health and accrediting breast cancer programs. Both, the NAPBC and CoC develop standards to improve patient care and outcomes in conjunction with expert panels utilizing evidence‐based practices [2,3].
Definition of Oncologic Outcomes in Relation to Accreditation Oncologic outcomes follow the structure and processes established by the principles of accreditation. The definition of oncologic outcomes is not simply survival rates. It includes demonstrated compliance and improvement of evidence‐based standards, quality measure improvement, patient and family engagement, and a wide variety of patient‐centered programs within accredited centers. In essence, oncologic outcomes encompass the entire spectrum of cancer patient diagnosis including survivorship and palliation and hospice. Survivorship is a vital component of cancer care and a measurable outcome. In 2012, there were an estimated 13.7 million Americans alive with a history of cancer; by 2022 this is expected to grow to 18 million cancer survivors [4]. In addition, palliative and end‐of‐life care is important to ensure patients receive care consistent with their needs, values, and preferences. In 2014, over a half million Americans are expected to die of cancer; these patients deserve well‐conceived palliative services. Each of these important components of cancer care
ß 2014 Wiley Periodicals, Inc.
are addressed in the CoC and NAPBC accreditation standards and accredited programs are required to provide on‐site or by referral survivorship care plans and palliative care for patients.
Relationship Between Quality Improvement Measures and Accreditation One aspect of CoC and NAPBC accreditation is collecting standardized data from accredited healthcare organizations to measure cancer care quality. This data is used to monitor treatment patterns and outcomes, enhance cancer control and clinical surveillance activities, and to improve cancer prevention, early detection, delivery of care, and outcomes. High quality cancer data is an essential requisite for cancer program accreditation. Without this, oncologic outcomes cannot be assessed. Cancer registries collect information on all types of cancer in CoC‐accredited centers and submit annually to the National Cancer Database (NCDB).
The NCDB and Quality Improvement Measures The NCDB, established in 1989, is an oncology outcomes database capturing approximately 70% of newly diagnosed cancer cases in the United States from all CoC‐accredited cancer programs each year, which currently contains over 30 million records captured from hospital cancer registries [5,6]. Cancer registry data that is captured is reported back to cancer programs via the NCDB’s Data Quality Reporting Tools,
Disclosure: The author(s) of this publication have a direct interest to the subject matter being reported and are affiliated with the accreditation programs mentioned; including employment by the American College of Surgeons. *Correspondence to: David P. Winchester, MD, FACS, American College of Surgeons, Commission on Cancer, 633 N. Saint Clair Street, Chicago, IL 60611. Fax: þ1‐312‐202‐5009. E‐mail: [email protected] Received 12 March 2014; Accepted 2 May 2014 DOI 10.1002/jso.23680 Published online 8 July 2014 in Wiley Online Library (wileyonlinelibrary.com).
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Knutson et al.
including the Cancer Practice Program Profile Report (CP3R) and the Rapid Quality Reporting System (RQRS) based on data supplied through the cancer registry. With access to their own and comparative data, accredited cancer programs are able to determine areas for quality improvement and assess changes in the quality of their care over time. Responding to a call from the National Quality Forum (NQF), the NCDB submitted measures to the NQF. Five breast and colon measures were originally endorsed in 2007 (Table I).
Value of CoC and NAPBC Accreditation Accreditation encompasses the principle that adherence to evidence‐ based standards will translate to higher quality healthcare services, and improve patient care and outcomes. CoC‐accredited programs are required to meet 34 standards (27 standards for NAPBC) that encompass the full continuum of cancer care from prevention to survivorship to palliative care [2,3]. Standards help to establish a framework for organizing patient‐centered cancer care that address the full continuum of care and needs identified by Institute of Medicine reports [7]. Standards set a bar of internal and external monitoring in order to improve quality, care coordination and ensuring compliance with national treatment guidelines. CoC‐accredited cancer programs also commit to improvements in quality by both analyzing data from the NCDB to improve outcomes for patients and implementing at least two patient care improvements annually. Studies may assess patterns of care and identify cancer disparities. This is a mechanism of accreditation targeted at evaluating and improving patient outcomes. Improvements can be developed throughout the continuum of care and are based on a need within each individual cancer program [2,3]. Benefits that CoC and NAPBC accredited programs gain include access to the NCDB to monitor and report outcomes, determine patterns of care, identify cancer disparities and focus on areas for quality improvement initiatives. This provides extensive data on patients treated within the facility to use for internal quality improvement, administration and research. Administrative uses and benefits include cancer program growth, resource allocation, in/out migration of cancer patients, patterns of care, and utilization of technology.
Constituents’ Views on the Value of Accreditation With a disjointed health system, in which a patient can move among different providers, employers, and payers, challenges arise in aligning
the financial incentives for improving the quality of care [8]. Accredited organizations demonstrate their commitment to quality patient care to patients, providers, payers, and policymakers. Cancer programs are dedicating time, staff, and resources to provide or refer the healthcare services that are required to earn accreditation, as well as quality treatment and support to cancer patients. These services include, but are not limited to, risk assessment and genetic counseling, cancer screening and prevention programs, palliative care, clinical trial accrual, and community outreach. Accreditation has a strong impact on the results that are put forth from the organizations’ self‐assessment, availability and delivery of health care services, and areas in need of improvement.
Study Aims The aims of this article are to explore members of CoC and NAPBC accredited facilities’ beliefs and perceptions regarding the importance of accreditation, and to evaluate possible correlations between standard compliance and improved patient care and oncologic outcomes. It also assesses how utilizing the NCDB data to report compliance with cancer quality metrics have impacted adherence to NQF endorsed process measures to improve patient care. By evaluating the perceptions of accredited programs and data submitted to the NCDB, we are able to address both the value of accreditation at the local level and global improvements in accredited cancer programs’ quality of care.
MATERIALS AND METHODS CoC/NAPBC Accreditation Questionnaires Two 15‐item questionnaires (CoC and NAPBC specific) were constructed using the Internet design software, SurveyMonkey (SurveyMonkey, Portland, OR). Questions were designed to assess views and perceptions about the importance and impact of accreditation, and how it may correlate with patient and cancer program improvements and outcomes. The questionnaires were sent to various staff and cancer program members from all currently accredited CoC programs (N ¼ 1,513) and/or NAPBC programs (N ¼ 525). Because of their unique position to assess impacts on patient care the questionnaire was targeted to members of accredited facilities who designated themselves in a specific leadership role, such as Cancer Committee Chair and Cancer Program Administrator. Participants were identified through the CoC and NAPBC’s database, which houses
TABLE I. Reported Annual Compliance With National Quality Forum Endorsed Cancer Measures Over Time Quality measure Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III hormone receptor negative breast cancer At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer
2005 % (CI)
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2009 % (CI)
91.0 (90.8, 91.2)
2011 % (CI)
92.2 (92.0, 92.4)
85.0 (84.7, 85.3)
87.3 (87.0, 87.6)
72.2 (71.9, 72.5)
81.3 (81.0, 81.6)
87.8 (87.6, 88.0)
90.1 (89.9, 90.3)
84.5 (83.9, 85.1)
88.2 (87.7, 88.7)
90.7 (90.2, 91.2)
92.6 (92.2, 93.0)
61.9 (61.4, 62.4)
78.2 (77.8, 78.6)
84.9 (84.5, 85.3)
87.8 (87.5, 88.1)
86.6 (86.0, 87.2)
89.6 (89.1, 90.1)
91.8 (91.3, 92.3)
90.6 (90.0, 91.2)
CI, confidence interval. Significant increase in reported compliance to prior reported diagnosis year.
2007 % (CI)
The Role of the American College of Surgeons’ Cancer Program contact information for accredited facilities, including facility affiliation, email address, credentials, and roles at the accredited facility. An electronic link to the questionnaire and explanation of the survey were emailed to these individuals. The questionnaire was open for 2 weeks and included close‐ended questions (varying between binomial, Likert‐ scale and multiple choices). Frequency distributions were reported for all items. Respondents completed the survey online once and anonymously. The titles of the services and standards listed within questions were pulled directly from the CoC and NAPBC Standards manuals.
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outcomes.” For the analysis of level of agreement, the response options were on a four‐point Likert scale from “Strongly Agree” to “Strongly Disagree.” 600 of 664 (90%) of the participants who answered the question responded with “Strongly Agree” or “Agree” (N ¼ 125 skipped the question). The same question was asked in the NAPBC survey: “NAPBC‐ Accreditation correlates with the improvement of patient care and outcomes.” 200 of 219 (91%) of the participants who answered the question responded with “Strongly Agree” or “Agree” (N ¼ 20 skipped the question).
Tracking Compliance With Cancer Quality Measures Data from the Cancer Practice Program Profile Report (CP3R) was used to assess changes in compliance with NQF endorsed cancer quality measures (Table I). Accredited programs are able to view aggregate compliance rates for multiple diagnosis years of data within this application and edit case information as follow‐up treatment information becomes available. Case information for patients diagnosed between 2005 through 2011 was used for this study. To ensure the most accurate information aggregate annual compliance was calculated based on the latest date for which the diagnose year was available in CP3R, allowing cancer registries ample time to update, and find accurate adjuvant therapy information for all cases. Aggregate annual compliance with the measures was calculated for all programs, which were CoC accredited at the time of data capture. An alpha of 0.05 was used to determine significance.
RESULTS A total of 790 individuals responded to the CoC questionnaire and 239 to the NAPBC questionnaire. Job titles and CoC or NAPBC‐ designated roles (based on standard compliance for cancer committee membership) of the participants are listed in Table II. Participants could select multiple roles if applicable. Approximately, 59% of survey respondents were members of cancer programs that had been CoC accredited for 11 or more years. Of the 239 responders to the NAPBC survey, 210 (87%) stated that their facility was also CoC accredited. Both surveyed groups were queried about why their facilities decided to seek accreditation. Seventy‐seven percent of CoC and nearly ninety percent of NAPBC respondents stated that “validation of the cancer program quality” as the top reason for becoming accredited (Table III).
Respondents’ Perceptions on Importance and Direct Impact of Selected Healthcare Services We asked each group to rate the importance of various healthcare services and programs (that accredited programs are required to have on‐site or by referral to be in compliance with standards) have on improving patient care and outcomes. From the CoC questionnaire, all eight healthcare services had an average importance rating of 3.12 or higher (Likert scale rating of 1—“Not at All Important” to 4—“Very Important”). The following question asked the respondents’ whether the selected services and programs had a direct impact on improving patient care and outcomes. Six of the eight healthcare services surveyed had average direct impact ratings of 4.0 or higher (Likert scale rating of 1—“Not at All” to 5—“Definitely”), with palliative care as the highest score at 4.49 (Fig. 1). From the NAPBC questionnaire, all eight selected healthcare services had an average importance rating of 3.46 and above, with medical oncology consultation/treatment having the highest rating at 3.87 (Likert scale rating of 1—“Not at All Important” to 4—“Very Important”). Of the selected NAPBC required services, all eight that were surveyed had average direct impact ratings of 4.25 or higher (Likert scale rating of 1—“Not at All” to 5—“Definitely”) (Fig. 2).
Respondents’ Perceptions on CoC Quality Improvement Standards and Outcomes Participants were asked to rate the level of correlation between selected CoC quality improvement standards and improved patient care and outcomes. For all nine standards surveyed, responses showed an average correlational rating between 3.88 and 4.31 on the five‐point rating scale from 1 being “Not At All” correlated to “Definitely” being correlated (Fig. 3).
Respondents’ Perceptions on CoC/NAPBC Accreditation and Outcomes
Respondents’ Perceptions on Accredited Program Improvement
We attempted to determine respondents’ overall perceptions of the correlation between accreditation and improved patient care and outcomes by classifying their level of agreement with the statement: “CoC‐Accreditation correlates with the improvement of patient care and
Both surveyed groups were asked if CoC or NAPBC accreditation encouraged the improvement for selected areas of their cancer (breast) program’s activity. These areas are all required standards to earn
TABLE II. Cancer Program Role of Respondents Within CoC or NAPBC Accredited Facilities
TABLE III. Respondents’ Reasons for Why Their Facilities Decided to Initial Seek or Maintain Accreditation
Cancer (breast) program roles
CoC N (%)
NAPBC N (%)
Reasons for seeking or maintaining accreditation
Chief Executive Officer Cancer Program Administrator Breast Program Leader Physician Leadership Role CoC‐Designated Role NAPBC‐Designated Role Cancer Registrar Member of more than one cancer program Other
20 (2.6) 274 (35) NA 258 (33) 287 (36.8) NA 74 (9.5) 41 (5.2) 69 (8.8)
NA NA 122 (61.9) 27 (13.7) NA 65 (33) 11 (5.6) NA 51 (35.9)
Respondents were asked to check all that apply in response to this question.
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Executive Leadership decision Pay‐for‐performance Marketing decision Wanted access to the National Cancer Data Base and tools Validation of the cancer [breast cancer] program quality
CoC N (%) 419 75 245 274
(54.6) (9.8) (31.9) (35.7)
588 (76.7)
Respondents were asked to check all that apply.
NAPBC N (%) 128 14 77 39
(55.2) (6.0) (33.2) (16.8)
208 (89.7)
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Fig. 1. Average direct impact rating of respondents for selected, Commission on Cancer‐required healthcare services and programs on improving patient care and outcomes.
Fig. 3. Average rating of respondents’ perceptions of the correlation between the selected Commission on Cancer Quality Improvement Standards and improved patient care and outcomes.
DISCUSSION accreditation. The majority of respondents for both questionnaires indicated that across various aspects of program activity, that accreditation did result in improvements. The highest rated activities in the CoC questionnaire were Cancer Program goals and Cancer Registry and Quality Control Plans, with 85% of respondents stating that these areas of activity were improved (Fig. 4). Public Reporting of Patient/Cancer Care Outcomes had a 71% “improved” response rate, with 11% of respondents being “Unsure” (Fig. 4). The NAPBC questionnaire responses regarding the quality improvements and outcomes (the focus of this study), showed that 86% of respondents believe that quality improvement and outcomes improved due to NAPBC accreditation.
Since NQF first assessment of endorsed measure compliance in 2005, the CoC has shown that by developing quality measures and reporting adherence compliance increases significantly over time (Table I). Table I displays the average annual compliance to breast and colon measures available in CP3R. Between 2005 and 2011, the average compliance to the measure “removal of at least 12 regional lymph nodes for resected colon cancer” increased by 41.8%. Significant increases in compliance were noted in the other measures as well. Reported compliance with “receipt of hormone therapy for hormone receptor positive women” increased from 72.2% in 2005 to 90.1% in 2011.
This study confirms the value physicians and administrators place on CoC and NAPBC accreditation and the willingness of facilities to commit significant, recurring resources for maintaining their programs. Over 90% of survey respondents stated that accreditation improves patient care and outcomes. The results of this survey corroborate recent events depicting the importance of CoC and NABPC accreditation in advancing the quality of patient care. Recently, state governments and popular organizations have touted the importance of accreditation and standards. In 2013, the Cancer Center of Excellence Award was created by the Florida state legislature. One of the requirements for this award is that cancer programs seek and maintain CoC accreditation [9]. The Lizzie B. Byrd Act in Ohio requires surgeons treating breast patients to follow the NABPC standards regarding referrals of care [10]. In addition, the Woman’s Choice Award recognizing America’s best breast centers required programs be NAPBC‐accredited to be eligible for their award [11]. NCDB represents a vital need for improved systems for clinical information storage and retrieval, with the ability to use the data for internal and external monitoring of clinical measures and other facility information [12]. Publications suggest that both government and private payers have a strong interest in the rapid maturation of the technology platforms and standards, as well as the organizational frameworks that have a better chance of placing information and decision support for cancer care [8]. This serves as a concrete benefit for which to gauge the value of accreditation.
Fig. 2. Average direct impact rating of respondents for selected, National Accreditation Program for Breast Centers‐required healthcare services and programs on improving patient care and outcomes.
Fig. 4. Respondents views on if Commission on Cancer accreditation improves select areas of cancer program activity.
Compliance With Cancer Quality Measures
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The Role of the American College of Surgeons’ Cancer Program The IOM notes that developing clinical practice guidelines is not enough; the guidelines must be translated into practice, measured, and systems should monitor and assess performance [13]. CoC‐accredited cancer programs may publically report compliance with the NQF endorsed measures. This has been initiated formally through the Centers for Medicare and Medicaid Services (CMS) with 11 Prospective Payment System Exempt (PPS‐exempt) hospitals in accordance with Section 3005 of the Patient Protection and Affordable Care Act. These programs utilize the CoC’s RQRS application to track and assess compliance with three accountability measures to publically report compliance [14]. The Pennsylvania Health Care Quality Alliance and the ACS CoC recently collaborated to allow for programs in the state to publically report their compliance with measures through the CP3R application [15]. Public reporting of outcomes is an important avenue to inform patients, providers and payers about the quality of care delivered at CoC‐accredited cancer programs. The CoC assumes the position that increasing the number of clinical quality measures increases the benefits of accreditation for constituents. Since the CoC has reported adherence to NQF clinical quality measures, CoC‐accredited cancer program compliance has increased significantly with these measures, underscoring the importance to improvements in patient care. Observed increases include enhancements in the completeness of adjuvant therapy information found in the cancer registry, as well as improvements in adherence to the standard of care. To assess true changes in care, this study assessed compliance rates after CoC‐ accredited cancer programs had time to review and update patient treatment information but it is possible that a portion of the observed improvements were due to incomplete data. However, the significant improvements in compliance with the removal of twelve regional lymph nodes for resected colon cancer from 62% in 2005 to 88% in 2011, signifies an important change in practice. Regardless of the nature of the observed increases in compliance with these measures, accredited facilities are able to document improvement and high quality adherence to clinical quality measures. The NAPBC recently gained access to the breast file of the NCDB. It is expected that their facilities will soon be able to show similar improvements in compliance with NAPBC’s approved breast measures. Some limitations need to be considered with the administration of the questionnaires. It is difficult to know the response rate based on the large amount of recipients that were emailed the survey based on email addresses that were no longer functioning or entered incorrectly into the CoC and NAPBC contact database. There may be a bias to the level of importance and value of accreditation from surveying only individuals
Fig. 5. Respondents views on if National Accreditation Program for Breast Centers accreditation improves select areas of cancer program activity.
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that were part of accredited programs, however, these individuals are the most familiar with the requirements and standards of CoC and/or NAPBC accreditation. Respondents were also allowed to skip questions on the questionnaires preventing opinions being obtained for selected questions. To be generalized, our results may need to be compared to broader sample of clinicians and health care providers of cancer programs that are not currently accredited. In conclusion, this study adds evidence to the existing literature that accreditation supports internal monitoring and program improvement allows organizations to focus on outcomes measurements to allow them to benchmark their cancer programs with other healthcare facilities [16]. CoC and NAPBC accreditation standards continuously evolve to propelling accredited centers to assess and improve patient care. This high level of agreement is evidence (Figs. 4 and 5) that CoC and NAPBC accreditation is regarded as important in improving oncologic outcomes through compliance with standards that include continuous quality improvement.
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