AGENDA Standards and Accreditation Committee Friday, June 17, West Conference Room 2:30-4:30 pm

Transcription

1 AGENDA Standards and Accreditation Committee Friday, June 17, West Conference Room 2:30-4:30 pm Combined Committee Session: Standards and Accreditation and QI/IT Committees 1:00 pm 1. Expansion of Class of Case Exhibit 1 2. Data Points for Collection Benign Breast Disease group discussion 3. Standard 2.7 Template for collection and submission of discrepant diagnoses data Exhibit 2 4. Clinical Trial Template Exhibit 3 5. Annual Reporting of Quality Measures Re-implementing Standard Welcome, Introductions, and Call to Order Terry Sarantou, MD, FACS, Chair 2:30 pm 2. Review and approval of minutes October 8, 2015 Dr. Sarantou - Exhibit 4 2:35 pm Standards Manual Revisions Karen Pollitt and Dr. Sarantou - Exhibit 5 2:40 pm 4. Revisions to the 2017 Survey Process - Karen Pollitt 4:00 pm Annual Billing Requirement for Annual SAR submission SAR closure 30 days prior to survey date 5. Surveyor Team Ashley Logan 4:10 pm 6. Survey of Rural Surgeons Exhibit 6 4:15 pm 7. New Business 4:25 pm 8. Adjourn 4:30 pm

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5 6/9/2016 Standard Second Opinion Pathology Consultation Tuesday, June 07, 2016 Powered by 184 Total Responses Date Created: Wednesday, August 06, 2014 Complete Responses: 175 1

6 6/9/2016 Q2: What is your role on the breast care team? Answered: 170 Skipped: 14 Q3: When this standard is implemented do you anticipate your center will be in compliance? Answered: 178 Skipped: 6 2

7 6/9/2016 Q4: If you anticipate being non-compliant, what period of time would it take for you to become compliant? Answered: 119 Skipped: 65 Q5: Please indicate the statement that best describes the current second opinion pathology consultation procedure at your center: Answered: 179 Skipped: 5 3

8 6/9/2016 Q6: Our center reviews select outside pathology slides/reports. The review is based on the following criteria (check all that apply) Answered: 173 Skipped: 11 Q7: Is your center willing to begin to track discrepant diagnoses if given a tool to do so? Answered: 169 Skipped: 15 4

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13 Current fields in SAR: Revised Accrual Table NAPBC Clinical Trials Accrual Type of Trial # Active Trials Location Last complete year # of patients accrued Industry Sponsored Cooperative Group Screening Interventional Behavioral Tissue Collection Only Other Total Annual Analytic Caseload Percent Accrual %

14 National Accreditation Program for Breast Centers Members Present Terry Sarantou, MD, Chair Allison Laidley, MBA Claudia Lee, MBA Michael McGuire, MD Dana Smetherman, MD Jean Paquelet, MD Barbara Rabinowitz PhD Jean Simpson, MD Scott Weissman, MS Gary Whitman, MD Joann Zeller, CTR Standards and Accreditation Committee Minutes Thursday, October 8, 2015 Members Absent Douglas Arthur MD Paul Baron MD Anees Chagpar, MD James Connolly, MD Carl D'Orsi MD Richard Fine MD Teresa Heckel, MD Nora Hansen MD Cary Kaufman MD Scott Kurtzman MD F. Lee Tucker, MD Staff Ashley Logan Karen Pollitt David Winchester, MD Agenda Item Discussion Action/Outcome Welcome Dr. Sarantou called the meeting to order at 5:04 pm CST Review and Approval of Minutes Dr. Sarantou presented the minutes from the September 10, 2015 conference call. ACTION: The minutes from the September 10, 2015 meeting were approved.

15 Standards and Accreditation Committee October 8, 2015 Page 2 Recommendations from June Board Meeting Compliance requirements Standards 2.7 -Pathology Reports -Exhibit 2 1. The committee reviewed the reworded standard, by Dr. Laidly. The following was discussed: The statement does not state the number center will be required to achieve be compliant with the intent of the standard. Karen Pollitt suggested the center develop a policy and upload it into the SAR and the BPL review all cases that are not incompliance with the breast disease programs policy. Then review the information after one year. The breast disease program documentation of why the center was unable to achieve 100% compliance. New 2016 Data Fields Standard 2.7 Pathology Reports -Exhibit 2 Karen Pollitt stated a separate compliance statement will be added into the SAR for data collection of compliance. ACTION: The Committee approved the standard as written, with the additional of a statement requiring why a second opinion was not obtained. Dr. Laidly stated she would submit the standard revision to the NAPBC staff. ("The goal of this standard is to have 100% compliance. If that is not possible, the rational for the exception must be documented for each case.") Dr. Sarantou stated the revision will be sent to the committee by staff for approval. Proposed Revision of Key Definitions Standard 1.1 Level of Responsibility and Accountability - Exhibit 3 Sample Revisions Exhibit 4 Dr. Sarantou reviewed the proposed revisions in their entirety. The following changes were suggested in the discussion: The Executive Breast Committee should be renamed Breast Program Leadership Committee. A educational document should be distributed to centers and the surveyors. All previous titles/definitions should be identified in parentheses next to the new title. ACTION: Karen Pollitt will add compliance statement into the SAR for data collection. ACTION: The Standards and Accreditation Committee approved the standard with the following changes: incorporating the previous title/definition in parentheses next to the new title/definition and the name of the Executive Breast Committee should be changed to Breast Program Leadership Committee. Dr. Sarantou stated the revision will be sent to the committee by staff for approval. 2

16 Standards and Accreditation Committee October 8, 2015 Page 3 Standard 2.8 Diagnostic imaging Exhibit 5 Standard 2.6 Breast Cancer Staging Exhibit 6 Dr. Sarantou stated he sent an to the radiology members of the NAPBC Board requesting their input on the standards revisions. Dr. Jean Paquelet stated MRI will not be a part on BICOE so it should not be mentioned separately in the standard. The following information was discussed: The nationally recognized mammography screening guideline should not be reworded. The standard should refer breast disease programs to the ACR accreditation site for additional information. The standard should be update to account for the change in BICOE accreditation. Dr. Smetherman volunteered will review and reword the BICOE requirements. It was suggested that a question be added to the SAR indicating if a breast disease program refers or provides MR services. And continue to work on the requirement. Adding a high risk component to the standard. It was stated there are other places located in the standards to identify the risk. Dr. Sarantou stated in the future the standard should include a statement for second opinion review for breast cancers only. Dr. Sarantou reviewed the revision of the standard with the committee. Dr. Sarantou stated the standard was approved as written. ACTION: Dr. Sarantou requested that Karen send a screenshot of the Standard 2.8 for changes to the second paragraph. Dr. Smetherman volunteered will review and reword the BICOE requirements. Karen Pollitt will add a question to the SAR indicating if a breast disease program refers or provides MR services. Dr. Sarantou requested a summary of the calls discussions be ed NAPBC radiology members, prior to approving the revisions. ACTION: Dr. Sarantou stated the standard was ok as written. Next call - Tentative Call Dates at 6 pm E.S.T. New Business Adjourn Dr. Sarantou stated the next Committee call would be held at 6 pm E.S.T on the following dates: October 15 and November 11. There was no new business. The meeting was adjourned at 5:10 p.m. 3

17 Standards Review 1. Examine complaints, common questions ( s, phone calls), common deficiencies and appeals to determine areas in need of revision. 2. Review need for consistent language to all content. 3. Review standard compliance based on recent clarifications. 4. Review the intent of the standard and what is being measured. 5. Develop Intent statements for each standard. Proposed Revisions All standards 1. Incorporate new BPD, BPLC and BCT definitions into all standards. 2. Standardize language to all content; trim text and edit for clarity 3. Class of Case applied to all standards; only patients seen by BCT members. 4. Remove non-napbc organization-specific information from standards and replace with appropriate links to content on Web. 5. Create web resource page with same link in Center Resources. 6. Incorporate information from deficiency resolution document. 7. Addition of a Glossary. 8. Update all front matter, accreditation process information. Specific Standard Changes Standard BPLC Standard Name Changes audit 1.1 Level of Responsibility and Accountability Move requirement for annual audit of components to each standard Requirement that BPD must be a physician (Oct. Call) Use of template to capture listing of BPLC members Use of org chart template Define BPLC Meeting Frequency as quarterly 1.2 X Interdisciplinary Breast Cancer Conference Define prospective Define cases to be reviewed (Class of Case vs ) Only applicable to cases seen by BCT Analytic case load numbers need to be adjusted

18 Plastic surgery needs to be added Define conference attendance rates bct vs. other program personnel Surgeon, Med Onc, Rad onc 75% Pathology/Radiology may be lower as defined by BPLC Other personnel 75% 1.3 Evaluation and Management Guidelines Add selection of breast cancer screening guidelines here vs. 2.8 Data collection only Confirm orgs listed in standard 2.1 Delete Interdisciplinary Patient Management Data collection standard only will be assessed on Medical Record Review Proposed incorporation into Patient Navigation Need to define criteria for appropriate credentials and acceptable documentation. Are lay navigators acceptable need to define in standard Remove table 2.3 X Breast Conservation 50% still applicable? QI/Standards to discuss Add SAR question for annual evaluation 2.4 X Sentinel Node Biopsy No changes 2.5 Breast Cancer Surveillance 2.6 X Breast Cancer Staging Requirement that staging policy define where stage is recorded, when staging is performed and who performs it. Operative and all office notes must contain stage. 2.7 New audit Pathology Reports Clarify that slides must be reviewed Annual review by BPLC (new requirement) Add tracking of discrepant diagnoses? QI/Standards to discuss 2.8 Diagnostic Imaging Remove all references to ACR requirements - replace with URL to assure accurate/timely information link Requirement to Identify screening guidelines vs. Standard 1.3 Add a SAR question about which screening guidelines they selected here MQSA is Standard of Care does MQSA certification need to be validated at time of survey?

19 2.9 X Needle Biopsy Define minimum rate in standard 2.10 Ultrasonography Remove references to ACR requirements replace with URL to assure accurate/timely information link New survey process Assign deficiency on initial survey until ASBS certification received 2.11 Stereotactic Core Needle Biopsy Remove references to ACR requirements New survey process Assign deficiency on initial survey until ASBS certification received 2.12 X Radiation Oncology Add meeting frequency for centers with self-administered QA New survey process Assign deficiency on initial survey until certification received 2.13 Medical Oncology Remove references to NQF endorsement (based on QI discussion on NAPBC-endorsed measures 2.14 Nursing Incorporate ONS Changes see attached What are criteria for documented knowledge? 2.15 X Support and Rehabilitation Add requirement for BPLC audit in compliance rating 2.16 Genetic Evaluation and Management See attached 2.17 Educational Resources Add fertility and metastatic resources 2.18 X Reconstructive Surgery Take out references to ASPS replace with URL 2.19 Evaluation and Management of Benign Disease Requirement for documented policy and procedure on resource documentation and management of benign breast disease 2.20 X Breast Cancer Survivorship Care Move footnote re: metastatic into standard language Align with CoC on who can deliver SCP plans (per TS 8/2/15) An advanced practitioner Physician Credentialed clinical oncology patient navigator (required to be part of the patient s care team - Oncology Certified Nurses, Advanced Practice Nurses, Nurse Practitioners, Physician Assistants, and/or an OCN/RN navigator. This group does not include lay navigators.) 3.1 Clinical Trial Information Add information on who to include in clinical trials 3.2 X Clinical Trial Accrual Add template for SAR (QI/Standards Discussion)

20 4.1 Education, Prevention and Early Detection Programs No changes 5.1 Breast Center Staff Education Need to define whether training courses included 2 sessions, NOT CME s For reaccrediting centers this should be MDs on staff that start with new accreditation cycle 6.1 X Quality and Outcomes Clarify how many center specific are required Clarify how many physician specific are required Is it ok to do 3 center and 0 physician? Clarify that participation in NQMBC and/or CPR3 without quality improvement measures does not meet intent of standard 6.2 X Quality Improvement In measures table: Cut 1 (Standard 2.6) Cut 2 (Standard 2.9) Keep 3-6 New X Submission of Annual Program Activity New Medical Record Review Expand to Class of Case Survey Process Changes 1. Develop talking points for surveyors on deficiencies as opportunities for improvement , 2.11 and 2.12 give deficiency for non-certification for initial surveys to allow tracking. Staff will work with these centers to extend resolution beyond 1 year as needed. Sets center up for success rather than failure when deficient 3 years later.

21 Standard Nursing Nursing care is provided by or referred to nurses with specialized knowledge and skills in diseases of the breast. Nursing assessment and interventions are guided by evidence-based standards of practice and symptom management. Definition and Requirements The complex needs of cancer patients and their families require specialized oncology nursing knowledge and skills to achieve optimal patient care outcomes. The oncology nurse is an integral member of the multidisciplinary breast team. In larger centers, ccertification in oncology nursing is recommended. The certification should be through an accredited program. In smaller centers or private practice offices, ONS-certified nurses are optional. Nursing care should be provided by nurses with knowledge and experience in breast disease. Qualifications of a nurse with a specialized knowledge and skill may include: Holding one of the following certifications from the Oncology Nursing Certification Corporation: o Certified Breast Care Nurse (CBCN ) o Advanced Oncology Certified Nurse Practitioners (AOCNP ) (Oncology Nursing Certification Corporation) o Advanced Oncology Certified Clinical Nurse Specialists (AOCNS ) (Oncology Nursing Certification Corporation) o Oncology Certified Nurse (OCN ) (Oncology Nursing Certification Corporation) Certified Breast Care Nurse (CBCN) (Oncology Nursing Certification Corporation) o Advanced Oncology Certified Nurse (AOCN ) A nurse with documented knowledge and skills from previous education and experience in the care of women with breast disease Oncology nursing resources available at: ORGANIZATION Oncology Nursing Society Oncology Nursing Certification Corporation LINK Documentation The center completes the online SAR and indicates the following: Enter total number of oncology nurses on staff at the center, and enter the total number of Oncology Nursing Certification CorporationSociety (ONCCS) certified nurses on staff, if applicable. Rating COMPLIANCE STATEMENT Nursing care is provided by or referred to nurses with specialized knowledge and skills in diseases of the breast. Nursing assessment and interventions are guided by evidenced-based standards of practice and symptom management.

22 Genetic Evaluation and Management Standard 2.16 Cancer risk assessment, genetic counseling and genetic testing services are provided or referred. Definition and Requirements Cancer risk assessment and genetic counseling is the process of identifying and counseling individuals at risk for familial or hereditary breast cancer syndromes. An initial cancer risk assessment is generally conducted by treating clinicians, in the form of a basic family history, as an important part of normal patient care. The purpose of genetic counseling is to further educate patients about their risk of developing breast cancers, help them obtain personal meaning from cancer genetic information, and to empower them to make educated and informed decisions about genetic testing, cancer screening, and cancer prevention. Identifying patients at increased risk of developing breast and other cancers due to a family history of breast and other cancers or a known hereditary cancer syndrome can have dramatic effects on early detection and cancer outcome. For this reason, cancer risk assessment and genetic counseling is rapidly becoming a standard of care for patients with a personal and/or family history of breast cancer. Not all breast cancer patients will need to be referred to a cancer genetics professional and referral should be based on national guidelines (e.g., NCCN, ASCO, ASBS, and others). Genetic counseling is performed by a cancer genetics professional who has extensive experience and educational background in genetics and cancer genetics, counseling and hereditary cancer syndromes, to provide accurate risk assessment and empathetic genetic counseling to cancer patients and their families. Specialized training in cancer genetics should be ongoing and documented with CME/CEU in the fields of cancer genetics. Two CMEs/0.2 CEUs should be obtained annually, ideally with 1 related to BRCA1/2 and the other related to genes other than BRCA1/2 that cause hereditary breast cancer. Formatted: Font: Italic Formatted: Font: Italic Educational seminars should include the spectrum of services for breast cancer genetics including genetic risk assessment, genetic counseling, indications and decision-making regarding genetic testing and appropriate post-test counseling. Education limited to learning how to order a genetic test is not considered adequate training for risk assessment and genetic counseling. Genetic counseling is provided by: An American Board of Genetic Counseling (ABGC) board certified/board eligible or (in some states) a licensed genetic counselor. An American College of Medical Genetics (ACMG) physician board certified in medical genetics. A Genetics Clinical Nurse (GCN), an Advanced Practice Nurse in Genetics (APNG) or an Advanced Genetics Nursing-Board Certified (AGN-BC) credentialed through the American Nurses Credential Center (ANCC). Credentialing is obtained through successful completion of a professional portfolio review process An advanced practice oncology nurse (APON) that is prepared at the graduate level (master s or doctorate) with specialized education in cancer genetics and hereditary cancer predisposition syndromes; certification by the Oncology Nursing Certification Corporation as AOCNP or AOCNS is preferred.

23 A Genetics Clinical Nurse (GCN) credentialed through the Genetics Nursing Credentialing Commission (GNCC). GNC credentialing is obtained through successful completion of a professional portfolio review process. Formatted: Indent: Left: 0.25", No bullets or numbering A genetics nurse credentialed by the ANCC A genetics nurse who holds a current Advanced Practice Nurse in Genetics (APNG) credential awarded by the GNCC. A genetics nurse who holds a current Genetics Clinical Nurse (GCN) credential awarded by the GNCC. A board certified/board eligible physician or other trained healthcare professional with expertise and experience in cancer genetics (defined as providing cancer risk assessment on a regular basis) employing a model that includes both pre-test and post-test counseling. o Patients identified to have a variant of uncertain significance (VUS) on a hereditary cancer panel, and tested by one of the above providers listed in this specific bullet point need to be referred to a genetics professional for assistance with interpretation for the patient and the patient s family. Surveyors will review consult notes and pedigrees for healthcare providers providing cancer risk assessment, genetic counseling and genetic testing to ensure that appropriate pre- and post-test counseling is being provided. Therefore, it is expected that documentation will include the elements of pre- and post-testing counseling outlined below. Formatted Formatted: Indent: Left: 0.25", No bullets or numbering * Please note, specialized training in cancer genetics should be ongoing and documented with CME in the fields of cancer genetics. Educational seminars should include the spectrum of services for breast cancer genetics including genetic risk assessment, genetic counseling, indications and decision-making regarding genetic testing and appropriate post-test counseling. Education limited to learning how to order a genetic test is not considered adequate training for risk assessment and genetic counseling. Formatted: Font: (Default) Times New Roman Insert American Nurses Credentialing Center Insert Delete Genetic Nursing Credentialing Commissions American Nurses Credentialing Center

24 Centers that are geographically challenged or do not have access to a board-certified or licensed genetic counselor may utilize the services of a nationwide network of genetic experts available by telephone to provide consultation and guidance. An An eeexamples of such a networnetwork isks areis noted below. There may be other networks available to the center. Insert Delete DNADirect Formatted: Highlight Formatted: Highlight Formatted: Highlight Formatted: Font: (Default) Times New Roman Pre-Test Counseling American Nurses Credentialing Center Collecting relevant information needed to assess a patient s personal and family medical history. A three to four generation pedigree, including detailed medical information about the patient s first, second, and third degree relatives should be obtained. Gathering information about both paternal and maternal family history, ancestry/ethnicity, and consanguinity is necessary. Evaluation of patient s cancer risk. One aspect of risk assessment is discussing the absolute risk that the patient will develop a specific type of cancer or cancers based on the family history. The second aspect is the risk that the patient carries a heritable or germline mutation in a cancer susceptibility gene. This should include a discussion of the differential diagnosis. Performing a psychosocial assessment. Educating the patient about the suspected hereditary cancer syndrome, if appropriate. The provider should review cancer risks associated with gene mutations including basic concepts such as genes and inheritance patterns and more advanced concepts of penetrance and variability expressivity and the possibility of genetic heterogeneity. Obtaining informed consent for genetic testing, if recommended. The purpose of informed consent should include the purpose of the test and who the ideal person is to test, possible test results, likelihood of positive results, technical aspects and accuracy of the test, the possibility of inconclusive test results and how these results affect medical management, economics and insurance considerations, laws protecting against genetic discrimination, utilization of test results, alternatives to genetic testing, and the storage and potential reuse of genetic material. Post-Test Counseling Disclosure of the results and post-test counseling should include a discussion of the results, significance and impact of the test results, medical management options, informing other relatives, future contact and available resources. If not already performed, patients with tests demonstrating mutations should have further assessment by a genetics professional. Guidelines and recommendations for cancer risk assessment and genetic counseling for hereditary breast cancer syndromes are available at: Formatted: Highlight Formatted: Highlight Comment [SW1]: This statement needs to be deleted. We define what a genetics professional is and this person needs to be able to assess positive results. This statement, to me, inadvertently creates two levels of genetics professionals. Formatted: Highlight Formatted: Highlight

25 Documentation The center completes the online SAR and indicates the following: Check the genetic evaluation and management services provided, referred, or not available. The surveyor will confirm certification/credentialing for the genetic healthcare professional at the time of survey. Rating Compliant Cancer risk assessment, genetic counseling and genetic testing services are provided or referred.??????? more 1. Non-compliant Cancer risk assessment, genetic counseling and genetic testing services are not provided or referred.

26 6/9/2016 Rural and Small Community Surgeon Survey Friday, May 20, 2016 Powered by 107 Total Responses Date Created: Friday, February 19, 2016 Complete Responses: 107 1

27 6/9/2016 Q2: Do you provide surgical breast care to patients in your facility? Answered: 106 Skipped: 1 Q2: Do you provide surgical breast care to patients in your facility? Answered: 106 Skipped: 1 2

28 6/9/2016 Q3: How would you describe your practice? Answered: 105 Skipped: 2 Q3: How would you describe your practice? Answered: 105 Skipped: 2 3

29 6/9/2016 Q4: What is the population of the town in which your practice is located? Answered: 103 Skipped: 4 Q4: What is the population of the town in which your practice is located? Answered: 103 Skipped: 4 4

30 6/9/2016 Q5: What is the distance from your primary practice to the closest radiation facility (in miles): Answered: 104 Skipped: 3 Q5: What is the distance from your primary practice to the closest radiation facility (in miles): Answered: 104 Skipped: 3 5

31 6/9/2016 Q6: Identify the barriers you experience locally (check all that apply): Answered: 78 Skipped: 29 Q6: Identify the barriers you experience locally (check all that apply): Answered: 78 Skipped: 29 6

32 6/9/2016 Other responses: Unable to do plastic reconstruction same day No longer do breast surgery Outside radiology tends to lead patients to their institution for breast care after mammography finding Patients have perception that Breast Center is better. Not better but have broader range of options for which I have no hesitation to send patients. We do not have ability to do stereotactic bx. MRI only day a week and no MRI bx. No Nuclear MD. No plastics. No onsite radiology. I do US guided core. I do needle loc US and Mamo for lumpectomy. I do SLN with meth blue. I do mastectomy but not reconstruction. Most patients get multidisciplinary care via a telemedicine Oncology Center associated with a University. No nuclear medicine options at my rural hospital. Can only do sentinel lymph node with blue dye. No radiation options locally, so many older women choose mastectomy without reconstruction because they don t want to travel for radiation. I don t have access to a plastic surgeon at my rural hospital so reconstruction options are not available. I have to refer out patients wanting reconstruction. I also have a medical oncologist who is old school with results in resistance to neoadjuvant chemotherapy when I think it would allow better results in certain patients. I perform my own stereotactic biopsies as there is no radiologist to do so. I also do my own BRCA GENE testing. I do have digital mammography, breast MRI and oncology available. The radiation oncology and plastics portions are the only 2 areas I feel are missing. We do have a volunteer van that drives our patients daily to the radiation treatment center so that we can offer breast conserving therapy. I offer second opinions to patients at Karmonos, U of M and the Mayo Clinic and am happy to see that they almost all return to have their care locally. Part of rural medicine is knowing what you can do as well as others and sending out that which you cannot. I am happy to report breast care is an area we manage well. Lack of marketing resources I practice in a multispecialty clinic with an associate 40 bed hospital. About 30% of my practice is breast. We have resources to do breast surgery locally, but patients leaving for the Twin Cities (45 miles) or Rochester Mayo (40 miles) is one major challenge. I do not try to stand in their way if they wish to go for treatment elsewhere. However, collecting and knowing my data (re-excision lumpectomy rate, BCT rate, use of needle biopsy, etc) allows me to have a very nice conversation with patients regarding my performance and ability to be their surgeon. The ASBrS Mastery of Breast Surgery log is what I use for this. It is somewhat onerous to enter in all the data, but I really enjoy knowing and understanding my performance so I can work to do better. I feel a system that would allow a surgeon to track these metrics would be very helpful for rural surgeons. I don t think that system would need to track every metric that Mastery or similar systems do, but having those few core measures involved would be great. A nice system would be an Add-on or separate pop up box that would trigger ACS case log (SSR) for breast Cases. I suspect several rural surgeons use SSR already for MoC, and this would be an easy place to add just a few more metrics specific to breast surgery that currently are not a part of SSR. Other responses (cont d) Our biggest challenge is that distance patient have to travel for stereotactic biopsy or radiation therapy. So most patients will choose to have mastectomy. All of these affect my practice to a slight degree. None of which keep me from providing quality care but some cases I do send elsewhere because of these. Since we are close to regional centers (UCSF, Stanford, UC Davis), many patients are referred to the centers by our local oncologists. Of course, these places push back some of the Medicaid patients. We cannot offer reconstruction due to lack of plastics and lack of interested on their part they don t like 3 rd party billing. I am trained to do my own needle localizations and stereotactic biopsies, but the offsite radiologist is unwilling to credential me for same. I could arrange for a mobile service to come, but volume would be an issue. I am currently doing guided surgery for non-palpable lesions. Most of my mastectomy patients do not want reconstruction due to cost. I am also trained to perform sentinel node biopsies and have nuclear medicine available several days a week but no gamma camera. Administration is interested, but we need more data as to volume. We are working on same. RT and oncology available in three locations, two of which are 50 miles away and one which is 90 miles away. Our service area encompasses several counties. In a previous location, my practice was 75% breast. I am a member of the American Society of Breast Surgeons. We have 3 hospitals close by in our system. We have some duplication of resources. Not all facilities have all needed equipment. Nuclear medicine is at 1 site but wire localization is at another site. Patients have to be transferred back and forth in the same day for cancer care. I work at two hospitals. This one is a critical access hospital. I take patients to other hospitals for sentinel nodes, mastectomy etc. I use oncology services at other hospital. One problem I encounter is that when I send my patients for u/s guided biopsies, technicians/radiologists entice them to come for everything to their breast center and try to refer them to their breast center. They routinely call them and discuss results. It is not infrequent that even the benign biopsy do not return. Recently I almost quit doing breast frustrations though one of the local primary cares asked me to reconsider. I am concerned as to be set up to fail and judged wrongly by patients and families. I often spend a lot of time previously and never ended up doing surgery. We don t have stereotactic unit here nearest is 150 miles. However, we do offer open needle-localized biopsies when lesion not amenable to stereotactic or patient prefers not to travel. We don t have plastic surgery or radiation center- nearest XRT 150 miles, nearest plastic surgeon 280 miles- but patients rarely ask for simultaneous reconstruction. Mostly we re just very rural with limited patient population. No immediate reconstruction since no plastic surgeon. Frozen section unreliable due to lack of volume. No problems in performing any type of breast surgery. 7

33 6/9/2016 Other (cont d) Continual statements by colleagues from University settings in press, publications, and to patients stating improved outcomes at the university. This may be true in some areas, but we have great results with local care. These statements are made in self serving fashion in publications by people who benefit and chosen to print by their colleagues. The bias is overwhelming. I, and many other great general surgeons in rural areas, could go on ad infinitum, but I doubt anybody from the asking organizations will listen, and has bias not only by being in that setting, but self declared the bias by choosing to be in that setting. I know you disagree...(sigh) Cannot offer immediate reconstruction due to lack of plastic surgeon staff. I can do most procedures, unless patients want to go to the big city. Do not have sentinel node capabilities however. Do have oncological support, but radiation facility 45 miles away. Now we have breast imaging which has been a great support for my breast patients. But many women still want to leave town to get big city medicine. We do not have radiation therapy and this is another reason women leave at the start of their diagnosis. No immediate plastic reconstruction available, but will be coming in July. I would like to apply for accreditation but do not have the resources for data collection and to do the necessary quality studies. Also there is no way to be able to put pt's on clinical trials other than sending them to a bigger city. The bigger centers do not want to make us a satellite or would charge a large amount to do so which we simply do not have. We do adhere to national guidelines in our practice and provide good care but there is no way we can become accredited with our limited resources. No real barriers except local genetic counselor. Some think they need to go to the big city. NAPBC accredited center will full services except for plastic surgery for reconstruction. Q7: Rank the following: Answered: 104 Skipped: 3 8

34 6/9/2016 Q7: Rank the following: Answered: 104 Skipped: 3 Q8: What tools or resources could the NAPBC provide that would be most beneficial to you or your facility (check all that apply): Answered: 99 Skipped: 8 9

35 6/9/2016 Q8: What tools or resources could the NAPBC provide that would be most beneficial to you or your facility (check all that apply): Answered: 99 Skipped: 8 Other Hard to say, I feel my limitations are due to being rural with limited technology and specialty physicians. Single biggest limitation is no stereotactic ability. Webinars are fine, but I can never get away from patient care to sit in front of a computer. They are useful if they can be watched at our convinience. Ways to overcome lack of equipment and specialists. Opportunities for formal training in indirect breast skills like stereotactic biopsies, ultrasound biopsies since you don t get that training in residency but radiologists are stretched thin in local communities, on whom you are dependent for these services. Help with collection and analysis of quality benchmarking. 10

36 6/9/2016 Q9: Are you from a NAPBC accredited center? Answered: 104 Skipped: 3 Q9: Are you from a NAPBC accredited center? Answered: 104 Skipped: 3 11

37 6/9/2016 If yes, please list the standard(s) that are most challenging to meet (list all that apply): Can t get it because of no plastic surgeons, genetic counselor or cancer registry. We are trying to attain this certification Equipment on site, no radiologist on site We are short surgeons and have overbooked OR. It is difficult to get patients to OR in expected time frame. We have to make moral judgements like - do I bump this breast cancer patient up and delay the colon cancer patient s treatment so I can keep my facility accredited for breast (and no one is looking at the colon time to surgery.) Our center stopped surgeons from doing image guided biopsy. I had been doing about 50 per year. I had taken the courses put on by ASBS. I had trouble meeting 100 ultrasounds per year unless I did them without indication. Therefore I was not able to sit for the official exam. ( I took the exam in a practice setting after it was developed and was given at the end of a training coarse so ASBS could test exam.) Enough breast volume to stay current within NAPBC standards Quality improvement Several are difficult, the main one is the requirement for weekly multidisciplinary conference Standard 1.2 Two meetings per month is just not doable with the limited numbers of staff (only one med-onc and one rad-onc, one pathologist, one radiologist and 3 surgeons doing all the endo, trauma and general surgery. Also with only cases we would be discussing 1 and 1/2 cases per meeting. Standard 2.8 The ACR Breast MRI standard of 50 per year would prevent small centers from earning a BICoE and therefore not fulfill 2.8 although the new NAPBC standards mention only mammography, stereotactic bx and U/S bx. It is confusing the way it is stated. Standard 2.12 and 2.13 Peer review processes are difficult with only one of each specialist and each reviewer seems to have a different explanation of how much peer review needs done. One reviewer says that some percentage of med-inc and rad-inc charts need reviewed and another says that 100% need reviewed. Standard 3.2 The majority of our breast pts are treated by NCCN guidelines making it difficult to accrue 2% of the total for trials. We are working to identify opportunities for local research studies. Q11: Are you from a CoC accredited center? Answered: 101 Skipped: 6 12

38 6/9/2016 Q11: Are you from a CoC accredited center? Answered: 101 Skipped: 6 Comments: I have elected to stop performing breast surgery in my practice because of the complexity of the field. My practice is more focused on laparoscopy. I have 2 partners that perform breast surgery in this area. We Were accredited for many years but the new standards were too expensive and required too much manpower to comply in light of our size and available resources Oncologists with primary loyalty to tertiary center. I do not get the feeling that you understand our situation in rural America. I find the idea of having to have special credentials for every thing I do annoying. First conscious sedation, now breast surgery. Where does it stop? I am a recently retired Breast/General Surgeon. The answers reflect the nature of my practice accurately. A major problem I faced was that I became the only surgeon among my colleagues that did any breast surgery at all. Hence, I found it difficult to know 'where I stood' in the community of breast surgeons except at meetings such as the Miami and San Antonio breast meetings, etc. The American College of Surgeons is helping to fill that void currently with their on-line Breast Surgery community forum but that was not available to me during my practice. The biggest problem I faced was the "bigger is better" perception that took many patients down the highway to the nearest big city. Were I still in practice I would STRONGLY insist my facility seek and receive the NAPBC and/or C of C accreditation. Having that imprimatur would go a long way toward resolving that issue. Plastic surgeons were available but would rather do cosmetic surgery than bother with the time consuming breast cancer patients. They doled out appointments to women with cancer like they were coming in to consider a face-lift. Good care in this area is essential. Just a general comment that smaller centers have very limited resources and have to work very hard to fulfill each standard with a limited number of staff all wearing "multiple institutional hats". It seems that every single year there are one or more new standards or requirements passed by the CoC and it becomes harder and harder for smaller programs to keep up. I fear that this process will very soon drive all smaller programs out of the CoC system and limit the CoC to large community and academic institutions. It really needs to be an inclusive system that takes into account the sometimes very limited resources in small or rural communities with the understanding that patients in these areas will continue to be treated locally whether the programs are CoC Accredited or not. Processes need to be developed to help these smaller programs to provide the best care possible with the resources at hand and not to exclude them from the CoC system. 13