Accreditation Award: Three Year Full Accreditation Accredited Through November 02, Accreditation Award Summary

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1 Accreditation Award: Three Year Full Accreditation Accredited Through November 02, 2019 Accreditation Award Summary Name of Center CenterID Name of Director Arkansas Breast Cancer Specialists The Breast Center of Northwest Arkansas 55 W. Sunbridge Drive Fayetteville, AR,United States Kevin Pope, Director Date of Survey November 03, 2016 Name of Surveyor Charlene Wallace, RN, MS, OCN

2 January 18, 2017 Kevin Pope, Director Breast Program Director (BPD) Arkansas Breast Cancer Specialists The Breast Center of Northwest Arkansas 55 W. Sunbridge Drive Fayetteville, AR, United States RE: Center ID Dear Kevin Pope, Director: On behalf of the American College of Surgeons National Accreditation Program for Breast Centers (NAPBC), I am taking this opportunity to congratulate you and your team at Arkansas Breast Cancer Specialists on achieving Three Year Full Accreditation as a result of your recent survey! NAPBC Accreditation is the seal of approval for Arkansas Breast Cancer Specialists from the American College of Surgeons and formally acknowledges your commitment to providing the highest quality evaluation and management of your patients with breast disease. Included in this communication is your Performance Report reflecting ratings for all NAPBC standards including your surveyor comments. As a result of your accreditation, information about your breast program is included on the listing of accredited programs that can be found on our website Additionally, you will be able to promote your center's accreditation award locally. Your marketing/public relations department has access to a web based marketing page that has resources that can be used to publicize your accreditation both internally and externally. As a first step, please encourage your marketing/public relations staff to post the NAPBC logo in a prominent place on your facility web site. If you have any questions regarding this decision, please contact the NAPBC Administrative office at or at napbc@facs.org. I want to thank you for your support of the breast center and all that you do to meet the needs of breast patients and their families. Once again, congratulations on this achievement! Sincerely, Terry Sarantou, MD, FACS Chair, Standards and Accreditation Committee National Accreditation Program for Breast Centers (NAPBC) James L. Connolly, MD, FCAP Chair, National Accreditation Program for Breast Centers (NAPBC)

3 Center ID# Center Name: Accreditation Award: Accreditation Type: Arkansas Breast Cancer Specialists Three Year Full Accreditation Initial Accredited: November 03, 2016 To: 11/2/ :00:00AM Performance Report Chapter 1 - Center Leadership Standard 1.1 Level of Responsibility and Accountability Standard 1.2 Interdisciplinary Breast Cancer Conference Standard 1.3 Evaluation and Management Guidelines Chapter 2 - Clinical Management Standard 2.1 Interdisciplinary Patient Management Standard 2.2 Patient Navigation Standard 2.3 Actual rate was below 50%. This center services a large rural area where many Breast Conservation patients are not able to travel for radiation therapy. This affects their BCS rate. Standard 2.4 Sentinel Node Biopsy Standard 2.5 Breast Cancer Surveillance Standard 2.6 Breast Cancer Staging Standard 2.7 Pathology Reports Standard 2.8 Diagnostic Imaging Standard 2.9 Needle Biopsy Standard 2.10 Ultrasonography Arkansas Breast Cancer Specialists Page 3 of 6

4 Standard 2.11 Stereotactic Core Needle Biopsy Standard 2.12 Radiation Oncology Standard 2.13 Medical Oncology Standard 2.14 Nursing Standard 2.15 Support and Rehabilitation Standard 2.16 Genetic Evaluation and Management Standard 2.17 Educational Resources Standard 2.18 Reconstructive Surgery Standard 2.19 Evaluation and Management of Benign Breast Disease Standard 2.20 The majority of records reviewed included a survivorship care plan. Breast Cancer Survivorship Care Chapter 3 - Research Standard 3.1 Clinical Trial Information Standard 3.2 Clinical Trial Accrual Chapter 4 - Community Outreach Standard 4.1 Education, Prevention, and Early Detection Programs Chapter 5 - Professional Education Standard 5.1 Breast Center Staff Education Chapter 6 - Quality Improvement Standard 6.1 Quality and Outcomes Arkansas Breast Cancer Specialists Page 4 of 6

5 Standard 6.2 Quality Improvement Summary of Overall Comments This center is an unusual collaboration between separate entities that have come together to form a great breast program. Each group has committed their time and resources to make it successful. Members are very engaged and excited about their accomplishments and should be proud of their program and the services they provide. Well done! Arkansas Breast Cancer Specialists Page 5 of 6

6 Accreditation Award Defined The accreditation award is based on compliance with 29 standards at the time of survey. Three-Year/Full Accreditation is awarded to centers, either new or upon reaccreditation, that comply with all standards at the time of survey. This award is also applied to programs that received a deficiency rating for 1-3 non-critical standards at the time of survey. Resolution of all deficient standards must be documented within 12 months from the date of survey. A performance report is issued and these centers are surveyed at three-year intervals from the date of survey. Three-Year Contingency Accreditation is awarded to centers, either new or upon reaccreditation, that receive a deficiency rating for 4-8 non-critical standards. The contingency status is resolved by documentation of compliance with all deficient standards within 12 months from the date of survey. Three-Year/Full Accreditation is granted following submission, review, and approval of documentation to establish compliance with all standards. A performance report is issued after resolution of all deficiencies and these centers are surveyed at a three-year interval from the date of survey. Accreditation Deferred is given to centers that receive a deficiency rating in any of the critical standards outlined above, or 9 or more standards at the time of survey. The deferred status is resolved by submission of documentation for compliance and/or resurvey within 12 months. Deficiency Resolution A deficiency is defined as any standard with a rating of (2) non-compliant. Deficiencies identified during survey must be corrected within 12 months of the date of the on-site visit. Based on the resolution of deficiencies and survey results, a performance report and certificate of accreditation are issued. Centers that do not resolve all deficiencies within a 12-month period from the date of survey will be at risk of losing their NAPBC accreditation status and will be required to reapply for accreditation. A center is eligible for reaccreditation if all previously identified deficiencies have been resolved and are documented in the NAPBC Survey Application Record (SAR) within 12 months from the date of the previous survey. Appealing a Decision Centers that have been surveyed by the NAPBC have the right to appeal an accreditation award or a deficiency. If you wish to appeal a decision, please submit the Appeal Form, posted on the NAPBC accreditation resources web page, with documentation to napbc@facs.org. All appeals must be received within 45 days of receipt of your center performance report. Accreditation Certificate and Marketing Resources Marketing Materials and resources to help you promote your NAPBC-accredited center and explain what NAPBC accreditation means to your staff, patients, and community are available on the Marketing Resources website, We encourage you to use these resources to publicize your center s accomplishment at your facility and to your community. Accreditation Certificates are issued through an online vendor. To order your complimentary certificate and/or purchase additional certificates or other promotional products, visit the e-store at Your NAPBC Center ID is required when placing orders. Arkansas Breast Cancer Specialists Page 6 of 6