Download commission on cancer - Mercy Medical Center

COMMISSION ON CANCER
2013 Cancer Program Practice Profile Reports (CP3R)
Women often choose to have a mastectomy with breast reconstruction surgery instead of breast conservation following a breast cancer
diagnosis. Women are offered the added benefit of our highly skilled and widely recognized breast cancer surgeons working hand-inhand with our breast reconstruction team who offer surgical expertise and advanced procedures and techniques.
(pictured l to r – Neil B. Friedman, M.D., Director, The Hoffberger Breast Center, Gauri Bedi, M.D., Associate Director, and Jennifer Joh, M.D.,
Bernard Chang, M.D., Director, Plastic and Reconstructive Surgery, and Brendan Collins, M.D.)
The Institute for Cancer Care at Mercy is committed
to providing high-quality care to our patients and
their families.
We are especially proud that the
Commission on Cancer (CoC) of
the American College of Surgeons
awarded our Cancer Program
Accreditation with Commendation
– Gold Status. This accreditation
acknowledges Mercy’s commitment
to offering the highest standard of
care, an instrumental element to our
cancer program.
As a CoC accredited cancer
program, Mercy is able to gather
information from the CoC’s Cancer
Program Practice Profile Reports
(CP3R) to examine outcomes data
from other local providers and
hospitals to compare to standard of
care therapies for major cancers.
This provides an arena which to
further improve upon quality of
patient care locally as well as share
in how other hospitals care for
patients. Additionally, allowing all
CoC programs to recognize issues
in caring for and delivering and
applying best practices that will
help eliminate any discrepancies
in care throughout CoC accredited
cancer programs.
Commission on Cancer Program Practice Profile
continued
CP3R measures: accountability,
quality improvement, and
surveillance.
• Accountability: High level of
evidence supports the measure,
including multiple randomized
control trials. These measures
can be used for such purposes
as public reporting, payment
incentive program, and the
selection of provides by
consumers, health plans,
or purchasers.
Debra A. Vachon, M.D., Surgical Director for The Center for Inflammatory Bowel and
Colorectal Diseases, part of The Melissa L. Posner Institute for Digestive Health & Liver
Disease at Mercy, is a recognized surgical specialist in the diagnosis and treatment of
inflammatory bowel and colorectal diseases. She is committed to helping her patients
learn how to manage their illness.
The CP3R provides feedback to
Commission on Cancer (CoC)
accredited cancer programs to:
•
Report compliance with CoC
approved quality measures
•
Improve the quality of data
across several disease sites
•
Foster preemptive awareness of
the importance of charting and
coding accuracy
•
Improve clinical management
and coordination of patient
care in the multidisciplinary
setting
Each year, CoC standards require
Cancer Committees to review the
quality of patient care using the
CP3R tool to evaluate care within
and across disciplines, to discuss
successful processes, and to
evaluate how procedures that can
be improved to promote evidencedbased practice. The Cancer
Committee is expected to address
performance rates that fall below
specific thresholds established
by the CoC as well as document
findings. There are three types of
• Quality Improvement:
Evidence from experimental
studies, not randomized control
trials supports the measure.
These are intended for internal
monitoring of performance
within an organization.
• Surveillance: Limited evidence
exist that supports the measure
or the measure is used for
informative purposes to
accredited programs. These
measures can be used to
identify the status quo as well as
monitor patterns and trends of
care in order to guide decisionmaking and resource allocation.
Note: This page and all content are
a Copyright© 2013 by the NCDB
and American College of Surgeons,
Chicago, IL 60611-3211.
Listed below are Mercy Medical Center’s results of the 2013 CP 3R measures
as well as a definition and type for each measure:
BCS Measure
BCS – Breast conservation surgery rate for women
with AJCC Clinical Stage 0, I, or II breast cancer
(Measure: Surveillance)
nBx Measure
nBx – Image or palpation-guided needle biopsy
(core or FNA) of the primary site is performed to
establish diagnosis of breast cancer
(Measure: Quality Improvement))
There is no specific performance rate that must be met
to comply with the CoC requirement for this measure.
Mercy’s breast conservation rate is lower than the other
groups; however, many times women choose to have
a mastectomy with reconstruction rather than breast
conservation.
HT Measure
The CoC requires an 80% performance rate, which
Mercy far exceeds.
HT – Tamoxifen or third generation aromatase
inhibitor is recommended or administered within 1
year (365 days) of diagnosis for women with AJCC T1c
or Stage IB-III hormone receptor positive breast cancer
(Measure: Accountability)
The CoC requires a 90% performance rate to comply
with this measure. Mercy has a 95.1% performance
rate, which exceeds all the other groups.
Listed below are Mercy Medical Center’s results of the 2013 CP 3R measures
as well as a definition and type for each measure:
MASTRT Measure
MASTRT – Radiation therapy is recommended or
administered following any mastectomy within 1 year
(365 days) of diagnosis of breast cancer for women
with >= 4 positive regional lymph nodes.
BCSRT Measure
BCSRT – Radiation is administered within 1 year
(365 days) of diagnosis for women under the age of 70
receiving breast conservation surgery for breast cancer
(Measure: Accountability)
(Measure: Accountability)
Mercy has a performance rate of 100% for this
measure, which exceeds the requirement of 90% by
the CoC and far exceeds the other comparison groups.
MAC Measure
The CoC requires a performance rate of 90% for this
measure. Mercy exceeds this requirement and exceeds
the comparative groups as well.
MAC – Combination chemotherapy is recommended
or administered within 4 months (120 days) of
diagnosis for women under 70 with AJCC T1cN0, or
Stage IB-III hormone receptor negative breast cancer
(Measure: Accountability)
Mercy exceeds the 90% performance rate required
by the CoC and exceeds the other comparative group
percentages as well.
Listed below are Mercy Medical Center’s results of the 2013 CP 3R measures
as well as a definition and type for each measure:
ACT Measure
ACT – Adjuvant chemotherapy is recommended
within 4 months (120 days) of diagnosis for patients
under the age of 80 with AJCC Stage III (lymph node
positive) colon cancer
12RLN Measure
BCSRT – At least 12 regional lymph nodes are
removed and pathologically examined for resected
colon cancer
(Measure: Quality Improvement)
(Measure: Accountability)
Mercy has a performance rate of 100%, which far
exceeds the other comparative groups as well as the
90% requirement by the CoC for this measure.
The CoC requirement for 12RLN measure is an 85%
performance rate. As indicated in the chart above,
Mercy far exceeds this requirement as well as the
other comparative groups displayed.
Quality Results Exceed Standards
Based on the CoC 2013 data, Mercy Medical Center met and/or exceeded the required performance
rates for all measures. Our outcome measures support Mercy’s commitment to provide high-quality
cancer care services.
The
Institute for
Cancer Care
227 St. Paul Place
Baltimore, Maryland 21202
MDMercy.com