In the NQMBC™ Program, a center may wish to measure performance in all or any selection of indicators. The participant may provide data for some indicators at one point of time, due to data availability and enter data points on other indicators at a later date. All this is possible in the NQMBC™ Program. This data is the center's data, a way to record and compare performance.
To become eligible for certification, centers are required to respond to indicators appropriate for their breast center type. This is determined by the profile questions each center completes in Phase I.
Each center should look at the top right of its Profile page in the NQMBC™ Program, and locate its type of Quality Breast Center. Each breast center should be able to measure their performance on select indicators based upon its Quality Breast Center Type.
The indicators that each type of Quality Breast Center should be able to measure (provide data points) are noted below. For each level of certification, a percentage of these must be measured to meet certification requirements.
Screening Breast Center
2. Mammography Call Back Rate©
Diagnostic Breast Center
- 1. Imaging Timeliness of Care – Time Between Screening Mammogram and Diagnostic Mammogram©
- 2. Mammography Call Back Rate©
- 3. Surgical Timeliness of Care – Time Between Diagnostic Mammogram and Open Surgical Biopsy/Excision (no needle biopsy performed)©
- 4. Imaging Timeliness of Care – Time Between Diagnostic Mammogram and Needle/Core Biopsy©
- 6. Needle/Core Biopsy Rate©
- 7. Pathology Timeliness of Care - Time Between Initial Breast Biopsy (excluding open surgical) and Pathology Results©
- 1. Imaging Timeliness of Care – Time Between Screening Mammogram and Diagnostic Mammogram©
- 3. Surgical Timeliness of Care – Time Between Diagnostic Mammogram and Open Surgical Biopsy/Excision (no needle biopsy performed)©
- 5. Surgical Timeliness of Care – Time Between Needle Biopsy and Initial Breast Cancer Surgery©
- 6. Needle/Core Biopsy Rate©
- 7. Pathology Timeliness of Care - Time Between Initial Breast Biopsy (excluding open surgical) and Pathology Results©
- 8. Pathology Timeliness of Care –Time Between Open (incisional/excisional) Initial Breast Biopsy and Pathology Results©
- 9. Pathology Timeliness of Care – Time Between Initial Breast Cancer Surgery and Pathology Results©
- 10. Pathology Report Completeness - Tumor Size©
- 11. Pathology Report Completeness - Margin Analysis©
- 12. Pathology Report Completeness - Margins Identified©
- 13. Pathology Report Completeness - Lymph Node Analysis©
- 14. Pathology Report Completeness - Specimen Sampling Adequacy© Likely will need to change to 3 cm instead of 5 cm in future.
- 16a. Pathology Report Completeness - ER AND PR Receptor Measurement for Invasive Disease©
- 16b. Pathology Report Completeness - ER AND PR Receptor Measurement for Insitu Disease©
- 17. Surgical Care - Sentinel Node Biopsy©
- 23a. Breast Conservation Surgery - Overall Rate (actual patients)©
- 23b. Breast Conservation Surgery Rate for Eligible Patients (potential eligible candidates)©
- 25a. Post-Lumpectomy Radiation - Rate for Invasive Breast Cancer (actual)©
- 25b. Post-Lumpectomy Radiation - Rate for Invasive Breast Cancer (potential)©
performance should be able to be measured for all indicators listed above AND:
- 21. Patient Satisfaction Survey Measure - Shared Decision Making for Choice of Surgical Option for Breast Surgery
- 22. Patient Satisfaction Survey Measure - Cosmetic Results Following Breast Reconstruction
- 26a. Adjuvant Endocrine Therapy - Rate for Invasive Breast Cancer (actual)©
- 26b. Adjuvant Endocrine Therapy - Rate for Invasive Breast Cancer (potential)©
- 27. Radiation Therapy – Break in Treatment©
- 28. Reconstructive Breast Surgery- Myocutaneous Tissue (Flap) Complication Rate©
- 29. Adjuvant or Neoadjuvant Chemotherapy- Complications Resulting in Inpatient Hospitalization Rate©
- 30. Ambulatory Breast Cancer Surgery-Unplanned Overnight Stay Rate©
- 31. Breast Conservation Surgery - Re-Excision Rate©31. Breast Conservation Surgery - Re-Excision Rate©
