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.
| Measures Reported | By Breast Center Type | ||||||
|---|---|---|---|---|---|---|---|
| # | Measure | Description | Screening | Diagnostic | Clinical | Treatment & Comprehensive | |
| Imaging 1 | Imaging Timeliness of Care | Time Between Screening Mammogram and Diagnostic Mammogram. © | X | X | X | ||
| Imaging 2 | Mammography Re-call Rate © | Percent of screening mammogram patients recommended for additional imaging. | X | X | X | ||
| Imaging 3 | Imaging Timeliness of Care | Time Between First Diagnostic Imaging Study and First Needle/Core Biopsy. | X | X | X | ||
| Imaging 4 | Surgical Timeliness of Care | Time Between First Positive Needle Biopsy and Initial Breast Cancer Surgery. | X | X | X | ||
| Imaging 5 | Needle/Core Biopsy Rate © | Percent of patients having biopsy who received a needle or core biopsy rather than open biopsy. | X | X | X | ||
| Imaging 6 | Cancer Detection Rate | The number of breast cancer patients found per one thousand screening (asymptomatic) examinations. | X | X | X | ||
| Imaging 7 | Positive Biopsy Rate (PPV2) | Percent of screening patients who were recommended for biopsy or surgical consultation that result in a diagnosis of breast cancer within 1 year. | X | X | X | ||
| Imaging 8 | Percent Use of Screening Tomosynthesis | Percentage of all screening cases that use tomosynthesis. | X | X | X | ||
| Pathology 1 | Pathology Timeliness of Care | Time Between Initial Breast Biopsy (excluding open surgical) and Pathology Results. © | X | X | |||
| Pathology 2 | Pathology Timeliness of Care | Time Between Initial Breast Cancer Surgery and Pathology Result. | X | X | |||
| Pathology 3 | Pathology Report Completeness | Tumor Size. © | X | X | |||
| Pathology 4 | Pathology Report Completeness | Lumpectomy Closest Margin Analysis. | X | X | |||
| Pathology 5 | Pathology Report Completeness | All Lumpectomy Margins Identified. | X | X | |||
| Pathology 6 | Pathology Report Completeness | Lymph Node Analysis. | X | X | |||
| Pathology 7 | Pathology Report Completeness | ER AND PR Receptor Measurement for Invasive Disease. | X | X | |||
| Pathology 8 | Pathology Report Completeness | ER Receptor Measurement for In Situ Disease. | X | X | |||
| Surgery 1 | Surgical Timeliness of Care | Time Between First Positive Needle Biopsy and Initial Breast Cancer Surgery. | X | X | X | ||
| Surgery 2 | Surgical Care | Sentinel Node Biopsy. © | X | X | |||
| Surgery 3 | Breast Conservation Surgery | Overall Rate (administered). © | X | X | |||
| Surgery 4 | Breast Conservation Surgery | Re-Excision Rate. | X | X | |||
| Surgery 5 | Axillary Dissection Indication | Axillary dissection AFTER positive sentinel node biopsy if not receiving radiation therapy. | X | X | |||
| Surgery 6 | Positive Margin Rate for Initial Breast Lumpectomy | Percent of invasive breast cancer patients who had a positive margin after initial lumpectomy for breast conservation. | X | X | |||
| Surgery 7 | Use of nipple sparing mastectomy | Percent of breast cancer patients undergoing mastectomy receive a nipple sparing mastectomy. | X | X | |||
| Surgery 8 | Contralateral prophylactic mastectomy | Percent of patients having mastectomy for breast cancer who also have simultaneous contralateral mastectomy. | X | X | |||
| Surgery 9 (Same as Genetics 1 and Medical Oncology 7) |
Genetic testing for invasive breast cancer patients equal or under 45 years old. | Percentage of patients with invasive breast cancer 45 years old or younger who had genetic testing performed. | X | X | |||
| Surgery 10 (Same as Medical Oncology 8) |
Five Year Stage Specific Survival Rate | Overall survival stratified by Stage 0 to Stage IV. | X | ||||
| Medical Oncology 1 | Chemotherapy Use | Rate for women under 70 with AJCC T1cN0M0 or Stage IB - III hormone receptor negative breast cancer. (Administered) | X | ||||
| Medical Oncology 2 | Adjuvant Endocrine Therapy | Adjuvant Endocrine Therapy - Rate for Invasive Breast Cancer (Administered). | X | ||||
| Medical Oncology 3 | Adjuvant Endocrine Therapy | Rate for Invasive Breast Cancer (Recommended). | X | ||||
| Medical Oncology 4 | Genomic Assay Use | Use of Genomic Assay in ER+/PR+ Node negative tumors. | X | ||||
| Medical Oncology 5 | Use of Trastuzumab based Chemotherapy | Trastuzumab administered to Stage 1 (T1c) - 3 HER2 positive breast cancer patients who receive chemotherapy. | X | ||||
| Medical Oncology 6 | Fertility Preservation | Fertility preservation prior to systemic chemotherapy in age appropriate (or fertile) patients. | X | ||||
| Medical Oncology 7 (Same as Genetics 1 and Surgery 9) |
Genetic testing for invasive breast cancer patients equal or under 45 years old. | Percentage of patients with invasive breast cancer 45 years old or younger who had genetic testing performed. | X | X | |||
| Medical Oncology 8 (Same as Surgery 10) |
Five Year Stage Specific Survival Rate | Overall survival stratified by Stage 0 to Stage IV. | X | ||||
| Radiation Oncology 1 | Post-Lumpectomy Radiation | Rate for Invasive Breast Cancer (Administered). © | X | X | |||
| Radiation Oncology 2 | Post-Masectomy Radiation | Post Mastectomy Radiation is administered within 1 year of diagnosis for women with 4 or more positive regional nodes (Administered). © | X | X | |||
| Radiation Oncology 3 | Radiation Consultation | Radiation Consultation is provided for post mastectomy patients with positive nodes. | X | X | |||
| Radiation Oncology 4 | Post-Lumpectomy Hypofractionated Radiation | Hypofractionated Radiation Rate for Invasive Breast Cancer (Administered). | X | X | |||
| Radiation Oncology 5 | Post-Lumpectomy Partial Breast Irradiation Rate (APBI) |
Partial Breast Irradiation Rate for Invasive Breast Cancer (Administered). | X | X | |||
| Genetics 1 (Same as Medical Oncology 7 and Surgery 9) |
Genetic testing for invasive breast cancer patients equal or under 45 years old. | Percentage of patients with invasive breast cancer 45 years old or younger who had genetic testing performed. | X | X | |||
| Genetics 2 | Risk assessment performed for breast cancer patients equal or under 50 years old. | Percentage of patients with invasive breast cancer 50 years old or younger who have quantitative risk assessment for genetic mutations in the medical record. | X | X | |||
| Genetics 3 | Genetic testing for triple negative invasive breast cancer patients equal or under 60 years old. | Percentage of women with triple negative invasive breast cancer 60 years old and younger who underwent genetic testing. | X | X | |||
| Genetics 4 | Family history obtained for breast cancer patients equal or under 70 years old. | Percentage of women with invasive breast cancer 70 years old and younger who have a 3 generation family history in the medical record. | X | X | |||
| Navigation 1 | Navigation Performance by RN's | Percent of breast cancer navigation performed at your breast center by nurses (any RN). | X | ||||
| Navigation 2 | Navigation Performance by OCN's | Percent of breast cancer navigation performed at your breast center by oncology certified nurses (OCN). | X | ||||
| Navigation 3 | Percent workload of breast cancer patients for nurse navigator | Percent of patients assisted by nurse navigators that are breast cancer patients (not other cancers or benign breast disorders). | X | ||||
| Navigation 4 | Navigator contacts with patients over initial 6 months | Average number of contact episodes occurring with the nurse navigator in the first six months including in-person, telephone and written contacts. | X | ||||
| Navigation 5 | Nurse Navigator referral sources | Percent of nurse navigation connections by referrer source. | X | ||||
| Navigation 6 | Function of nurse navigator during regular multidisciplinary breast conference | Identifies what percentage of time the nurse navigator participates in a variety of roles. | X | ||||