Quality Measure Program - Quality Measures Program - National Consortium of Breast Centers

National Consortium of Breast Centers

Page Content Utility Links Main Links Footer Links Local Links Back to Full Site

Quality Measure Program

Quality Measures Program

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
1 Imaging Timeliness of Care Time Between Screening Mammogram and Diagnostic Mammogram © X X   X
2 Mammography Call Back Rate © % of screening mammogram patients recommended for additional imaging X X   X
3 Surgical Timeliness of Care Time Between Diagnostic Mammogram and Open Surgical Biopsy/Excision (no needle biopsy performed) © X X X X
4 Imaging Timeliness of Care Time Between Diag Mammogram & Needle/Core Biopsy   X   X
5 Surgical Timeliness of Care Time Between Needle Biopsy and Initial Breast Cancer Surgery ©     X X
6 Needle/Core Biopsy Rate © Percent (%) of patients having biopsy who received a needle or core biopsy rather than open biopsy   X X X
7 Pathology Timeliness of Care Time Between Initial Breast Biopsy (excluding open surgical) and Pathology Results ©   X X X
8 Pathology Timeliness of Care Time Between Open (incisional/ excisional) Initial Breast Biopsy and Pathology Results     X X
9 Pathology Timeliness of Care Time Between Initial Breast Cancer Surgery and Pathology Results ©     X X
10 Pathology Timeliness of Care Tumor Size ©     X X
11 Pathology Report Completeness Margin Analysis ©     X X
12 Pathology Report Completeness Margins Identified ©     X X
13 Pathology Report Completeness Lymph Node Analysis ©     X X
14 Pathology Report Completeness Specimen Sampling Adequacy ©     X X
16a Pathology Report Completeness ER and PR Receptor Measurement for Invasive Disease ©     X X
16b Pathology Report Completeness ER Receptor Measurement for Insitu Disease ©     X X
17 Surgical Care Sentinel Node Biopsy ©     X X
18 Patient Satisfaction Survey- Use Patient Satisfaction Survey is Used ©     X X
19 Patient Satisfaction Survey Development Survey Created in House or Externally ©     X X
20 Patient Satisfaction Survey Response Rate Survey Return Rate ©     X X
21 Patient Satisfaction Survey Measure Shared decision making for Choice of Surgical Option for Breast Surgery       X
22 Patient Satisfaction Survey Measure Cosmetic Results Following Breast Reconstruction       X
23a Breast Conservation Surgery Overall Rate (actual patients) ©     X X
23b Breast Conservation Surgery Rate For Eligible Patients (potential eligible candidates) ©     X X
24a Chemotherapy Use Rate for Stage II and III ER Negative and PR Negative Breast Cancer       X
24b Chemotherapy Use Rate for Stage II and III ER Negative and PR Negative Breast Cancer       X
25a Post-Lumpectomy Radiation Rate for Invasive Breast Cancer (actual) ©     X X
25b Post-Lumpectomy Radiation Rate for Invasive Breast Cancer (potential) ©     X X
26a Adjuvant Endocrine Therapy Rate for Invasive Breast Cancer (actual) ©       X
26b Pathology Report Completeness Rate for Invasive Breast Cancer (potential) ©       X
27 Radiation Therapy Break in Treatment ©       X
28 Reconstructive Breast Surgery Myocutaneous Tissue (Flap) Complication Rate ©       X
29 Adjuvant or Neoadjuvant Chemotherapy Complications Resulting in Inpatient Hospitalization Rate ©       X
30 Ambulatory Breast Cancer Surgery Unplanned Overnight Stay Rate ©     X X
31 Breast Conservation Surgery Re-Excision Rate ©       X

Main Links