Analysis of Patterns of Compliance with Accreditation Standards of National Accreditation Program for Rectal Cancer
Shankar Raman1, Steven S Tsoraides2, Patricia Sylla3
1From the MercyOne Des Moines Surgical Group, Des Moines, IA (Raman).
Background:
We identified commonly deficient standards across rectal cancer programs that underwent accreditation review by the National Accreditation Program for Rectal Cancer to evaluate for patterns of noncompliance.
Study Design:
With the use of the internal database of the American College of Surgeons, programs that underwent accreditation review from 2018 to 2020 were evaluated. The occurrence and frequency of noncompliance with the standards, using the 2017 standards manual, were evaluated. Programs were further stratified based on the year of review, annual rectal cancer volume, and Commission on Cancer classification.
Results:
A total of 25 programs with annual rectal cancer volume from 14 to more than 200 cases per year underwent accreditation review. Only 2 programs achieved 100% compliance with all standards. Compliance with standards ranged from 48% to 100%. The 2 standards with the lowest level of compliance included standard 2.5 and standard 2.11 that require all patients with rectal cancer to be discussed at a multidisciplinary team meeting before the initiation of definitive treatment and within 4 weeks after definitive surgical therapy, respectively. Patterns of noncompliance persisted when programs were stratified on the basis oof the year of survey, annual rectal cancer volume, and Commission on Cancer classification. The corrective action process allowed all programs to ultimately become successfully accredited.
Conclusion:
During this initial phase of the National Accreditation Program for Rectal Cancer accreditation, the majority of programs undergoing review did not achieve 100% compliance and went through a corrective action process. Although the minimal multidisciplinary team meeting attendance requirements were simplified in the 2021 revised standards, noncompliance related to presentation of all patients at the multidisciplinary team meeting before and after definitive treatment highlights the need for programs seeking accreditation to implement optimized and standardized workflows to achieve compliance.
Insights
Most rectal cancer programs failed initial accreditation due to noncompliance with multidisciplinary team meeting standards. Optimized workflows are needed for successful National Accreditation Program for Rectal Cancer compliance.
Area of Science:
- Oncology
- Healthcare Administration
- Quality Improvement
Background:
- Rectal cancer program accreditation is crucial for standardizing care.
- The National Accreditation Program for Rectal Cancer (NAPRC) was established to ensure high-quality rectal cancer treatment.
- Identifying common areas of noncompliance is key to improving accreditation outcomes.
Purpose of the Study:
- To identify frequently deficient standards in rectal cancer programs during NAPRC accreditation.
- To analyze patterns of noncompliance across different program characteristics.
- To evaluate the effectiveness of the corrective action process in achieving accreditation.
Main Methods:
- Analysis of a database from the American College of Surgeons for programs reviewed between 2018-2020.
- Evaluation of compliance rates using the 2017 NAPRC standards manual.
- Stratification of programs by review year, annual rectal cancer volume, and Commission on Cancer classification.
Main Results:
- Only 2 out of 25 reviewed programs achieved 100% compliance.
- Compliance rates varied widely, with the lowest adherence to standards for multidisciplinary team (MDT) meeting discussions before and after treatment.
- Noncompliance patterns persisted across different program sizes and classifications.
Conclusions:
- The initial phase of NAPRC accreditation revealed widespread noncompliance, necessitating corrective action for most programs.
- Persistent noncompliance with MDT meeting requirements underscores the need for standardized workflows.
- Optimized processes are essential for rectal cancer programs to meet NAPRC standards and achieve accreditation.
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