Creating the Annual Audit Report for the Breast Leadership Committee (NAPBC)


Marketing Manager

Standard 1.1 for the NAPBC Accreditation requires the Breast Program Leadership (BPL) Committee to review and analyze data for the breast conservation rate, sentinel lymph node biopsy rate, needle biopsy rate and breast cancer staging. What our Consultants find is that the fact that the NAPBC surveyors review class of case 10-14 cases only is confusing to almost everyone.   That does not indicate the Breast Program Leadership Committee should only be concerned with patients who have been diagnosed at the facility.   The distinction for class of case 10-14 for chart review is to allow the surveyor to review patients who have had both diagnostic and treatment at the facility being surveyed. The effectiveness of a chart review where the diagnostic work up is done elsewhere would be minimal.

The Breast Program Leadership Committee is charged with monitoring the entire breast program of the facility and, in many cases, that will include patients with an initial diagnosis elsewhere.   Our programs present the annual audit date in two separate sample groups; those with class of case being diagnosed at the facility and those diagnosed elsewhere. The BPL must review and consider the care provided to both of these subsets of patients. In some facilities, more patients may be diagnosed elsewhere. The care they are receiving is as just as important to an accredited program.

Our Cancer Program Consultants are experienced with data analysis and presentation to the committees. Often this data can be confusing and very detailed. We have found our presentation methods allow for effective analysis by the BPL committee and an opportunity to evaluate changes in processes and education.