National Consortium of Breast Centers, Inc. 
National Quality Measures for Breast Centers Program (NQMBC™) 

Quality Indicators For Which Each Quality Breast Center Type* Should Be Able to Measure Performance

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© 

 

Clinical Breast Center 

  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) © 

 

Treatment 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©

  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.

15.    Five Year Stage Specific Survival Rate©

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©

18.      Patient Satisfaction Survey - Use©

19.      Patient Satisfaction - Survey Development©

20.      Patient Satisfaction Survey Response Rate©

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©

23a.  Breast Conservation Surgery - Overall Rate (actual patients) ©

23b.  Breast Conservation Surgery Rate for Eligible Patients (potential eligible candidates) ©

24a.  Chemotherapy Use - Rate for Stage II and III ER Negative and PR Negative Breast Cancer (actual) ©

24b.  Chemotherapy Use - Rate for Stage II and III ER Negative and PR Negative Breast Cancer (potential) ©

25a.  Post-Lumpectomy Radiation - Rate for Invasive Breast Cancer (actual) ©

25b.  Post-Lumpectomy Radiation - Rate for Invasive Breast Cancer (potential) ©

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© 

 

Comprehensive 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©

 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.

15.   Five Year Stage Specific Survival Rate©

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©

18.     Patient Satisfaction Survey - Use©

19.     Patient Satisfaction - Survey Development©

20.     Patient Satisfaction Survey Response Rate©

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©

23a.  Breast Conservation Surgery - Overall Rate (actual patients) ©

23b.  Breast Conservation Surgery Rate for Eligible Patients (potential eligible candidates) ©

24a.  Chemotherapy Use - Rate for Stage II and III ER Negative and PR Negative Breast Cancer (actual) ©

24b.  Chemotherapy Use - Rate for Stage II and III ER Negative and PR Negative Breast Cancer (potential) ©

25a.  Post-Lumpectomy Radiation - Rate for Invasive Breast Cancer (actual) ©

25b.  Post-Lumpectomy Radiation - Rate for Invasive Breast Cancer (potential) ©

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©

 

* Breast Center Definition

The treatment of breast diseases including the screening, diagnosis, and treatment of breast cancer require the interaction of multiple specialists in multiple departments.  These include, but are not limited to, surgery, medical oncology, radiation oncology, radiology, pathology, plastic surgery, physical therapy, behavioral medicine and nursing.

While many or most of these services exist in most health systems, the idea of a breast center is to organize these services into a coordinated, integrated, multidisciplinary approach for the patient.  The direct interaction of these services is synergistic, providing much higher quality care to the patient than she would receive from the same specialists working in isolation. 

Breast centers may provide a full complement of services to encompass all needs of the breast patient or may focus on specific portions of care such as imaging or surgical care.  Breast centers may have all their services available under one roof, or may be a “center without walls,” organizing their services located at different locations under unified leadership. 

For services to be considered as “provided” services by the breast center, the center must maintain “quality control” of that service.  Other services available without “quality control” are considered “referred” services.  (See footnote below). 

Breast Center Types

Breast Centers vary in many ways.  We classify breast centers using two main variables:

1) breast center profile characteristics and
2) “provided” components of services. 

After these two variables have been clearly defined, centers can be separated into five types:

a) Screening Breast Center
b) Diagnostic Breast Center
c) Clinical Breast Center
d) Breast Cancer Treatment Center
e) Comprehensive Breast Cancer Treatment Center    

1)  Breast Center Profile CharacteristicsThese would include the size of their breast cancer treatment facility/hospital, size of the community they serve, volume of breast cancer patients seen, number of mammograms performed annually, patient characteristics, regional location and provider compensation structure.  These characteristics will aid centers to compare themselves with similarly structured centers.

2) Components of Service: Depending on the type of breast center, breast centers offer varied services.  We distinguish the types of breast centers by the components of service “provided” by that center (with quality control) not by the components of service available.  In order for a center to be considered “providing” a component of service, they must have “quality control” of that component of service.  Quality control of a service occurs 1) if there is data to review of that service AND 2) if the center can impact the type of care provided.  (See definitions below)

Definitions

“Quality Control” means 1) there is quantitative data of that component of service available to the center AND 2) the breast center has the direct ability to modify that component of service (procedural influence not complete control).  This allows the center to have quality monitoring and influence on the services they provide. 

“Provided” components of service are those for which the breast center has “quality control.”  The location of those components of service does not impact the definition of “provided” services as long as quality control exists. Services may occur “on-site” or locally “off-site.”    

“Referred” components of service are performed without “quality control” by the center.  This means the center does not have BOTH quantitative data AND direct ability to modify that component of service. Services are “referred” to outside vendors who may not readily share quality information or allow influence on their services. 

Footnote:  The type of center viewed by the NQMBC program is based upon only services provided for which there is quality control by that center.  The type of breast center viewed by patients is usually based upon services both provided and referred by that center.  Therefore, a center may be viewed by the public as one type and viewed by the NQMBC program as another.