5.3 Quality Improvement Principles & CoC Chapter 7 (Standards 7.1–7.3)
Key Takeaways
Standard 7.1 requires the cancer committee to monitor the program's performance on CoC-selected quality measures against the expected Estimated Performance Rate (EPR) and to implement an action plan for any measure below it.
Standard 7.2 requires a physician to perform an annual retrospective, medical-record-based analysis of whether diagnostic evaluation and first-course treatment were concordant with evidence-based national guidelines.
A 7.2 study reviews all cases of one site (or stage within a site) up to 100 cases, or an identified concern within a site or stage; case discussions at conferences do not satisfy it.
Standard 7.3 requires at least one QI initiative per year with a numeric problem statement, a recognized performance improvement tool (such as Lean, DMAIC, or PDCA/PDSA), and at least two status reports to the committee each year.
QI initiatives last about one year and may be extended to a second year, but a new initiative must still start at the beginning of each calendar year.
Quality improvement principles
Quality improvement (QI) is the systematic use of data to improve care processes and outcomes. The exam's "quality improvement principles" topic tests ideas that appear in every QI method:
- Start from a known problem measured with data. A CoC QI initiative must address an already identified problem. It cannot be a study "to see whether a problem exists."
- Measure a baseline and set a numeric goal, for example "raise X from 71% to 85% within 12 months."
- Find the root cause before you intervene. Tools include cause-and-effect (fishbone or Ishikawa) diagrams, the 5 Whys, process flow maps and Pareto charts.
- Test changes in cycles and keep measuring, using run charts or control charts to see whether the change worked and whether it lasts.
- Benchmark against peer, state and national performance, such as NCDB quality measure reports.
Common performance improvement models
| Model | Steps | Typical use |
|---|---|---|
| PDSA / PDCA | Plan, Do, Study (or Check), Act, repeated in small rapid cycles | Testing a process change on a small scale before spreading it |
| Six Sigma DMAIC | Define, Measure, Analyze, Improve, Control | Reducing variation and defects in a measurable process |
| Lean | Map the value stream and remove waste (waiting, rework, unnecessary steps) | Speeding up referral or treatment pathways |
| Root cause analysis | Identify contributing causes of a specific problem or event | Understanding why a care gap occurred |
The CoC glossary defines PDCA and PDSA as QI methods, and Standard 7.3 names Lean, DMAIC and PDCA/PDSA as examples of the recognized, standardized tools a QI initiative must use.
Standard 7.1: Quality Measures
- The CoC selects quality measures each year and publishes the specifications, evaluation years and performance thresholds on the NCDB website. Performance rates come from the NCDB reporting tools.
- The cancer committee monitors the program's performance against the expected Estimated Performance Rate (EPR) for each selected measure and documents the monitoring in the minutes each year.
- For any measure below the expected EPR, the program develops and implements an action plan that investigates the causes and works to remove barriers.
- A program with no eligible cases for a measure is exempt from that measure.
Accurate registry data come first. A measure can look "failed" because the registry is missing treatment given at another facility, such as radiation or hormone therapy. Following up on treatment given elsewhere before concluding that care was not given is one of the most valuable things a registrar does for quality measures.
Standard 7.2: Monitoring Concordance with Evidence-Based Guidelines
Each calendar year, a physician performs an in-depth analysis of individual patients' care. The study must include:
- A study population of either all cases from one site (or one stage within a site) up to a maximum of 100 cases, or an identified need or concern within a specific site or stage.
- A medical record review of each patient to decide whether the pre-treatment diagnostic evaluation (pathology, imaging, laboratory tests and recommended consultations) followed evidence-based national guidelines.
- A review of each patient's first course of treatment to decide whether it was appropriate for the stage or prognostic indicators and concordant with the guidelines.
- A reporting format that supports analysis and improvement.
- A presentation of the results to the cancer committee in the same calendar year, documented in the minutes with any recommendations.
Two rules are often tested. Case discussions at cancer conferences do not satisfy Standard 7.2, and patient data reviewed for the Standard 6.1 registry quality control plan cannot be reused as the 7.2 study. Problems a 7.2 study uncovers are a good source for a 7.3 QI initiative.
Standard 7.3: Quality Improvement Initiative
Under the guidance of the Cancer Liaison Physician, the Quality Improvement Coordinator and the cancer committee, the program completes at least one cancer-specific QI initiative each year.
| Step | Requirement |
|---|---|
| 1. Review data to find the problem | Sources, in order of preference: an NCDB quality measure problem; a 7.2 study finding; the annual review of other standards (palliative care, genetics, operative standards); NAPRC or NAPBC initiatives; NCDB or CQIP data; cultural competency, shared decision-making or health equity data; any other cancer-specific quality problem the committee identifies |
| 2. Write the problem statement | Name a specific, already-identified problem, the numeric baseline and goal metrics, and the expected timeline |
| 3. Choose a methodology and a team | The QI Coordinator and the CLP identify the content experts needed (for example, a breast surgeon and a radiation oncologist for a radiation-after-lumpectomy measure) and use a recognized tool such as Lean, DMAIC or PDCA/PDSA to analyze causes and design an intervention |
| 4. Implement and monitor | Put the intervention in place, and change it if monitoring shows it is not working |
| 5. Present a summary | The data reviewed, the problem statement, team members, the tool used, the intervention and any adjustments, and the results (compared with national data where possible), documented in the minutes |
Reporting and timing:
- The CLP or QI Coordinator gives status updates at least twice each calendar year. The final summary may count as one of them.
- An initiative should last about one year and may be extended to a second year. The intent to extend must be documented before or during the last meeting of the first year, and a new initiative must start each calendar year anyway.
- Programs also accredited by the NAPBC and/or NAPRC may count one completed breast-specific and/or rectal-specific QI initiative toward Standard 7.3 during each accreditation cycle.
The registry's role
| QI activity | Registry contribution |
|---|---|
| Finding the problem | Pull NCDB quality measure performance, 7.2 results and registry reports, and check that apparent gaps are not missing data |
| Baseline | Define the cohort precisely (site, stage, diagnosis years, analytic cases) and calculate the rate |
| Monitoring | Produce periodic run charts from registry data during the intervention |
| Reporting | Prepare the tables and figures for status updates and the final summary |
Worked example
A program's performance on a colon measure (at least 12 regional lymph nodes examined after resection) is 78%, below the expected EPR. The registry first confirms the node counts against the pathology reports and finds no abstracting errors. The problem statement reads: "12-node examination rate is 78% (baseline 2025); goal 90% by December 2026." A PDSA team of surgeons, pathologists and pathology assistants finds that grossing protocols vary between shifts. The team standardizes grossing with a fat-clearing step for low counts, and the registry tracks the monthly rate. The CLP reports status in the second and fourth quarters, and the final summary compares the results with national data.
A cancer committee proposes a QI project "to find out whether our lung cancer patients receive timely treatment." Why does this proposal not meet CoC Standard 7.3?
A QI initiative must address an already identified quality problem, with numeric baseline and goal metrics, rather than a study to see whether a problem exists.
Lung cancer is not an eligible site for QI initiatives.
QI initiatives must be led by the Cancer Registry Quality Coordinator, not the committee.
QI initiatives must address NCDB quality measures only.
Which activity satisfies CoC Standard 7.2 (Monitoring Concordance with Evidence-Based Guidelines)?
The ODS reviews 10% of the analytic caseload for coding accuracy of stage and treatment items.
The tumor board discusses 40 breast cancer cases prospectively using NCCN Guidelines.
A physician retrospectively reviews the medical records of all 2025 stage III colon cancer cases (86 patients) for guideline-concordant workup and first-course treatment, and presents the results to the committee the same year.
The CLP presents the program's NCDB survival report at two committee meetings.
Under CoC Standard 7.3, how often must the CLP or Quality Improvement Coordinator report the status of the QI initiative to the cancer committee?
Once, when the initiative is complete
Quarterly, at every committee meeting
Only during the triennial site visit
At least twice each calendar year, documented in the minutes
Sections you finish are checked off in the contents.