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Home > Publications > Cancer Program Guidelines > Chapter 8

Cancer Program Guidelines

Chapter 8: Quality Improvement

Section 1: Quality Improvement

Guideline I
Patient care is monitored and evaluated for the quality of services.  Quality improvement plans are developed to address priority improvement opportunities in the cancer program.  Multidisciplinary teams may be formed to address improvement opportunities generated from quality review data, including attributes of timeliness, appropriateness of care, clinical outcomes, and effective management of disease sequelae and treatment toxicities.

Quality patient care depends on the contributions of the healthcare team and the organization’s care guidelines and policies. The Cancer Committee approves these guidelines and policies as well as all quality improvement plans to ensure that improvement priorities are appropriately addressed.


  1. The Cancer Committee establishes the program’s mission, goals, and objectives, and it prioritizes and plans for continuous performance improvement in program goals.
  2. Examples of opportunities for improvement may include, but are not limited to:
    1. Enhanced accuracy and/or efficiencies in patient care processes
    2. Development of treatment guidelines
    3. Implementation of community-wide initiatives
    4. Enhancement of access
    5. Increased patient satisfaction
    6. Risk reduction.
  3. The quality improvement plan is defined, documented, and reviewed for relevance and efficiency at least annually by the Cancer Committee.
  4. All service locations, whether owned and operated by the facility/network, contracted to the facility/network, or part of a documented referral process, are reflected in the written quality improvement plan.
  5. The quality improvement plan is implemented by facility-provided support staff with expertise.  The administrative leader assumes accountability for successful implementation.
  6. Quality outcome measures are defined in the quality improvement plan. Outcome measures for a quality improvement plan address key components of patient care delivery, processes, or disease/treatment management, such as clinical or financial, psychosocial support, survival, length of stay, satisfaction, and other issues.
    1. Data are retrieved consistently and accurately, compiled, analyzed, reviewed, and reported to the Cancer Committee.
    2. Based on the data and reports, the Cancer Committee approves quality improvement plans and their implementation.  Data should be retrieved again and reported to assess the improvements’ (evaluation’s) success and the need for further intervention.
    3. The quality improvement plans and reports are regularly forwarded to a facility and/or board quality committee.
    4. Examples of methods to evaluate data can be, but are not limited to 1) statistical analysis and 2) comparison to “best practices,” to literature, or to regional or national data (National Cancer Data Base [NCDB]; Surveillance, Epidemiology, and End Results [SEER] Registry).


Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

  1. Joint Commission on Accreditation of Healthcare Organizations. Standards 2010
    Phone: 630.792.5900.

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