Implementation of Commission on Cancer Operative Standards

In 2013, the Institute ofMedicine reporteda “looming crisis” in the cancer care system, citing the lack of quality monitoring systems and a paucity of cancer-specific quality measures that impact disease outcomes.1 Cancer care delivery standardization measurements put in place by the Commission on Cancer (CoC) aim to decrease variations in care. Surgical technique is linked to outcomes in surgical patients.2 Standardization of operative technique has the potential to improve outcomes for cancer patients, yet there was no consensus on this surgical harmonization until recently. As the new CoC operative standards are rolling out, there are key organizational and surgeon implementation factors to consider (Fig. 1). Herein, we highlight the CoC operative standards and associated implementation considerations.FIGURE 1: Multi-level barriers and facilitators to implementing the new Commission on Cancer Operative standards. There are 5 domains in Consolidated Framework for Implementation Research (CFIR) to assess factors affecting implementation: intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. Domain I is characteristics of the intervention that will be implemented. Domain II is the outer influence such as peer pressure and external policies. Domain III, inner setting, can blend with outer setting (domain II) and includes organizational social context. Domain IV includes those involved with the intervention and implementation process (i.e. organizational leaders). Domain V refers to the implementation process such as engaging, executing, planning and evaluating. Example barriers and facilitators corresponding to each domain are listed on the right.The CoC provides treatment guidance to the 1500 accredited centers where 70% of Americans with a cancer diagnosis are treated. The CoC periodically updates their standards. in 2020, the new revision was poised to standardize surgical approaches to cancer by incorporating the operative standards in surgery, specifically with the use of synoptic operative and pathology reporting. Currently, many surgeons dictate narrative-style operative reports. It is difficult to discern adherence to evidence-based techniques based on these traditional operative reports.3 Electronic synoptic reporting in surgery has not previously been used widely in the US and represents an opportunity to both standardize surgical care and audit intraoperative best practices.4,5 The implementation of CoC operative standards will proceed largely through the use of Synoptic Operative Reports (SOR) and will require substantial practice change. Through a templated field-based data collection form, synoptic reporting has successfully provided high value data elements and improved efficiency in complete documentation. The major benefit of synoptic reporting has been demonstrated in synoptic pathology reports.6 Synoptic pathology reports implementation strategies varied widely - clinical audits, educational meetings, attachment of synoptic report hard copy to the request form of resection specimen, and mandated inclusion based on guideline changes (such as College of American Pathologists guideline).6 Most importantly, there was wide acceptance of synoptic reporting both from the pathologists and clinicians. This has led to the subsequent abstraction of important information, increased ease of finding important information by other providers, and allowed for important quality measurements and research. In a US study on rectal cancer surgery, use of SOR educated surgeons on the important elements in formal cancer resection and acted as a checklist to ensure the necessary steps of a sound cancer operation.4 The Alberta Web Synoptic Medical Record (WebSMR), a breast SOR launched in Canada in 2005, found the total mastectomy rate decreased from 56% to 42% as a result of the program.7 WebSMR achieved this result because it collected surgeon input data and provided explicit guidelines (ie, National Comprehensive Cancer Network guidelines) and access to real-time outcomes of specific metrics within 24 hours of input. Given that SOR can profoundly impact adherence to guidelines for oncologic operations by acting as a reminder system, it is critical to ensure that the implementation of SOR allows for widespread uptake to benefit the greatest number of patients and ensure equity in cancer outcomes. The 2020 CoC accreditation standards underwent major revisions to include the conduct and documentation of key elements of cancer operations in synoptic format. These surgical standards were based, in part, on a book entitled “Operative Standards for Cancer Surgery” that was developed by the Alliance, the American College of Surgeons (ACS) Cancer Research Program, and surgical oncology societies. The new surgical standards in breast, melanoma, colon, rectum and lung are highlighted in Standards 5.3–5.8, which can be accessed through the ACS website (https://www.facs.org/quality- programs/cancer/coc). For total mesorectal excision and lung resection (Standards 5.7 and 5.8), the documentation will require synoptic pathology reporting of the critical elements. For breast, melanoma, and colon (Standards 5.3–5.6), the CoC has introduced templated electronic SOR. The checklist format report will require documentation of certain critical elements surrounding the conduct of the operation. Compared to narrative-style operative reports, the synoptic format will allow ease of auditing and monitoring adherence to surgical standards through checklist style documentation. Furthermore, by displaying the specific surgical techniques and elements that are required for documentation the SOR can help educate and integrate the necessary standards. As the CoC looks to roll out the new operative standards in the form of electronic SOR, it remains critically important that cancer programs and surgeons do not underestimate the process of implementation, which can be deceptively complex (Fig. 1). Specifically, there are multi-level factors to consider for the implementation of the new standards and the strategies for implementation should be targeted specifically at the barriers identified through this multilevel assessment. In the past, insufficient resources have been the most common barrier for implementing other CoC standards such as psychosocial distress screening, tobacco cessation, and survivorship care plans.8–10 As a result, there have been large variations in uptake with many small rural hospitals foregoing accreditation due to insufficient institutional resources, further widening disparities in care. Thus, CoC standards cannot be effective in improving patient outcomes if they are not successfully implemented across all patient demographics and facility types. The status quo, as it pertains to CoC accreditation standards, has been for individual cancer programs to determine the approach for implementation at their own respective institutions. While the newly formed ACS Cancer Surgery Standards Program developed tools to help educate the relevant stakeholders on the new operative standards, the process of implementation will still largely fall upon the individual cancer programs (Fig. 1). This creates complex implementation challenges at the organizational and individual surgeon level. For example, large academic programs may have a formal accreditation committee and administrative support for their Cancer Liaison Physician to help organize a team to help disseminate the information to surgeons, develop and institute the SOR that best fits the hospital's electronic medical record system, and educate the surgeons (including trainees) on its use. To help offset limitations in resources, the Cancer Surgery Standards Program has launched programs focused beyond educational material and also on SOR implementation tools such as electronic templates for cancer programs to use. Even if the necessary tools are set in place, changing a surgeon's attitude and behavior to be adherent to the CoC's standards also introduces implementation complexities. While the CoC has provided numerous webinars and educational resources on the new standards, these resources only help if lack of knowledge is the primary barrier to implementing the new standards. It does not help to address other barriers such as electronic medical record infrastructure issues and individual surgeon-level barriers to changing practice patterns. While knowledge of the operative standards is the first step to achieving a change in behavior, this is only a small piece for effective behavior change. Resistance to practice change is a known barrier, especially since dictating a narrative-style operative report is embedded into the surgical culture. Another big unknown is if the actual conduct of the operation will be performed as stated in the SOR. Thus, the individual surgeon buyin will be a major contrast from how synoptic reporting was accepted by pathologists and clinicians, which was critical to its successful implementation. Implementation Science is a field of research that focuses on using theory-based frameworks to help the uptake of evidencebased interventions across multi-level stakeholders. Utilizing systemic approaches to evaluate barriers can help organizations identify relevant barriers that can be targeted for successful implementation. The example provided in Fig. 1 highlights a popular framework called Consolidated Framework for Implementation Research, which can provide pragmatic structure on the multilevel factors that contribute to successful implementation. The process of using Consolidated Framework for Implementation Research involves the following: 1) identify potential barriers and facilitators to implementing the new standard from the perspective of stakeholders; 2) identify or develop strategies to overcome the barriers; 3) produce protocols to implement; and 4) assess implementation outcomes and make necessary changes to implementation strategies. CONCLUSION The establishment of CoC operative standards represents a paradigm shift in the surgical care standardization of cancer patients. Successful integration of the operative standards hinges on thoughtful use of implementation science in the roll out of the new standards at each institution. Explicit consultation with implementation scientists at the forefront can assist in this process. Future efforts should focus on ways to promote effective and efficient implementation of these surgical standards by utilizing implementation science methods.

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