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Program earns 3-year accreditation with commendation

The Program in Women's Oncology and Breast Health Center at Women & Infants Hospital of Rhode Island was recently awarded a three-year full accreditation, with commendation, by the National Accreditation Program for Breast Standards.

The accreditation was awarded after a one-day visit in late September, in which a physician reviewed the Breast Health Center's clinical facilities, patient charts and the minutes of the quarterly Cancer Committee meetings, according to Margaret M. Steinhoff, MD, chair of the Cancer Committee. The Committee also submitted data to document the Center's compliance with the 36 standards required by the American College of Surgeons Commission on Cancer, and what had been accomplished since the most recent accreditation visit, in 2007.

In the accreditation, the surveyor commented, "This program is a true gem. Highlighted strengths include the experienced staff and leadership, support teams, interdisciplinary conference, integrative care, social work and breast navigation teams.

"I am greatly impressed by the well-focused, multiple-campus, multidisciplinary breast conference and the case complexity, discussions and care plan integration," the surveyor added, referring to the weekly Tumor Board sessions held at the Program in Women's Oncology in which experts from various disciplines gather to discuss the care of each patient.

In issuing the accreditation, the Breast Health Center was also given eight commendations for:

  • Outcomes analysis - publishing an annual report that includes an outcomes study
  • Abstracting timeframe being 100% compliant per surveyor case review
  • Submission of quality criteria to the national database all data was submitted without error
  • Compliance with College of American Pathology guidelines being 100% compliant with protocols per surveyor review
  • Clinical trial accrual accrual to clinical trials that is well in excess of the amount needed for commendation
  • Prevention and early detection offering three or more prevention or early detection programs each year
  • Cancer education for cancer registry staff the cancer registry staff who are certified tumor registrars attend a national cancer-related educational activity once during the survey cycle
  • Cancer-related quality improvements implementing more than two improvements a year that directly affect cancer patient care

"Surgical, medical oncology, radiation oncology, pathologic and radiologic expertise is well documented in patient care plans and closely adhere to National Comprehensive Cancer Network guidelines," the surveyor noted. "The team easily meets criteria for compliance including breast conservation rates, sentinel node biopsy rates, pathology reports, hormonal therapy, benign breast disease management and clinical trials enrollment.

"Overall, the Breast Health Center is a phenomenal program that is an asset to the medical and patient community."

In addition to Dr. Steinhoff, the Cancer Committee includes the following staff: Anna Bailey, RN, BSN, OCN, oncology nurse manager; AnneMarie Bradley, RN, MS, OCN, oncology nurse manager; Don Dizon, MD, medical oncology; Linda Donegan, MD, diagnostic imaging; David Edmonson, MD, general surgery; Heidi Fogarty, CTR, cancer registry; Wendy Fox, PT, DPT, GCS, WCS, physical therapy; Jennifer Gass, MD, assistant director of the Breast Health Center and surgeon-in-chief at Women & Infants; Amanda Goldstein Collins, RN, MS, OCN, oncology administration; Cornelius "Skip" Granai, MD, director of the Program in Women's Oncology; Ellen Healy, MA, LMHC, social work; Susan LaSalle, quality management; Donna Loranger, RD, LDN, CNSD, nutrition; Janet Mari, RN, research; Carol Opiekun, RN, MS, hospital administration; Caroline Patterson, MDiv, chaplain; Maureen Pearlman, RN, MS, health education; Leslie Pires, MS, PharD, pharmacy; Mohamed Puthawala, MD, radiation oncology; Debborah Smith, American Cancer Society; Rina Stamas, CTR, cancer registry; Lisa Stors, LSW, American Cancer Society; Suzanne Trabucco, cancer conference; and Mary Warburton, RTR, Med, patient management.

In addition to this most recent announcement, the Breast Health Center at Women & Infants Hospital enjoys national acclaim for the following reasons:

  • Earning a five-year accreditation from the Society of Surgical Oncology for the Breast Fellowship Program, the longest possible duration of certification from the society
  • Offering the nation's first joint breast fellowship for gynecologic oncologists, as developed by the Society of Gynecologic Oncologists and the American College of Obstetricians and Gynecologists
  • Earning a three-year accreditation as a Breast Center of Excellence from the American College of Radiology


Contact: Susan McDonald
Women & Infants Hospital

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