Division
East Florida
Hospital
HCA Florida Westside Hospital
Specialty
Pathology
Document Type
Poster
Publication Date
2025
Keywords
commission on cancer, CoC, surgery
Disciplines
Neoplasms | Pathology | Quality Improvement | Surgery
Abstract
Background: The Commission on Cancer (CoC) was established by the American College of Surgeons in 1922. In 2020, they launched the Cancer Surgery Standards Program that introduced six operative standards. Standard 5.8 requires curative intent lung resections to include sampling from at least 1 hilar, and at least 3 mediastinal lymph node stations.
Goal: To increase our institution’s compliance with CoC standard 5.8 to greater than 80% overall adherence.
Method: Included in the study were patients undergoing curative intent lung resection for lung cancer. A protocol, including a documentation paper worksheet with metric requirements, was implemented in February 2024. Monthly data was collected to evaluate metric performance and presented quarterly at our institution’s Cancer Committee meeting. The hospital is also part of a national CoC standard 5.8 improvement project and reports quarterly to the CoC.
Results: The percentage of compliant cases was 70.5% in 2023, and rose to 75% in 2024. So far in 2025, the compliance percentage has risen to 87.5%, successfully surpassing the 80 percent metric target compliance goal.
Conclusion: Implementation of this documentation protocol enables a quantitative method of monitoring compliance with the CoC 5.8 standard. With a little over a year since implementation, our institution successfully met the desired 80% compliance target threshold.
Original Publisher
HCA Healthcare Graduate Medical Education
Recommended Citation
Bender, Robert; Sant 'Elia, Nicole; and Ferra, Susana, "Quality Improvement Project to Increase Compliance with Standard 5.8: A Community Hospital Institutional Experience." (2025). East Florida Division GME Research Day 2025. 10.
https://scholarlycommons.hcahealthcare.com/eastflorida2025/10