Pam Barlow, Adrienne S Russell and Vickie Gerrard. Pictured in back is Dr. Phillip Ley

Baptist Breast Health Center accreditations boost acclaimed program

In early spring, Baptist Health Systems became the first organization in Mississippi and one of only seven nationwide to achieve Disease-Specific Care Certification for Breast Cancer from the Joint Commission. It’s a stamp of approval that Phillip Ley, MD, surgical director of Baptist Breast Health Center, calls “an enormous lift to an already highly acclaimed breast health program.”

“It completely validates the quality of the program, the people in it, and the care they deliver,” he said. (See related story below.)

The prestigious designation, which the Joint Commission states “represents the highest level of recognition achievable by a healthcare provider,” demonstrates Baptist’s commitment to be accountable for the quality of care being provided while also continuously improving the care, treatment and services, said Vickie Gerrard, RN, director of accreditation, who was instrumental in achieving the special certification status from the Joint Commission and other national accrediting bodies.

The Joint Commission Disease Specific Certification for Breast Cancer was achieved by undergoing an objective evaluation against standards for disease specific care to evaluate the effectiveness in using clinical guidelines and performance improvement to continuously improve care for patients with breast cancer, and is applicable to the Breast Center, Radiation Oncology, and the Outpatient Infusion Clinic.

Disease Specific Certification was achieved in addition to Joint Commission hospital accreditation.

“The Joint Commission accreditation means that the entire organization (Baptist Medical Center) has had an evaluation led by surveyors that evaluate the overall quality and safety of the entire organization to see if the organization meets established standards of criteria,” explained Gerrard. “Although accreditation is a voluntary process in general, accreditation is required to receive reimbursement of services, provide clinical settings for professionals while being trained—physicians, nursing students, and radiology students, to name a few.”

Baptist Breast Health Center has also achieved designation from the American College of Radiology (ACR), designed by the U.S. Food and Drug Administration (FDA) to regulate quality care in mammography. Translation: the mammography facility has achieved the highest quality standards after review by expert board-certified radiologists and medical physicists.

“Everything from personnel, equipment, and quality control and assurance is evaluated,” explained Deborah Perilloux, RT (R)(M). “This certification is awarded to a facility every three years after submission of appropriate materials about the facility as requested by the ACR.”

Even though the ACR accreditation is mandatory for all mammography facilities as outlined in the Mammography Quality Standards Act, passed by Congress in

 1992, and made official in 1994, the additional accreditations for Stereotactic Breast Biopsy and Breast Ultrasound are optional to pursue.

“Our facility was awarded these also, which is recognized as a Breast Center of Excellence,” noted Perilloux. “These accreditations ensure our patients and physicians the highest standard of care at our facility.”

In early summer, Baptist Breast Health Center was granted a three-year full accreditation designation by the NAPBC (National Accreditation Program for Breast Centers), a program administered by the American College of Surgeons, demonstrating a commitment to improve the quality of care relating to breast disease. NAPBC accreditation is only given to those centers that have voluntarily committed to provide the highest level of quality breast care and that undergo a rigorous evaluation process and performance review.

“NAPBC-accredited centers demonstrate that a multidisciplinary, team approach is used to coordinate the best care and treatment options available to each patient with breast disease,” Gerrard explained, noting that Ley, medical director Larkin Carter, MD, director Merlene Myrick, patient navigator Adrienne Russell, and cancer registry coordinator Pam Barlow also played key roles in the accreditation process. “This accreditation, like many others, is the culmination of many hours of work by numerous professionals in all disciplines to provide documentation to a national organization that demonstrates quality improvement, leadership, community outreach, research, in addition to staff and physician education, training, and competency.” 

The NAPBC, whose mission is pursued via standard-setting, scientific validation, and patient and professional education, also takes into consideration the services, support, and breast-cancer related information provided to patients.

The consortium of professional organizations is dedicated to the improvement of quality of care and monitoring of outcomes of patients with diseases of the breast and also focuses on breast cancer data, evidence of continuous improvement of care, and information about clinical trials and new treatment options. Data is rigorously reviewed and validated on site to determine compliance by a surveyor for the NAPBC, whose board membership represents professionals from 15 national organizations that reflect the full spectrum of breast care.

“Receiving care at a NAPBC-accredited center ensures that a patient will have access to comprehensive care, including a full range of high-tech services, a multidisciplinary team approach to coordinate the best treatment options, information about ongoing clinical trials and new treatment options, and most importantly, quality breast care close to home,” said Gerrard.

 Related Story

Lending Surgical Oncology Expertise

Phillip Ley, MD, Leads Baptist Breast Health Cancer as Surgical Director 

When Phillip Ley, MD, was named Baptist Breast Health Center’s surgical director last year, he was already a prolific surgical oncologist. He was the first surgeon in Mississippi to introduce sentinel lymph node biopsy for breast cancer, a procedure he performed regularly at The University of Texas MD Anderson Cancer Center in Houston, Texas, during fellowship training in surgical oncology. Since his arrival in Mississippi in 1996, he has performed roughly 3,000 such procedures.

“This particular procedure is a boon for the patients because of a greater detection of breast disease, and also provides a reduction of side effects for the patient,” said Ley, one of few surgical oncologists in Mississippi and arguably the only fellowship-trained surgical oncologist in the state.

The advent of the Baptist Breast Health Center, where the screening, diagnosis, and treatment of breast disease and breast cancer takes place in one space, “is available in most major cities, and we’ve needed it here,” he said. “The quality of care is equal to any major center in the United States, and the community needs to know that.”

Initially a pharmacy school graduate, the Baylor College of Medicine-schooled Texas native completed post-medical school training in general surgery at the Scott & White Clinic/Texas A&M University Health Science Center before heading to MD Anderson Cancer Center in Houston for fellowship training. Time spent as an attending trauma surgeon at Ben Taub General Hospital, a 586-bed Level 1 trauma center considered one of the busiest trauma centers in the United States –more than 100,000 emergency patients visit annually, and it’s the only hospital in Houston with a psychiatric emergency room open around the clock—provided him with additional expertise in surgical techniques.

Initially, his primary focus areas involved three major areas— melanoma/carcinoma, thyroid/parathyroid, and breast cancer. Now his emphasis is largely on breast cancer. He is also trained to perform cancer-related surgical procedures including liver tumors, pancreas tumors, bile duct and gallbladder, gastric, esophageal, colon/rectal, sarcoma, laparoscopic splenectomy and laparoscopic adrenalectomy.

“I always wanted to be a surgeon and I was intrigued by the advancements being made in cancer care, and so I did want to be a part of that, but it’s not the sole reason I chose this specialty,” he explained. “I chose it primarily because of the many different facets that come with being a surgical oncologist.”

Ley has conducted research and participates in ongoing clinical trials on breast cancer, has written extensively for professional journals, and has served on numerous national and state boards to champion the causes of better healthcare for women.

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