Supporting Implementation of the National Standards for Cancer Survivorship Care: Development of the Cancer Survivorship Maturity Model (CSMM)

Technical Summary: Supporting Implementation of the National Standards for Cancer Survivorship Care

Problem Statement
While national organizations (e.g., NCI, ASCO, Institute of Medicine) have established comprehensive standards for cancer survivorship care, a critical gap exists in assessing organizational readiness to implement these standards. Existing frameworks, such as Commission on Cancer Standard 4.8 or ASCO's QOPI, function primarily as compliance checklists or performance metrics. They lack a structured, quantitative framework to characterize an organization's progressive stage of implementation across specific care domains. Consequently, healthcare institutions struggle to operationalize survivorship care consistently due to variations in infrastructure, workflows, and staffing, with few tools available to diagnose specific readiness gaps or guide staged improvement.

Methodology
The authors employed a mixed-methods, participatory model development study to create and preliminarily evaluate the Cancer Survivorship Maturity Model (CSMM).

• Model Development: A preliminary "strawman" model was constructed based on the National Guidelines for Cancer Survivorship Care. To ensure operational feasibility, related care elements were consolidated into seven broader operational domains: Survivorship Care Planning, Risk of Recurrence, Specialty Care, Financial Hardship/Toxicity, Lifestyle Behaviors & Supportive Services, Practical & Social Impacts, and Physical & Psychological Effects.
• Internal Refinement (Focus Groups): Five multidisciplinary focus groups were conducted at a comprehensive cancer center (Baylor College of Medicine) involving 14 participants (oncologists, nurses, social workers, etc.). Using consensus-building techniques adapted from the Nominal Group Technique (NGT), participants:
  • Ranked domains by clinical impact, implementation ease, and patient priority.
  • Iteratively refined domain definitions and maturity level descriptors.
  • Assessed the current maturity of their own practice settings.
• Maturity Scale: The model utilizes a five-level maturity scale adapted from established informatics frameworks:
  1. Ad Hoc
  2. Planned
  3. Unified
  4. Reportable
  5. Optimized
• External Validation: The refined CSMM was distributed electronically to 12 external stakeholders from the National Cancer Institute Survivorship Supplement Awardees (NCISS) network for self-assessment to evaluate transferability and usability.
• Analysis: Quantitative data (prioritization rankings and maturity ratings) were analyzed using weighted rankings, descriptive statistics, and ordinal logistic regression. Qualitative data from focus group discussions were analyzed thematically to identify implementation barriers and refine the model.

Key Contributions

• Development of the CSMM: The primary contribution is the creation of a clinician-informed framework that translates national survivorship standards into an actionable organizational readiness assessment tool.
• Operationalization of Standards: The model consolidates complex survivorship standards into seven distinct, assessable domains with clear descriptors for five progressive maturity levels, moving beyond static checklists to a dynamic assessment of capability.
• Identification of Implementation Barriers: The study systematically identifies recurring organizational barriers, including unclear workflows, role ambiguity, resource constraints, and technical fragmentation.

Results

• Prioritization Divergence: Participants identified significant misalignment between different prioritization lenses. Domains perceived as having the highest clinical impact (Risk of Recurrence, Specialty Care, Survivorship Care Planning) were not necessarily those perceived as most important to patients (Physical & Psychological Effects, Financial Hardship/Toxicity) or easiest to implement.
• Low Overall Maturity: Across both internal (BCM) and external (NCISS) respondents, survivorship care maturity was generally low. Most domains clustered between Level 1 (Ad Hoc) and Level 2 (Planned).
  • Highest Maturity: Risk of Recurrence and Specialty Care (mean scores ~2.1).
  • Lowest Maturity: Lifestyle Behaviors & Supportive Services and Practical & Social Impacts (mean scores ~1.5–1.6).
• External Validation: The external evaluation showed similar low-maturity patterns to the internal group, with an overall mean maturity rating of 1.93 for external respondents compared to 1.85 for internal respondents. Ordinal logistic regression indicated limited systematic differences between groups, suggesting the model is transferable, though "Practical & Social Impacts" showed a statistically significant difference (p=0.0064).
• Qualitative Findings: Focus groups highlighted that barriers are often organizational rather than conceptual. Key issues included a lack of workflow clarity regarding roles, insufficient clinician time, fragmented Electronic Health Record (EHR) systems, and the high resource intensity of survivorship care without dedicated funding.

Significance and Claims
The paper claims that the CSMM provides a structured approach for healthcare organizations to assess their readiness to implement survivorship care standards and to identify specific domain-level gaps. By distinguishing between areas of strength and areas requiring investment, the model aims to support strategic implementation planning and resource allocation.

The authors emphasize that the CSMM is designed to help institutions move from broadly endorsed principles to actionable organizational expectations. It serves as a planning tool to identify where processes break down (e.g., referral pathways, documentation) and where infrastructure development is needed. The study concludes that while national standards define what survivorship care should include, tools like the CSMM are necessary to determine if and how organizations are prepared to deliver it consistently. The authors note that the model's utility lies in its ability to facilitate cross-institutional learning and guide quality improvement efforts, though they acknowledge limitations regarding the modest sample size and the reliance on clinician-perceived patient priorities rather than direct survivor input.