Contextual assessment of health system alignment with National Standards for Cancer Survivorship Care in the American Southeast

Technical Summary: Contextual Assessment of Health System Alignment with National Standards for Cancer Survivorship Care

Problem Statement
The United States faces a growing population of cancer survivors (over 18 million), yet survivorship care remains fragmented, often leaving patients with unmet needs and inconsistent access to coordinated services. While the National Cancer Institute (NCI) developed the "National Standards for Cancer Survivorship Care" to provide a consensus blueprint for health systems, there is limited data on how well existing large-scale healthcare systems align with these standards in practice. This study addresses the gap in understanding the extent of alignment between current oncology practices in a large American Southeast healthcare system and the NCI National Standards, while identifying specific barriers and facilitators to implementation.

Methodology
The authors employed a qualitatively dominant mixed-methods design to assess alignment across a healthcare system serving urban and rural areas of North and South Carolina, as well as parts of Georgia and Virginia. The study utilized three primary data collection streams:

1. Quantitative Survey: An electronic survey, adapted from the NCI Organizational Assessment Tool, was distributed to key informants at 51 oncology practices. The survey covered three domains: Health System Policy, Health System Processes, and Health System Evaluation. It included 30 core questions with refinements based on input from a "Survivorship Insights Council" to clarify terminology and differentiate between routine and inconsistent implementation.
2. Qualitative Interviews and Observations: Four representative practices (two large main campuses and two smaller regional sites) were selected for in-depth assessment. Researchers conducted 12 semi-structured interviews with providers, administrators, and staff, and performed four clinic observations. These activities were guided by the Consolidated Framework for Implementation Research (CFIR) to identify contextual factors influencing implementation.
3. Integration: Data analysis involved descriptive statistics for survey responses and a rapid analysis approach for qualitative data (interview transcripts and field notes). A joint display was constructed to integrate quantitative findings with qualitative themes, specifically mapping barriers and facilitators to CFIR domains.

Key Contributions

• Systematic Contextual Assessment: The study provides a comprehensive, multi-site evaluation of how a large, diverse healthcare system currently aligns with the National Standards, moving beyond theoretical guidelines to operational reality.
• Identification of Implementation Gaps: The research highlights specific disparities in care delivery between main campus and regional practices, particularly regarding resource availability and the consistency of survivorship care protocols.
• CFIR-Based Barrier Analysis: By applying the CFIR framework, the study categorizes implementation challenges into specific domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals, and Process), offering a structured approach for future quality improvement initiatives.
• Stakeholder Engagement: The study integrates perspectives from a Survivorship Insights Council and a Community Advisory Board, ensuring that findings reflect the views of clinicians, administrators, and patient advocates.

Results

• Survey Findings: Of the 51 practices contacted, 16 consented, and 10 completed at least one survey item. On average, informants reported meeting 55.4% of the National Standards at least some of the time.
  • Strengths: Practices reported high alignment with Health System Processes (91% of items met at least some of the time), particularly regarding the establishment of survivorship programs (on-site, telehealth, or referral).
  • Weaknesses: Significant gaps were identified in Health System Policy (e.g., 88% lacked policies for collecting longitudinal data on survivor experiences) and Health System Evaluation (e.g., no informant reported a process for collecting data on survivors' return to work or productive activities; 86% lacked data collection on staff training).
• Qualitative Findings:
  • Variability: Survivorship services were more extensive at main campuses compared to regional sites, where visits were often limited to once a week or less, and supportive services were restricted.
  • Intervention Characteristics: Partners found the National Standards too broad and vague, with confusing distinctions between "policy" and "process." The language was perceived as difficult to operationalize.
  • Outer Setting: Patient barriers included transportation, food insecurity, and lack of internet access in rural areas, which hindered virtual care adoption. Partners noted that without external incentives (e.g., Commission on Cancer accreditation requirements), implementing these standards is difficult due to competing priorities.
  • Inner Setting: A lack of provider and staff knowledge regarding available resources was a major barrier. Staff at regional sites were often unaware of resources available at main campuses. There was a expressed need for more navigators, social workers, and mental health counselors.
  • Process: Successful implementation was viewed as dependent on engaging key decision-makers (administration) to budget for additional full-time equivalents (FTEs) and staff.

Significance and Claims
The paper claims that while most informants reported meeting at least half of the National Standards, there is significant variability in the consistency of application across practices. The authors acknowledge a likely response bias, noting that those who completed the survey may have provided more favorable responses than non-respondents.

The study concludes that implementing the National Standards requires a balance between consistent service delivery and adaptation to local demands. The findings suggest that current infrastructure is insufficient for systematic evaluation and that future efforts must focus on:

1. Clarifying and simplifying the language of the standards to improve operationalization.
2. Linking standards to external incentives (such as accreditation) to drive adoption, particularly in smaller or resource-constrained practices.
3. Addressing workforce capacity and knowledge gaps through targeted training and staffing.
4. Developing robust data collection mechanisms to evaluate the impact of survivorship care.

Ultimately, the authors posit that these data demonstrate a systematic process for assessing alignment and identifying opportunities to improve survivorship care, emphasizing that addressing these gaps requires coordinated efforts across organizational levels to advance equitable and high-quality care.