Invited Commentary 

The Mechanics of Improving Compliance

Meghan C. O’Leary, Jessica R. Schumacher, Gita N. Mody

JAMA Surg Published Online: April 15, 2026

doi: 10.1001/jamasurg.2026.0897

We were pleased to read the report by Chan et al¹ about an American College of Surgeons national quality improvement (QI) collaborative. The Lung Nodal, Operative, Dissection, Evaluation, and Staging (NODES) initiative involved a collection of multilevel interventions (“guided root cause analyses [RCA], educational webinars, peer-to-peer learning, and the development and implementation of targeted interventions”). The observed 26.5% improvement in hospital-level compliance rates with the Commission on Cancer (CoC) standard 5.8 (ie, harvest of ≥3 mediastinal/≥1 hilar lymph nodes during ≥80% of curative intent lung cancer resections) following participation in NODES is impressive. This finding reinforces the importance of QI collaboratives for large-scale practice improvement.

Additional analyses will be helpful in guiding future improvement efforts. First, further details about the extent of multilevel engagement in various initiative components are critical. This information could be used to understand variation in engagement and whether there is a relationship between the number and/or combination of activities performed and compliance. This could facilitate the prioritization of intervention activities that are most effective. Moreover, increased documentation of activities completed, as well as their causal connections to improved outcomes, across practice types is needed to inform maintenance, sustainment, and scale-up.²

Next, more information is needed on the time and resources required to participate in these activities, an important gap given some activities (eg, RCA) are both time and resource intensive.³ Prioritizing components of the intervention that are most impactful may be particularly important for sustained implementation at lower-volume community hospitals that are more likely to be resource constrained (and represented half of the participating sites in the study).

Lastly, because a control group of hospitals was not included and all sites started the intervention simultaneously, it is not possible to know the degree of improvement that would have happened without the intervention, as we would expect improved compliance over time as new standards diffuse. A sensitivity analysis could be considered, for example, a 1-to-many propensity-matched set of comparison hospitals to help isolate the effect of the intervention from background secular trends. The finding that the improvement in median compliance was largest in community hospitals (37.1%) is especially meaningful and underscores the importance of collaborative improvement efforts that support hospitals in identifying local gaps and providing evidence-based tools and approaches to address context-specific challenges. In an era with ongoing discussions to regionalize care,⁴ there is increasing recognition that recommendations should not be 1-size-fits all and that lower-risk patients with lung cancer resection can continue to receive care in community settings.⁵ This approach could better ensure equitable access while helping patients receive what components of care they can access closer to home,⁶ a strategy that is often more feasible than regionalization given patient-level barriers to and preferences for care.⁷ Personalized tailored guidance on QI activities for hospitals with fewer thoracic surgery patients and/or those that operate in areas with fewer resources should be prioritized.