MOC DR Part4 PQI

Maintenance of Certification

 

Diagnostic Radiology and Its Subspecialties

 

Part 4: Practice Quality Improvement (PQI)

PQI Participation Reporting and Frequency

With the implementation of Continuous Certification and its annual look-back approach, diplomates must have completed at least one PQI Project or Participatory Quality Improvement Activity in the previous three years at each annual look-back. A PQI Project or Activity may be conducted repeatedly or continuously to meet PQI requirements.

The first evaluation of PQI diplomate participation will take place during the 2016 MOC annual look-back. Participation is recorded by diplomates through self-attestation on myABR. Submission of documentation materials to the ABR is required ONLY if a diplomate is audited. Routine submission of such proof of participation to the ABR is neither required nor accepted.

Quality Improvement Definition

The ABR defines “quality improvement” as a systematic approach to the study of healthcare and/or a commitment to continuously improve performance and outcomes in healthcare. The ABR honors each diplomate’s privilege to choose PQI activities or projects that are pertinent to his or her own practice and that meet the spirit of this definition.

PQI Activity/Project Options

PQI ACTIVITY involves continuous engagement of healthcare professionals in efforts anticipated to lead to better health outcomes for patients and better system performance, leading to improved patient care and/or enhanced professional development.

The ABR recognizes two categories of activities that demonstrate a diplomate’s commitment to and participation in quality improvement that satisfy ABR MOC Part 4 requirements:

  • Practice Quality Improvement (PQI) Projects either designed by the diplomate using any standard quality improvement methodology, such as the Plan-Do-Study-Act (PDSA) cycle approach, or created and offered by professional societies.
  • Participatory Quality Improvement Activities in which a diplomate is engaged by choice as a volunteer or by duty during his or her workday, and which may be reasonably expected to contribute directly to or increase the likelihood of advancement or improvement of quality and/or safety in healthcare at the local or national level.

Practice Quality Improvement (PQI) Projects

Completion of a Practice Quality Improvement (PQI) Project using any standard quality-improvement methodology (including, but not confined to, the PDSA cycle approach) meets the criteria for MOC Part 4 requirements. A PQI project may be developed by an individual, group practice, department at a healthcare or academic institution, a healthcare system, or a society at the local, regional, or national level. Examples include the following:

  • Improving report turnaround time
  • Improving patient access (next available appointment)
  • Optimizing radiation dose/examination or frequency of repeat examinations
  • Improving time-out process for procedures
  • Decreasing wrong patient/wrong procedure events
  • Standardizing reports
  • Reducing MRI safety events
  • Improving critical results notification
  • Improving handoffs of care

PQI Project Resources 

The ABR has worked with societies to develop a wide selection of qualified PQI projects with templates to guide diplomates through initiation and completion. Many societies are also working to develop centralized databases for these projects, which ultimately can be used to benchmark a participating diplomate’s practice with national performance data. For diplomate convenience, qualified society projects are listed on the ABR website with links to the respective societies. For a list of these projects, go to www.theabr.org/moc-dr-pqi-projects.

Approved projects are also available through the ABMS Multi-Specialty MOC Portfolio Approval Program (see www.theabr.org/moc-institutional-pqi-projects). For a list of approved portfolio sponsors, please visit the ABMS Multi-Specialty MOC Portfolio Program website: http://mocportfolioprogram.org.

Please note that a project developed by an individual, group practice, department, or healthcare system for its own use need not go through the formal ABR qualification process.

The ABR has developed comprehensive PQI Project guidelines for individuals, groups, and institutions. The guidelines may be downloaded here as a PDF file: ABR Guide to Practice Quality Improvement Projects.

Templates for performing and recording PQI Projects are also available:

PQI Project Recording Template for Individuals
PQI Project Recording Template for Groups

 

Participatory Quality Improvement Activities1

Documentation of individual active participationin any of the activities in the table below meets the criteria for MOC Part 4 requirements.1,2

 

Participatory Quality Improvement Activities

Acceptable Documentation of Active Individual Participation (retain for use if audited)

Participation as a member of an institutional/departmental clinical quality and/or safety review committee

Examples include meaningful participation as a member responsible for creating, reviewing, and/or implementing clinical quality improvement safety activities; service as radiation safety officer (RSO).

One of the following bulleted options:

  • Institution/department documentation of attendance at committee meetings (such as minutes, if available), OR

Active participation in a departmental or institutional peer-review process, including participation in data entry/evaluation and peer-review meeting process or Ongoing Professional Practice Evaluation (OPPE)

One of the following bulleted options:

  • Minutes, with peer-protected information redacted, showing attendance at peer-review meetings, or other forms of participant feedback, OR
  • Logs showing active participation in submitting and reviewing cases as well as having your own individual work reviewed in the course of daily workflow, OR

Participation as a member of a root cause analysis team evaluating a sentinel or other quality- or safety-related event

One of the following bulleted options:

  • Minutes or other institutional/ departmental documentation showing attendance at RCA meetings, OR

Participation in at least 25 prospective chart rounds every year (peer review of the radiation delivery plans for new cases - radiation oncology and medical physics only).

One of the following bulleted options:

  • Conference attendance sheets, OR
  • CME credit logs (if appropriate), OR
  • Submission of completed and signed MOC Part 4 Participatory Quality Improvement Activity: Participation Confirmation Form

Active participation in submitting data to a national registry

One of the following bulleted options:

  • Log of cases/data submitted to organization, OR
  • Letter from registry stating participation (including dates of participation)

Publication of a peer-reviewed journal article related to quality improvement or improved safety of the diplomate’s practice content area

  • Copy of journal article

Invited presentation or exhibition of a peer-reviewed poster at a national meeting related to quality improvement or improved safety of the diplomate’s practice content area

  • Copy of the meeting program showing that the poster was presented/exhibited and listing the diplomate as an author

Regular participation (at least 10/year) in departmental or group conferences focused on patient safety 
 

Examples include regular attendance at tumor boards, M&M conferences, diagnostic/therapeutic errors conferences, interprofessional conferences, surgical/pathology correlation conferences, etc.

One of the following bulleted options:

  • Conference attendance sheets, OR
  • CME credit logs (if appropriate), OR

Creation or active management of, or participation in, one of the elements of a quality or safety program

Examples include a department dashboard or scorecard, a daily management system to ensure quality and safety, a daily readiness assessment using a huddle system.

One of the following bulleted options:

  • Other documents describing and documenting work (i.e., copies of scorecards created, minutes from daily readiness huddles, etc.), OR

Local or national leadership role in a national/international quality improvement program, such as Image Gently, Image Wisely, Choosing Wisely, or other similar campaign

Local participation roles include implementation and/or maintenance of, or adherence to, program goals and/or requirements.

Completion of a Peer Survey (quality or patient safety- focused) and resulting action plan. Survey should contain at least five quality or patient safety-related questions and have a minimum of five survey responses.

  • Summary of process, including a copy of the survey administered, results, and action plans taken

Completion of a Patient Experience-of-Care (PEC) survey with individual patient feedback. Survey should contain at least five quality/patient safety-related questions and have a minimum of 30 survey responses.

  • Summary of process, including a copy of the survey administered, results, and action plans taken

Active participation in applying for or maintaining accreditation by specialty accreditation programs such as those offered by ACR, ACRO, or ASTRO

Annual participation in the required Mammography Quality Standards Act (MQSA) medical audit or ACR Mammography Accreditation Program (MAP)

Completion of a Self-directed Educational Project (SDEP) on a quality or patient safety-related topic (medical physics only)

  • Summary of process, including results and action plans taken

Active participation in an NCI cooperative group clinical trial (for diagnostic radiologists, radiation oncologists, and interventional radiologists, entry of five or more patients in a year. For medical physicists, active participation in the credentialing activities)

One of the following bulleted options:

  • Log of cases submitted, OR
  • Letter from registry stating participation (including dates of participation), OR
  • Other documents showing individual participation

1Please note that some activities may not apply to all disciplines.

2Submission of documentation of active participation in PQI Activities to the ABR is required ONLY if a diplomate is audited. Routine submission of such proof of participation to the ABR is neither required nor accepted.

 

New Practice Quality Improvement Policy FAQs

1. Does the ABR need to approve my PQI Project or Participatory Activity before I can count it toward fulfillment of the Part 4 PQI requirement?

No. The ABR does not need to approve PQI Projects and Participatory Activities at any time for them to count toward the ABR’s requirements. Please see the ABR website for additional details.

2. What paperwork do I need to send to the ABR to document my participation in a PQI Project or Participatory Activity?

You do not need to submit anything to the ABR unless you are selected for an MOC Audit. If selected for an audit, the ABR will provide you with the necessary template(s) to document your PQI Project or Participatory Activity.

3. Can I use the same PQI Project or Participatory Activity repeatedly to meet the PQI requirement?

Yes. You may use the same PQI Project or Participatory Activity multiple times toward the fulfillment of the PQI requirement as long as you are still fulfilling the required elements as outlined on the ABR website.