Continuing Certification for Radiation Oncology

  Radiation Oncology

Participatory Activities

Last verified on December 18, 2023
 
Documentation of individual active participation in any of the activities in the table below meets the criteria for Continuing Certification (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 a health equity project or program.
Examples include meaningful participation as a member responsible for creating, reviewing, and/or implementing a project or program focused on health equity.
One of the following bulleted options:
  • Institution/department documentation of attendance at committee meetings (such as minutes, if available), OR
  • Completed and signed Continuing Certification (MOC) Part 4 Participatory Quality Improvement Activity: Participation Confirmation Form
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
  • Completed and signed Continuing Certification (MOC) Part 4 Participatory Quality Improvement Activity: Participation Confirmation Form
Active participation in a departmental or institutional peer-review or peer-learning process, including participation in data entry/evaluation and peer-review or peer-learning 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 or peer-learning 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
  • Completed and signed Continuing Certification (MOC) Part 4 Participatory Quality Improvement Activity: Participation Confirmation Form
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
  • Completed and signed Continuing Certification (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
  • Completed and signed Continuing Certification (MOC) Part 4 Participatory Quality Improvement Activity:
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
  • Completed and signed Continuing Certification (MOC) Part 4 Participatory Quality Improvement Activity:
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)
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.

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