ORIGINAL ARTICLE

TRAINING AND EDUCATION

Recent Changes to ABR Maintenance of Certification Part 4 (PQI): Acknowledgment of Radiologists’ Activities to Improve Quality and Safety Lane F. Donnelly, MDa, Vincent P. Mathews, MDb, David J. Laszakovits, MBAc, Valerie P. Jackson, MDc, Milton J. Guiberteau, MDd Abstract The ABR has recently reviewed and revised its policy establishing how ABR diplomates may comply with requirements for Maintenance of Certification Part 4: Practice Quality Improvement (PQI). The changes were deemed necessary by the Board of Trustees to acknowledge and credit the numerous ways in which radiology professionals contribute to improving patient care through existing and evolving activities available to them within the radiology community. In addition to meeting requirements by completing a traditional PQI project, the policy revision now allows diplomates to meet criteria by completing one of a number of activities in an expanded spectrum of PQI options recognized by the ABR. The new policy also acknowledges the maturing state of quality improvement science by permitting PQI projects to use “any standard quality improvement methodology,” such as Six Sigma, Lean, the Institute for Healthcare Improvement’s Model for Improvement, and others in addition to the previously prescribed three-phase plan-do-study-act format. Key Words: Maintenance of Certification, board certification, Practice Quality Improvement J Am Coll Radiol 2016;13:184-187. Copyright  2016 American College of Radiology

The ABR has recently reviewed and revised the policy establishing how ABR diplomates meet criteria to be compliant with Maintenance of Certification (MOC) Part 4: Practice Quality Improvement (PQI) to acknowledge and credit its diplomates for numerous efforts through which they contribute to improving patient care. In addition to meeting criteria by completing a PQI project, as has been the only option historically, diplomates may now also meet Part 4 criteria by completing

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Department of Radiology, Texas Children’s Hospital, Houston, Texas. Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin. c American Board of Radiology, Tucson, Arizona. d Department of Radiology, Baylor College of Medicine, Houston, Texas. Corresponding author and reprints: Lane F. Donnelly, MD, Department of Radiology, Texas Children’s Hospital, 6701 Fannin Street, Suite 470, Houston, TX 77030; e-mail: [email protected]. Disclosure: Drs Donnelly, Mathews, and Guiberteau are trustees of the ABR. Mr Laszakovitz and Dr Jackson are employees of the ABR. Dr Jackson is the executive director of the ABR. b

one of a number of ABR-recognized PQI activities. Details are available on the ABR website [1] and described in recent ABR publications [2]. In this article, we review background related to MOC and discuss the changes recently made by the ABR Board of Trustees to MOC Part 4 (PQI).

BACKGROUND Much attention has been given recently to the magnitude of perceived benefit of MOC to physicians and the public [3,4]. This discussion has been especially vigorous between the American Board of Internal Medicine and its diplomates and has played out in both the literature and the lay press [3,4]. Sometimes lost in reports of this debate are the fundamental reasons why board certification and MOC are important to medical professionals. Physicians are one of the few professional groups that have been granted the right of self-regulation. Board certification is the framework by which the medical ª 2016 American College of Radiology

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community enacts self-regulation, and MOC demonstrates an ongoing commitment to improve the quality of care we provide to our patients [2]. The ABR believes that most radiologists support the concept that radiologists themselves are the best qualified to govern the regulation of radiology. Previous surveys have also shown that board certification is of major importance to the public [5,6]. Board certification is a trusted brand for patients and helps build relationships between physicians and patients by reassuring them that physicians are selfpolicing [7]. Three-fourths of the public state that they would rather choose a board-certified physician over one who is not certified [5,6]. MOC also seems to be important when related to known data regarding the practice of medicine over a prolonged period of time. It has been documented that the knowledge base and skills of many physicians decay over time [8]. In addition, physicians’ ability to independently and accurately selfassess has been shown to be poor [9,10], and that overconfidence inhibits physicians’ diagnostic accuracy [11]. Finally, studies have shown that only a small percentage of physicians evaluate their own performance data in an effort to continuously improve [12]. There are robust data supporting the value of initial board certification [13-15], and this value is rarely challenged. Because MOC is still new, with Part 4 of MOC being launched only in 2007, there are much fewer data demonstrating its value, and thus the value of MOC relative to effort expended is more easily challenged. These challenges are exacerbated by the increasingly burdensome administrative and regulatory tasks currently confronting physicians in their practices. However, there are a number of publications linking the physician effort invested in MOC Part 4 (PQI) with improved clinical care in multiple areas [16-20], and the list of such publications is growing. A successful ABR MOC program shows to both the public and our medical peers that the radiology community supports high-quality patient care as well as continuous improvement in that care. The goal of the ABR has always been to create an MOC process that accomplishes these goals without becoming overly intrusive or time consuming for radiologists [2]. Achieving that balance is obviously challenging and requires periodic revisions of MOC policy after lessons learned. For MOC Part 4, which is now eight years old [21] and which remains relatively confusing and unpopular among the ABR’s diplomates as well as the medical community at large, now seems to be an appropriate time to reflect on our experience with PQI

and make appropriate adjustments. With the maturation of approaches to quality improvement processes since 2007, there are many new areas in which our diplomates are contributing to improved care in their practices, which should be recognized by the ABR as worthy of credit toward meeting the requirements of MOC Part 4. Accordingly, the ABR has instituted changes reflecting this philosophy.

RECENT CHANGES IN ABR MOC PART 4: PQI Expanded Options for Meeting Requirements Under the previous ABR MOC Part 4 policy, the only option for ABR diplomates to satisfy the Part 4 requirement was to complete a PQI project using the plan-dostudy-act (PDSA) methodology at least once every three years. Because the ABR has adopted a broadened view of quality improvement as a systematic approach to the study of as well as efforts to continuously improve performance and outcomes in health care [1,2], it seems only fitting that a diplomate’s choice of PQI activities and projects should be concomitantly expanded to meet the spirit of this definition. Thus, under the new, revised policy, diplomates may now choose from a list of activities related to quality and safety in which to participate to satisfy the Part 4 requirement [1,2]. Participatory quality improvement activities include documentation of an individual’s active participation in any of the following [1]: n

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Participation as a member of an institutional or 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; and so on. Active participation in a departmental or institutional peer review process, including participation in data entry and evaluation and peer review meeting process or Ongoing Professional Practice Evaluation. Participation as a member of a root-cause analysis team evaluating a sentinel or other quality- or safety-related event. Active participation in submitting data to a national registry. Publication of a peer-reviewed journal article related to quality improvement or improved safety of the diplomate’s practice content area. Invited presentation or exhibition of a peer-reviewed poster at a national meeting related to quality

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improvement or improved safety of the diplomate’s practice content area. Regular participation (at least ten per year) in departmental or group conferences focused on patient safety. Examples include regular attendance at tumor boards, morbidity and mortality conferences, interprofessional conferences, surgery-pathology correlation conferences, and so on. 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, and so on. A local or national leadership role in a national or international quality improvement program, such as Image Gently, Image Wisely, Choosing Wisely, or other similar campaign. Completion of a peer survey (quality or patient safety focused) and resulting action plan. Completion of a patient experience-of-care survey with individual patient feedback. Annual participation in the required Mammography Quality Standards Act medical audit or ACR Mammography Accreditation Program. Active participation in applying for or maintaining accreditation by specialty accreditation programs such as those offered by the ACR or the American Society for Radiation Oncology. Active participation in a National Cancer Institute cooperative group clinical trial (for diagnostic radiologists, radiation oncologists, and interventional radiologists with entry of five or more patients in a year; for medical physicists, active participation in the credentialing activities). Participation in at least 25 prospective chart rounds every year (peer review of the radiation delivery plans for new cases; radiation oncology only). Completion of a self-directed educational project on a quality- or patient safetyerelated topic (medical physics only).

As in the past, attestation is the means by which diplomates are credited for participating in activities to satisfy Part 4 of the ABR MOC [1], with documentation needed only if a diplomate is subjected to a random audit, analogous to how most state medical licensure boards perform random audits. Examples of documentation acceptable to the ABR are available on the ABR website [1]. For audit purposes, a specific attestation form is also

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available to assist in providing the correct information needed by ABR staff members to process the audit [1]. As long as participation in PQI activities is meaningful and ongoing, it is permissible for a PQI project or activity to be used repeatedly to meet PQI requirements [2,3]. For example, if a diplomate was the institutional radiation safety officer for nine years, this activity could count for meeting Part 4 criteria for any of the three-year look-backs that occur during that period of time. In conjunction with moving to continuous certification in 2013, the first complete three-year look-back for meeting all four parts of MOC will commence in early 2016 [1]. Please note that this new policy regarding expanded quality activities for MOC Part 4 is in place for diplomates to use for this upcoming 2016 three-year look-back.

Flexibility in Methodologies for Performing PQI Projects Another major change in the new MOC Part 4 (PQI) policy relates to an increase in flexibility regarding choice of improvement methodology for PQI projects [1]. Previously, PQI projects were required to use a prescribed three-phase PDSA process with inherently defined phases. This was an appropriate first step when MOC Part 4 started for radiology in 2007 and concepts in quality improvement were new to most of the radiology community. However, going forward, diplomates who choose to do PQI projects may use “any standard quality improvement methodology” [1]. There are numerous quality improvement methodologies that can be used to design a PQI project. Diplomates may employ Six Sigma, Lean, the Institute for Healthcare Improvement’s (IHI) Model for Improvement, and other methods in addition to the familiar PDSA cycle. Thus, the ABR MOC Part 4 policy has been expanded to accommodate these different approaches in recognition of the interval advancements in quality improvement science over the past decade. The ABR still emphasizes that PQI projects remain at the heart of quality improvement and encourages diplomates to meet Part 4 criteria by completing a PQI project whenever possible. SUMMARY The ABR has revised its policy regarding MOC Part 4 (PQI) to both recognize and credit the many ways in which its diplomates contribute to improving quality and safety and to adjust the policy to meet the maturing state of quality improvement science developing within the Journal of the American College of Radiology Volume 13 n Number 2 n February 2016

radiology community. The new policy allows diplomates to meet criteria either by completing a PQI project or by actively participating in a number of PQI activities. The new policy also allows PQI projects to use “any standard quality improvement methodology,” such as Six Sigma, Lean, the IHI’s Model for Improvement, and others, in addition to the previously prescribed three-phase PDSA process. Whenever possible, the ABR encourages diplomates to strongly consider PQI projects to comply with MOC Part 4.

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The ABR has revised its policy regarding MOC Part 4 (PQI) to both recognize and credit the many ways in which its diplomates contribute to improving quality and safety and to adjust the policy to meet the maturing state of quality improvement science developing within the radiology community. The new policy allows diplomates to meet criteria either by completing a PQI project or by actively participating in a number of PQI activities. The new policy also allows PQI projects to use “any standard quality improvement methodology,” such as Six Sigma, Lean, the IHI’s Model for Improvement, and others in addition to the previously prescribed three-phase PDSA process.

REFERENCES 1. American Board of Radiology. Maintenance of Certification. Available at: http://www.theabr.org/moc-gen-landing. Accessed August 3, 2015. 2. Donnelly LF. From the editor: Maintenance of Certification: continuously improving the process—focus on Part 4 (Practice Quality Improvement). Beam 2015;8:23-6. 3. Teirstein PS. Boarded to death—why maintenance of certification is bad for doctors and patients. N Engl J Med 2015;372:106-8. 4. Baron RJ, Krumholz HM, Jessup M, Brosseau JL. Board certification in internal medicine and cardiology: historic success and future challenges. Trends Cardiovasc Med 2015;25:305-11.

5. The Gallup Organization. Awareness of and attitudes toward boardcertification of physicians. Available at: https://www.abim.org/pdf/ publications/gallup_report.pdf. Accessed August 3, 2015. 6. Guiberteau MJ, Becker GJ. Counterpoint: maintenance of certification: focus on physician concerns. J Am Coll Radiol 2015;12:434-7. 7. Jha S. Point: twin dogmas of maintenance of certification. J Am Coll Radiol 2015;12:430-3. 8. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260-73. 9. David DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296:1094-102. 10. Eva KW, Regehr G. I’ll never play professional football and other fallacies of self-assessment. J Contin Educ Health Prof 2008;28:14-9. 11. Meyer AD, Payne VL, Meeks DW, Rao R, Singh H. Physicians’ diagnostic accuracy, confidence, and resource requests: a vignette study. JAMA Intern Med 2013;173:1952-8. 12. Audet AM, Doty MM, Shamasdin J, Schoenbaum SC. Measure, learn, and improve: physicians’ involvement in quality improvement. Health Aff (Millwood) 2005;24:843-53. 13. Reid RO, Friedberg MW, Adams JL, McGynn EA, Mehrotra A. Associations between physician characteristics and quality of care. Arch Intern Med 2010;170:1442-9. 14. Curtis JP, Luebbert JJ, Wang Y, et al. Association of physician certification and outcomes among patients receiving an implantable cardioverter-defibrillator. JAMA 2009;301:1661-70. 15. Turchin A, Shubina M, Chodos AH, Einbinder JS, Pendergrass ML. Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation 2008;117:623-8. 16. Hagen MD, Sumner W, Fu H. Diuretic of choice in ABFM hypertension self-assessment module simulations. J Am Board Fam Med 2012;25:805-9. 17. Duffy FD, Lynn LA, Didura H, et al. Self-assessment of practice performance: development of the ABIM Practice Improvement Model (PIM). J Contin Educ Health Prof 2008;28:38-46. 18. Miller MR, Griswold M, Harris JM II, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010;125:206-12. 19. Peterson LE, Blackburn BE, Puffer JC, Phillips RL Jr. Family physicians’ quality interventions and performance improvement through the ABFM diabetes performance in practice module. Ann Fam Med 2014;12:17-20. 20. Vernacchio L, Francis ME, Epstein DM, et al. Effectiveness of an asthma quality improvement program designed for maintenance of certification. Pediatrics 2014;134:e242-8. 21. Strife JL, Kun LE, Becker GJ, Dunnick NR, Bosma J, Hattery RR. American Board of Radiology perspective on Maintenance of Certification: Part IV—Practice Quality Improvement for diagnostic radiology. Radiographics 2007;27:769-74.

Credits awarded for this enduring activity are designated “SA-CME” by the American Board of Radiology (ABR) and qualify toward fulfilling requirements for Maintenance of Certification (MOC) Part II: Lifelong Learning and Self-assessment. Scan the QR code to access the SA-CME activity or visit http://bit.ly/ACRSACME.

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Recent Changes to ABR Maintenance of Certification Part 4 (PQI): Acknowledgment of Radiologists' Activities to Improve Quality and Safety.

The ABR has recently reviewed and revised its policy establishing how ABR diplomates may comply with requirements for Maintenance of Certification Par...
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