RESIDENTS’ AND FELLOWS’ COLUMN
C. MATTHEW HAWKINS, MD
Translating an ACGME-Required Practice Quality Improvement Project Into Preparation for the Maintenance of Certification Part IV Kevin Day, MD PRACTICE QUALITY IMPROVEMENT
During diagnostic radiology residency, there is quite a bit to do in a relatively short amount of time. As trainees, we are expected to master the basics of all the radiology subspecialties and demonstrate competence by the end of our 4 years. In addition to becoming clinically competent radiologists, to maintain ABR certification, we are also acquiring skills needed to complete Parts I to IV of the Maintenance of Certification (MOC) [1]. Part I, Professional Standing, requires the possession of an unrestricted medical license. Part II, Lifelong Learning and Self-Assessment, requires the completion of continuing medical education credits each year. Part III, Cognitive Expertise, requires passing an examination with 3 selected modules testing our clinical skills and 1 module designated by the ABR testing noninterpretive skills content that every practicing radiologist should know. Part IV, Practice Quality Improvement (PQI), requires the completion of PQI projects. Most, if not all, radiology residents have been trained and exposed to similar requirements during our medical school and residency training to meet the MOC Parts I to III requirements, which focus on continuous studying and passing examinations. However, MOC Part IV (PQI) is likely new for many residents. Luckily, the ACGME’s diagnostic radiology program requirements specify that residents must “actively participate in interdisciplinary clinical improvement and safety
programs” [2]. Many residents find this graduation requirement burdensome, but all residents should embrace it, and here is why. Given the new MOC structure, radiologists are required to participate in PQI projects throughout their careers to maintain their certification. Participating actively in a PQI project during residency will be the only exposure most of us will have before being expected to complete PQI projects to maintain our certification. Understanding the MOC Part IV requirements will help residents understand the opportunity inherent in the ACGME-required PQI project. MOC PART IV
The American public’s concerns with the health care system include the quality of care, reduction of medical errors, and patient safety. In response to the public’s concerns, the American Board of Medical Specialties mandated the development of MOC programs to demonstrate physicians’ support for continued quality improvement and patient care [3]. The PQI initiative aspect of the ABR’s MOC program is a framework that permits radiologists to demonstrate their commitment to improving the quality of care delivered, reducing errors, and improving safety. The plan-do-study-act (PDSA) process is a 4-step process used commonly for continuous quality improvement and is an integral tool in the PQI project process [4]. Understanding the 4 steps ensures a well-thought-out and subsequently successful project. In the “plan” stage, an area of practice in
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.05.007
need of improvement is initially identified with a selected metric to assess the degree of need. A plan is then developed to implement the metric and obtain data. A goal should also be set. Next, in the “do” stage, the plan should be implemented and data collected. In the “study” stage, the collected data are compared with the predefined goal while possible causes for failing to meet the goal are studied. Finally, in the “act” stage, reasons for failing to meet the goal are considered, and an improved plan for the next PDSA cycle is developed. Repeated use of the PDSA cycle can lead to incremental improvements until the goal is achieved. Five PQI topic areas have been defined, including patient safety, practice guidelines, accuracy of interpretation (double reading), referring physician surveys, and reporting timeliness and critical value reporting [5]. PQI projects can be accomplished as an individual, as a group, or at the institutional or organizational level. Proactive radiologists may selfdesign projects, but sponsored PQI projects for the individual or group level are available, including ABR-approved projects with included standardized formats and project-specific templates, which are all available on the ABR’s website. Additional PQI projects can be found on the websites of societies such as the ACR [6], the RSNA [7], and the ARRS [8]. The number of required PQI projects to be completed was initially defined for the 10-year MOC cycle and dependent on 1009
1010 Residents’ and Fellows’ Column
the starting date. Within the continuous certification system, candidates must complete at least one PQI project in the previous 3 years [9]. It is important to note that continuous certification began with certificates issued after 2012 and therefore affects all current diagnostic radiology residents. ACGME-REQUIRED PQI PROJECT
I imagine that few residents have been involved in PQI projects before their ACGME-required PQI projects, and I expect that many see these projects as a nuisance before graduation. But given the implementation of continuous certification and the requirement to complete a PQI project every 3 years, it is important to realize that the ACGME-required PQI project is an opportunity to work with experienced radiologists on a PQI project before facing the MOC Part IV requirement. Given the timing of ABR certification, most staff radiologists who do not hold lifetime certificates will likely be part of PQI projects during a trainee’s 4year residency. PQI projects allow groups to work together, and in my experience, staff radiologists are always interested in getting residents involved in their PQI projects. Staff radiologists get much needed help, while residents get vital exposure and training in the details of PQI projects. The alternative is to wait until you are a staff radiologist and
figure it out yourself. But your residency is giving you an opportunity to learn on the job, and isn’t that what residency is all about— to acquire the tools you need to be a successful radiologist when you graduate? As an added bonus for those interested in research, quality improvement projects continue to find acceptance as abstracts at annual meetings and publication in well-respected journals. For those interested in changing the world, PQI projects can implement lasting change at your institution, with documentation of your impact. But for those who are just trying to survive residency and get a job, PQI projects will be part of your career whether you like it or not. In summary, the ACGMErequired PQI project is an opportunity for residents to be exposed to the details of a PQI project in preparation for the MOC Part IV requirement. With the new ABR continuous certification, which affects all current diagnostic radiology residents, candidates must complete at least one PQI project in the previous 3 years, and the skills obtained during the ACGME-required PQI project will serve radiologists for the duration of their careers. ACKNOWLEDGMENTS Thanks to Dr Clinton Jokerst for all of his help and guidance during our PQI project, for helping me
complete my ACGME-required PQI project, but more importantly, for preparing me for the MOC Part IV. REFERENCES 1. American Board of Radiology. What is MOC? Available at: http://www.theabr.org/ moc-landing. Accessed April 23, 2014. 2. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in diagnostic radiology. Available at: https://www.acgme. org/acgmeweb/Portals/0/PFAssets/2013-PRFAQ-PIF/420_diagnostic_radiology_07012 013.pdf. Accessed April 23, 2014. 3. Kun LE, Haffty BG, Bosma J, Strife JL, Hattery RR. American Board of Radiology Maintenance of Certification—Part IV: practice quality improvement for radiation oncology. Int J Radiat Oncol Biol Phys 2007;68:7-12. 4. American Board of Radiology. Maintenance of Certification Part 4: ABR guide to practice quality improvement 2014. Available at: http:// www.theabr.org/sites/all/themes/abr-media/pdf/ ABR-PQI-Guide.pdf. Accessed April 23, 2014. 5. American Board of Radiology. PQI topic areas. Available at: http://www.theabr.org/ pqi-topics. Accessed April 23, 2014. 6. American College of Radiology. PQI projects. Available at: http://www.acr.org/ Quality-Safety/Quality-Measurement/Qualityin-Practice/PQI-Projects. Accessed April 23, 2014. 7. Radiological Society of North America. Practice quality improvement projects. Available at: https://www.rsna.org/Practice_Quality_ Improvement_Projects.aspx. Accessed April 23, 2014. 8. American Roentgen Ray Society. PQI connect. Available at: http://www.arrs.org/pqi/. Accessed April 23, 2014. 9. American Board of Radiology. Part 4: Practice Quality Improvement (PQI). Available at: http://www.theabr.org/moc-dr-comp4. Accessed April 23, 2014.
Kevin Day, MD, University of Arizona Medical Center, Department of Medical Imaging, 1501 N Campbell Avenue, PO Box 245067, Tucson, AZ 85724; e-mail: [email protected].
C. MATTHEW HAWKINS, MD
Translating an ACGME-Required Practice Quality Improvement Project Into Preparation for the Maintenance of Certification Part IV Kevin Day, MD PRACTICE QUALITY IMPROVEMENT
During diagnostic radiology residency, there is quite a bit to do in a relatively short amount of time. As trainees, we are expected to master the basics of all the radiology subspecialties and demonstrate competence by the end of our 4 years. In addition to becoming clinically competent radiologists, to maintain ABR certification, we are also acquiring skills needed to complete Parts I to IV of the Maintenance of Certification (MOC) [1]. Part I, Professional Standing, requires the possession of an unrestricted medical license. Part II, Lifelong Learning and Self-Assessment, requires the completion of continuing medical education credits each year. Part III, Cognitive Expertise, requires passing an examination with 3 selected modules testing our clinical skills and 1 module designated by the ABR testing noninterpretive skills content that every practicing radiologist should know. Part IV, Practice Quality Improvement (PQI), requires the completion of PQI projects. Most, if not all, radiology residents have been trained and exposed to similar requirements during our medical school and residency training to meet the MOC Parts I to III requirements, which focus on continuous studying and passing examinations. However, MOC Part IV (PQI) is likely new for many residents. Luckily, the ACGME’s diagnostic radiology program requirements specify that residents must “actively participate in interdisciplinary clinical improvement and safety
programs” [2]. Many residents find this graduation requirement burdensome, but all residents should embrace it, and here is why. Given the new MOC structure, radiologists are required to participate in PQI projects throughout their careers to maintain their certification. Participating actively in a PQI project during residency will be the only exposure most of us will have before being expected to complete PQI projects to maintain our certification. Understanding the MOC Part IV requirements will help residents understand the opportunity inherent in the ACGME-required PQI project. MOC PART IV
The American public’s concerns with the health care system include the quality of care, reduction of medical errors, and patient safety. In response to the public’s concerns, the American Board of Medical Specialties mandated the development of MOC programs to demonstrate physicians’ support for continued quality improvement and patient care [3]. The PQI initiative aspect of the ABR’s MOC program is a framework that permits radiologists to demonstrate their commitment to improving the quality of care delivered, reducing errors, and improving safety. The plan-do-study-act (PDSA) process is a 4-step process used commonly for continuous quality improvement and is an integral tool in the PQI project process [4]. Understanding the 4 steps ensures a well-thought-out and subsequently successful project. In the “plan” stage, an area of practice in
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.05.007
need of improvement is initially identified with a selected metric to assess the degree of need. A plan is then developed to implement the metric and obtain data. A goal should also be set. Next, in the “do” stage, the plan should be implemented and data collected. In the “study” stage, the collected data are compared with the predefined goal while possible causes for failing to meet the goal are studied. Finally, in the “act” stage, reasons for failing to meet the goal are considered, and an improved plan for the next PDSA cycle is developed. Repeated use of the PDSA cycle can lead to incremental improvements until the goal is achieved. Five PQI topic areas have been defined, including patient safety, practice guidelines, accuracy of interpretation (double reading), referring physician surveys, and reporting timeliness and critical value reporting [5]. PQI projects can be accomplished as an individual, as a group, or at the institutional or organizational level. Proactive radiologists may selfdesign projects, but sponsored PQI projects for the individual or group level are available, including ABR-approved projects with included standardized formats and project-specific templates, which are all available on the ABR’s website. Additional PQI projects can be found on the websites of societies such as the ACR [6], the RSNA [7], and the ARRS [8]. The number of required PQI projects to be completed was initially defined for the 10-year MOC cycle and dependent on 1009
1010 Residents’ and Fellows’ Column
the starting date. Within the continuous certification system, candidates must complete at least one PQI project in the previous 3 years [9]. It is important to note that continuous certification began with certificates issued after 2012 and therefore affects all current diagnostic radiology residents. ACGME-REQUIRED PQI PROJECT
I imagine that few residents have been involved in PQI projects before their ACGME-required PQI projects, and I expect that many see these projects as a nuisance before graduation. But given the implementation of continuous certification and the requirement to complete a PQI project every 3 years, it is important to realize that the ACGME-required PQI project is an opportunity to work with experienced radiologists on a PQI project before facing the MOC Part IV requirement. Given the timing of ABR certification, most staff radiologists who do not hold lifetime certificates will likely be part of PQI projects during a trainee’s 4year residency. PQI projects allow groups to work together, and in my experience, staff radiologists are always interested in getting residents involved in their PQI projects. Staff radiologists get much needed help, while residents get vital exposure and training in the details of PQI projects. The alternative is to wait until you are a staff radiologist and
figure it out yourself. But your residency is giving you an opportunity to learn on the job, and isn’t that what residency is all about— to acquire the tools you need to be a successful radiologist when you graduate? As an added bonus for those interested in research, quality improvement projects continue to find acceptance as abstracts at annual meetings and publication in well-respected journals. For those interested in changing the world, PQI projects can implement lasting change at your institution, with documentation of your impact. But for those who are just trying to survive residency and get a job, PQI projects will be part of your career whether you like it or not. In summary, the ACGMErequired PQI project is an opportunity for residents to be exposed to the details of a PQI project in preparation for the MOC Part IV requirement. With the new ABR continuous certification, which affects all current diagnostic radiology residents, candidates must complete at least one PQI project in the previous 3 years, and the skills obtained during the ACGME-required PQI project will serve radiologists for the duration of their careers. ACKNOWLEDGMENTS Thanks to Dr Clinton Jokerst for all of his help and guidance during our PQI project, for helping me
complete my ACGME-required PQI project, but more importantly, for preparing me for the MOC Part IV. REFERENCES 1. American Board of Radiology. What is MOC? Available at: http://www.theabr.org/ moc-landing. Accessed April 23, 2014. 2. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in diagnostic radiology. Available at: https://www.acgme. org/acgmeweb/Portals/0/PFAssets/2013-PRFAQ-PIF/420_diagnostic_radiology_07012 013.pdf. Accessed April 23, 2014. 3. Kun LE, Haffty BG, Bosma J, Strife JL, Hattery RR. American Board of Radiology Maintenance of Certification—Part IV: practice quality improvement for radiation oncology. Int J Radiat Oncol Biol Phys 2007;68:7-12. 4. American Board of Radiology. Maintenance of Certification Part 4: ABR guide to practice quality improvement 2014. Available at: http:// www.theabr.org/sites/all/themes/abr-media/pdf/ ABR-PQI-Guide.pdf. Accessed April 23, 2014. 5. American Board of Radiology. PQI topic areas. Available at: http://www.theabr.org/ pqi-topics. Accessed April 23, 2014. 6. American College of Radiology. PQI projects. Available at: http://www.acr.org/ Quality-Safety/Quality-Measurement/Qualityin-Practice/PQI-Projects. Accessed April 23, 2014. 7. Radiological Society of North America. Practice quality improvement projects. Available at: https://www.rsna.org/Practice_Quality_ Improvement_Projects.aspx. Accessed April 23, 2014. 8. American Roentgen Ray Society. PQI connect. Available at: http://www.arrs.org/pqi/. Accessed April 23, 2014. 9. American Board of Radiology. Part 4: Practice Quality Improvement (PQI). Available at: http://www.theabr.org/moc-dr-comp4. Accessed April 23, 2014.
Kevin Day, MD, University of Arizona Medical Center, Department of Medical Imaging, 1501 N Campbell Avenue, PO Box 245067, Tucson, AZ 85724; e-mail: [email protected].
