1. Maintenance of Certification – Part IV PQI Practice Quality Improvement The Summit August 19, 2006

2. The Summit - Objectives Learn more about Quality Improvement and the ABR’s PQI Program Learn more about Quality Improvement and the ABR’s PQI Program the tangible Benefits of PQI the tangible Benefits of PQI Learn about ideas-projects-plans of participating organizations/societies Learn about ideas-projects-plans of participating organizations/societies Identify ways for societies to engage in PQI to help their members Identify ways for societies to engage in PQI to help their members how to engage, support, challenge Radiologists how to engage, support, challenge Radiologists Beginning to develop a National Database Beginning to develop a National Database

3. Maintenance of Certification Mandate of the American Board of Medical Specialties Mandate of the American Board of Medical Specialties Goal to improve the quality of health care through physician- initiated learning and quality improvement Goal to improve the quality of health care through physician- initiated learning and quality improvement Response to public expectation for physician competence Response to public expectation for physician competence generation of new knowledge  application in practice generation of new knowledge  application in practice recognition of medical errors recognition of medical errors To Err is Human: Building a Safer Health Care System - Institute of Medicine, 2000 public concerns re underuse, overuse, misuse of health care in U.S. public concerns re underuse, overuse, misuse of health care in U.S. MOC – a physician-based response to demonstrate, ensure physician competence and continuing competence MOC – a physician-based response to demonstrate, ensure physician competence and continuing competence Clinical practice, delivery of health care Clinical practice, delivery of health care

4. The General Competencies – the Basis of Maintenance of Certification medical knowledge medical knowledge patient care patient care interpersonal & communication skills interpersonal & communication skills professionalism professionalism practice-based learning & self-improvement practice-based learning & self-improvement systems-based practice systems-based practice

5. Maintenance of Certification - ABR From certification toward demonstration of competency in practice of medicine From certification toward demonstration of competency in practice of medicine Responsibility of Responsibility of - physicians - institutions/organizations in medical education, continuing medical education/training ABMS identification of components of MOC ABMS identification of components of MOC Part I – Professionalism Part I – Professionalism Part II – Lifelong Learning and Periodic Self-Assessment Part II – Lifelong Learning and Periodic Self-Assessment Part III – Cognitive Expertise Part III – Cognitive Expertise Part IV – Practice Performance Part IV – Practice Performance

6. Maintenance of Certification for Radiologists (DR, RO, RP) MOC introduced for Radiology in 2005 MOC introduced for Radiology in 2005  Formal implementation Parts I-IV: 2007  Formal implementation Parts I-IV: 2007 Parts I-III developed for radiology, radiation oncology, radiation physics Parts I-III developed for radiology, radiation oncology, radiation physics Part IV under development – ABR, educational and professional societies Part IV under development – ABR, educational and professional societies

7. Maintenance of Certification - Part IV highlights competencies in medical practice, delivery of care highlights competencies in medical practice, delivery of care Practice Quality Improvement (PQI) Practice Quality Improvement (PQI) practice-based focus practice-based focus based upon metrics based upon metrics includes action plan for quality improvement includes action plan for quality improvement engage physicians, societies/organizations in Practice Improvement (PQI) engage physicians, societies/organizations in Practice Improvement (PQI)

8. Maintenance of Certification - Part IV Features of Practice Quality Improvement (PQI) Project  choose Project  choose Process  learn Process  learn Participate  complete review Participate  complete review Plan  ongoing improvement Plan  ongoing improvement Progress  document Progress  document Potential  benchmarks, national database Potential  benchmarks, national database

9. Practice Quality Improvement – Role of Societies George S. Bisset Department of Radiology Duke University Medical Center Durham, NC or Why are you here?

10. American Board of Radiology Mission “To serve patients, the public, and the medical profession...” “By certifying that its diplomates have acquired, demonstrated, and maintained a requisite standard of knowledge, skill, and understanding...”

11. ABR Transition OLD Physics Exam Clinical Exam Oral Exam NEW Physics Exam Clinical Exam Oral Exam Maintenance of Certification

12. ABMS and MOC All 24 Boards committed to MOCAll 24 Boards committed to MOC ABMS must approve each board’s programABMS must approve each board’s program

13. Why “not” MOC? New administrative and financial burdens New administrative and financial burdens May not improve patient care May not improve patient care Self-assessment components – rigor? Self-assessment components – rigor? Not fully defined (WIP) Not fully defined (WIP)

14. Why MOC?(Pragmatic) All Boards – Time-limited certificates All Boards – Time-limited certificates All Boards – MOC participation All Boards – MOC participation Provider privileging Provider privileging Market forces pushing pay-for- performance Market forces pushing pay-for- performance Federation of State Medical Boards – “responsibility to public to ensure competence of physicians seeking relicensure” Federation of State Medical Boards – “responsibility to public to ensure competence of physicians seeking relicensure”

15. Why MOC?(Philosophical) We are all lifelong students of medicine We are all lifelong students of medicine Perversity Perversity Hypocrisy Hypocrisy Patient expectations Patient expectations External regulators External regulators Prerogative of self-regulation (maintaining autonomy) Prerogative of self-regulation (maintaining autonomy) Public accountability Public accountability

16. MOC Goals Lifelong learning Lifelong learning Self-directed learning Self-directed learning Based on needs assessment Based on needs assessment Practice specific Practice specific Recognition of diversity of practice Recognition of diversity of practice Continuous quality improvement Continuous quality improvement

17. Benefits of Practice Improvement Better patient…. Better patient…. Care Care Outcomes Outcomes Safety Safety Better practice-based learning Better practice-based learning Quality of care puts us all on the same side Quality of care puts us all on the same side

18. Why do we need PQI? Lack of documentation for quality of care for most important diseases Lack of documentation for quality of care for most important diseases Lack of resource evaluation Lack of resource evaluation Huge variations in care at local, regional and national levels Huge variations in care at local, regional and national levels Lack of outcome assessment Lack of outcome assessment

19. Pay-for-Performance Push Bridges to Excellence Bridges to Excellence The Leapfrog Group The Leapfrog Group The Integrated Healthcare Association The Integrated Healthcare Association Health Care Value Initiatives Health Care Value Initiatives CMS/Premier CMS/Premier

20. How is PQI done? Select issues where change may be useful to the practice Select issues where change may be useful to the practice Incorporate different types of evidence Incorporate different types of evidence Continuously refresh data during process Continuously refresh data during process Utilize data to monitor departmental progress Utilize data to monitor departmental progress Sharing of results (national database) Sharing of results (national database)

21. Why do we need database? Need to know our baseline at a national level Need to know our baseline at a national level Public disclosure of quality measurement data lead to improvements in quality of care Public disclosure of quality measurement data lead to improvements in quality of care

22. What should Societies do? Design tools to support radiologists in their efforts to enhance quality of patient care Design tools to support radiologists in their efforts to enhance quality of patient care Strong physician leadership – develop and execute radiologist-led initiatives appropriate to subspecialty Strong physician leadership – develop and execute radiologist-led initiatives appropriate to subspecialty Focus on evidence-based clinical guidelines Focus on evidence-based clinical guidelines Form work groups to move process forward Form work groups to move process forward

23. Choose topic to be measured based on importance Create leadership-driven ad hoc committee Review current established guidelines Develop measures -Accurate and meaningful -Trackable over time -Universally available Measure performance Evaluate performance in relation to agreement with guidelines Interventions Remeasure performance

24. Summary MOC is essential for quality healthcare MOC is essential for quality healthcare Practice Quality Improvement is a vital component of MOC Practice Quality Improvement is a vital component of MOC Societies can assist with development of PQI projects Societies can assist with development of PQI projects

25. DIAGNOSTIC RADIOLOGY & SUBSPECIALTIES MOC Component 4 DIAGNOSTIC RADIOLOGY & SUBSPECIALTIES Gary J. Becker, MD PQI Summit Chicago, Illinois, August 19, 2006

26. Then… Pass a test, earn a lifetime certificate Now… Maintenance of Certification depends on continuing competence…

27. Competent Physician “Maintenance of competence should be demonstrated throughout the physician’s career by evidence of lifelong learning and ongoing improvement of practice.” “Maintenance of competence should be demonstrated throughout the physician’s career by evidence of lifelong learning and ongoing improvement of practice.” ABMS, September 1999

28. “Competency is not just knowing what to do; it is doing it.” 1 1 Blackwell et al. [DRAFT] Final report of the committee on recognizing new and emerging disciplines in internal medicine; ABIM 2006

29. MOC Components MOC Components Evidence of: 1: Professional standing 2: LLL and periodic self-assessment 3: Cognitive expertise 4: Evaluation and improvement of performance in practice

30. In MOC, Component 4 is where “the rubber hits the road”!

31. The main purpose of MOC is…

32. …to improve the quality of care we deliver individually & collectively

33. To accomplish this… …we must participate in Practice Quality Improvement (PQI)

34. What Do We Need? 3 Essentials of Improvement  Will –acknowledge defects exist; desire to improve  Ideas –changes that will result in improvement  Execution –effectively apply changes; sustain D. Berwick, MD, Institute for Healthcare Improvement

35. PQI project: diplomate focuses on an important aspect of practice, …measures performance, then… plans, improves, & measures again

36. Engagement in process Simple PQI Projects Understanding of systems-based practice Best practices emerge Regional, national databases begin Practice-based learning, improvement routine Data sharing, comparison Robust databases, improvement targets QUALITY OF CARE IMPROVES NATIONALLY!!! PQI topics updated based on healthcare priorities Years 1-5 Years 6-10 PQI Timeline Where are we heading?

37. Mission: “…establishes standards for physician specialty certification and MOC…to support the public’s quest for safe, high-quality healthcare.” Role of ABMS

38.  MOC guidelines  Timetable (deadlines)  Oversight, feedback  Approval of plans of member boards  Resources  Benchmarking  Advice and consultation  Education (symposia)  Addressing issues common to all boards -FSMB licensure verification -Surveys, questionnaires -Software, especially to support Part 4 Role of ABMS in MOC Process

39. Applying ABMS Guidelines to Radiology Every Diagnostic Radiology PQI Project MUST:  Be relevant to diplomate’s practice  Be doable in practice setting  Be suited to trending over MOC cycle  Effect quality improvement  Include these competencies * : Patient care Patient care Practice-based learning and improvement Practice-based learning and improvement Systems-based practice Systems-based practice * May also include others

40. Participating in Diagnostic Radiology PQI  Select PQI project  Communicate selection to ABR  PW-protected reporting on ABR diplomate Webpage  Reporting follows template  >1 PQI project in 1 st 10-yr cycle (begins 01/2007)  Trended data collection >3X/cycle  Diplomate also reports on 6 competencies

41. DR PQI  EXPECT CHANGE PQI is under development (WIP) PQI is under development (WIP) ABR monitoring national healthcare priorities for critical PQI opportunities ABR monitoring national healthcare priorities for critical PQI opportunities Incorporation of priorities into Part 4 Incorporation of priorities into Part 4 Expert consensus evolves with evidence Expert consensus evolves with evidence Regional/national normative databases Regional/national normative databases Participation in institutional CQI Participation in institutional CQI Accreditation status (JCAHO, VA, ACR, etc.) as basis for PQI projects Accreditation status (JCAHO, VA, ACR, etc.) as basis for PQI projects Practice-relevant SAMs; improvement plan Practice-relevant SAMs; improvement plan  Random audits

42. To Develop ABR’s Part 4 Program ABR faced challenges of DR landscape, larger healthcare picture  Practice diversity  Generalists & subspecialists  Active practitioners, administrators  Consultative & direct patient care  Hospital-based, office-based & mixed  Radiology: no disease-specific focus  National healthcare priorities

43. 5 PQI Project Categories for DR  Practice guidelines & technical standards  Referring physician surveys  Patient safety  Double reading  Turnaround time

44. Two PQI Project Types  Type I: local level  Physicians compare performance against own baseline  Some comparison among peers  Normative databases lacking  Type II: sponsored by national specialty society or organization  Regional or national database participation  Benchmarking  Feedback

45. Type II PQI Project Examples  RADPEER TM  Peer review of routine image interpretation  Summary stats for each participant by modality  Summary data for facility by modality  Data from all participating facilities by modality  ABMS’ CAHPS Peer Survey 1  ABMS’ Web-based Patient Safety Project  Available mid-2007 1 Consumer Assessments of Health Plans Survey

46. PQI Timeline & Milestone Tracking DR Diplomates Year of Cycle What I must do each year of 10-year MOC cycle Submit report / attestation via the Personal Web Page 1  Select project and metric(s)  Collect, analyze baseline data Yes 2  Develop improvement plan  Implement plan  Begin collecting improvement plan data Yes 3  Complete collection of improvement plan data  Analyze data  Summarize data Yes 4  Modify improvement plan  Implement plan  Begin collecting improvement plan data Yes 5  Continue collecting data Yes

47. PQI Timeline & Milestone Tracking DR Diplomates Year of Cycle What I must do each year of 10-year MOC cycle Submit report / attestation via the Personal Web Page 6  Complete collection of improvement plan data  Analyze data  Summarize data Yes 7  Refine improvement plan  Implement plan  Begin collecting improvement plan data Yes 8  Continue collecting data Yes 9  Complete collection of improvement plan data  Analyze data  Summarize data Yes 10  Prepare final report of results and conclusions  Sustain the gain of 1 st cycle  Select topic for next cycle Yes

48. PQI: Patient Safety TOPIC LIST (MUST CHOOSE ONE)  Safe use of iodinated RCM  ALARA  MR Safety  JCAHO Universal Protocol  National Patient Safety Goals  NQF Safe Practices for Better Healthcare  Prevention of medication errors  ABMS Web-based patient safety module  Other (with ABR approval)

49. PQI: Double Reading MUST INCLUDE ALL 3 OF THESE ELEMENTS:  Study of error rate; objective of rate reduction  Analysis of root causes; plan to minimize  Changes by 2 nd reader: significance, time, cost

50. PQI: Turnaround Time SUBTOPICS (Both):  Access: FROM exam/procedure request TO completion  Reporting: FROM exam/procedure completion TO final report availability

51. PQI Practice Guidelines & Technical Standards REQUIREMENTS  ACR Communication Guideline (select at least 1) - Comparison reports -Communicating preliminary/final report discrepancies -Communication of urgent/serious findings to referring physician -Communication to self-referred patients  Other Guidelines & Standards (select at least 1) -Widely accepted standard of national specialty/subspecialty organization -ACR: ~100 available

52. PQI: Referring Physician Surveys  CAHPS 1 or institutional survey (>50 referring physicians)  All subtopics must be included in years 1-3 -Exam/procedure access -Urgent examination and consultation -Satisfaction in the interaction -Comments about professionalism -Report turnaround 1 Consumer Assessments of Health Plans Survey

53. ABR MOC: the 4 MOC Components & the 6 Competencies Professional Standing Lifelong Learning and Self-assessment Cognitive Expertise Practice Performance Medical Knowledge State board license requirements and actions Documentation and completion of 500 CME credits. Minimum of 250 Category 1. Achieve a passing score on the ABR cognitive exam.  Patient Safety  Double Reading  Practice Guidelines Patient CareState board license requirements and actions Documentation: CME with review of new techniques and protocols. Achieve a passing score on the ABR cognitive exam, which includes patient care content.  Patient Safety  Double Reading  Turnaround Time  Practice Guidelines  Referring Physician Survey Interpersonal & Communication Skills SAMs with emphasis on communications.  Patient Safety  Double Reading  Turnaround Time  Practice Guidelines  Referring Physician Survey ProfessionalismState board license requirements and actions SAMs content on professionalism. General questions about ethics and charter on professionalism  Practice Guidelines  Referring Physician Survey Practice-based Learning & Improvement Specific CME and SAMs developed for practice-based learning and improvement. General questions about essential core knowledge and practice improvement principles.  Patient Safety  Double Reading  Turnaround Time  Practice Guidelines  Referring Physician Survey Systems-based Practice Specific CME and SAMs developed for systems-based practice. General questions about CQI content.  Patient Safety  Double Reading  Turnaround Time  Practice Guidelines  Referring Physician Survey

54. Competencies Report for Diagnostic Radiology Diplomate Name:____________ ABR ID:_________ Check one: 1 st yr___ 5 th yr___ Final___ Professional Standing Lifelong Learning and Periodic Self-Assessment Cognitive ExpertiseEvaluation of Performance in Practice Medical KnowledgeCME required by state board for licensure Practice-related exam questions Patient CareUnrestricted licensure Fundamental (“general content”) exam questions Interpersonal & Communication Skills ProfessionalismUnrestricted licensure Practice environment- related exam questions Practice-based Learning & Improvement Practice environment- related exam questions Systems-based Practice Practice environment- related exam questions

55. Part 4: Roles for Professional Societies  Educational courses, SAMs on Part 4  Identify key PQI focus areas  Develop new tools, guidelines, metrics, project templates  How-to workshops for your members  Work with other societies on database development  Deliver message: PQI is work-in-progress!!! Expect change!!!

56. Practice Performance Radiation Oncology PQI Bruce G. Haffty, MD

57. Radiation Oncology MOC 10-Year Cycle Professional Standing Professional Standing Licensure-Maintained Throughout Licensure-Maintained Throughout Life-long Learning and Self Assessment Life-long Learning and Self Assessment CME-20 Hours/Year Total 200 Hours CME-20 Hours/Year Total 200 Hours Self-Assessment Modules-8 Required over 10 Years Self-Assessment Modules-8 Required over 10 Years Cognitive Expertise Cognitive Expertise Examination-Year 8,9 or 10 Examination-Year 8,9 or 10 Practice Performance Improvement Projects (PQI) Practice Performance Improvement Projects (PQI) 3 Required Over 10 Years 3 Required Over 10 Years

58. PQI Projects Fundamentals Individual Physician Based Individual Physician Based Patient Care Related Patient Care Related Measurable Endpoints/Benchmarks Measurable Endpoints/Benchmarks Evidence Based Guidelines, Consensus or Peer comparison Evidence Based Guidelines, Consensus or Peer comparison Action Plan/Improvement Plan Action Plan/Improvement Plan Baseline Assessment Baseline Assessment Improvement Plan Improvement Plan Follow-up assessment of the effect of improvement Follow-up assessment of the effect of improvement

59. PQI Projects Fundamentals Each of 6 Competencies Should be assessed at least once during MOC cycle Each of 6 Competencies Should be assessed at least once during MOC cycle Medical Knowledge Medical Knowledge Patient Care Patient Care Interpersonal and communication skills Interpersonal and communication skills Practice Based learning and Improvement Practice Based learning and Improvement Professionalism Professionalism Systems Based Practice Systems Based Practice

60. Radiation Oncology PQI Projects Type I and Type II Type I Type I Individual/Departmental/Institutionally Developed Individual/Departmental/Institutionally Developed Should Address the fundamental elements of a PQI program (Physician based, patient care, measurable endpoints, Action Plan, etc) Should Address the fundamental elements of a PQI program (Physician based, patient care, measurable endpoints, Action Plan, etc) Self Attestation Self Attestation Subject to ABR Random Audit Subject to ABR Random Audit Creativity/Novel Approaches Encouraged Creativity/Novel Approaches Encouraged

61. Radiation Oncology-Type I Projects Institutional Quality Improvement Projects Institutional Quality Improvement Projects Physician-or Practice-Based Patient Care Physician-or Practice-Based Patient Care Measurable outcomes Measurable outcomes Benchmarks Benchmarks Action Plans Action Plans Outcomes projects ( i.e., retrospective reviews) Outcomes projects ( i.e., retrospective reviews) Should be related to patient care outcomes Should be related to patient care outcomes Physician based Physician based Action Plans Action Plans

62. Radiation Oncology PQI Projects Type I and Type II Type II Type II Developed externally by Professional Societies Developed externally by Professional Societies Should address the fundamental elements of a PQI program (physician based, patient care, measurable endpoints, action plan, etc.) Should address the fundamental elements of a PQI program (physician based, patient care, measurable endpoints, action plan, etc.) Requires submission to and qualification by ABR Requires submission to and qualification by ABR Establishment of centralized databases, pooled data for comparisons and benchmarks encouraged Establishment of centralized databases, pooled data for comparisons and benchmarks encouraged

63. Type II (Society Initiated) Submitted and “Qualified” by ABR in RO Submitted and “Qualified” by ABR in RO Must meet fundamental elements of ABMS PQI type programs Must meet fundamental elements of ABMS PQI type programs Current examples: Current examples: ACR-RO - PEER ACR-RO - PEER ASTRO - PAAROT ASTRO - PAAROT ABS - under development ABS - under development

64. Radiation Oncology PQI Projects Proposed model is as follows: Proposed model is as follows: Three Projects over 10 Year Cycle Three Projects over 10 Year Cycle Type II - at least one of the 3 must be Type II Type II - at least one of the 3 must be Type II Up to two of the three can be Type I - Individual/Institutional Up to two of the three can be Type I - Individual/Institutional creativity is encouraged creativity is encouraged

65. Radiation Oncology PQI Projects-Phase in for MOC 3 Projects over the 10-year Cycle 3 Projects over the 10-year Cycle Goal of one project within each 3-year interval Goal of one project within each 3-year interval For those diplomates whose time-limited certificates expire within the next few years, PQI requirement will be phased in For those diplomates whose time-limited certificates expire within the next few years, PQI requirement will be phased in diplomates with TLC expiring in 2090 or 2010 will need to complete one PQI by December 2009 or 2010, respectively) diplomates with TLC expiring in 2090 or 2010 will need to complete one PQI by December 2009 or 2010, respectively)

66. Radiation Oncology Practice Quality Improvement This element of MOC remains the least developed and most difficult to manage This element of MOC remains the least developed and most difficult to manage Remains the component that can have the greatest impact on one of the critical goals of the MOC program - Improvement in the Quality of Patient Care and Outcomes Remains the component that can have the greatest impact on one of the critical goals of the MOC program - Improvement in the Quality of Patient Care and Outcomes

67. Practice Quality Improvement RO Objectives for the Summit Discuss Fundamental Elements of PQI Programs Discuss Fundamental Elements of PQI Programs Discuss Type I and Type II Programs Discuss Type I and Type II Programs Provide Guidance to Individuals/Practices for Developing Type I Programs Provide Guidance to Individuals/Practices for Developing Type I Programs Provide Guidance to Societies for Developing Type II Programs Provide Guidance to Societies for Developing Type II Programs Encourage the Engagement of ABR Diplomats Encourage the Engagement of ABR Diplomats Discuss Options for Reporting, Documentation and Validation of PQI Programs Discuss Options for Reporting, Documentation and Validation of PQI Programs

68. Practice Quality Improvement: The Specifics for Radiologic Physics Trustees, Radiologic Physics: G. Donald Frey, Ph.D. – Medical Nuclear Physics G. Donald Frey, Ph.D. – Medical Nuclear Physics Richard L. Morin, Ph.D. – Diagnostic RP Richard L. Morin, Ph.D. – Diagnostic RP Bhudatt R. Paliwal, Ph.D. – Therapeutic RP Bhudatt R. Paliwal, Ph.D. – Therapeutic RP Assoc Exec Director, Radiologic Physics: Stephen R. Thomas, Ph.D. Stephen R. Thomas, Ph.D.

69. PQI Summit: Additional Considerations for Radiologic Physics (1) Review the Challenges: Define how PQI applies to radiologic physics and identify the potential role of PQI projects in promoting quality improvement in RP practice. Review the Challenges: Define how PQI applies to radiologic physics and identify the potential role of PQI projects in promoting quality improvement in RP practice. Call to Action: Encourage societies with a component of RP to participate in the development of PQI programs for medical physicists. Call to Action: Encourage societies with a component of RP to participate in the development of PQI programs for medical physicists.

70. PQI Summit: Additional Considerations for Radiologic Physics (2) Establish a Working Environment: Create a framework wherein both medical physicists and RP societies work together defining tools for enabling medical physicists to incorporate PQI programs as an integral part of their practice. Establish a Working Environment: Create a framework wherein both medical physicists and RP societies work together defining tools for enabling medical physicists to incorporate PQI programs as an integral part of their practice. Projections for the Future: Where do we want to go? How will we get there? What happens after we arrive? Projections for the Future: Where do we want to go? How will we get there? What happens after we arrive?

71. PQI for Radiologic Physics – The Unique Position of Medical Physicists Only 2 of the 24 boards of the ABMS have non- physician members. Only 2 of the 24 boards of the ABMS have non- physician members. ABMS Website description of Part IV: Directed toward evidence of evaluation of performance in practice for physicians. ABMS Website description of Part IV: Directed toward evidence of evaluation of performance in practice for physicians. The PQI program development in RP will be focused on the physicist as a medical professional who contributes to and supports patient care within the healthcare system, while not having primary responsibility for the patient. The PQI program development in RP will be focused on the physicist as a medical professional who contributes to and supports patient care within the healthcare system, while not having primary responsibility for the patient.

72. ABMS Guidelines for Part IV: Application to the Practice of Medical Physics The challenges for Radiologic Physics: What fits - What doesn’t (Quite)! What fits - What doesn’t (Quite)!

73. Selected Guideline Illustrations Guideline #1: PQI programs: Phase-in, evaluate effectiveness, systematically improve, update diplomates on development: Guideline #1: PQI programs: Phase-in, evaluate effectiveness, systematically improve, update diplomates on development: RP – Ok in concept. Guideline #2: Assessment process reflective of activities related to patients or patient care: Guideline #2: Assessment process reflective of activities related to patients or patient care: RP – Ok under the label of patient care.

74. Selected Guideline Illustrations Guideline #6: Assessment of patient care focus on sampling of patients in practice with a key disease or clinical process. Guideline #6: Assessment of patient care focus on sampling of patients in practice with a key disease or clinical process. RP – Needs adjustment Guideline #12: Assessment of physician performance begin during residency and continue throughout practice. Guideline #12: Assessment of physician performance begin during residency and continue throughout practice. RP – Currently, the residency considerations are not applicable.

75. The Evolving Nature of PQI Projects for Radiologic Physics Recognition that operational PQI projects for RP have not been finalized at this point. Recognition that operational PQI projects for RP have not been finalized at this point. Importance of this Summit as a vehicle for open communication, brainstorming options, and establishing cooperative engagement in moving forward. Importance of this Summit as a vehicle for open communication, brainstorming options, and establishing cooperative engagement in moving forward. Importance of initiating PQI projects even if understood to be interim/evolving - Getting RP Diplomates committed to the concepts and started down the pathway. Importance of initiating PQI projects even if understood to be interim/evolving - Getting RP Diplomates committed to the concepts and started down the pathway.

76. Society Initiation of PQI Projects for Radiologic Physics: American Association of Physicists in Medicine (AAPM) American Association of Physicists in Medicine (AAPM) AAPM TG-127 on MOC Educational Council Professional Council ACMP, RSNA, ASTRO, ACR, SNM, …. ACMP, RSNA, ASTRO, ACR, SNM, …. CAMPEP – Commission on Accreditation of Medical Physics Educational Programs CAMPEP – Commission on Accreditation of Medical Physics Educational Programs

77. PQI Principles for Radiologic Physics: Framework for Consideration Choose 1 RP PQI project for the 10-year cycle Choose 1 RP PQI project for the 10-year cycle Selected from a list of defined and approved projects Selected from a list of defined and approved projects Data collected and reported at 2 time points – potentially within the 4 th and 7 th years Data collected and reported at 2 time points – potentially within the 4 th and 7 th years A normative peer review process to be used A normative peer review process to be used Diplomates identify/contact their own qualified reviewer who will use ABR prescribed instruments for the evaluation Diplomates identify/contact their own qualified reviewer who will use ABR prescribed instruments for the evaluation

78. PQI Projects under consideration for Radiologic Physics ABMS application (Dec 2005) ABMS application (Dec 2005) 1.) Professional and Regulatory Guidelines: Performance based on fulfillment of physics component according to established criteria. 2.) Safety for Patients, Employees, Public: Performance based on fulfillment of established standards related to safety program responsibilities. 3.) Educational Activities: Performance based on documented evaluation according to national standards for teaching. Evaluation of Scope of Practice Evaluation of Scope of Practice

79. PQI Project Example for RP: Professional & Regulatory Guidelines Normative guidelines RP based procedures: AAPM Task Group Reports RP based procedures: AAPM Task Group Reports Practice Guidelines/Technical Standards: ACR, ACMP Practice Guidelines/Technical Standards: ACR, ACMP Mammography Quality Standards ACT: MQSA Mammography Quality Standards ACT: MQSA Accreditation programs (RP component): ACR, ACRO Accreditation programs (RP component): ACR, ACRO Equipment Acceptance Testing: NEMA Equipment Acceptance Testing: NEMAEndpoints Compliance: Dichotomous outcome – Successful or not-successful, but…. Compliance: Dichotomous outcome – Successful or not-successful, but…. Identify the opportunities for quality improvement Identify the opportunities for quality improvement

80. PQI Project Example for RP: Professional & Regulatory Guidelines Methodology: Implementation of activities according to protocols as defined in the programs. Methodology: Implementation of activities according to protocols as defined in the programs. Measurement: Comparison of performance as documented by the diplomate to the criteria as established by the program. The results are peer reviewed using the practice performance evaluation instrument. Measurement: Comparison of performance as documented by the diplomate to the criteria as established by the program. The results are peer reviewed using the practice performance evaluation instrument. Feedback: Local self-assessment of performance according to the degree of fulfillment of the established criteria/standard, and feedback by the peer reviewer. Feedback: Local self-assessment of performance according to the degree of fulfillment of the established criteria/standard, and feedback by the peer reviewer.

81. Evaluation of Scope of Practice: Model Example AAPM TG 103 Report: Peer Review in Clinical Radiation Oncology Physics (2005) Guidelines: Primarily focused on the solo practice, but, may also be appropriate for group settings. Guidelines: Primarily focused on the solo practice, but, may also be appropriate for group settings. Time Frame: Site visit designed to be completed in one working day. Time Frame: Site visit designed to be completed in one working day. Review Areas Specified: Review Areas Specified: Processes used in routine clinical practice at facility Processes used in routine clinical practice at facility Product of the physics group work Product of the physics group work Physics policies of the institution Physics policies of the institution Checklists: Provided as tools for the reviewer Checklists: Provided as tools for the reviewer

82. Goals in Establishing Effective Scope-of-Practice PQI Tools Thoughts under consideration: Develop streamlined review templates for all RP disciplines (subsets of AAPM TG 103 Report) Develop streamlined review templates for all RP disciplines (subsets of AAPM TG 103 Report) Develop guidelines for implementation of Scope-of-Practice reviews Develop guidelines for implementation of Scope-of-Practice reviews Establish a pool of trained reviewers Establish a pool of trained reviewers Provide courses in PQI Scope-of-Practice procedures at upcoming AAPM annual meeting Provide courses in PQI Scope-of-Practice procedures at upcoming AAPM annual meeting

83. In Summary … We are underway in the opening stages of defining PQI projects for Radiologic Physics. We are underway in the opening stages of defining PQI projects for Radiologic Physics. Processes will evolve as we move through the first cycle. Processes will evolve as we move through the first cycle. It is expected that enhanced tools for assessing quality improvement in RP will be forthcoming as experience is acquired. It is expected that enhanced tools for assessing quality improvement in RP will be forthcoming as experience is acquired. Of importance for this Summit: Of importance for this Summit:  To identify and reach consensus on initial pathways for implementation of viable PQI programs for RP.  To engage in a collaborative, intersociety effort to provide effective PQI projects for RP.

84. “Nuts and Bolts” The ABR’s Part IV Program: Practice Quality Improvement Jennifer Bosma, PhD

85. Some Essential Elements Every PQI project must include: Every PQI project must include: Data collection based on own practice Data collection based on own practice Measures – the “metric” Measures – the “metric” Data analysis/synthesis Data analysis/synthesis Documentation of improvement plan based upon performance Documentation of improvement plan based upon performance

86. What does ABR want? Keeping it simple this first 10-year DR cycle Keeping it simple this first 10-year DR cycle Allowing creativity by individuals & societies Allowing creativity by individuals & societies Allowing diplomates to gain knowledge of QI Allowing diplomates to gain knowledge of QI The diplomate: The diplomate: Reports project selected Reports project selected Attests to participation: answers “yes, I have participated” in the current step of the PQI process Attests to participation: answers “yes, I have participated” in the current step of the PQI process Is ready to provide evidence of activity if asked, similar to state board random audits of CME Is ready to provide evidence of activity if asked, similar to state board random audits of CME

87. The Process - DR PQI: Years 1-3 Collect & analyze baseline data. Collect & analyze baseline data. Develop & implement improvement plan. Develop & implement improvement plan. Collect & analyze more data. Collect & analyze more data. First segment complete.

88. The Process – DR (cont’d) PQI: Years 4-6 Modify & implement improvement plan. Modify & implement improvement plan. Collect more data. Collect more data. Analyze data. Analyze data. Second segment complete. PQI: Years 7-9 Refine & implement improvement plan Collect more data. Analyze data. Third segment complete.

89. PQI - DR: Year 10 Brief summary of results and conclusions. Brief summary of results and conclusions. Work to sustain the gains. Work to sustain the gains. Select project(s) for the next cycle. Select project(s) for the next cycle.

90. Reporting MOC Participation “Personal Page” on ABR web site “Personal Page” on ABR web site 11,000+ time-limited certificate holders 11,000+ time-limited certificate holders First phase complete First phase complete Update contact information Update contact information Pay annual fee online Pay annual fee online Access via initial registration process Access via initial registration process Second phase – Rad Physics example Second phase – Rad Physics example Professional Standing Professional Standing Lifelong Learning Lifelong Learning

94. PQI Timeline & Milestone Tracking Diagnostic Radiology Diplomates Year of Cycle What I must do each year of 10-year MOC cycle Submit report / attestation via the Personal Web Page 1  Select project and metric(s)  Collect baseline data Yes √ 2  Develop improvement plan  Implement plan  Begin collecting improvement plan data Yes 3  Complete collection of improvement plan data  Analyze data  Summarize data Yes 4  Modify improvement plan  Implement plan  Begin collecting improvement plan data Yes

95. Personal Page - future PQI participation PQI participation Project selected Project selected Attestation Attestation Gateway Gateway CME: Authenticated credits direct from societies CME: Authenticated credits direct from societies PQI credit ? PQI credit ?

96. Summary PQI process – 3 cycles in 10 years PQI process – 3 cycles in 10 years PQI reporting – ABR personal page, Gateway potential PQI reporting – ABR personal page, Gateway potential The process will evolve and improve as we all learn The process will evolve and improve as we all learn