MOC Credit
Procedural Pause/Universal Protocol PQI Project
Qualified by the American Board of Radiology in meeting the criteria for practice quality improvement (PQI) toward the purpose of fulfilling requirements in the ABR Maintenance of Certification Program. Qualification granted until 12/31/2024.
PROJECT OVERVIEW
BACKGROUND:
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BACKGROUND:
A comprehensive satisfaction survey of physicians that refer patients for imaging revealed an opportunity for improvement regarding referencing prior comparison studies in the interpretation of new studies. This feedback was the most consistent across all radiology subspecialties. Comparing with prior imaging is a very useful adjunct in assessing the chronicity of imaging findings and thus limiting the provided differential diagnosis. Utilizing comparison studies has a direct impact on patient care since broad differential diagnoses, as well as indeterminate findings, typically warrant additional imaging or clinical investigation, some of which may be avoided.
IMPORTANCE:
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IMPORTANCE:
The target is to have a 20% improvement or achieve > 80% of radiology interpretations having either a comparison to a prior study, when available, or document that there were no prior studies for comparison.
METRIC/
BENCHMARK:
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METRIC/BENCHMARK:
The target is to have a 20% improvement or achieve > 80% of radiology interpretations having either a comparison to a prior study, when available, or document that there were no prior studies for comparison.
PROJECT STEPS
Make a login to MOCcredit.com and document each completed step
Step 1 (Select project and metric):
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Step 1 (Select project and metric):
After selecting the procedural pause project, the diplomat will review the requirements of the PQI process and The Joint Commission guidelines regarding the procedural pause. Resources, including example procedural pause/universal protocol documentation, can be found on The Joint Commission website:
http://www.jointcommission.org/standards_information/up.aspx.
Step 2 (Collect baseline data):
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Step 2 (Collect baseline data):
Each institution will determine its optimum data source. Ideally, a search of electronic billing codes or electronic medical records will be utilized to identify procedures performed in the radiology department. The records of these procedures will be reviewed to assess for accurate documentation of the procedural pause. A member of the allied health staff can perform a chart review. The numerator is the number of appropriately documented procedures. The denominator is the total number of procedures. The recommended measurement time frame is one month. During the designated month, the following table should be used to decide the minimum number of occurrences that should be evaluated for compliance.
Number of Cases | Sample Size |
< 30 | 100% cases |
30 – 100 | 30 |
101 – 500 | 50 |
> 500 | 70 |
Step 3 (Analyze the data):
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Step 3 (Analyze the data):
The collected baseline data will be analyzed and reviewed. Results will be entered into the MOCcredit.com database, where the results will be stored, and the diplomat may compare their results to those of others across the nation. If 100% compliance is achieved and it is felt that there is no need or opportunity for improvement, then the diplomat will discontinue this project and choose another. If there is room for improvement, i.e., compliance rates being less than 100%, or if there is a need to ensure continued 100% compliance, then the diplomat will proceed to Step 4.
Step 4 (Create improvement plan):
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Step 4 (Create improvement plan):
The diplomat will make an improvement plan based on their baseline data acquisition findings. Three suggested improvement plans are as follows. The first recommended improvement plan is to review and refine each institution’s existing procedural pause policy. Communication of this policy to radiologists performing procedures must be shared via personal or written communication. The next improvement plan option is the development of guidelines defining what constitutes appropriate documentation of the procedural pause. The institution’s Joint Commission specialist should review changes in institutional documentation if one exists. These guidelines should then be implemented. The final recommended improvement plan option involves directly educating individuals failing to comply with the procedural pause. One-on-one discussion with individuals is performed to identify and remove obstructions to their compliance. One of the above-suggested improvement plans or a plan developed by the diplomat is documented on the MOCcredit.com website and implemented.
Step 5 (Collect data, compare to initial data, and summarize results):
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Step 5 (Collect data, compare to initial data, and summarize results):
After the institution of the improvement plan, the compliance data will then be again collected using the same method as the baseline data. This data will be analyzed and summarized. The data will be compared with both the internal baseline data and with other institutions/individuals submitting to the centralized MOCcredit.com database.
Step 6 (Control & Close Project):
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Step 6 (Control & Close Project):
It is of utmost importance to maintain the advances you have achieved. A final project report, including the data from the different collection points and the improvement plan undertaken at each step, should be generated using the MOCcredit.com website. Achieved goals from this project are to be maintained by assigning the continued intermittent collection of data with a scheduled review of this data by a designated individual. After the appropriate handoff of this responsibility is performed, the project is closed, and a new project is started.