Practice improvement
Practice Improvement Resources
- The goal of the Continuous Certification practice improvement requirement is for diplomates to regularly assess their performance, by reviewing their outcomes, addressing identified areas for improvement, and evaluating the results. This can be satisfied by ongoing participation in a local, regional or national outcomes registry or quality assessment program.
- The activity should be related to some aspect of your current practice. Diplomates who hold multiple ABS certificates do not have to complete this requirement for each certificate.
- Diplomates are encouraged to find out what programs are available through their hospital. Many hospitals already participate in outcomes registries or require participation in a performance improvement or quality assessment program, such as the ABMS Portfolio Program. In addition, some surgical organizations have programs available to individual surgeons.
- Please see the list of resources below for examples.
Independent Option: If there are no hospital-based or individual programs available to you, the ABS expects you will select an area of practice for practice improvement. You should identify a practice area or types of procedures to evaluate; define the measures and goals; track and analyze the outcomes; and then compare them with your goals to identify areas for improvement. You should then reassess your performance after implementing changes to gauge improvement.
When reporting on this requirement, diplomates who are participating through the independent option will be required to briefly summarize the key points of the activity. Please also refer to the suggested options and essential and desirable characteristics below to aid you in developing an activity.
Submitting Information
- The ABS does not collect your individual results. When updating your Continuous Certification profile, you will be asked to indicate or describe the type of practice improvement activity in which you are participating.
- The ABS audits a percentage of the submitted forms each year. If audited, you will be asked to provide verification of enrollment or participation. No patient data will be collected.
Resources
The list below is not meant to be all inclusive, but rather to provide examples of good programs.
General surgery-related programs:
- ACS Surgeon Specific Registry (Case Log System)
(with tracking of 30-day complications) Available to non-ACS members
- Americas Hernia Society Quality Collaborative (AHSQC)
- Burn Registry Programs (ABA)
- Collaborative Endocrine Surgery Quality Improvement Program (CESQIP)
- Commission on Cancer Rapid Quality Reporting System (RQRS)
- ELSO Registry
- Mastery of Breast Surgery (ASBrS)
- Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
- Portfolio Program (ABMS)
A pathway for health care organizations to have their quality improvement efforts be approved across multiple boards
- National Cancer Data Base (NCDB)
- National Surgical Quality Improvement Program (ACS NSQIP®)
- National Trauma Data Bank® (NTDB)
- Organ Procurement and Transplantation Network
- Statewide Collaboratives (e.g., SCOAP, MSQC, etc.)
- STS National Database
- Trauma Quality Improvement Program (ACS TQIP®)
- VA Surgical Quality Improvement Program (VASQIP)
- Vizient Healthcare Performance Improvement
Vascular surgery-related programs:
Pediatric surgery-related programs:
- ACS Surgeon Specific Registry (Case Log System)
(with tracking of 30-day complications) Available to non-ACS members
- ELSO Registry
- National Surgical Quality Improvement Program - Pediatric (ACS NSQIP Peds)
- Pediatric Trauma Quality Improvement Program (ACS Peds TQIP)
Examples of independent options:
- Participation in a government sponsored prescription drug monitoring program (see pdf)
- Participation in an enhanced recovery after surgery (ERAS) protocol
- Development and evaluation of an intervention designed to improve service in your office or clinic
- Participation in a Focused Professional Practice Evaluation (FPPE)
- Developing and/or actively participating in an on-time operating room start project
Guidelines
The ABS approved in June 2012 the following parameters to guide organizations in the development of practice improvement resources. Programs are expected to adhere to these criteria.
Essential Characteristics
- The activity tracks meaningful and measureable patient outcomes. Processes of care or composite indicators associated with improved outcomes, reduced complications, or a better quality of life may be included.
- The parameters assessed are important, scientifically acceptable, useable, relevant, and easy to collect.
- Individual results are provided to the surgeon at least yearly, preferably a minimum of every six months.
- A comparative analysis of individual and group results is provided.
- The method for tracking procedures and outcomes minimizes selection bias.
- The activity includes the ability for re-measurement after implementation of a quality improvement activity based on analysis of the results.
Desirable Characteristics
- The information is risk-adjusted when possible.
- The time period between recording of data and reporting of results is minimized as much as possible.
- Resources are provided to enable completion of quality improvement activities based on the results.
- The activity provides comparisons over different time periods to track the effect of quality improvement activities.
- Data entry is done by trained third-party personnel when possible.
- The information is subject to audit to assure its validity and reliability.
