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Part IV – Evaluation of Performance in Practice

Part IV of ABCRS MOC requires ongoing participation in a local, regional or national outcomes registry or quality assessment program. Diplomates are expected to regularly review their outcomes and complication rates, address identified weaknesses, and reassess the results. The Part 4 activity should be related to your current practice. Diplomates are encouraged to find out what programs are available through their hospital. Many hospitals participate in national registry programs (see list below).

If there are no hospital-based or individual programs available to you, the ABCRS expects that diplomates will select a focused area of practice for practice assessment/quality improvement. You should identify an area of practice or types of procedures to study; define the measures to be assessed and goals of the activity; track patients’ outcomes; analyze the outcomes and compare them with the activity goals; and identify areas for improvement. They should then reassess their performance after implementing changes to gauge improvement.

If there are no hospital-based or other programs available, diplomates can maintain a log of their own cases and morbidity outcomes utilizing the ACS Surgeon Specific Case Log System (with tracking of 30 day complications).

Below are some examples of Part IV Vehicles that are accepted:  This list continues to grow as our MOC program evolves.  The ABCRS has an open door policy regarding Part IV vehicles.  

  • ACS Surgeon Specific Case Log System  (with tracking of 30 day complications)  https://www.facs.org/quality-programs/ssr

  • Cancer Quality Improvement Program (CQIP)
  • Florida Surgical Care Initiative
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
  • Mayo Clinic
  • Michigan Surgical Quality Collaborative (MSQC)
  • National Cancer Database (NCDB)
  • National Surgical Quality Improvement Program  ACS (NSCIP)
  • Ongoing Professional Practice Evaluation (OPPE)
  • Piedmont Society Program
  • Press Ganey
  • Surgical Care and Outcomes Assessment Program (SCOAP)  (Washington State)
  • Surgical Care Improvement Project (SCIP)
  • University Health System Consortium (UHC)
  • VHA Surgical Quality Improvement Program (VASQIP)

Part IV Program Guidelines

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.

How to document Evidence of Participation in your MOC Profile:

Part IV (Self -Attestation Allowed)    Click on memberlogin  at the top right corner of this page. Enter Your username and password. Click on MOC. Underneath the Year that Part IV is due (yellow signifies action needed/green signifies requirement is complete) document the type of national, regional or local outcomes database or quality assessment activity you are participating in and the name of the institution in the white box. Click on SUBMIT. No paperwork/copies are required at this time,  however the information is subject to audit to assure its validity and reliability.