Practice Performance Assessment

Physicians seeking to maintain their certification must evaluate their clinical practice according to specialty-specific standards for patient care. They are asked to demonstrate that they can assess the quality of care they provide compared to peers or national benchmarks and then utilize quality improvement methods and evidence-based practice standards to improve that care.

Physicians are asked to participate in various activities that document quality patient care and participation in practice improvement based on personal practice characteristics or data. Based on specialty requirements, physicians may be required to complete one or more of the following activities:

  • Verification of clinical activity (e.g., surgical cases) by logging in data into a secure portal accessed from the Member Board website.
  • Verification of activity working in quality improvement or quality assurance. A physician may be required by their Member Board to provide documentation regarding their work in this area as proof of their ongoing efforts to improve the quality of their laboratory, division or department.
  • Peer attestations of performance, including interpersonal and communication skills, professionalism, ethics, and effectiveness in practice.
  • Practice assessment and improvement activity in which practice data is gathered on a small number of patients, the data is reviewed and compared to standards, and feedback is given by the Member Board on performance. Other Member Boards require this review and comparison but the physician is required to design and implement a change to improve practice and data is again gathered and reviewed. These changes can include implementing clinical reminders, improvements in clinical knowledge, or making changes to a clinical or system process. Some boards require self-designed activities while others offer activities supported by interactive websites that explain each step of the process. Some boards allow these activities to be completed in groups rather than individually. Many Member Boards offer modules designed for physicians who practice in a variety of clinical situations and who may be interested in specific areas of clinical work. Additionally, many Member Boards allow reciprocal credit for a practice improvement module offered by another Member Board.
  • Patient safety and clinical communication web-based modules that focus on improvement of knowledge in these specific content areas. Some Member Boards require completion of patient and/or peer communication surveys.
  • Non-clinical web-based modules for physicians who no longer have a clinical practice or see a very limited number of patients on their own (i.e., researchers, teaching faculty who do not see patients on their own, etc.)
  • Patient surveys regarding various aspects of clinical practice from the patient perspective. These surveys have been implemented by some Member Boards and are under development by others.

Though all boards are moving toward some type of practice assessment and improvement activity, not every board requires completion at this time. Some boards do not require participation in Part IV activities for those physicians who no longer see patients, while others provide alternate activities for these physicians.

Refer to the Overview of Member Board Requirements for more information.

Division of Continuing Medical Education
410 W. 10th Street, HS 2100 | Indianapolis, IN 46202 | Phone: (317) 274-0104 | Fax: (317) 274-5182