APEx Facility Self-Assessment PQI Template

  • The APEx Facility Self-assessment PQI template is a free companion offering to facility self-assessment component of ASTRO's Accreditation Program for Excellence (APEx). It guides participants through the required steps to complete an American Board of Radiology (ABR) qualified PQI project. Download the APEx Facility Self-assessment PQI template today!

    APEx Overview

    The mission of ASTRO’s Accreditation Program for Excellence (APEx) is to recognize facilities by objectively assessing the radiation oncology care team, policies and procedures, and the facility. APEx was created to support quality improvement in radiation therapy practices. The APEx program provides an objective review by practicing radiation oncology professionals of essential functions and processes of radiation oncology practices. It offers transparent, measurable, evidence- and consensus-based standards that emphasize a professional commitment to safety and quality. Facilities that obtain practice accreditation will have the systems, personnel and policies and procedures needed to provide high-quality, safe patient care. The length of the accreditation cycle is four years.

    The self-assessment is a preliminary process in which practices assess their readiness for the facility visit. Compliance with APEx accreditation standards is assessed by completing the self-assessment via the Web-based tool. Practices submit their self-assessment, which includes medical record abstraction, uploaded policies and procedures and other supportive materials. The practice will be provided with a detailed interim feedback report that identifies the extent to which the practice is in compliance with each of the APEx evaluation criteria and may indicate deficiencies that must be addressed in order to progress to the facility visit. The feedback report notifies the practice if they are ready to proceed for a facility visit or if they must complete the self-assessment again.
    More information on the APEx program is available online at www.astro.org/apex.

    PQI Project Overview

    This project outlines how participants can use the ASTRO’s live on-site or online eContouring events towards fulfilling the Part IV Practice Quality Improvement (PQI) requirements of Maintenance of Certification (MOC) that have been established by the American Board of Radiology (ABR). To begin, interested participants should download the free template.

    This project is based on the ABR’s four-part Plan-Do-Study-Act (PDSA) process for continuous quality improvement. Participants will link two PDSA cycles together to create an action-oriented improvement plan that assesses the effects of their quality improvement strategy.

    • In the first PDSA cycle, groups will enter medical record abstraction data into the APEx Self-assessment Web-based portal, review their facility’s performance using the Medical Record Feedback Report, identify areas of improvement, develop an improvement plan, and implement the improvement plan.
    • In the second PDSA cycle, a new set of medical records will be identified and used to re-measure if the facility’s implementation of the improvement plan was successful and determine what additional actions may be needed to reach the facility’s target level of performance. The project concludes with a written participant reflection.

    How to Participate

    1. Register for and download the free APEx Facility Self-assessment PQI template.
    2. Save a digital copy of the template in a location that you will have continual access to throughout the entire length of your project (typically a minimum of one calendar year).
    3. Read through the entire template to familiarize yourself with the project outline.
    4. Enroll in ASTRO's APEx program.
    5. Complete the first PDSA cycle which includes hosting two group meetings, entering medical record abstraction data into the APEx Self-assessment Web-based portal, reviewing your facility’s performance using the Medical Record Feedback Report, identify areas of improvement, developing an improvement plan, and implementing the improvement plan.
    6. Complete the second PDSA cycle which includes a follow-up group meeting, identifying a new set of medical records to use for re-measurement to determine if the facility’s implementation of the improvement plan was successful and determine what additional actions may be needed to reach the facility’s target level of performance. The project concludes with each individual participant writing a project reflection.
    7. Each of the group's individual participants must attest to their project completion on the ABR website.

    Recording Progress and Reporting Completion

    Participants are responsible for documenting their project using the outline included in the template. Participants will not submit their partially or fully completed template to ASTRO at any point during their project. Once completed, participants must personally attest to its completion on the myABR website in accordance with the ABR’s MOC requirements. While ASTRO is able to confirm a group's participation in APEx, ASTRO will not be collecting, reviewing, or validating a group's participation in the PQI activity.

    Qualification

    The APEx Facility Self-assessment PQI Template is qualified for physicians and physicists 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. The activity was approved on April 23, 2015, and expires on April 22, 2021.

    Please contact the Education Department with any questions about the PQI template and APEx with any questions about ASTRO's APEx program.