Using Your Registry Data

Design a Registry-Based Improvement in Medical Practice Project

The ABO is pleased to launch a new program using the data supplied through the American Academy of Ophthalmology IRIS® Registry dashboard to create custom practice improvement projects. Diplomates are invited to design an improvement activity based on the 15 clinical quality measures and 6 quality improvement measures reported monthly to participants of the IRIS Registry. Diplomates can use the monthly reports to identify areas for improvement, set specific goals for each measure, outline the steps (changes in care delivery processes) to achieve these goals, and evaluate success by analyzing the subsequent monthly performance reports. Applications may be submitted by clicking the link on your Status Page and are processed and reviewed on a monthly basis. The project review and approval lifecycle takes about 4-6 weeks from submission through approval.

Step 1: Develop Your Project

  • Review the ABO’s project submission template and use this as a guide to develop your project.
  • Review your monthly IRIS Registry performance report and select 1-3 measures to improve.
  • Create an improvement action plan in which you set a goal(s) for each measure you would like to improve and outline the changes in your care process that you believe will improve the measure and achieve your goal(s).
Not sure where to start? View examples of past clinical and non-clinical improvement projects where diplomates used insights from their performance data to identify gaps in care, set improvement goals, and make changes that resulted in meaningful improvement in their practice.


Step 2: Submit Your Project to the ABO for Review and Approval

From your MOC status page, you can submit your registry-based practice improvement activity for review and approval by ABO. The submission template includes the following sections which are important in documenting your proposed project. Submissions are reviewed and approved monthly.

  • Title of Project:(a succinct description of what you intend to improve)
  • Project Description: (identify the exact measures from your monthly IRIS Registry report you will focus on in 100 words or less)
  • Background Information: (the month you pulled the baseline IRIS Registry performance report and any additional information that may be pertinent)
  • Project Setting: (describe the practice setting):
  • Study Population: (describe the type of patient for whom the care process will be improved, e.g., all patients in your practice, patients with diabetes, patients presenting for emergency care)
  • Project Team(include roles for yourself and all members of your team): List the individuals who will be involved in your quality improvement project (i.e., solo project, partners in practice, office staff, OR personnel, anesthesiologists) and the roles they will contribute.
  • Quality Indicators/Performance Measures: It is important to identify the measures that will be quantified at baseline (before the care process is changed) and at re-measurement (after you have implemented the proposed improvement) to quantify the impact of your care process change. For the registry-based improvement activity, you will use the monthly performance reports generated on your IRIS Registry dashboard.
  • Improvement Plan: State the improvement goal(s) you are aiming for and describe the change(s) you intend to introduce to achieve the goal(s). Quality improvement requires that you analyze your care delivery processes and identify changes, which if implemented, you believe will improve care and outcomes. Generally, educational interventions are thought to be weak and demonstrate little impact. The introduction of tools, strategies or systematic approaches to care delivery is more powerful. A tool is a thing, for example a preoperative checklist, or written standardized process or protocol. Strategies include changes in procedures or policies like the introduction of a surgical time out before surgery is initiated. Systematic approaches to care delivery involve the comprehensive integration of tools and strategies into the care delivery process.

Step 3: Follow Your Plan, Measure Your Success, and Submit a Summary of Your Completed Project to the ABO

  • For the next three months, follow your plan and make modifications and tweaks in pursuit of your goal(s).
  • At the conclusion of the improvement period, pull the IRIS Registry performance report and compare your performance on the measures you targeted for improvement. Did you meet your goals for improvement? Why or why not?
  • Submit a summary of your project to the ABO for completion. Using the template provided by the ABO, you will provide a brief summary of the project highlighting the data collected, effectiveness of your measurement approach, interventions, and the overall impact of the project. 

Step 4: Provide Feedback on Your Experience and the Impact of Your Project

Following completion of the project, you will be sent a short survey in which you can share your reflections on the project. Completion of this survey is important to ABO in our efforts to improve MOC improvement in care delivery activities. With your permission, it is the ABO’s intention to share these projects with other Diplomates so they may benefit from your experience and lessons learned in improving care delivery processes.