Transcript MOC Part IV Self-Directed PIM How-To
MOC Part IV Self Directed PIM: Your Guide To Making It Happen
Joseph P. Drozda Jr., MD, FACC
Mercy Health
Richard J. Kovacs, MD, FACC
Krannert Institute of Cardiology
Charles R. McKay, MD, FACC
Harbor-UCLA Medical Center
Paul D. Varosy, MD, FACC, FHRS
University of Colorado, Denver VA Eastern Colorado Health Care System
Joseph P. Drozda Jr., MD, FACC
Overview
• History & Role of the ABIM • ABIM’s Maintenance of Certification Process • MOC Part IV PIM Options • What, Why, Who, When, Where and How of ABIM’s Self-Directed PIM • Part A – Orientation • Part B – Measures and Data • Part C – Action Plan • Part D – Re-Measurement • Part E – Completion and Credits
History & Role of the ABIM ABIM Mission Statement
To enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care
“Of the Profession, For the Public”
History & Role of the ABIM
• Founded in 1936 • Physician-led, not-for-profit, independent of professional societies and government • Sets the standards for certifying internists and subspecialists • Accountable to both to the profession of medicine and to the public • Certifies 1 out of 4 practicing physicians in the U.S. (>200,000 ABIM Board Certified physicians)
History & Role of the ABIM
Most relevant certifications: Internal Medicine (1936) Cardiovascular Diseases (1941) Clinical Cardiac Electrophysiology (1992) Interventional Cardiology (1999) Advanced Heart Failure & Transplant Cardiology (2010) Adult Congenital Heart Disease (proposed)
History & Role of the ABIM Development of Certification Process
• Certification
Pre 1990 1990 2006
• Recertification • Maintenance of Certification (MOC)
2006
Certification Pre 1990
• Certification • Secure exam after completing fellowship • Lifetime certification with no end date
Recertification 1990 2006
• Recertification • Secure exam after completing fellowship • Time-limited certification with an end date • Recertification exam every 10 years
Maintenance of Certification 2006-
• Maintenance of Certification (MOC) • Secure exam after completing fellowship • Time-limited certification with an end date • Maintenance of Certification exam every 10 years • MOC includes completion of Parts I, II, III and IV
Maintenance of Certification – Four Parts Part I
Licensure and Professional Standing
Part II
Self-Evaluation of Medical Knowledge
Part III
Cognitive Expertise and Secure Examination
Part IV
Self-Evaluation of Practice Performance
Maintenance of Certification – 100 Points
20 points Part II
100 Points Every 10 years
20 points Part IV 20 points Either II or IV 20 points Either II or IV 20 points Either II or IV
Completing MOC Part IV Self Evaluation of Practice Performance
• Goal: – To improve some aspect of your practice • Tasks: – Measure practice using 3 performance measures – Analyze data and select one measure with potential for improvement – Develop and implement an action plan for improvement – Re-measure practice using same 3 measures
Performance Improvement Modules (PIMs)
• Allow physicians to report on their quality improvement work using a standardized web-based platform • Structured tools that guide physicians through a review of patient data and support the implementation of and/or reporting on a performance improvement project in their practice
MOC Part IV PIM Options
• Condition/topic-specific PI modules – From ABIM, e.g.
• Preventive Cardiology PIM • Communication with Referring Physicians PIM – From medical specialty societies or academic medical centers (Approved QI Pathway PIMs) • Generic PI modules – From ABIM • Self-Directed PIM (If you are beginning a new QI project) • Completed Project PIM (If you are reporting on QI activities that have already taken place)
Richard J. Kovacs, MD, FACC
What, Why, Who, When, Where and How of PIMs
• What is ABIM’s Self-Directed PIM?
• Why is completing a PIM necessary for me?
• Who can participate in a PIM project?
• When should I complete a PIM?
• Where can I find ABIM’s Self-Directed PIM?
• How do I complete a Self-Directed PIM?
What Is ABIM’s Self-Directed PIM?
• Generic PI module that allows physicians to report on quality/performance improvement activities being implemented in any specialty or sub-specialty
Why Is Completing A PIM Necessary For Me?
• ABIM require physicians to complete one of these projects to maintain board certification • Physicians not needing or wishing to maintain board certification need not complete a PIM
Who Can Participate In A PIM Project?
• Can be completed by hospitalists and other physicians working in an in-patient or out-patient setting • ABIM encourages completion as a multi-disciplinary team • All physicians in the team can claim MOC Part IV credit
Who Can Participate In A PIM Project? ABIM/ABMS Reciprocal Credit for Dual Boarded Diplomates
• ABIM-certified physicians who are dual-boarded by one or more of the American Board of Medical Specialties’ (ABMS) 24 member boards (e.g. the American Board of Pediatrics) are eligible to receive self-evaluation credit in ABIM's MOC program • To receive credit, ABIM diplomates will need to attest that they are current and participating in the other board's MOC program
Who Can Participate In A PIM Project?
• Doctors of Osteopathy must certify with the American Osteopathic Board of Internal Medicine (AOBIM) which introduced new Osteopathic Continuous Certification (OCC) January 1, 2013
When Should I Complete A PIM?
• Takes a minimum of 3 months • Recommend starting at least 6 months prior to expiration of certification
Where Can I Find ABIM’S Self-Directed PIM?
• Information on the Self-Directed PIM and a link to order it is at: http://www.abim.org/moc/earning points/productinfo-demo-ordering.aspx
• The Self-Directed PIM tutorial is at: http://www.abim.org/moc/earning points/productinfo-demo-ordering.aspx?self directed#58A
How Do I Complete A Self-Directed PIM?
• This session will familiarize attendees with the module and describe key steps involved in using data from ACC’s NCDR registry • Can use a variety of data sources to complete • Step-by-step directions are being developed by ACC to help our members navigate the module. These will be available after March 23, 2013 at: www.CardioSource.org/MOCPartIV
Charles R. McKay, MD, FACC
Part A – Orientation
Part B – Measures and Data
Part B – Measures and Data
Three sections of Part B 1. Tell us about your care setting • Select care setting (IP or OP) 2. Describe your data • Reporting period • Where did baseline data come from? 3. Enter baseline data
Part B – Measures And Data Section 2 – Describe Your Data
Where Did Baseline Data Come From?
• If NCDR - check “Medical Society Registry” box – Executive Summary and full Outcome Report from hospital RSMs or practice QI lead – Outcome Reports also available by logging on to www.ncdr.com
Where Do I Find The Outcome Report?
• • • •
On NCDR.com
Via secure log-in Registry specific Under the Dashboard tab
Executive Summary Review
• • •
Rolling 4 quarters (R4Q) Most significant measures/metrics included in the Executive Summary Measures and Metrics are organized by
–
Performance Measures
o
NQF endorsed
– – o
ACC/AHA performance measures Process of Care Metrics
o
Utilization metrics Patient Outcome Metrics
o
Adverse Events
o
Mortality
Outcome Reporting Executive Summary And Detail Section Executive Summary Detail Section
Where Is The Data Value And Sample Size?
A Closer Look At The Details . . .
Detail line 1018
NCDR’s 4-Part Data Quality Program
1. Training and Clinical Support Team
–Orientation webinars –Online FAQs –Live customer support –Email –Monthly webinars –Annual meeting with case reviews, etc.
2. Data Entry Integrity
–Software value checks –Field level range parameters –Parent:Child fields
3. Data Completeness
–Sites receive completeness reports to resubmit with missing fields completed –predetermined levels of completeness and consistency required for data to be included in national and comparison group averages
4. Data Accuracy
–Upto 650 records are audited annually .
Part B – Measures And Data Section 2 – Describe Your Data
• Other data sources: –National reporting database (e.g. PQRS, Bridges to Excellence) –Regional database (e.g. State QIO) –Local registries (e.g. Facility based) –Health plan data –Report from EMR/EHR –Manual abstraction (Chart Reviews) –Other (Crimson Continuum of Care; Quality Advisor)
Part B – Measures And Data Section 3 – Enter Baseline Data
ABIM’s Measures Library • Choose a measure set OR • Submit alternative measures for approval
Part B – Measures And Data ABIM’s Measures Library
Part B – Measures And Data Section 3 – Enter Baseline Data
– Guidelines for choosing measures • Choose at least three measures • Minimum of 25 patients in the data sample
Part B – Measures And Data Choosing Your Measures
Part B – Measures And Data Selecting Alternative Measures For Approval
• Find “Submit alternative measures for approval” at bottom of page • Click on link for form • Complete and submit form • Approval time is usually around 5 working days
Submitting Alternative Measures For Approval
Enter Baseline Performance Data For Your Measures
Richard J. Kovacs, MD, FACC
Part C – Action Plan Download And Complete An Action Plan
• The Action Plan contains: – Recommended tools – Exercises to be completed – Blank spaces for questions to be answered
Part C – Action Plan Preparation
1. Organize a Team 2. Target a Measure for Improvement
Part C – Action Plan Preparation: 1. Organize A Team
• Common roles in your care setting • Identify individuals and groups involved in care, interested in results and will be implementing the solution(s) to the selected measure – List possible members, e.g., hospital leadership, QI consultant and RSM – Identify by titles or roles rather than names – Select team leader (?you) and facilitator
CV Service National Data Registries
NCDR Cath/PCI Registry Robin Zwinski, RN; Cindy Humphrey, RN; Elisabeth Von der Lohe, MD • Society of Thoracic Surgeons (STS) Larissa Berty, RN and Arthur Coffey, MD • • • • ACTION / GWTG Tricia Helms, RN and Richard Kovacs, MD
Coordinator paired with Physician “Champion” for
PINNACLE
each database
Rachel Nation & Richard Kovacs, MD ICD Registry Miriam Lowe and William Groh, MD TAVR Registry Colin Terry; Anjan Sinha, MD and Arthur Coffey, MD • SVS Registry Shelby Markey and Michael Dalsing MD
CV Program Quality Structure and Processes
Hospital Quality Committee PV TEAM SVS AMI TEAM ACTION
CV Operations
Cardiology/CT Surgery/Vascular Surgery Nursing, Pharmacy, ED, Administration
CV Outcomes & Quality Committee
CV SRG TEAM STS AMB TEAM PINNACLE PCI TEAM PCI Physician Group Quality Committee
Each PI team is led by the same coordinator/ MD pair
ICD TEAM ICD
Part C – Action Plan Preparation: 2. Target A Measure For Improvement
• How to use NCDR reports to identify good results and opportunities for improvement • Tools to prioritize opportunities for improvement
Part C – Action Plan Preparation: 2. Target A Measure For Improvement
Part C – Action Plan Preparation: 2. Target A Measure For Improvement A tool used to select one option from a group of alternatives or to put the options into priority order if all need to be done. Quality Impact Criteria # Opportunities Patient Safety 1 2
2:2 Proportion of elective PCIs with prior positive stress or imaging study 2:3-Median time to immediate PCI for STEMI patients in (minutes) High High
3
2:6-Median time from ED arrival at STEMI transferring facility to immediate PCI at STEMI receiving facility among transferred patients.
Low
Patient Outcome
High Medium Medium
Patient Satisfaction
High Low Low
Financial Impact Improvable Measurable
High Low Low Medium Medium Medium High High High
4
2:18-PCI in-hospital risk adjusted mortality (patients with STEMI) Medium Medium Low Low Medium High
Part C – Action Plan Preparation: 2. Target A Measure For Improvement
• Guidelines for targeting a measure – Outcome versus process – Lowest performance – Likely to change – Ability to have an impact (clinical/satisfaction) on most patients – Has the most variability • Least disruptive to workflow or operations • Will make care more efficient • Organizational priorities
Part C – Action Plan Preparation: 2. Target A Measure For Improvement
• Choose a single measure to improve • Why did you choose it?
• Write a brief problem statement
Part C – Action Plan Preparation: 2. Target A Measure For Improvement
• Guidelines for setting a realistic performance goal – Self-comparison – Referenced–based (performance by other organizations) – Benchmarking/Best Practice – Use of NCDR reports – Examples: absolute number, % increase/decrease
Part C – Action Plan Preparation: 2. Target A Measure For Improvement
• Enter your performance goal into the Self Directed PIM platform
Part C – Action Plan
STEP 1 STEP 2 STEP 3 STEP 4
• Identify the Root Causes of Your Measured Performance • Examine the Current State of Your Practice Systems • Propose a Change in Your Practice System • Enter Your Plan for a Rapid-Cycle Test Online
Part C – Action Plan Step 1: Identify Root Causes Of Your Performance
Team identifies root causes: • Key to problem solving is understanding the problem • Using quality improvement tools and resources, your team will work together to identify the most significant causes of your current performance in the area you have targeted for improvement
Part C – Action Plan Step 2: Examine Your Practice Systems
• Team assesses systems and processes of care related to measure • For example, consider developing a flowchart of each step in the process (decide on start and end points) • Document all the specific steps involved in the process • Put all the steps in order • Purpose is to identify gaps, duplications, complexities, variations
Part C – Action Plan Step 2: Examine Your Practice Systems
Part C – Action Plan Step 2: Examine Your Practice Systems
• Using a brief survey, your team will explore your practice systems and care processes that may be relevant to your improvement target
Part C System – Action Plan Step 3: Propose A Change In Your Practice
• Drawing on insights gained from the previous steps, your team will propose a change in the way your system operates in order to improve performance on your target measure
Part C System – Action Plan Step 3: Propose A Change In Your Practice
Team identifies and prioritizes actions/changes that will allow you to reach your goal • Examples: adjust job responsibilities, provide education, change inventory • Use of creative thinking to identify potential solutions • Use of team techniques to evaluate solutions
Part C – Action Plan Step 4: Enter Your Plan Online
• With this completed guide in hand, you will return to the online PIM and enter the results of your work
Part C – Action Plan Resources
• ACC’s Quality Improvement 101 Toolkit http://www.cardiosource.org/Science-And Quality/Quality-Programs/PINNACLE Network/Quality-and-Performance Improvement/QI-101-Toolkit.aspx
• Other QI approaches: – Six Sigma (DMAIC) – Institute for Healthcare Improvement (FOCUS-PDSA) www.ihi.org
Paul D. Varosy, MD, FACC, FHRS
An Actual Self-Directed PIM: University of Colorado Hospital – NCDR-ICD
•ICD Registry Data •2 years “Rolling 4 quarter (R4Q)” •2012Q3 •2011Q3
Three Measures Suggesting “Opportunity for Performance Improvement”
Proportion meeting Class I or II ICD indications Proportion with decreased LVEF d/c with ACEI or ARB Proportion receiving antibiotics prior to surgery
Proportion Meeting Class I or II Guideline Indications
• 2-year Data: – UCH NCDR Data: 83.2% – National 50 th percentile benchmark: 90.5%
Proportion With LV Systolic Dysfunction Discharged with ACEI or ARB
• 2-year Data: – UCH NCDR Data: 70.0% – National 50 th percentile benchmark: 81.3%
Proportion Receiving IV Antibiotics Prior to Surgery (ICD Implantation)
• 2-year Data: – UCH NCDR Data: 98.9% – National 50 th percentile benchmark: 100%
Understanding the Data – Deeper Dive
• On further review, we found the following: – Abstraction errors • All the patients actually received antibiotics (100%) • Half the patients that failed to meet Guideline based indications • A fifth of the patients that didn’t get credit for receiving ACEI/ARB – Inadequate physician Documentation • Present in 40% of the patients that failed to meet guideline-based indications
Understanding the Data – Guideline Based Indications (Class I or II)
• Clinical review of all the cases: All but one single case were clinically appropriate – Data abstraction and/or inadequate MD documentation present in many – In some, actual guideline indications NOT included in NCDR’s algorithm • Example: Hypertrophic cardiomyopathy
Understanding the Data – Summary of Findings
• 99.5% had Class I or II indications for ICD implantation • 100% of patients received preoperative antibiotics • 72% received ACEI or ARB at discharge
Understanding the Data – Key Issues We Need to Tackle
• Quality of Physician Documentation (completeness) • Fidelity of Data Abstraction • Improving Discharge prescriptions
Assembling a Performance Improvement Team
• EP Physician faculty • EP Nurse Manager • EP Lab Charge Nurse • CV Center Director • Quality Improvement Specialist and team • HF and Cardiology MD Quality Liaisons
Action Plan
• Improve physician documentation • Improve data abstraction • More frequent internal auditing of data quality • Prompts to referring MDs before/after ICD implant about ACEI/ARB
Remeasurement
• Will reexamine the same three metrics with the NCDR Report at the end of 2 nd Quarter, 2013 (2013Q2)
Completion of ABIM MOC Self-Directed Performance Improvement Module
MOC Credit for ALL 7 EP Faculty Physicians!
Joseph P. Drozda Jr., MD, FACC
Part D – Re-Measurement
• Implement your Action Plan for at least 3 months • Review the next quarter of data from NCDR or other data source • Enter re-measurement data into Self Directed PIM – Identify the reporting period for re measurement data – Enter re-measurement data for the targeted measure
Part E – Completion And Credits
• Reflect on your improvement project – Tell ABIM about your quality improvement project • Describe your future projects – What do you plan to do next to improve quality in your practice?
• Complete a survey and claim credit
20 Part IV MOC