MOC Part IV: The Role of the ABP in Improving Quality of Care for Children

Practice Performance Improvement Summit American Board of Radiology Chicago, Il August 19, 2006 Paul V. Miles MD Vice President, Director of Quality Improvement And Practice Assessment

“I am sorry for you, young men (and women) of this generation. You will do great things. You will have great victories, and standing on our shoulders, you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is not given to every generation.” …Sir William Osler ABP

Demands on Physicians for Quality of Care

Professional obligation Maintenance of board certification Career development Maintenance of licensure Credentialing Malpractice Pay for performance ABP

The Program for Maintenance of Certification in Pediatrics™

PMCP-G ™  Generalist Pediatricians PMCP-S ™  Pediatric Subspecialists ABP

ABP: Maintenance of Certification PMCP-G PMCP-S Part One: Professional Standing Valid license, no restrictions Part Two: Lifelong Learning ABP Knowledge self assessment AAP PREP (ABP approved) ABP Decision Skills Assessment ABP Knowledge self assessment via literature review AAP Neo Reviews (ABP approved) Part Three: Cognitive Expertise Secure, proctored exam Part Four: Performance in Practice A. Pediatric CAHPS Survey (and Peer Survey) B. eQIPP or eQIPP-like modules or local QI effort

Part 1

Valid, unrestricted license – Maintenance of licensure (MOL) Pediatric patient survey (CAHPS) 2007 Professionalism survey - future ABP

Part 2: Knowledge Self Assessment (Open book, low stakes, requires passing score) Existing ABP Knowledge self-assessment ABP Decision Skills AAP PREP (broad based general knowledge) Subspecialty modules (current best articles) Subspecialty prep programs (eg. Neoreviews) In Development Patient Safety Self Assessment QI Self Assessment & QI Basics Module ABP Available 2006 2006 2006 2006-10 2006-10 2008 2008

Part 3

ABP is considering requiring the secure exam every 10 years instead of every 7 years ABP

Part 4

Diplomate enrolls in MOC On the ABP Web-site

Part 4 Practice Assessment & Improvement

Option A Option B Web based modules Participate in Established Such as eQIPP or ABMS Improvement Project Patient Safety Module (including attestation forms) Complete QI Knowledge Self Assessment or Stand Alone QI Module with Assessment (Required with Option B) Credit for Part IV MOC

ABP

Part 4

Existing (Web based) eQIPP modules (Asthma & ADHD) In Development – 4A Web based ABMS Patient Safety Module eQIPP Nutrition & other modules Performance Improvement Modules (PIMs) In Development – 4B Credit for ongoing projects ABP Available 2006 2007 2007-10 2007 2007

Medical Knowledge Quality Improvement Knowledge Measurement Improvement Re Measurement ABP

e

QIPP allows the learner to quickly assess their practice online.

ABP

A real-time data analysis allows the learner to begin to identify opportunities for improvement.

ABP

e

QIPP offers an interactive learning environment. The program also includes practical, easy-to-use tools that can be implemented quickly into the office setting.

ABP

After completing the clinical content, the learner uses the

Model for Improvement

to identify opportunities for improvement in their practice.

ABP

ABP Within each step, the learner will receive advice for identifying, prioritizing, refining, and launching new improvement cycles.

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e

QIPP subscribers have access to the modules for three years. You will be able to track your progress, and monitor your successes over time.

Additional eQIPP Modules

• Nutrition • Bright futures (well child care) • Six to ten additional common topics by 2009 ABP

ABMS Patient Safety Module

Accurate and Complete Medication List Safer Prescription and Medication Order Writing Accurate and Complete Allergy Information Hand Hygiene Correct Patient/Site/Procedure Critical Test Results Notification ABP

Performance Improvement Modules (PIMs)

Diplomate Registers & Chooses Module Diplomate Measures Practice Quality Clinical Data Survey Data Rapid Cycle Improvement ABP Diplomate Chooses Change Package Change Package 1 Change Package 2 Change Package 3 Diplomate Re Measures Quality

Annotated Comparative Run Chart

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Annotation Annotation Annotation Annotation Annotation

Baseline

Time 

Test #1 Test #2 Your Practice Test #3 Comparison Test #4

Goal ABP

Part 4

Diplomate enrolls in MOC On the ABP Web-site

Part 4 Practice Assessment & Improvement

Option A Option B Web based modules Participate in Established Such as eQIPP or ABMS Improvement Project Patient Safety Module (including attestation forms) Complete QI Knowledge Self Assessment or Stand Alone QI Module with Assessment (Required with Option B) Credit for Part IV MOC

ABP

Competence in Quality Improvement

Pass a QI Knowledge Self Assessment Exercise: an open book multiple choice question exam Part 2 (in development) Complete a valid QI project ABP

ABP Standards for Part 4 B

Standards for Established Programs to receive ABP approval for Part 4 Standards for meaningful participation by a diplomate in an Established Program ABP

Cumulative % of Asthma Population with "Perfect Care": Network and Select Practices 100% Long Term Goal = 95% 90% 80% 70% 60% 50% Project Inception | q Performance Feedback Reports | q Improvement Collaborative on Reliability | q P4P Program | q z Self Management Collaborative Initiated p Web-based Registry Launched 40% 30% p P4P Deadline 20% 10% p "Perfect Care" Including Flu Shot 0% Oc t 0 3 No v 03 De c 0 3 Ja n 04 Fe b 04 Ma r 0 4 Ap r 0 4 Ma y 04 Ju n 04 Ju l 0 4 Au g 04 Se p 04 Oc t 0 4 No v 04 De c 0 4 Ja n 05 Fe b 05 Ma r 0 5 Ap r 0 5 Ma y 05 Ju n 05 Ju l 0 5 Au g 05 Se p 05 Oc t 0 5 No v 05 OVPCA Network Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 “Perfect Care”: composite measure of severity classified, identified management plan, and controller medications for patients with persistent asthma Copyright © 2005 Cincinnati Children’s Hospital Medical Center; all rights reserved ABP Practice 6

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cumulative % of Asthma Population with "Perfect Care": Commercial vs. Medicaid/Uninsured Commercially Insured Medicaid/Uninsured Copyright © 2005 Cincinnati Children’s Hospital Medical Center; all rights reserved ABP

Subspecialty Care: What to do about small numbers?

Collaborative practice with standardization of care Enroll patients in multicenter studies with shared data to determine best practices ABP

Acute Lymphoid Leukemia

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1960-63 70-73 74-76 77-79 80-82 83-90

Simone J., Lyons, J: J Clin Oncology 1998 Sep;16(9):2904-5 ABP

Percent of Patients Meeting the NKF DOQI Target Urea Reduction Ratio of 65%

figure 4.25, prevalent hemodialysis patients, 1999, by HSA 91.2 + (93.1) 89.2 to 91.2

87.1 to 89.2

83.6 to 87.1

below 83.6 (81.0) USRDS Atlas ABP

Quality of Care (ESRD)

35 30 25 20 15 Ave ra ge UR R 1993: 62.7% 1994: 63.8% 1995: 65.5% 1996: 66.8% 1997: 68.0% Oc t-De c '93 Oc t-De c '94 Oc t-De c '95 Oc t-De c '96 Oc t-De c '97 10 5 0 <50% 50-54% 55-59% 60-64% 65-69% 70-74% 75-79% 80+%

Ure a Re duction Ratio (URR)

* Sixteen Network areas participated in the first ESRD Core Indicators assessment (Oct-Dec 1993); all Network areas participated in subsequent years. ABP

Adequacy of Hemodialysis

Hemodialysis Dose by Race 100 80 60 40 20 0 46 36 53 43 62 54 70 63 73 69 76 70 85 83 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 87 84

Sehgal A, JAMA 2003;289:1996-1000 ABP

Whites Blacks

Initial Efforts in Subspecialty Care

PIBDnet – Inflammatory Bowel Disease Cystic fibrosis - Pulmonology High risk newborns – Neonatology Catheter Related Blood Stream Infections in PICU – Critical care Neonatal Congenital Heart Disease – Cardiology ABP

Prevention of Catheter-related Blood Stream Infections

Marlene R. Miller, M.D., M.Sc.

Christopher T. McKee, DO Ivor Berkowitz, M.D.

Claire Beers, R.N., M.S.N.

Johns Hopkins Children’s Center and Hospital Epidemiology and Infection Control

ABP

Subsequent BSI Outcomes

25 1

Rate of BSI per 1000 CL Days (reordered)

1 2 20

PRE POST

15 10 5 0 1 5 UCL=15.19

9 13 17 21 25

time period

ABP 29 33 37 41 _ X=3.99

45 LB=0

New Products and Programs that ABP has invested in

Part 2     General pediatric knowledge self assessment Decision skills exercise Subspecialty specific (13 subspecialties) knowledge modules Quality Improvement knowledge self assessment exam ABP

New Products and Programs that ABP has invested in

Part 4   Web based modules    AAP eQIPP nutrition module Performance Improvement Modules Patient safety module Practice based QI efforts     Pediatric GI – inflammatory bowel disease database and collaborative Critical care – catheter related blood stream infections Cardiology – Congenital heart disease project General pediatrics – RWJF funded Improving Performance in Practice (IPIP) with internal medicine and family medicine ABP

Alliance for Pediatric Quality

A collaboration of four major national pediatric organizations formed to measurably improve the quality of health care for America’s children.

ABP

Timeline

Certificates expiring between 2003 and 2009 – Parts 1 and 3: Valid license and secure exam Certificates expiring in 2010 and 2014 – all four Parts: One activity each in Parts 2 and 4 ABP