Transcript Radiation Oncology

ABR SUMMIT ON PRACTICE
QUALITY IMPROVEMENT
RO-Breakout Session
August 19, 2006
RO Summit Breakout – Bruce G. Haffty, M.D.
1
RADIATION ONCOLOGY BREAKOUT SESSION
OUTLINE
•
•
•
•
•
•
•
•
Brief Review of ABMS Guidelines
Brief Review of ABR Submission to ABMS on PQI
Timeline for Projects
Discussion of Fundamental Elements of any PQI
Project
Type I Projects
Discussion of Type I and Type II Projects
Type II Projects Developed or Under Development
Reporting and Documentation
RO Summit Breakout – Bruce G. Haffty, M.D.
2
GENERAL ABMS GUIDELINES FOR
PRACTICE PERFORMANCE IMPROVEMENT
1.
2.
3.
A program of practice assessment should be phased in,
periodically evaluated for its effectiveness, and
systematically improved. Diplomates should be kept
informed of the development of practice performance
assessment.
The assessment process should reflect the activities of a
diplomate related to patients or patient care.
Standards for measurement of clinical practice
performance should be based on evidence-based
guidelines, explicit expert consensus, or normative peer
comparison.
RO Summit Breakout – Bruce G. Haffty, M.D.
3
GENERAL ABMS GUIDELINES FOR
PRACTICE PERFORMANCE IMPROVEMENT
4.
5.
The assessment process should compare the diplomate’s
practice performance to evidence-based guidelines or explicit
expert consensus, where available, and to peers. After an initial
baseline assessment, diplomates should be asked to develop an
implementation plan for how they would improve performance.
Diplomates should submit a follow-up assessment of the effect
of the improvement plan. Each board should have a plan for
what to do with diplomates whose performance does not meet
acceptable expectations.
Initially each of the six general competencies should be
assessed at least once during a board’s repeating maintenance
of certification cycle. It is expected that by the end of the
second cycle, this should be a continuous process.
RO Summit Breakout – Bruce G. Haffty, M.D.
4
GENERAL ABMS GUIDELINES FOR
PRACTICE PERFORMANCE IMPROVEMENT
6.
7.
Assessment of patient care initially should focus on a sampling
of patients in a practice with a key disease or clinical process
(such as asthma, diabetes, pregnancy, immunizations, surgical
procedure or processes central to that specialty) at least once
per cycle. By the end of the second cycle, each board should
move to a more continuous sampling of patients that will
enable diplomates to demonstrate, at any point in time, the
quality of his/her care for a defined number of consecutive
patients or specialty-related key activities.
An effective method for boards to consider for assessment and
improvement of clinical performance is to be part of a
collaborative effort with other practices using shared databases.
RO Summit Breakout – Bruce G. Haffty, M.D.
5
GENERAL ABMS GUIDELINES FOR
PRACTICE PERFORMANCE IMPROVEMENT
8. The measurement of practice performance should
use proven educational and assessment methodology.
9. Practice assessment should provide performance
feedback, improve workflow, improve efficiency of
practice, and should not duplicate other assessment
efforts.
10. Practice assessment should include appropriate
collaboration with specialty societies and other
organizations with relevant education and
assessment expertise.
RO Summit Breakout – Bruce G. Haffty, M.D.
6
GENERAL ABMS GUIDELINES FOR PRACTICE
PERFORMANCE IMPROVEMENT
11. Boards should develop a consistent approach
regarding the status of Maintenance of
Certification© for diplomates who are not involved
in direct patient care.
12. The assessment of physician performance should
begin during residency and continue throughout
practice. The board’s evaluation of physician
performance during residency should be linked to
the six general competencies described by the
ABMS-ACGME.
RO Summit Breakout – Bruce G. Haffty, M.D.
7
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
Evaluation of Performance in Practice
[Assessment of Practice Performance]
Each diplomate is expected to maintain active, professional
involvement in radiation oncology. Individuals and groups are
expected to understand and participate in the concepts of
continuous quality improvement and lifelong learning.
The ABR, like several boards, has struggled to identify
components of its Practice Performance Program (PPP) with
outcomes data and benchmarks in the first cycle of MOC. In
RO Summit Breakout – Bruce G. Haffty, M.D.
8
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
conjunction with our specialty societies, our initial efforts
have resulted in a sophisticated, physician-directed practice
assessment module (PPM) based upon published standards
for the field, including measures directly linked to published
outcomes data. As well, we have encouraged development of
relatively simple, relevant measures of physician practice
clearly related to the process of continuous quality
improvement. Quality improvement is key for a rapidly
developing, technologically oriented medical specialty.
Practice performance modules currently in development (with
the first now in alpha testing) are based upon common central
components of the practice of radiation oncology.
RO Summit Breakout – Bruce G. Haffty, M.D.
9
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
1) Practice Performance Assumptions
 Self-Assessment Modules (SAMs) are essential elements of an overall
PPP in measuring gaps in practice related knowledge and identifying
resources for improvement.
 Hospital privileges within the standards of JCAHO/VAH accredited
hospitals are required for physicians practicing in hospitals because they
are one indicator of acceptable performance in practice. Privileges will
be tracked at regular intervals over the MOC cycle.
 Practice performance modules are specifically designed to be relevant
and applicable in both hospital-based and freestanding radiation oncology
settings. Freestanding radiation oncology practices can employ AAAHC
(Accreditation Association for Ambulatory Health Care) standards.
JCAHO also provides volunteer accreditation processes for ambulatory
care settings.
RO Summit Breakout – Bruce G. Haffty, M.D.
10
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
2) Initial Practice Performance Modules
PPMs are currently in development in response to parameters identified
by the ABR. We anticipate at least two basic modules will be available
at implementation in 2007, and that several additional PPMs will be
proposed for ABR qualification over the next few years. Qualified
PPMs will meet basic ABR requirements for both content and design.
All modules will include feedback to the diplomate regarding his or her
level of performance in comparison to identified standards and his/her
peers, as well as suggestions regarding learning opportunities in areas of
relative weakness. Specific aspects of quality improvement intended to
enhance the individual’s practice performance will be highlighted.
RO Summit Breakout – Bruce G. Haffty, M.D.
11
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
The two practice performance modules currently in development
(ACR’s R-O Peer® and Chart Rounds) were previously
submitted to the ABMS. Alpha testing has been initiated for the
ACR’s R-O Peer®. The largest radiation oncology society
(ASTRO) is studying plans for timely development of the Chart
Rounds PPM. Modules include feedback to the physician,
documenting successful completion, as well as identifying areas
that should be addressed in the context of continuous
improvement. For physicians who do not meet the standards for
successful completion of the PPM, feedback will include areas
of weakness and recommendations for improvement.
RO Summit Breakout – Bruce G. Haffty, M.D.
12
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
3. Meeting Practice Performance Program Requirements
Physicians’ participation in Part IV will be documented through
completion of three (3) PPMs during each ten-year MOC
interval. It is anticipated that diplomates will document
successful completion of one PPM with every three-year period
of MOC. The ABR’s MOC website will include entry to an
individual diplomate password-protected profile. The profile
will document participation in qualified PPMs, including
successful completion, areas identified for improvement, and
action plans that may be required as fundamental components of
quality improvement. In successfully completing the PPM, each
RO Summit Breakout – Bruce G. Haffty, M.D.
13
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
diplomate will be required to file an action plan as part of his/her
personal profile entry for the Practice Performance Program.
Action plans are under development by the ABR, and will allow
the diplomate to identify areas that may require improvement based
upon the results of the required PPMs. A diplomate who fails to
successfully complete a PPM will include in his/her action plan
steps to meet the standards of practice performance; successful
completion of a subsequent PP module within three years will
document improvement. Failure to complete a second PPM will
require the diplomate to file an action plan directly with the MOC
Coordinating Committee for review and monitoring. The
Committee will work with the diplomate to ensure successful
documentation of the action plan within an appropriate time
interval.
RO Summit Breakout – Bruce G. Haffty, M.D.
14
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
4) Performance Assessment Timeline
Year
1
Practice Performance Program (PPP) Timeline
2
3
Documentation of completion of one PPM and filing
of related Action Plan
4
RO Summit Breakout – Bruce G. Haffty, M.D.
15
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
Year
5
Practice Performance Program (PPP) Timeline
6
7
Documentation of completion of second PPM and
related Action Plan. (Any individual unable to
document successful completion of at least one of
the PPMs will file an Action Plan directly with
the MOC Coordinating Committee.)
RO Summit Breakout – Bruce G. Haffty, M.D.
16
ABR SUBMISSION TO ABMS-PART IV
PRACTICE PERFORMANCE SECTION
Year
8
Practice Performance Program (PPP) Timeline
9
Documentation of completion of third PPM and
related Action Plan. (Any individual unable to
document successful completion of at least one of
the PPMs will file an Action Plan directly with
the MOC Coordinating Committee.)
10
(Successful completion of the MOC-CC monitored
Action Plan as may be required; see Year 9 above.)
RO Summit Breakout – Bruce G. Haffty, M.D.
17
FUNDAMENTALS OF PQI PROJECTS
• REFLECT THE ACTIVITIES OF THE DIPLOMATE RELATED TO
PATIENT CARE
• RELATED TO INDIVIDUAL PHYSICIAN PRACTICE
• MEASURABLE ENDPOINTS
• BENCHMARKS, EVIDENCE BASED, CONSENSUS OR PEER
COMPARISON
• ACTION PLAN-FOLLOWUP PLAN FOR IMPROVEMENT
• INCORPORATION OF SIX COMPETENCIES (not all competencies
need to be addressed for each PQI, but over 10 years the six
competencies should be addressed)
RO Summit Breakout – Bruce G. Haffty, M.D.
18
TYPE I vs TYPE II PROJECTS
TYPE I
TYPE II
INDIVIDUAL/INSTITUTIONAL
SOCIETY INITIATED
QUALIFIED BY ATTESTATION
QUALIFIED BY ABR
SUBJECT TO AUDIT
SUBJECT TO AUDIT
UP TO 2 OF 3 PQI MAY BE TYPE I
AT LEAST 1 OF 3 MUST BE TYPE II
MUST MEET FUNDAMENTALS
• INDIVIDUAL DIPLOMATE
• PATIENT CARE RELATED
• MEASURABLE ENDPOINTS
• BENCHMARK OR COMPARISON
• ACTION PLAN
• COMPONENT OF SIX
COMPETENCIES
MUST MEET FUNDAMENTALS
• INDIVIDUAL DIPLOMATE
• PATIENT CARE RELATED
• MEASURABLE ENDPOINTS
• BENCHMARK OR COMPARISON
• ACTION PLAN
• COMPONENT OF SIX
COMPETENCIES
RO Summit Breakout – Bruce G. Haffty, M.D.
19
TYPE I PROJECTS DISCUSSION
• WHAT ABOUT CHART ROUNDS-DOES THAT
COUNT?
• WHAT ABOUT A RETROSPECTIVE REVIEW OF MY
PRACTICE OUTCOMES?
• WHAT ABOUT PRESS-GANEY OR OTHER PATIENT
SURVEYS?
• WHAT ABOUT HOSPITAL OR INSTITUTIONALLY
INITIATED QI PROGRAMS?
RO Summit Breakout – Bruce G. Haffty, M.D.
20
TYPE I PROJECTS DISCUSSION
In my view, any of the above, and other creative programs
that we will discuss may be totally reasonable practice quality
improvement projects. They should, however, meet the
fundamental elements previously discussed, and be formatted
in such a way that there is a clear patient care focus, the
program is being carried out with respect to the individual
diplomats practice, there is a measurable endpoint which is
being compared to some norm (benchmark, consensus, or
evidence based guideline), with an action plan. I have
outlined below a hypothetical “project” and how it might fit
the guidelines for discussion.
RO Summit Breakout – Bruce G. Haffty, M.D.
21
HYPOTHETICAL PHYSICIAN INITIATED
TYPE I PQI PROJECT
Review of patients following mastectomy with positive nodes
• Physician reviews both his own practice and hospital tumor registry
records in patients treated by mastectomy with node positive disease.
(Reflects diplomats activities in patient care)
• He will review his own practice patterns, and referral of patients from
the hospital for post-mastectomy radiation (measurable endpoint)
• He finds that in his own practice, 100% of patients with 4 or more
nodes were offered radiation therapy and 30% of patients with 1-3
nodes were offered radiation (Patient Care-Measurable endpoint)
• He compares this to ASCO and ASTRO guidelines, with which his
practice appears to be consistent (Comparison to Benchmark/
Consensus standard)
RO Summit Breakout – Bruce G. Haffty, M.D.
22
HYPOTHETICAL PHYSICIAN INITIATED
TYPE I PQI PROJECT
• He finds, however, that of patients in the hospital tumor registry with 4
or more nodes, only 50% were referred for radiation therapy after
mastectomy, which is clearly not consistent with ASCO and ASTRO
guidelines (Comparison with standards)
• He also compares his general policies (doses, fields treated, use of
bolus, etc.) to published ACR appropriateness criteria for postmastectomy radiation. (Measurable endpoints –compared to published
standards)
• He is in compliance in general, but treated the full axilla in several
patients who had only 1-3 nodes involved, which was not in
accordance with ACR appropriateness criteria.
RO Summit Breakout – Bruce G. Haffty, M.D.
23
HYPOTHETICAL PHYSICIAN INITIATED
TYPE I PQI PROJECT
• His action plan is two-fold. Modify treatment policy in patients with
1-3 nodes involved to not include the full axilla. He will present data
in a hospital wide forum on the merits of post-mastectomy radiation
in patients with 4 or more nodes, ASCO and ASTRO guidelines.
• Follow-up. He will reexamine in 3 years the referral patterns for
patients with 4 or more involved lymph nodes for post-mastectomy
radiation.
• He will self-attest to the ABR that he conducted this PQI program
and keep a record of his efforts.
• If audited by the ABR, will this program stand up as a legitimate PQI
It should also be noted that the program above incorporates
the majority of competencies (patient care, medical
knowledge, professionalism, systems based practice, practice
based learning, and interpersonal communications).
RO Summit Breakout – Bruce G. Haffty, M.D.
24
OTHER INSTITUTIONAL OR GROUP TYPE I
PROJECTS
Hospital initiated Type I projects
Practice efficiency
Patient satisfaction
Patient safety
Referring satisfaction
These programs, typically developed within an institutional
“QUALITY IMPROVEMENT” programs, may be ideally suited to
qualify for TYPE I initiatives. Provided they meet the essential
elements of PQI which include
Related to individual physicians practice
Related to patient care
Measurable endpoints
Comparable to benchmark, evidence based standard or peer comparison
Action plan for improvement and follow-up plan
Addresses at least some of the six competencies
RO Summit Breakout – Bruce G. Haffty, M.D.
25
OTHER INSTITUTIONAL OR GROUP TYPE I
PROJECTS
Example: As an overall component of their Quality
Improvement Program and Marketing Strategy in a
competitive environment, a Hospital or Group practice with
multiple specialties initiates a multi-specialists-wide program
to evaluate practice efficiency/patient satisfaction, employing
measurable endpoints such as turn-around time of consults,
patient waiting time for consults, time between initial
consultation request and visit, patient and referring
satisfaction. Radiation oncology is included in this program.
At the end of the assessment, the radiation oncologist is
RO Summit Breakout – Bruce G. Haffty, M.D.
26
OTHER INSTITUTIONAL OR GROUP TYPE I
PROJECTS
informed that they scored well in comparison to other
departments, with the exception of patient waiting times.
They develop an action plan to improve patient waiting by
modifying the way in which they schedule consults. Action
plan is also to re-assess patient waiting 6 months after they
modify the scheduling to evaluate impact of action plan.
In my view, this addresses the fundamental elements and
remains within the scope and spirit of the PQI initiatives. It
directly relates to the diplomates practice and patient care, it
RO Summit Breakout – Bruce G. Haffty, M.D.
27
OTHER INSTITUTIONAL OR GROUP TYPE I
PROJECTS
has measurable endpoints, compares to a standard of peer
performance, and includes an action plan and follow-up.
Again, it is easy to also justify how this program addresses
most of the competencies and is perhaps more focused than
the previous Type I example, with respect to professionalism
and interpersonal skills, particularly if patient satisfaction
surveys included some measure of the physician-patient
interaction.
RO Summit Breakout – Bruce G. Haffty, M.D.
28
SOCIETY INITIATED TYPE II PROJECTS
ACR RO-PEER
ASTRO-PAAROT
ABS-IN DEVELOPMENT
RO Summit Breakout – Bruce G. Haffty, M.D.
29
ACR-RO PEER
Developed by the ACR to comply with part IV (PQI) of the
MOC process
Two options within plan
• OPTION 1
o This option will be available as part of the process of a facility
undergoing the current ACR facility accreditation process, as a
separate component of the process
• OPTION 2
o This will be a remote review of cases submitted, and not a component
of the facility accreditation process.
RO Summit Breakout – Bruce G. Haffty, M.D.
30
RO-PEER PROGRAM
• Review of randomly selected cases from a submitted list
• Reviewed by trained reviewers/members of a reviewing
committee-radiation oncologists
• Pre-determined areas, included H&P, treatment summary,
follow-up, physics, etc. will be reviewed
• Compliance in these areas will be evaluated and “scored”
• Acton Plan for improvement will be incorporated
• HIPPA regulations will be adhered to in this process
RO Summit Breakout – Bruce G. Haffty, M.D.
31
ASTRO’s PAAROT PROGRAM
(Performance Assessment for the Advancement of Radiation
Oncology Treatment)
Recently developed by ASTRO and submitted to ABR for
review and comment
• Baseline Performance where 10-15 charts are randomly selected
and specific questions are asked related to the diagnosis, staging
and treatment.
• Answers will be compared to “ideal” answers, and suggestions for
answers that deviate from “ideal” will be made.
• A patient satisfaction survey will be incorporated.
• Physician will select one performance indicator to focus on for
practice “improvement”.
• Re-measurement will be performed to assess effectiveness of
action plan.
RO Summit Breakout – Bruce G. Haffty, M.D.
32
REPORTING AND DOCUMENTATON
Discussion of automated reporting, validation and documentation
of PQI projects
ABR
Society Initiated
Gateway -DI employs this model to coordinate CME and SAM
documentation for diagnostic diplomats in MOC. Various
Societies evidently electronically enter the information into this
central gateway for recording and tracking this information.
Incorporating PQI into this will be discussed. Whether RO can do
something similar with our CME, SAM and PQI will be
discussed.
RO Summit Breakout – Bruce G. Haffty, M.D.
33