Transcript Maintenance of Certification: PQI

PQI Summit Conference and Workshop
Dallas, TX
August 18, 2007
Part IV: Roles for Societies/Leaders:
Education/Commitment
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Educational courses, SAMs on Part IV
Workshops on subtopics of PQI
Identify key PQI focus areas
New/additional guidelines, metrics
Provide PQI tools, project templates
Work with other societies on database
development
Sharing with other societies
what we are asking from
…..Society
PQI projects development ..partnering with
the ABR
Emphasize safety, error reductions,
opportunity to improve quality
SAMS Course on how to reduce errors,
improve safety and improve quality
Website links to yours involving lectures,
programs for all diplomates
Where do we go from here?
PQI Summit Conference and Workshop
Dallas, TX
August 18, 2007
PQI Summit Conference and Workshop
Dallas, TX
August 18, 2007
PQI Summit Conference and Workshop
Dallas, TX
August 18, 2007
Changes will occur!
PQI will evolve
Programs will develop
“Getting Real with Practice
Qualty Improvement”
Diversity of Practice; DR, RO,
RP
Overview Questions
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Why did you choose the project?
How did you decide on the metric?
How will your Society sponsor it?
– Is it a template?
How will data be collected and recorded?
Do you anticipate multiple projects?
Action ideas
Insights/issues
PQI Summit Conference Workshop
Radiation Oncology
Bruce Haffty, M.D., ABR Moderator
 American
Society for Therapeutic Radiology and
Oncology: Performance Assessment
– Kathy Thomas, M.D.
 American Brachytherapy Society Project
– W. Robert Lee, M.D.
 Type I Project
– Peter Johnstone, M.D.
– Jonathan Beitler, M.D.
Overview Questions
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Why did you choose the project?
How did you decide on the metric?
How will your Society sponsor it?
– Is it a template?
How will data be collected and recorded?
Do you anticipate multiple projects?
Action ideas
Insights/issues
PQI Summit Conference Workshop
Radiology Physics
Richard Morin, PhD, ABR Moderator
American Association of Physicists in Medicine
– Michael Yester, PhD
 ABR Trustees: Templates for Type I Projects
– Richard Morin, PhD
– Geoff Ibbott, PhD
– Donald Frey, PhD
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Overview Questions
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
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Why did you choose the project?
How did you decide on the metric?
How will your Society sponsor it?
– Is it a template?
How will data be collected and recorded?
Do you anticipate multiple projects?
Action ideas
Insights/issues
Why PQI?
To demonstrate that radiologists use
measures of quality in their practice
To continuously improve the quality of
radiologic practice in the U.S.
To respond to public outcry for better
patient safety standards and to improve
the quality of care in all of medicine
ABR DIPLOMATES
Life-Time Certification
Time-Limited Certification
(11,000)
Optional Entry MOC
MUST
Entry MOC
Yes
Personal Commitment
State Requirement
Hospital Requirement
Desires not to recertify
ABR’s Components of MOC
Part I: Professional Standing
Part II: Lifelong Learning and Periodic
Self-assessment
Part III: Cognitive Expertise
Part IV: Practice Quality Improvement
Why do we need Part IV:
PQI?
Huge variations in care at local,
regional and national levels
Regional differences in cost/outcomes
Lack of evidence based practice
Reduce errors, improve patient safety
Why do we need database?
Need to know our baseline at a
national level
Public disclosure of quality
measurement data lead to
improvements in quality of care
Analyzing the System Flaws
Almost all improvable errors result from
flawed systems
Identify areas where breakdowns occur
Create a feasible plan to fix these areas
Institute plan
Wait a suitable time—new system “up and
running”
Remeasure original metric
Part IV: Practice Quality
Improvement (PQI)
Focus on practice improvement
Potential areas (select ONE):
Patient safety
Accuracy of interpretation
Referring physician surveys
Report turnaround time
Compliance with established Practice
Guidelines and Technical Standards
Patient Safety
National Patient Safety Goals
- Hand-hygiene
- Medication error prevention
- Universal protocol
- Patient identification
- Improve communication between caregivers
Radiology specific error reduction programs
- Radiation dose
- MR safety
- Safe use of contrast material
- Others
PQI Process
Learn about PQI ….2007 year
Select project appropriate for you, in your
practice, or one from a national society
Measure certain percent of cases
Review and analyze data
Create and implement improvement plan
Re-measure and track
Report participation to ABR
PQI Timeline & Milestone Tracking
Diagnostic Radiology Diplomates
Year of
Cycle
What I must do each year of 10-year MOC cycle
Submit report / attestation via
the Personal Web Page
1
Learn about PQI
 Select a project
2
Measure
 Analyze the data
Yes
3
 Develop an improvement plan
 Begin collecting data again
Yes
4
Modify improvement plan
Implement plan
Begin collecting improvement plan data
Yes √
Yes
PQI Project Type
Local level/ group/department/individual
Physicians compare performance against
own baseline
Some comparison among peers
Normative databases lacking
Sponsored by national specialty society
or organization
Regional or national database participation
Benchmarking
Feedback
Provider Performance Based
Privileging Plan: CCHMC
DEPARTMENT OF RADIOLOGY
Provider Performance Based Privileging Plan
JCAHO-ACGME-ABMS 2007-2008
Clinical
Division
Division
Director
1/1/07 thru
12/31/08
Standard
Professional Performance
Behaviors reflecting a
commitment to continuous
professional development,
ethical practice, cultural
competence, and a responsible
attitude toward patients,
families, colleagues and care
teams
Performance Measures
 PALS certification or Radiology Advanced
Life Support Certification
 CPR Certification (by end of FY2008 and then
each year forward)
 Meets CME requirements to maintain Ohio
license
 Zero violations of “Hold Point” Procedure for
invasive procedures
 Unapproved abbreviations: Mean of < 0.001%
for use of “CC” discovered via Radiology
report monitoring system
 Fellow evaluations of faculty performance in
category “Role Model for Professionalism”
(Acceptable = score of 3 .0 or 4.0)
 Meets CME requirements to maintain Ohio
license
 Completion of JCAHO Patient Safety test
Part IV: Roles for Societies/Leaders:
Education/Commitment







Educational courses, SAMs on Part IV
Workshops on subtopics of PQI
Identify key PQI focus areas
New/additional guidelines, metrics
How-to workshops for diplomates
Provide PQI tools, project templates
Work with other societies on database
development
Part IV: Roles for Leaders/ Professional
Societies:
Communication
Share descriptions about MOC/PQI
PQI projects/project leadership
Give feedback to ABR members
Participate in building the future
Discuss value added for members
Quality in what we do!
ABMS General Competencies
Medical knowledge
Patient care
Interpersonal and communication skills
Professionalism
Practice-based learning and improvement
Systems-based practice
ABR
Part I
Professional
MOC:
the 4
Standing
Part II
Part III
Lifelong Learning and
Cognitive
MOC
Components
&
the 6
Self-assessment
Expertise
Part IV
Practice
Competencies
Performance
Medical
Knowledge
State board license
requirements and
actions
Documentation and completion
of 500 CME credits. Minimum of
250 Category 1.
Achieve a passing
score on the ABR
cognitive exam.
Patient Safety
Double Reading
Practice Guidelines
Patient Care
State board license
requirements and
actions
Documentation: CME with review
of new techniques and protocols.
Achieve a passing
score on the ABR
cognitive exam,
which includes
patient care content.
Patient Safety
Double Reading
Turnaround Time
Practice Guidelines
Referring Physician Survey
Interpersonal &
Communication
Skills
Patient Safety
Double Reading
Turnaround Time
Practice Guidelines
Referring Physician Survey
SAMs with emphasis on
communications.
SAMs content on
professionalism.
General questions
about ethics and
charter on
professionalism
Practice Guidelines
Referring Physician Survey
Practice-based
Learning
&
Improvement
Specific CME and SAMs
developed for practice-based
learning and improvement.
General questions
about essential core
knowledge and
practice
improvement
principles.
Patient Safety
Double Reading
Turnaround Time
Practice Guidelines
Referring Physician Survey
Systems-based
Practice
Specific CME and SAMs
developed for systems-based
practice.
General questions
about CQI content.
Patient Safety
Double Reading
Turnaround Time
Practice Guidelines
Professionalism
State board license
requirements and
actions
DEPARTMENT OF RADIOLOGY
Provider Performance Based Privileging Plan
JCAHO-ACGME-ABMS 2007-2008
Clinical
Division
Standard
Performance Measures
Interpersonal/Communication  Number of parent, patient & coworker
Skills Enable the establishment
complaints to Radiologist in Chief concerning
and maintenance of
behavior, communication & professionalism
professional relationships with
(Acceptable < 1 per year)
patients, families, colleagues,
and care teams
 Fellow evaluations of faculty performance in
category “Effective Communication Skills”
(Acceptable = score of 3 .0 or 4.0)
 Fellow evaluations of faculty performance in
category “Role Model for Interacting with
Patients & Families” (Acceptable = score of 3
.0 or 4.0)
 Completion of CARES customer service
standards test
 Zero violations of Policy for documentation
and communication of changes between final
and preliminary reports
 MD report sign off in 24 hours (Acceptable
compliance rate = 95%)
Medical/Clinical Knowledge
 Assign & de-identify imaging studies for
Why PQI?
To demonstrate that radiologists use
measures of quality in their practice
To continuously improve the quality of
radiologic practice in the U.S.
To respond to public outcry for better
patient safety standards and to improve
the quality of care in all of medicine
How to Do PQI?
Steps in the PQI process
Select a practice area to be improved
Determine the quality measurement(s)
and collect baseline data in target area
Analyze the practice processes that
impact on the target area
Devise an improvement plan
Institute the plan and remeasure data
Report your findings
For more information:
Papers on ABR MOC published in all major
radiology journals May 2007.
www.TheABR.org
Project Selection
Test of FIRE—projects should be
Feasible
Interesting
Relevant
Ethical
Project Selection
Five areas defined by ABR
Patient safety
Accuracy of interpretation
Report turnaround time
Practice guidelines/technical standards
Referring physician surveys
Project Selection
Diplomates may choose any project
Devised by a national society (must be
qualified by ABR)
Devised by a group practice
Devised by the practitioner
Like SAMs, CME, and the cognitive exam,
PQI projects are the responsibility of the
individual whether collaborating with a
larger group or not
Choosing the Metric
Should be a reliable indicator of quality
Should be easy to measure
Unambiguous
Reproducible
Should be measured enough times
Appropriate to frequency in practice
Target: 10 minimum, 100 maximum
what we are asking from
…..Society
PQI projects development ..partnering with
the ABR
SAMS Courses on How to do PQI projects
SAMS Course on How to reduce errors,
improve safety and improve quality
Website links to yours involving lectures,
programs for all diplomates developed by
your society
Analyzing the System Flaws
Almost all improvable errors result from
flawed systems
Identify areas where breakdowns occur
Create a feasible plan to fix these areas
Institute plan
Wait a suitable time—new system “up and
running”
Remeasure original metric
Accuracy of Interpretation
National program, such as ACR RadPeer
ABR DIPLOMATES
Life-Time Certification
Time-Limited Certification
(11,000)
Optional Entry MOC
MUST
Entry MOC
Yes
Personal Commitment
State Requirement
Hospital Requirement
Desires not to recertify
Why Participate?
May be required by
- Health system
- Payers
- State medical license
Pay for performance
To improve your practice
It’s the right thing to do
ABR Pediatric
Subspecialty Certification
(CAQ)
Time-Limited Certification
in DR
Time-Limited Certification
in subspecialty in pediatrics
Entry MOC
Recertify DR only
Entry MOC
Recertify
Pediatric and DR
Practice Profile
Examination
Desires not to recertify
Recertification
Pediatric Radiology and DR
ABR Pediatric Radiology
Subspecialty Certification
(CAQ) MOC
Life-Time Certification
in DR
Time-Limited Certification
in subspecialty in pediatrics
Optional Entry MOC
Entry MOC
(CAQ)
Yes
Personal Commitment
State Requirement
Hospital Requirement
Desires not to recertify
Recertification in
pediatric radiology and DR
ABR Life-Time Certification
Life-Time Certification
Enrolled in MOC
Life-Time Certification