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 SelfDirected 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 Pre1990 19902006 • Certification • Recertification • Maintenance of Certification (MOC) 2006 Certification Pre- • Certification 1990 • Secure exam after completing fellowship • Lifetime certification with no end date Recertification 1990- • Recertification 2006 • Secure exam after completing fellowship • Time-limited certification with an end date • Recertification exam every 10 years Maintenance of Certification • Maintenance of Certification (MOC) 2006- • • • • 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 100 Points Every 10 years 20 points Part II 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 qualityimprovement work using a standardized webbased 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 outpatient 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/productinfodemo-ordering.aspx • The Self-Directed PIM tutorial is at: http://www.abim.org/moc/earning-points/productinfodemo-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 • PINNACLE 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 Coordinator paired with Physician “Champion” for each database CV Program Quality Structure and Processes Hospital Quality Committee CV Operations Cardiology/CT Surgery/Vascular Surgery Nursing, Pharmacy, ED, Administration CV Outcomes & Quality Committee PV TEAM SVS Physician Group Quality Committee Each PI team is led by the same coordinator/ MD pair ICD TEAM AMI TEAM CV SRG TEAM ACTION STS AMB TEAM PCI TEAM PINNACLE PCI 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 # 1 Opportunities 3 4 Patient Outcome Patient Satisfaction Financial Impact Improvable Measurable High High High High Medium High High Medium Low Low Medium High Low Medium Low Low Medium High Medium Medium Low Low Medium High 2:2 -Proportion of elective PCIs with prior positive stress or imaging study 2 Patient Safety 2:3-Median time to immediate PCI for STEMI patients in (minutes) 2:6-Median time from ED arrival at STEMI transferring facility to immediate PCI at STEMI receiving facility among transferred patients. 2:18-PCI in-hospital risk adjusted mortality (patients with STEMI) 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 SelfDirected PIM platform Part C – Action Plan STEP 1 • Identify the Root Causes of Your Measured Performance STEP 2 • Examine the Current State of Your Practice Systems STEP 3 • Propose a Change in Your Practice System STEP 4 • 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 – Action Plan Step 3: Propose A Change In Your Practice System • 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 – Action Plan Step 3: Propose A Change In Your Practice System 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/QualityPrograms/PINNACLE-Network/Quality-and-PerformanceImprovement/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 50th percentile benchmark: 90.5% Proportion With LV Systolic Dysfunction Discharged with ACEI or ARB • 2-year Data: – UCH NCDR Data: 70.0% – National 50th percentile benchmark: 81.3% Proportion Receiving IV Antibiotics Prior to Surgery (ICD Implantation) • 2-year Data: – UCH NCDR Data: 98.9% – National 50th 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 2nd 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
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