MOC Part IV Self Directed PIM: Your Guide To Making It Happen

MOC Part IV Self Directed PIM: Your Guide To Making It HappenJoseph P. Drozda Jr., MD, FACC

Mercy Health Richard J. Kovacs, MD, FACC

Krannert Institute of CardiologyCharles R. McKay, MD, FACC

Harbor-UCLA Medical CenterPaul D. Varosy, MD, FACC, FHRS

University of Colorado, DenverVA Eastern Colorado Health Care

System

Melanie Stephens-Lyman (ACCF Contrator)

I just indented their facility name so that the faculty names pop out a little.

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 StatementTo 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”


• 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)

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 ABIMDevelopment of Certification Process

Certification

• Secure exam after completing fellowship

• Lifetime certification with no end date

Pre-

1990

•Certification

Recertification

• Secure exam after completing fellowship

• Time-limited certification with an end date

• Recertification exam every 10 years

1990-

2006

•Recertification

Maintenance of Certification

• 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

2006-•Maintenance of Certification (MOC)

Maintenance of Certification – Four Parts

Maintenance of Certification – 100 Points

100 Points Every 10 years100 Points Every 10 years

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


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


• 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 B1. 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 DataSection 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 MeasuresoNQF endorsedoACC/AHA performance measures

– Process of Care MetricsoUtilization metrics

– Patient Outcome MetricsoAdverse EventsoMortality

Outcome ReportingExecutive 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

Part B – Measures And DataSection 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 DataSection 3 – Enter Baseline Data

ABIM’s Measures Library• Choose a measure set

OR• Submit alternative measures for

approval

Part B – Measures And DataABIM’s Measures Library

Part B – Measures And DataSection 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 DataChoosing Your Measures

Part B – Measures And DataSelecting 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 PlanDownload 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 PlanPreparation

1. Organize a Team2. Target a Measure for

Improvement

Part C – Action PlanPreparation: 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 RegistryColin 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

CV OperationsCardiology/CT Surgery/Vascular Surgery

Nursing, Pharmacy, ED, Administration

CV Outcomes & Quality Committee

PV TEAM

ICDTEAM

AMBTEAM

CV SRGTEAM

AMITEAM

PCITEAM

Each PI team is led by the same coordinator/MD pair

HospitalQuality Committee

PhysicianGroupQuality Committee

SVS

ACTION STS PCI

ICD

PINNACLE

Part C – Action PlanPreparation: 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


# OpportunitiesQuality Impact Criteria

Patient Safety

Patient Outcome

Patient Satisfaction

Financial Impact Improvable Measurable

1 2:2 -Proportion of elective PCIs with prior positive stress or imaging study

High High High High Medium High

2 2:3-Median time to immediate PCI for STEMI patients in (minutes) High Medium Low Low Medium High

3 2:6-Median time from ED arrival at STEMI transferring facility to immediate PCI at STEMI receiving facility among transferred patients.

Low Medium Low Low Medium High

4 2:18-PCI in-hospital risk adjusted mortality (patients with STEMI) Medium Medium Low Low Medium High


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.


• 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


• Choose a single measure to improve• Why did you choose it?• Write a brief problem statement


• 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


• Enter your performance goal into the Self-Directed PIM platform

Part C – Action Plan

Part C – Action PlanStep 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 PlanStep 2: Examine Your Practice Systems

Part C – Action PlanStep 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 PlanStep 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 PlanStep 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 PlanStep 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 PlanResources

• ACC’s Quality Improvement 101 Toolkithttp://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

•ICD Registry Data•2 years “Rolling 4 quarter (R4Q)”

•2012Q3•2011Q3

An Actual Self-Directed PIM:University of Colorado Hospital – NCDR-ICD

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


81.3%

Proportion Receiving IV Antibiotics Prior to Surgery (ICD Implantation)


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 credit20Part IVMOC

20Part IVMOC

Documents

MOC Part IV Self Directed PIM: Your Guide To Making It Happen