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

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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

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Joseph P. Drozda Jr., MD, FACC
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Overview

• History Role of the ABIM
• ABIMs Maintenance of Certification Process
• MOC Part IV PIM Options
• What, Why, Who, When, Where and How of ABIMs
  Self-Directed PIM
• Part A Orientation
• Part B Measures and Data
• Part C Action Plan
• Part D Re-Measurement
• Part E Completion and Credits

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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

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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. (gt200,000 ABIM Board Certified physicians)

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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)

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History Role of the ABIMDevelopment of
Certification Process
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Certification

• Secure exam after completing fellowship
• Lifetime certification with no end date

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Recertification

• Secure exam after completing fellowship
• Time-limited certification with an end date
• Recertification exam every 10 years

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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

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Maintenance of Certification Four Parts
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Maintenance of Certification 100 Points
100 Points Every 10 years
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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

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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

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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)

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Richard J. Kovacs, MD, FACC
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What, Why, Who, When, Where and How of PIMs

• What is ABIMs 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 ABIMs Self-Directed PIM?
• How do I complete a Self-Directed PIM?

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What Is ABIMs Self-Directed PIM?

• Generic PI module that allows physicians to
  report on quality/performance improvement
  activities being implemented in any specialty or
  sub-specialty

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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

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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

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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

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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

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When Should I Complete A PIM?

• Takes a minimum of 3 months
• Recommend starting at least 6 months prior to
  expiration of certification

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Where Can I Find ABIMS 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-directed58A

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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 ACCs 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

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Charles R. McKay, MD, FACC
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Part A Orientation
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Part B Measures and Data
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Part B Measures and Data

• Three sections of Part B
• Tell us about your care setting
• Select care setting (IP or OP)
• Describe your data
• Reporting period
• Where did baseline data come from?
• Enter baseline data

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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

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Where Do I Find The Outcome Report?

• On NCDR.com
• Via secure log-in
• Registry specific
• Under the Dashboard tab

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Executive Summary Review

• Rolling 4 quarters (R4Q)
• Most significant measures/metrics included in the
  Executive Summary
• Measures and Metrics are organized by
• Performance Measures
• NQF endorsed
• ACC/AHA performance measures
• Process of Care Metrics
• Utilization metrics
• Patient Outcome Metrics
• Adverse Events
• Mortality

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Outcome ReportingExecutive Summary And Detail
Section

• Executive Summary

• Detail Section

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Where Is The Data Value And Sample Size?
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A Closer Look At The Details . . .
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NCDRs 4-Part Data Quality Program

• Training and Clinical Support Team
• Orientation webinars
• Online FAQs
• Live customer support
• Email
• Monthly webinars
• Annual meeting with case reviews, etc.
• Data Entry Integrity
• Software value checks
• Field level range parameters
• ParentChild fields
• 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
• Data Accuracy
• Upto 650 records are audited annually.

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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)

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Part B Measures And DataSection 3 Enter
Baseline Data

• ABIMs Measures Library
• Choose a measure set
• OR
• Submit alternative measures for approval

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Part B Measures And DataABIMs Measures Library
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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

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Part B Measures And DataChoosing Your Measures
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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

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Submitting Alternative Measures For Approval
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Enter Baseline Performance Data For Your Measures
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Richard J. Kovacs, MD, FACC
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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

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(No Transcript)
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Part C Action PlanPreparation

1. Organize a Team
2. Target a Measure for Improvement

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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

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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
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CV Program Quality Structure and Processes
CV Operations Cardiology/CT Surgery/Vascular
Surgery Nursing, Pharmacy, ED, Administration
Physician Group Quality Committee
Hospital Quality Committee
Each PI team is led by the same coordinator/MD
pair
CV Outcomes Quality Committee
PV TEAM
ICD TEAM
AMI TEAM
PCI TEAM
AMB TEAM
CV SRG TEAM
SVS
ICD
ACTION
STS
PCI
PINNACLE
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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

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Part C Action PlanPreparation 2. Target A
Measure For Improvement
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Part C Action PlanPreparation 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.
Opportunities Quality Impact Criteria Quality Impact Criteria Quality Impact Criteria Quality Impact Criteria Quality Impact Criteria Quality Impact Criteria
Opportunities Patient Safety Patient Outcome Patient Satisfaction Financial Impact Improvable Measurable
1 22 -Proportion of elective PCIs with prior positive stress or imaging study High High High High Medium High
2 23-Median time to immediate PCI for STEMI patients in (minutes) High Medium Low Low Medium High
3 26-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
4 218-PCI in-hospital risk adjusted mortality (patients with STEMI) Medium Medium Low Low Medium High
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Part C Action PlanPreparation 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

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Part C Action PlanPreparation 2. Target A
Measure For Improvement

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

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Part C Action PlanPreparation 2. Target A
Measure For Improvement

• Guidelines for setting a realistic performance
  goal
• Self-comparison
• Referencedbased (performance by other
  organizations)
• Benchmarking/Best Practice
• Use of NCDR reports
• Examples absolute number, increase/decrease

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Part C Action PlanPreparation 2. Target A
Measure For Improvement

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

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Part C Action Plan
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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

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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

continued
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Part C Action PlanStep 2 Examine Your
Practice Systems
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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

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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

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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

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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

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Part C Action PlanResources

• ACCs Quality Improvement 101 Toolkit
• http//www.cardiosource.org/Science-And-Quality/Qu
  ality-Programs/PINNACLE-Network/Quality-and-Perfor
  mance-Improvement/QI-101-Toolkit.aspx
• Other QI approaches
• Six Sigma (DMAIC)
• Institute for Healthcare Improvement (FOCUS-PDSA)
  www.ihi.org

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Paul D. Varosy, MD, FACC, FHRS
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An Actual Self-Directed PIMUniversity of
Colorado Hospital NCDR-ICD

• ICD Registry Data
• 2 years Rolling 4 quarter (R4Q)
• 2012Q3
• 2011Q3

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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
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Proportion Meeting Class I or II Guideline
Indications

• 2-year Data
• UCH NCDR Data 83.2
• National 50th percentile benchmark 90.5

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Proportion With LV Systolic Dysfunction
Discharged with ACEI or ARB

• 2-year Data
• UCH NCDR Data 70.0
• National 50th percentile benchmark 81.3

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Proportion Receiving IV Antibiotics Prior to
Surgery (ICD Implantation)

• 2-year Data
• UCH NCDR Data 98.9
• National 50th percentile benchmark 100

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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 didnt get credit
  for receiving ACEI/ARB
• Inadequate physician Documentation
• Present in 40 of the patients that failed to
  meet guideline-based indications

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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 NCDRs algorithm
• Example Hypertrophic cardiomyopathy

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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

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Understanding the Data Key Issues We Need to
Tackle

• Quality of Physician Documentation (completeness)
• Fidelity of Data Abstraction
• Improving Discharge prescriptions

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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

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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

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Remeasurement

• Will reexamine the same three metrics with the
  NCDR Report at the end of 2nd Quarter, 2013
  (2013Q2)

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Completion of ABIM MOC Self-Directed Performance
Improvement Module

• MOC Credit for ALL 7 EP Faculty Physicians!

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Joseph P. Drozda Jr., MD, FACC
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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

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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

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