• Primer on PI Activities

    A Primer on ABEM MOC APP Practice Improvement Requirements

    All Assessment of Practice Performance (APP) Practice Improvement (PI) activities must follow four steps: measure, compare, improvement intervention, and re-measure.

    The initial sample involves looking at ten or more patients with a specific condition or clinical situation. Measurements can involve any core measure (such as assessing oxygenation for the patient with community-acquired pneumonia) or patient demographic metric (patients who leave without being seen).

    If the emergency department (ED) or your physician group is looking at patients with low-frequency, high-acuity conditions (such as acute myocardial infarction, stroke, or neutropenic fever), then fewer than ten patients is acceptable as long as some of your patients are included in the measurement group.

    In most cases, your data will be incorporated into department-wide initiatives. It is acceptable to use group data if that is the primary metric by which improvement is being measured. Still, individual performance data is typically the most effective information to assess your knowledge and skills.

    When national benchmarks are available, they should be used for comparisons to your data. Other outcome targets might be found in peer review publications. For measures for which there are no readily available benchmarks, the first measure set can be used as a baseline for future comparison. Nonetheless, there should be a clearly defined metric to monitor change in performance.

    Improvement Intervention
    Improvement interventions can be as simple as reporting results at a department meeting with suggestions for improvement, or as elaborate as a LEAN intervention (e.g., a Kaizen event). The key element is that the individual physician chooses to amend his or her behavior to improve performance. Other forms of intervention could be a topic-specific journal club, monthly posting of data in the ED, or the development of condition-specific treatment guidelines (e.g., instituting a pediatric asthma protocol).

    The general guidelines for re-measurement are the same as those described in the measurement section above. The re-measure set should be compared to the initial set to determine the trajectory of performance. ABEM realizes that not every initiative will result in performance improvement, but the vast majority should better patient care processes or outcomes.

    Attesting to Your Activity
    Data-free Attestation
    ABEM requires that you attest to completing an APP activity using the aforementioned criteria. ABEM will not accept any patient data. As part of the attestation process, you will be asked to provide the name of someone familiar with your quality initiative who can verify that you have participated in the activity (such as a department chair or medical director).

    Ongoing Projects
    Many ED quality initiatives span a considerable length of time. For example, core measure adherence could extend for years. Tracking door-to-doctor times and patients who leave without being seen are also long-term, widely used metrics. Though APP attestations are generally required every five years, there are times when you might want to attest to completing an APP activity every year, such as when applying for PQRS MOC enhanced reimbursement through CMS (click here for more information about this topic). You can report an ongoing activity every year during which the initiative is active.

    Case Studies in MOC
    Below are four cases that emphasize certain common quality improvement scenarios that would meet APP requirements.

    Case 1: Core Measures
    Your ED is tracking statistics for adherence to Core Measures for community acquired (bacterial) pneumonia (CAP) for the entire physician group. Every three months it discusses the group performance at the Department of Emergency Medicine meeting. At the most recent meeting, it was reported that several patients did not have vital signs documented. There was a discussion about where to chart the vital signs taken in triage so that they could be better seen (or noticed if it is absent). At the next department meeting, the frequency of documentation of vital signs for CAP was reviewed for the time after the implementation of the new triage process.

    Case 2: Door-to-balloon Six Sigma Project
    Your ED has long door-to-balloon (DTB) times. Almost 40% of cases exceed 90 minutes. Using Six Sigma processes, the hospital forms a team to evaluate and redesign the care of the STEMI patient. The Six Sigma team works with the interventional cardiologists and the cath lab staff to redesign your processes for DTB times. Though you are not a member of the redesign team, you will be following the new treatment protocols and cath lab activation processes. In the ED break room or staff lounge, previous DTB times are posted. Last night, you cared for a STEMI patient and noticed that the DTB time for that patient is posted in the break room. The DTB time was 48 minutes.

    Case 3: EKG-to-read Times
    You work at a rural hospital with low ED volumes. During the last department meeting, while doing peer review quality audit, you reviewed a case of a patient who had an EKG that showed ischemic changes that did not get seen for a long time. You and your colleagues decide to measure the time from the completion of the EKG to the time that it is reviewed by an emergency physician. The EKG machine prints the paper copy of the EKG with the time on it. The ED staff hands you the EKG and you place your initials on it. At the next department meeting, each physician is given the mean time from EKG to interpretation as well as his or her own performance times. Some of the EKGs do not have initials on them, and finding out who cared for the patient takes considerable effort. You discuss improving the EKG-to-read times. Two decisions are made: 1) a stamp is created for the EKG, and 2) the staff is instructed to interrupt you to hand you the EKG to look at immediately. The stamp provides a place for the time you review the EKG and a place to insert your initials. After two months, the new system is reviewed and EKG-to-read times are shorter.

    Case 4: Throughput Times
    You work at a small community hospital. A patient recently collapsed in your crowded ED on a Monday evening. It is felt that the throughput times for the ED are too long and might have contributed to this incident. The nearly 1,400 throughput times for the past month are reviewed. The average time for a discharged (non-admitted) patient is three hours and 54 minutes. At your department meeting you plan to revise your triage process and “lab-back” notification process. The monthly trends over the next three months are reviewed. Even though the interventions are department-based and not physician-specific actions, you were part of the brainstorming session that identified the interventions. With these two processes in place, you reduce throughput times by an average of 19 minutes. You plan to bring up more ideas to your next department meeting.