1. Maintenance of Certification Group Quality Improvement Project Structure and Outcomes David Serlin, M.D. Jill Fenske, M.D. Grant Greenberg, M.D., M.A., M.H.S.A. December 5, 2014

2. Disclosures None

3. Maintenance of Certification: brief overview Over cycles (and subcycles) of time, evidence of: Part I: Professional standing Part II: Life-long learning and self-assessment Part III: Cognitive expertise (test) Part IV: Evaluation of performance in practice 1. Assessment of Practice performance 2. Communications/Professionalism

4. ABFM Requirements 10 Year Option: (Every 3 years) 1 Part II (SAM) module At least 1 Part IV module Additional Part II module or Part IV module 7 year Option: At least 3 Part II (SAM) modules At least 1 Part IV module Three additional Modules (Either Part II or Part IV Certified or recertified 2003-2010 Certified or recertified 2011 or after Every 3 Years 1 Part II (SAM) module (minimum) 1 Part IV module (minimum) One Additional Part II or Part IV module

5. Part IV- Performance in Practice ABFM options Performance in Practice Modules Alt. Part IV Activities Approval Program –Recognizes that many already participate in QI activities Approved Alternative Part IV Activities* Part IV Activities that do not require continuous patient care –Methods in Medicine Modules –Hand Hygiene Module *See next slide https://www.theabfm.org/moc/index.aspx

6. ABMS Multi-specialty Part IV MOC © Portfolio Program (MSPP)* Collaboration of most ABMS Boards 1. Created common standards for a Part IV QI option 2. Delegate to approved institutions ability to: Designate Part IV credit for their qualifying QI projects Award Part IV credit to physicians participating in those projects 3. UMHS 2 nd institution to be approved (now >30) *approved alternative Part IV for ABFM http://mocportfolioprogram.org/

7. Benefit of ABMS MSPP: align individual and institutional interests Individual physician’s interests Maintain board certification Recognizes QI work they are already doing – not extra work Projects selected for importance rather than convenience Institution provides resources and guidance Institutional interests Advances QI efforts that are priorities for overall functioning Helps maintain physician workforce certification Recognizes QI capabilities and resources of the institution Unit leaders to coordinate longer term plans for ongoing Part IV opportunities as part of overall QI planning [Interest in institutional program, not self-directed or isolated projects] (20-60 hr -> 1 hr) (no cert. = claims denied)

8. MSPP Project Structure 2 linked QI Cycles Identify problem, then: Plan: Collect baseline measure(s) of performance (Data1) Assess underlying causes, consider relevant interventions Do: Intervention Check: Collect post-intervention measure(s) of performance (Data 2) Act/Adjust – Re-Plan: further planning and intervention Re-Do: Intervention Re-Check: Post-adjustment measure(s) of performance (Data 3) Re-Act/Adjust: Further planning (assess underlying causes,...) Comparisons: Simple pre-post research design Patient care: exam & diagnosis, treatment, follow-up exam, adjust treatment

9. MSPP Participation Requirements Must be enrolled in board’s MOC © Program “Meaningful Participation”: Interpreting baseline data and planning intervention Implementing intervention Interpreting post-intervention data and planning changes Implementing further intervention/adjustment Interpreting post-adjustment data and planning changes Complete & sign attestation that includes reflections regarding effect of project & future plans.

10. Project Design The project lead and physician leads meet to review baseline data and discuss root causes and interventions The physician leads meet with physicians in their departments and divisions to review data and get further input The physician leads then incorporate input from physicians and finalize plans for interventions

11. Implementation within Family Medicine Department Family Medicine Population Improvement Group (FPIG) Medical Director Committee

12. FPIG Representatives from all major work groups –Faculty Physicians –Resident Physicians –Nurses –Medical Assistants –Panel Managers –Health Center Managers –Clerical

13. FPIG Design and implement solutions to identified QI concerns and priorities Evaluate and refine those solutions over time

14. Medical Directors’ Committee Physician leaders from our 6 clinical sites Set site based priorities and mesh with departmental and institutional priorities Implement QI projects tasked from FPIG

15. Additional Project Support Structure Team Meetings at each clinical site Standardized MA workflow Training materials: videos, tip sheets EMR support: developing new BPA (best practice advisory), smart-sets, orders Project manager, data analysts

16. Resident involvement in MOC-IV Family Medicine residents now required to complete one MOC-IV prior to graduation Residents included in our process starting 2014 with LDL screening project Ensures credit while providing experience in population management, quality and process improvement

17. Infrastructure – Lessons learned Local leads very helpful Information dissemination – Use multiple modalities GEMBA (leadership walks) and other Lean tools Share best practices across sites

18. Diabetic Neuropathy Screening Project MOC Project for 2013 Perform and document foot exam for all diabetic patients within the last year Identified as a Family Medicine priority as it was a low performing screening metric 38 family physicians participated across 5 sites Goal 85% with up to date exams

19. Baseline Foot Exam Data

20. Root Cause Analysis Physicians and MA’s not realizing patients were due Physicians not performing the exam –No time –No equipment Improper documentation of exam/accuracy of data Difficulty with Patient access

21. Interventions Panel Managers Physicians Medical assistants

22. Panel Manager Interventions Used Gap Reports to perform chart review Identified patients that had exam done but not documented properly Updated data appropriately Identified patients with upcoming appointments and added note to perform exam

23. Medical Assistant Interventions Note patient is due for screening exam Have patient remove shoes and socks Pend foot exam note Provide monofilament Perform monofilament exam(some sites)

24. Physician Interventions Training on the proper way to document the exam(both PCP and specialty) Education on the importance of the exam

25. First Intervention

26. Study/Refine Further education and reminders for physicians and medical assistants Panel Managers to contact patients due to offer appointments

27. Second Intervention

28. One Year Later

29. Conclusions Data accuracy and methodology are critical to success Physicians need help to remember/manage quality of care Appropriately utilizing support staff can have large impact on performance Need continued attention to maintain gains Keep making improvements

30. LDL Screening for High Risk Patients MOC-IV project for 2014 Aim to improve ordering of annual LDL test for patients with Ischemic Vascular Disease, Diabetes and Chronic Kidney Disease Quality Metric for many national programs (HEDIS, CMS, etc.) At time of project design Identified as UMHS priority due to lagging performance

31. Baseline LDL screening rates 75-78%, below HEDIS benchmark of 90-92%.

32. LDL Project Participants > 200 physicians across 6 Departments/ Divisions (Gen Med, Endocrinology, Nephrology, Cardiology, Geriatrics, Family Medicine) Residents and Physician Assistants included for first time as participants Leadership team included: Facilitator (Dr. Greenberg), Physician lead from each department/division (6 total), Project manager, Data/HER analysts

33. Goals 1.Improve LDL screening test rates for patients with Diabetes and IVD to ≥ 92% 2.Use this effort to develop efficient processes (a) for care shared across multiple specialties and (b) that can be applied to clinical care for other conditions

34. Root Cause Analysis Misconception by physicians about the need for fasting labs Lab turning away non-fasting patients Poor capture of outside lab records Suboptimal workflow/process for clinical decision support tool (Best Practice Advisory/BPA)

35. Intervention A new single BPA (best practice advisory) was developed for LDL screening in diabetes and IVD (replacing 2 previous BPAs) New BPA order set defaults to a non-fasting Lipid panel When the BPA is present, medical assistants “pend” the LDL order The physician signs the order if deemed appropriate Physicians, residents and physician assistants who participate in the project can get Maintenance of Certification credit

37. Change in Lipid Guidelines – Should we continue? UMHS formally endorsed new national guidelines recommending moderate or high intensity statin treatment without treating to a target LDL NCQA retired the HEDIS measurement for LDL screening in diabetes

38. Data Check Opportunities report data reviewed by project leads, and physician participants Data shows rates of smart set use, percent of LDL tests ordered and completed testing Variation noted across specialties and clinics

41. Process improvement opportunities Physicians don’t sign order prior to patient check-out Lack of understanding/education about non- fasting option Difficulty with communication about this large project at a local level BPA (best practice advisory) does not fire until patient is overdue (>365 days since last test)

42. Second intervention Adjustments made: Local Leads Release BPA 3 months before “overdue” Video education Emphasis on signing orders during patient encounters

43. LDL Project Outcomes Trend toward increased use of the LDL BPA smart-set and orders placed when due. Orders completed did not improve, suggesting the need for further analysis of the root cause for orders placed, but not completed Overall annualized rates of LDL completion remained stable to minimally improved. Department of Family Medicine overall LDL screening rate was 78% at the end of the project.

44. Ideas for maintenance of improvement for QI gains Lean in Daily Work (weekly posting on team of opportunity report)

45. Future Plans Yearly MOC IV project to provide physicians with maximum credit Financial incentives to reach goals and maintain them

46. Questions or Comments?

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