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
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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-
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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
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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
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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?
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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
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NCDR Cath/PCI Registry
Robin Zwinski, RN; Cindy Humphrey, RN; Elisabeth Von der Lohe, MD
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Society of Thoracic Surgeons (STS)
Larissa Berty, RN and Arthur Coffey, MD
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ACTION / GWTG
Tricia Helms, RN and Richard Kovacs, MD
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PINNACLE
Rachel Nation & Richard Kovacs, MD
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ICD Registry
Miriam Lowe and William Groh, MD
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TAVR Registry
Colin Terry; Anjan Sinha, MD and Arthur Coffey, MD
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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
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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
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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
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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
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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
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Part IV
MOC