EM Leaders Discuss ABEM’s Maintenance of Certification Program

March 2010

In late December, the American Board of Emergency Medicine (ABEM) sent out letters to its diplomates outlining the process for Part 4 of its Maintenance of Certification program.

ACEP does not set the requirements or mandate the process of continuous certification. However, because many ACEP members expressed confusion about the ABEM letter, ACEP leaders wanted to try to help clarify the process for its members.

ACEP President-Elect Sandy Schneider, MD, had a conversation with ABEM President Debra Perina, MD, to pose some of the questions asked by ACEP members and to give them some ideas about how to best complete the Part 4 section.

Dr. Sandy Schneider, ACEP President-Elect: The letter sent by ABEM outlines the requirements for Part 4 of the Maintenance of Certification (MOC) program. This mailing has been confusing to some and received some negative reaction. Can you tell me where the letter came from and the background behind these requirements and the timing?

Dr. Debra Perina, ABEM President: The American Board of Medical Specialties (ABMS) is the organization that oversees ABEM and the other 23 medical specialty boards. The ABMS set written requirements to guide MOC programs. All 24 ABMS member boards, including ABEM, must develop a MOC program. Each specialty can add additional specificity in their requirements consistent with the practice in their specialty. This program was developed in response to the patient safety movement, consumer advocacy groups, and the federal government asking for transparency and accountability in the physician ongoing education and credentialing process.

SS: Is it correct to say that the public is asking for more accountability regarding continuing medical education, even between board examinations?

DP: That’s correct. I know that ACEP and the emergency medicine community have been following testimony in House and Senate hearings from consumer advocates requesting assurances that physicians remain competent throughout the course of their practice. The public is questioning boards that test sporadically or in some cases offer lifetime certification.

SS: I remember getting a lot of information about this, some of which I read and some of which I didn’t. The new process looks different to me. Can you explain what has changed?

DP: Nothing has actually changed. I am an emergency physician and I know that, like my colleagues, I pay attention to those things that are in my immediate frame of reference. For the last several years, this has been a concept, not a reality. The very detailed letter that went out on Dec. 30, 2009 was meant to explain to every Diplomate their individual responsibility from this point forward. Our past communication outlined the Part 4 requirements and that it would begin in 2010; however we had not provided any specific personalized detail until this letter was mailed. For several years, we made general statements about the future of the program. Now we have more detail.

SS: Can you break this down so we can understand exactly what is going to happen? I see there are two parts. Start with the patient communication survey.

DP: The Communications Professional Activity must be conducted one time in your 10-year cycle, which starts at the point when you are certified or re-certified. At one time during that 10-year cycle, each physician must complete an activity related to communication and professionalism. There are multiple ways you can meet that requirement. If your hospital uses Press-Ganey and your patients are included in the results of that survey, you can use those results to meet this requirement. Many hospitals use that or other surveys to study communications between the physician and the patient. Acceptable surveys for Part 4 activities must include questions and measure communication/listening, providing information, and showing concern for the patient.

SS: My hospital uses Press-Ganey. Can I use the score from my department or do I have to do more?

DP: It depends on the specific feedback you are receiving. If you are getting feedback related to your practice in particular, it would be applicable. It depends how the survey is structured because some hospitals give you specific feedback and some don’t. Many hospitals have the information but just don’t drill down to that degree. You should definitely ask for specific feedback as a starting point.

SS: My hospital has that information. I have asked for it and they have given it to me.

DP: Then that would certainly count.

SS: What if I work in multiple emergency departments? Do I have to get surveys from each, or can I just pick one?

DP: Pick one. You do not need one from each emergency department you work in.

SS: What if my hospital doesn’t have Press-Ganey or a similar survey?

DP: There are a number of things you can do. Some groups actually have someone who follows-up with patients, either randomly selected or some sub-segment of patients, such as those who left against medical advice. These callers often ask patients about the communication they received and the experience they had. They compile the responses and give it back to the group. If ten of your patients were included, that would count. You could also create a four or five question survey that covers the communication categories mentioned previously and ask 10 patients to complete it and return it to you. Their responses would count because you are assessing your ability to communicate with those patients.

SS: What is the value of this? What do I hope to learn from doing this?

DP: Much of communication is perceptive. We may feel we are adequately communicating with our patients but they may or may not hear what we are saying or believe that we are effectively communicating. This provides an opportunity to get a reality check on how well we are communicating with our patients. It is good medicine. As we know, communication can go a long way towards preventing bad outcomes. It can also improve patient satisfaction, which can help in avoiding adverse outcomes.

SS: I can understand how people, if they have not done this in the past, could be anxious about it. However I think once physicians participate in this activity, they'll be surprised at how helpful the information will be in assessing their communication skills and even helping to improve them.

DP: And that’s exactly why ABMS included this criteria in the MOC, and why ABEM is behind this 100%. We can all improve our communication skills. We take it for granted that we communicate effectively. However, that may not always be the case. And we need to know if our patients feel good about the exchange of information.

SS: Let’s talk about Quality Assurance.

DP: The Patient Care Practice Improvement Activity is a four-step process that you have to complete twice during your 10-year cycle. You collect data that reflects what you are doing with your patients now. Then you compare that data to evidence-based guidelines. This allows you to assess where you are in your practice and answer questions like "Am I where I want to be?" and "Am I doing what I want to do?" If you are hitting those benchmarks, that’s great. You can move on to look at something else. But if you are not hitting those benchmarks, you have the chance to develop a plan to do things a little better. Once you develop the plan and implement some new strategies, you then go back and resurvey 10 patients to see if you have improved things.

A perfect example is the ubiquitous aspirin in suspected STEMI. You want to give aspirin to those patients 100% of the time. We know many hospitals are looking at this initiative and giving feedback on patients that should have received aspirin. If you are missing patients, you need to consider and plan for how to remember to give aspirin the next time. You resurvey, or in this case the hospital will resurvey for you. This allows you to determine whether you are improving your efforts at giving aspirin to chest pain patients. This is one very clear example of a qualifying activity that physicians are already doing.

SS: My group is doing that with pneumonia patients who should receive antibiotics every 4 hours. Every time I am over 4 hours, I receive a "ding" that asks me why I have gone over 4 hours. I could gather, or better yet, have my group gather, the information and provide it to me. Looking at the misses overall might help me to better meet those targets in the future.

DP: Exactly right. And that would meet the criteria. These two examples, pneumonia and aspirin for chest pain, would count and I suspect many practitioners are collecting data on of those right now.

SS: My group is also interested in length of stay. We have been working on this for quite some time. If I had group data that dealt with length of stay, and I knew how my group was doing with length of stay, would that count?

DP: As long as that group data in aggregate contained your patients.

SS: So I would not have to hunt up and figure out which of the 2,000 patients we treated were mine?

DP: Correct. As long as you know your patients were included in the 2,000 and your group as a whole discussed this initiative, created some benchmarks, implemented changes as a group, and re-measured for progress, this would count.

SS: Do I have to submit my data to you?

DP: No. We do not want your individual data. We believe most practitioners are engaged in qualifying activities already. We are only asking that you attest to the fact that you are doing these types of projects. We will then ask you to give us the contact information for someone who can verify that you are doing this data collection, individually or as part of a group. This maybe the QI director of your group, the director of the group, or whoever in your institution is collecting the data and providing it to you so you can react to it. ABEM will independently verify 10% of the individuals who confirm their activity online. This will be done by sending the verifier a written request to verify the activity you reported. ABEM will not ask them for the data – the request is simply to verify the activity.

SS: We have talked a lot about the minimums. There are so many things we can do that are more valuable if we want to improve. I am assuming we can do more than the minimum, especially regarding areas in our practice that we already know we want to improve upon.

DP: Absolutely. We encourage you to do that. We hope the system will ultimately encourage people to start looking at their practice and asking questions about what they can do to improve.

SS: Some emergency physicians work as locum tenens, provide care on cruise ships, or work internationally. What tips do you have for people who work in alternate types of practice?

DP: As far as the patient communication piece goes, you can develop your own questions and ask patients to complete and return them to you on site or through the mail. In terms of patient improvement activity, if you don’t have a patient survey instrument available to you,, there are patient improvement modules that you can take. The ABMS Quality Improvement in Practice (QIP) Program is approved to satisfy Part 4. The program has two parts, a tutorial and Performance Improvement Activities which can be used to enter data and complete the performance improvement activities. The price for QIP is $30. ABEM will receive independent verification for diplomates who complete this program. Diplomates must also attest to completion of the ABMS module through EMCC Online. There is additional information regarding this program on the ABEM website @abem.org under EMCC Assessment of Practice Performance frequently asked questions (FAQs)

SS: I wanted to discuss the importance of maintaining board certification. It is meaningful to me and to my patients. I have considered not taking my boards ... about every 10 years. But I continue to repeat that examination because I value being a Diplomate of the American Board of Emergency Medicine. Not only is it valuable to me, it is important to my patients and my employer. In the end, it is most important to me to confirm that I have reached and can maintain a certain level of competence in the field.

DP: I agree. Despite the angst of going through the process, board certification provides me with personal satisfaction. From a professional standpoint, once it has been achieved, it is not something I want to give up.

However beyond personal satisfaction, ABMS is working on aligning the Maintenance of Certification program with a number of other initiatives. For example, I think we are all aware that maintenance of licensure is coming down the pike. The goal is to allow the requirements for maintenance of certification to act as a proxy for maintenance of licensure. In addition, if you are current with MOC, you would also meet the PQRI initiative requirement. There is additional value being added to MOC and continuing certification that will help physicians streamline their professional activities to increase efficiency in remaining current.

SS: I believe one of the biggest reasons for the reaction to the new requirement is simply that it is new. I remember the same type of concerns came up when hospitals started doing quality assurance activities. But we now know that quality assurance activities implemented by hospitals have greatly added to our practice and our ability to provide better patient care. In the long run I believe the same thing will happen here.

DP: We believe most individuals are already engaged in most of the activities that are being required. We are just trying to create a system that makes it as painless as possible to report what folks are already doing.

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