Promoting Physician Competence Across the Lifespan Targeted - - PowerPoint PPT Presentation

Promoting Physician Competence Across the Lifespan

Targeted Structured Lifelong Learning and Practice Improvement

Sandra B. Sexson, MD Professor and Chief Child, Adolescent and Family Psychiatry Medical College of Georgia

Disclosures

• No financial conflicts of Interest
• Chair Organizational Components that develop

products and tools for Lifelong Learning and Assessment of Performance in Practice

– American Academy of Child and Adolescent Psychiatry

• Committee on Lifelong Learning

– American College of Psychiatrists

• Physician-in-Practice -Exam (PIPE) Commission

– Chair

– ABPN

• ABPN Ambassador

Presentation Objectives

• After this presentation, the learner will be

able to:

– Recognize the importance of maintaining physician competence across the lifespan – List the four components of maintenance of specialty certification – Discuss the ABPN requirements for MOC depending on whether you are in the 10 year cycle or the continuous MOC program

“The Duties of a Physician”

Bard, 1769

• “Do not therefore, imagine, that from this

time [the receipt of the MD degree] your studies are to cease; so far from it, you are to be considered as but just entering upon them; and unless your whole lives are one continued series of application and improvement, you will fall short of your duty.”

Bard, 1769 in his graduation address

Questions for Discussion or Thought

• What is your experience with

CME?

• How do you decide what continuing education

to pursue?

• What types of educational programs do you

prefer?

Traditional Measures of Physician Competence

• Successful completion of:
• Undergraduate Medical Education
• Graduate Medical Education
• Board Certification
• Ongoing participation in unstructured continuing

medical education

• Unquestioned as necessary by most physicians
• Required in most countries for ongoing licensure and board

certification

• Self-selected by the physician
• Usually characterized by passive knowledge acquisition

What and How do Physicians Choose?

• Topics that appeal to them

– Not necessarily gaps in knowledge – No efforts typically to focus on identifying areas that need updating, and when do consider areas of need, basis is unguided self assessment

• Traditional passive types of CME offerings

– Lectures in large group settings ( ? in nice places)

• Specialty association meetings most preferred setting

– Lack of active participation

Why Unguided Passive CME is not Enough

• 1999 Institute of Medicine report revealed high rates of medical errors

and unnecessary deaths

– In US alone there were medical errors annually that ended in 44000 patient deaths in the early 90s, a number that more than doubled in less than 10

• years. Kohn, et. al., 1999; Berlinger, 2008
• Studies on pass rates for recertification after the advent of time limited board

certification Rhodes, 2007 – Demonstrated significant decrease in pass rate as diplomates were further from initial certification suggesting clinical experience does not assure being up-to-date…also those in solo practiced fared less well than those in groups

• Exploding information

– Concerns that lifetime certification was insufficient to assure that physicians stayed current in age of burgeoning information advances

• The issue of the public trust

Medical Education: Not a Destination, But a Structured Lifelong Journey

Definition of Lifelong Learning Collins, 2009

• Continuous

– Never stops

• Supportive

– Done with others

• Stimulating and empowering

– Self directed, active

• Incorporates knowledge, skills, and attitudes

– More than knowing

• Spans the lifetime

– Implies the journey, not the destination or an end point

• Leads to creative, confident and enjoyable application

More than Knowing

• “Knowing is not enough; we must apply. Willing

is not enough; we must do.”

Goethe, Brainyquote

– Little evidence in past that CME leads to better patient care and outcomes – Experience with the lack of translation of scientific evidence to the bedside – Discrepancies between perceived competence and actual performance

• Reading the literature
• Applying EBM to clinical practice

Self-Assessment Not a New Idea outside of Medicine

• “He who knows best, best knows how little he

knows.” -- Thomas Jefferson Silver, et. al., 2008

• “In all affairs it’s a healthy thing now and then

to hang a question mark on the things you have long taken for granted.” Bertrand Russell

Brainyquote.com

Why is Guided Self-Assessment Important?

• Identifies the learning gaps for the individual

clinician

• Unguided self assessment does not work

– Comparisons of self-assessment vs. observed measures of competency

• Most studies demonstrated little, no or an inverse

relationship between self and external assessments (observations, comparisons to benchmarks, etc.)

• The worse accuracy in self-assessment was most

frequently among the least skilled, yet most confident physicians

“The whole problem with the world is

that fools…are always so certain of themselves, and wiser people so full of doubts.” -- Bertrand Russell

Brainyquote.com

Factors Contributing to Problems with Physician Competence

Failure to adhere to professional conduct standards Insufficient training to keep up in a time of burgeoning growth of knowledge Inability to adequately self-assess both our knowledge and what we actually are doing in practice Disregarding the effect of time on knowledge and skills Failure to use EBM in our practice Resistance to consider patient perspectives about care Resistance to feedback from peers

Why Not Maintenance of Competence ?

• Targeted lifelong learning that is informed by self

assessment and identification of “practice gaps”

– Using knowledge-based exams to identify areas of weakness and then seeking formal or informal opportunities to address those identified learning issues

• Openness to learning beyond the traditional lecture experience

– Small group interactive sessions, either formal or informal – Critical journal reading with post-test, either alone or in a group – Interactive computer programmed learning with assessment – Individually arranged study

– Personal commitment to ask questions and find answers for implementation at the point of care.

“The next time you’re at the doctor’s office, take a peek at those certificates hanging on the

• wall. Like gallons of milk, some of

them are expiring.” Associated Press April 5, 2010

ABPN Maintenance of Certification (MOC)

Jeffrey Hunt, MD Professor and Program Director CAP Fellowship and Triple Board Program Alpert Medical School of Brown University Chair ABPN CAP MOC Committee

Disclosures

• Financial

– Wiley Publishers

• Organizations

– American Academy of Child and Adolescent Psychiatry

• Co-chair Training and Education Committee

– ABPN

• Chair CAP MOC Committee

– ACGME

• Chair CAP Milestones Work Group

THE MOC PROCESS WILL HELP PSYCHIATRISTS GIVE BETTER CARE

I DISAGREE STRONGLY

Number of respondents = 96 Lifetime certification = 26 Time limited certification =70

Survey Results of RI Chapter of APA

LIFETIME CERTIFICATION TIME LIMITED CERTIFICATION

• THE MOC

PROCESS IS CONFUSING

I AGREE STRONGLY

Survey Results of RI Chapter of APA

Number of respondents = 96 Lifetime certification = 26 Time limited certification =70 LIFETIME CERTIFICATION TIME LIMITED CERTIFICATION

Maintenance of Certification (MOC) Requirements

• 1. Evidence of professional standing (licensure).
• 1. Evidence of CME and self-assessment (AACAP MOC

modules).

• 1. Evidence of cognitive expertise (proctored

recertification exam).

• 1. Evidence of improvement of performance in practice

(AACAP PIP tools).

10 year certification

Continuous ABPN MOC Program

• Implemented for those certified 2012 and later
• Requirements

– Unrestricted medical license – Cognitive exam every 10 years – Specific MOC activities every 3 years

• 24 CME hours of SA activities
• Total CME hours 90
• 1 PIP Unit
• Annual registration on individual ABPN Folio
• Annual MOC fee ($175 in 2015)

– No additional fee for the MOC cognitive exam

Summary of C-MOC

Medical Knowledge Quality Improvement Cycle

Self- Assessment Activities

Knowledge Deficiencies CME Activities

CME requirements

• 30 specialty and/or subspecialty CME

credits/year averaged over three years.

– CME credits must be relevant to the specialty and/or subspecialty – The CME activities do not need to come from ABPN Approved MOC Products list.

• At least 8 CME per year, averaged over three

years, must involve self-assessment and do need ABPN approval starting 2014

Self Assessment (SA) CME

• At least 8 CME per year
• Beginning in 2014, must come from ABPN-approved

SA activities.

• www.abpn.com/moc_products.asp
• Each SA activity must:
• cover new knowledge and/or current best practices
• guide focused CME, lifelong learning
• And include

– the correct answer, recommended literature resources for each question, and comparative performance to peers.

Waiver of SA for non-CME activities

• The ABPN will waive eight CME credits for

the completion of a non-CME SA activity.

• Maximum of 16 SA CME credits for two different non-

CME SA activities in one three-year MOC block.

• completed the approved non-CME SA activity during

the block for which they are earning non-CME Self- Assessment credit.

Self Assessment-CME waived 8 credits for one of the following:

• Passing another ABPN

cognitive cert or recert examination

• Approved scientific

grant application

• Academic/Scientific

Journal article accepted for publication

• with documented peer

review/feedback.

• Patient safety courses
• ABPN approved
• 4 hours of peer

supervision or Peer review

• with written feedback

about the diplomate's clinical performance, medical knowledge and patient care.

CME, cont.

• Diplomates certified in more than one area may

accrue CME credits that count for all certifications.

• Diplomates are required to maintain a record of

their CME activities.

Cognitive Expertise

• Must pass a cognitive (recertification) exam prior

to the expiration date of their certificates.

• Must satisfy all of the other MOC requirements

before they are eligible to complete the cognitive exam.

• The ABPN will audit 5% of the applications for the

exam to ensure that appropriate self assessment, CME, and performance in practice activities have been completed.

Clinical Activity Quality Improvement Cycle

Patient Care Data Collection Data Comparison with Care Standards Opportunities for Improvement Clinical Activity Modifications

Performance in Practice (PIP)

• A quality improvement program designed to evaluate

whether a physician has shown practice improvement over the 10-year continuous MOC cycle by chart review and second-party external review.

• Three PIP Units (over 10 years) required
• 1st PIP – years 1-3
• 2nd PIP – years 4-6
• 3rd PIP – years 7-9
• ABPN approved products in 2014
• Consists of both Clinical Module and Feedback Module
• Must maintain a record of PIP activities

Three ways to satisfy PIP

• ABPN Approved MOC Products List
• ABMS Portfolio Program:

– If institute QI program participates in the ABMS Portfolio Program, then that activity will satisfy the Clinical Module component.

• Individual Preapproval:

– Should submit an Individual Part IV Improvement in Medical Practice (PIP) Approval Request Form.

Feedback Modules

• Diplomates choose one type of Feedback Module they want to

complete.

• Patient Surveys (at least 5 patients selected by diplomate)
• Peer Surveys (of General Competencies)*
• Institutional Peer Review (of General Competencies)*
• Supervisor Evaluation (of General Competencies)
• Resident Evaluations (of General Competencies)*
• 360˚ Evaluation (of General Competencies)*
• Identify opportunities for improvement.
• Implement improvements.
• Re-solicit opinions within 2 years.

*Must include at least 5 evaluators.

PIP - Clinical Modules

• Obtain data from at least 5 cases in a specific

category (e.g., diagnosis, type of treatment, treatment setting) from diplomates’ own clinical practice over the previous 3 years.

• Diplomates select their own cases.
• Compare data to best practices, practice

guidelines published in the literature.

• Must have a minimum of 4 quality measures per

PIP activity.

PIP - Clinical Modules, cont.

– Must provide performance feedback to diplomates concerning improvements in the effectiveness and/or efficiency in their practices, as related to the core competencies. – Must require the development of plans by diplomates to improve their performance. – Must reassess data from a review of 5 additional cases in the same category within up to 24 months and must provide feedback similar to that in the

• riginal assessments.

• Diplomates who graduate from ACGME – accredited

subspecialty fellowships and pass an ABPN subspecialty examination in 2012 or later receive 3 years of MOC credit (SA, CME, PIP).

• Diplomates with “life-time” certificates may now join

the Continuous MOC Program in two ways.

• Pass the MOC examination
• Register for the Continuous MOC Program,

complete 3 years of required MOC activities, and pass the MOC examination within 3 years

Other important points

Keeping track: ABPN Physician folios

• www.abpn.com

NEW Patient safety course requirement

• Beginning in 2016 Diplomates will be

required to complete an approved Patient Safety Course

– either prior to board certification or in the first C-MOC block (2017-2019)

• The Patient Safety Course must include

didactic information, along with question and performance feedback.

AACAP’s Recertification Efforts

Sandra B. Sexson, M.D. and Andrew T. Russell, M.D. Lifelong Learning Committee, Co-Chairs

MOC – Lifelong Learning What it Means to CAPs and AACAP

• Implies a cooperative process between specialty

societies and corresponding ABMS Board

• Annual Lifelong Learning Module

– Provides 30 hours CME, 8 of which are SA if return the SA exam

• Rationale for our model involves both ability to

point practicing child and adolescent psychiatrists to up-to-date literature in child and adolescent psychiatry while keeping costs reasonable ($160- 180 plus S & H-often less if subscribe when pay dues)

AACAP Performance in Practice Tools - Now Available

• Chart review tools based on Practice Parameters

– Each has assessment one and follow-up tool – ADHD, Antipsychotics, Anxiety, Autism Spectrum Disorder, Bipolar Disorder, Depression, OCD, Early Onset Schizophrenia, ChronicTic Disorders

• Second party external review

– Two patient forms – parent/guardian form and adolescent form; also translated into Spanish – Peer form

• Download PIP tools from the Members Only section
• f the website (www.aacap.org).

Examples of PIP Tools

Example of Patient Feedback Form

Example of Peer Feedback Form

Questions ?

• Then let’s all try using a clinical module PIP
• form. Follow-up MDD and Initiation of

Atypical Antipsychotics.

How to Help your Faculty

• Understand the MOC requirements so that

you can decrease the hysteria and provide concrete information

• Find ways to meet the MOC requirements in

the course of other requirements faculty members have to meet as a part of their hospital staff privileges or medical school faculty requirements.

Using PIP Tools for Meeting Faculty Institutional QI & MOC Part IV Requirements

• Ongoing Professional Practice Evaluation

– Institutional requirements at MCG – Required much more frequently tha MOC PIP – Requires faculty to look at their professional practice

• CME
• Peer Review
• Documentation audits

Combine the Two

• Group process
• Faculty complete peer reviews and use ABPN

approved forms so count for MOC and OPPE

• Chart reviews – Use PIP tools to look at charts –

we shared charts and others reviewed them but could be individual. Counts for PIP MOC and OPPE

• Leave an hour long meeting having completed

both requirements

• Feedback very positive

Questions?

• MOC Program Information:

www.abpn.com/moc

• MOC Physician Folios to determine

personalized MOC requirements: www.abpn.com/folios

• MOC Questions:

Email – Questions@abpn.com

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