The new Performance in Practice (PIP) component of the Maintenance of Certification (MOC) process will be required for board-certified neurologists and child-neurologists due for recertification in 2014.
PIP is a two-part quality improvement program that requires neurologists to conduct chart reviews and to collect feedback from their peers and patients. It is one of four components of the 10-year mandatory MOC program developed by the American Board of Psychiatry and Neurology (ABPN). (See “MOC In Review.”)
Each clinical PIP component takes about two years to complete, and physicians are required by the ABPN to complete three sets — including one clinical and one feedback module — over a 10-year period.
That means those up for recertification need to begin working on the PIP component in 2011 to be prepared for the recertification application that will be made in 2013.
“Getting on-board the life-cycle for continuous learning through MOC seems like jumping on a spinning merry-go-round,” said Janice M. Massey, MD, professor of neurology at Duke University and a trustee of the ABPN board. But once on-board, she said, the ride should prove worthwhile by enhancing knowledge, performance, and other core competencies such as professionalism and patient care skills. The Academy will introduce tools and training in early 2011 to help members successfully complete — and learn from — the PIP component.
Ralph F. Józefowicz, MD, professor of neurology and medicine at the University of Rochester School of Medicine and Dentistry and a board member for both the Academy and ABPN, said some AAN members initially questioned the need for PIP, but the Academy is developing PIP products that members will find beneficial. “The goal is to have a product that will educate you and improve your practice,” he said.
WHAT IS THE PIP?
Each PIP unit consists of two modules: a chart review module designed to help neurologists assess the quality of their clinical performance, and a feedback module in which a neurologist's peers and patients assess his or her practice.
When fully implemented in 2017, three PIP units will be required for recertification to ensure that neurologists are continually working on practice improvement. Each unit is completed over two to three years because the process of integrating improvements takes time.
The first PIP unit must be completed during the first three years of the 10-year MOC cycle, while the second PIP unit will be completed in years four through six, and the third unit will be completed in years seven through nine.
The feedback module is fairly straightforward. “It involves getting feedback from five patients and five peers using a questionnaire, and then you cogitate on that,” Dr. Józefowicz said. “You repeat this within two years, using different patients and different peers — or the same ones; it makes no difference — and see if you improved in comparison to the initial survey.”
Eligible peers for the feedback module include physicians and other members the health care team, including psychologists, social workers, counselors, and nurses.
THE AAN ROLE
The Academy is providing these tools and services — all voluntary — to prepare members for quality improvement initiatives that are being incentivized though certification (MOC), licensure, and payment. The AAN PIP product is an online three-part PIP improvement program, which incorporates the evidence-base from guidelines and measures into daily practice. Several clinical module topics will be offered.
The structure of the clinical modules include: an assessment of performance at baseline — which may take up to four to six weeks; an intervention or improvement plan — which my require eight to ten months to implement; and then a re-evaluation of performance, which may take up to four to six weeks.
Participants can enroll online and access a coordinated set of resources with a linkage to myCME. They will be able to select from a variety of clinical modules, which help focus what to measure in conducting the chart review.
The results of the chart review determine the focus of the improvement and intervention planning. The program provides educational resources and tools.
Larry R. Faulkner, MD, ABPN president and CEO, said most neurologists will probably focus their chart review on a certain diagnosis, such as headaches or seizure disorders.
“In the process of that comparison — with best practices or other standards — they will see where they have complied or not complied with the latest thinking on how you care for those patients,” he said. “They will then have some ideas on how to change what they are doing to bring it more in line with what we know are the practice guidelines or best practices.”
Dr. Józefowicz said the AAN plans to develop 30 disease- or condition-specific online modules over the next three years. For each module, the neurologist will provide demographic information about each of the sampled patient charts and answer a series of questions about the management of that patient.
“For example, if we're talking about patients presenting with an acute stroke, the type of questions would be: Did you consider this patient for the acute TPA treatment? Yes or no? If no, why?” he said. “Did you evaluate for stroke risk factors — hypertension, diabetes, smoking, etc.? Did you get physical therapy and occupational therapy consultations? Did you get a speech and swallowing evaluation for your patient? Did you consider the patient for prophylaxis against deep vein thrombosis?”
The physician's responses to the questions would generate a score and a comparison of his or her own performance with that of peers who completed the same module. Further, the neurologist would be referred to resources, such as journal articles, that address specific questions or areas in which his or her actual performance was sub-par.
The next step: Create a plan to improve the effectiveness or efficiency of the neurologist's practice as identified in the assessment stage.
“Then, within two years, you will repeat the whole process in the same disease category, with additional patients, to see if you've improved,” Dr. Józefowicz said.
OTHER SOURCES FOR HELP
In addition to the modules available from the AAN, some institutions, such as Mayo, for example, may offer ABPN diplomates an institutional quality improvement program that involves collection of chart data, comparisons with peers, and establishing a plan to improve clinical activity. Physicians may elect to meet their MOC requirements via different venues: through their institutional programs or an AAN clinical PIP module; or they may construct their own PIP program, which documents they have met all of ABPN's requirements for PIP. For more information, www.abpn.com/moc_neuro.htm.
MOC IN REVIEW
The ABPN developed its 10-year maintenance of certification (MOC) program in response to a mandate by the American Board of Medical Specialties. In addition to the PIP component, the program includes three other elements:
- Professional standing. A neurologist must hold an unrestricted medical license from at least one state or U.S. territory.
- Self-assessment and lifelong learning. In addition to continuous medical education credits, a neurologist must complete the AAN's Self-Assessment Examination, the Neuromuscular Medicine Self-Assessment Examination published by the American Association of Neuromuscular & Electrodiagnostic Medicine or another ABPN-approved examination. Ongoing required CME activities should focus on areas of need as disclosed by the self-assessment activity.
- Cognitive expertise. After all other MOC requirements are met, recertification candidates must receive a passing score on an ABPN-approved cognitive examination.