Sarah K. Meadows, MS, CCMEP, had been manager, accreditation and programs, with Denver-based National Jewish Health’s Office of Professional Education for only a few months when she had the opportunity to explore integrating Maintenance of Certification Part II and Part IV with a performance-improvement CME project getting under way.

During her previous nine years in CME, she had heard a lot of talk about how MOC might be a good opportunity for CME providers, but exactly how to take advantage of it remained somewhat of a mystery. And not just to CME providers: Even some of the 24 member boards of the American Board of Medical Specialties that require their physicians to continuously measure their performance in six core competencies adopted by ABMS and the Accreditation Council of Graduate Medical Education are still exploring how to hook what they’re doing with what CME providers offer.

But after some team discussions on how to enhance the education they were currently providing with their performance improvement activities, Meadows decided to look into the incorporation of MOC Parts II and IV.
After all, PI CME activities already measure a performance baseline prior to the program, then measure the outcomes to determine what changed (or did not change) as a result. Though the specifics of how MOC is carried out can vary according to the specialty or subspecialty, all the boards use a four-part structure to ensure the process is continuous, and Parts II and IV happen to mesh pretty well with some CME initiatives. Part II—Lifelong Learning and Self-Assessment—requires docs to participate in educational and self-assessment programs set by their board; and Part IV—Practice Performance Assessment—asks them to evaluate how what they’re learning is being carried out in their clinical practices, again measured against specialty-specific standards. (Parts I and III require physicians to maintain their state licensure and demonstrate through formal exams that they satisfy specialty-specific knowledge and practice requirements.)

The biggest difference between providing MOC Part IV under the auspices of the American Board of Pediatrics and PI CME is the number of times you go in and really take a look at what you’re doing, says Meadows. “As we started thinking about that, we thought a possible improvement in our PI CME approach may be having more than two checkpoints, one at the baseline and one at the end. What made a lot more sense is to have a checkpoint in the middle to see if what you’re doing is working along the way. If it is, great. If it’s not, then what can we modify so that we have better outcomes?”

The MOC Challenge

So her office decided to think a bit differently about a PI program they were doing on atopic dermatitis. They had previously submitted an application for MOC Part IV for a different program to the American Board of Pediatrics. That was turned down, but the board had been supportive in working with National Jewish Health on it. By the time they heard their submission was turned down, it was too late in the process for that project. But that wasn’t the end of it. “One of the best things that could have happened is that the appropriate board for this particular project was the American Board of Pediatrics,” she says.

When Meadows and her colleagues heard that then-ABP vice president Paul Miles, MD, was coming to Denver to speak at the Colorado Alliance for CME Annual Meeting, she asked if he would sit down and talk about how they could align what her organization was doing in other PI CME projects and ABP’s MOC Part IV process. “Dr. Miles said there seem to be so many alliances between PI and MOC, but it would be unique to incorporate MOC Part II and Part IV in a PI CME project.” This was also a great opportunity to have an educational program that would assist physicians in obtaining points they need for their maintenance of certification while working on an organization-wide initiative to assess and improve their performance and patient outcomes.

Qualifying for MOC Part II

The project National Jewish Health chose to work with was designed to be a PI CME intervention that began in June 2012. Supported by an unrestricted educational grant from GlaxoSmithKline, it aims to improve the care of patients with atopic dermatitis (AD) in a pediatric network of clinics by educating the healthcare team on best practice tools, providing resources, and helping the clinics redesign their practices. Before the end of 2012, it was approved for MOC Parts II and IV.

The PI CME initiative, based on an identified practice gap and area of need for improvement in the treatment of pediatric patients who have the chronic inflammatory and prurific skin disease at the Metro Denver area Rocky Mountain Youth Clinics, began by conducting a baseline needs assessment. They worked collaboratively with the clinics to understand the barriers they face in caring for their patients with AD, reviewed AD care best practices, and developed a checklist for AD patient visits.

The intervention itself began with a half-day multidisciplinary training that included both lecture and hands-on activities. Physicians at the clinics filled out a self-assessment following a live training in September. ABP had several elements that had to be included to satisfy its Part II requirements, Meadows says. She reported the assessment design to the ABP board, which approved it for 10 MOC Part II points. The points were automatically credited to the participating providers’ ABP profiles once they completed the assessment with an established passing rate.

Mission: In Progress

The group of clinics, which includes three primary pediatric clinics, two mobile units, and two school-based clinics, serves a low-income, English- and Spanish-speaking population. In fact, though her office typically provides everything in English and Spanish, they ended up having to translate even more of their materials than they normally would into Spanish to meet the needs of one of the clinics in particular.

Tools and resources developed for the initiative include an educational manual for providers and staff, a patient workbook, and other materials to support both providers and patients. E-book content with patient education resources full of videos and interactive visuals, in both English and Spanish, was also developed for use on iPads in the clinics. “It’s been a huge hit with both the patients and caregivers, and the providers,” says Meadows. Other resources they provide include clinic resource carts with dolls clinicians can use to demonstrate how to properly apply moisturizers, laminated itch severity scales and life quality indexes, and patient information brochures provided by the National Eczema Foundation—after they too were translated into Spanish.

The initiative also includes two visits to each clinic led by a nurse educator and professional education staff who review different treatment methods, use of nine atopic dermatitis-specific prompts added to the clinics’ electronic health records, and questions providers have regarding the 15-item checklist of things clinicians should do for patients with an AD diagnosis. The CME team is collecting these checklists at four separate intervals.

“We got an astounding return on the checklists the first time around,” she says. “The maximum we could have had returned would have been 240 [10 checklists from each of the 24 providers]. We got 238 back.” She credits the clinic group’s leadership team—which her team meets with monthly—for the high rate of return. “We’re very much working side by side with them, which we have learned over the years is critical to the success of these programs.” In addition to the checklists, the other main data piece National Jewish is amassing is the electronic health records, which are being pulled at three intervals.

While Meadows said the MOC Part IV application was a long process to complete, they got through it. The program was approved for 25 Part IV points. While the final results are still being finalized, outcomes to date show improvement on all the metrics set at baseline.

She’s using an outside data analysis company, HealthCare Research, to crunch the numbers for the PI CME portion of the program and the final assessment, and for her office’s own outcomes reporting to Moore’s Levels 5 (performance) and 6 (patient health), which were completed this summer. But the program will live on—the next step is gathering a group of experts who were involved in the program, including National Jewish Health’s chairperson, to have a roundtable discussion of the program and its outcomes, which they’ll post online as a separate CME activity this fall. 

Learning from the Past

“I came at a good point,” says Sarah K. Meadows, MS, CCMEP, manager, accreditation and programs, with Denver-based National Jewish Health’s Office of Professional Education. She adds that she was able to learn from what did—and did not—work with some of the other performance improvement programs that were under way when she joined National Jewish Health. She credits the success to date of this program to her colleagues who “have been doing the difficult work of saying, ‘We said we want to do all this stuff but some of it has been a real challenge. What do we need to change to make it work?’ The MOC component is completely new for us, but so much of the modifications and groundwork for this program were lessons learned from our other projects.”

But there always will be new barriers. For example, while using electronic health record data is “working out great for this initiative because these clinics were very engaged and able to incorporate new prompts at the onset of the initiative,” there have been challenges with EHR systems with other programs. She says, “We didn’t realize how many barriers there were to things like getting spirometers hooked up to an EHR system, for example. If it doesn’t happen when we expect right at the beginning of a program, everything gets delayed because we can’t get to the data.” To get around the problem, they have to find another way to look at the data in addition to the EHR, “because the EHR doesn’t always tell the full story.”