IMPROVING QUALITY IMPROVEMENT

In February 2019, the Vision Committee recommended that the American Board of Medical Specialities (ABMS) chart a new course for improvement in medical practice.¹ Arguing that the Maintenance of Certification (MOC) requirement for improvement in medical practice had become onerous for some Diplomates and challenging to implement for many specialties, the Vision Committee called for the identification of new approaches to advancing practice while recognizing what Diplomates are already doing.

How did we start on the quality journey? Though systematic efforts to improve care date back at least as far as Semmelweis and Florence Nightingale, the 1999 and 2001 IOM reports “To Err is Human”² and the “Crossing the Quality Chasm”³ transformed professional and legislative discourse about patient safety and the quality of care in the United States. The authors argued powerfully that error was common in health care, that it had important consequences for patients and that it was not primarily due to clinicians’ mistakes but rather the lack of a culture of improvement and systems to prevent error and improve care. Closely following was empiric evidence of a dramatic gap between what all agreed should happen clinically and what actually happened in practice across the entire continuum of care.⁴ Thus, as ABMS developed the Maintenance of Certification program, a cornerstone was support of improvement of quality of care.⁵

What progress have we made in quality improvement in the 20 years since the publication of the original Institutes of Medicine report? An entire industry has developed around supporting this work: quality improvement goals and activities have been institutionalized in medical practices and hospital systems across the country. Reflecting this broad commitment, there are countless examples of improvement in measures of care across clinical settings ranging from primary care to inpatient care and long-term care. At the same time, however, the payers, agencies and others driving this process have worked largely independently from each other, resulting in an explosion of metrics, often with small differences that prevent comparisons across providers or geographies. Few measures have taken into account variations in patient populations and social determinants of health. Consequently, despite progress, major problems in care remain, and many promising quality improvement projects have failed to spread or be sustained.⁶ Moreover, the intrinsic motivation of physicians to improve the quality of care they provide has been challenged by administrative burden and often seemingly arbitrary metrics that vary by individual payers and organizations. Backlash is substantial, with both physicians and specialty organizations complaining about “meaningless” quality improvement activities.

So how will the American Board of Family Medicine proceed? Since its founding, ABFM has believed that assessment of cognitive expertise through periodic examination is insufficient for recertification. All Diplomates were required to recertify—an innovation across the Board Community—and all had to demonstrate excellence in practice, as measured by a practice audit, as well as continuing education and evidence of ethical professional conduct, in addition to an examination.⁷

In recent years, we have made increased performance improvement (PI) offerings available to Diplomates, aimed at increasing relevance by providing more options across a wide spectrum of practice types and scope. In particular, our Self-Directed pathway allows physicians who are already meaningfully participating in quality improvement (QI) efforts in their practice or hospital system to gain certification credit for that work. The requirement to measure, intervene, and remeasure remains, but the documentation is much easier, and it eliminates the need to do “extra work” just for certification. The Self-Directed pathway is also useful for family physicians working in nontraditional office settings, such as emergency/urgent care, hospice and palliative medicine practices, or sports medicine, to define projects that will have the most impact and meaning for them. For physicians who are not already involved in ongoing improvement activities and have questions about how to develop their own practice-based initiatives, we offer guidance on how to do so, and what is needed to meet PI credit requirements.

For Diplomates working in larger groups or health systems, our Organizational PI pathway allows the organization to report on quality improvement initiatives in which they are already meaningfully involved, or to develop and conduct performance improvement activities that facilitate family physicians receiving PI activity credit for their participation. In practices that include physicians of different specialties, the ABMS multispecialty portfolio https://mocportfolioprogram.org/similarly supports attainment of credit when meaningfully engaged in initiatives conducted in multispecialty groups. To support those physicians who teach medical students or residents in practice, we have partnered with the Society of Teachers of Family Medicine to provide Performance Improvement credit to preceptors who apply QI principles to improve their own teaching or engage learners in their clinical improvement efforts. ABFM staff regularly review and update options to provide Diplomates, and we continue to work with the AAFP and its state chapters as they develop new opportunities for Diplomates to identify gaps in their practice, obtain appropriate CME, and work to improve their practices. Finally, ABFM has waived the performance improvement requirement for individuals who are not clinically active.

Over the last year, as we have engaged our Diplomates, it has become clear that communication of these options and changes can be more effective, and this has become a major area of focus for our Communication and Outreach efforts. In the near term, we will be improving navigation and updating our performance improvement options. We have heard from Diplomates that it is difficult to find which performance improvement activities best fit their practices, especially now that the opportunities have expanded so significantly. To assist with this, we are developing an online tool which will point Diplomates to activities that are customized for their practice type and scope.

Our long-term goal is to rethink performance improvement, working with Diplomates and partners in other organizations and specialties. Despite the progress of the last 20 years, we believe that America’s health care continues to need dramatic improvement. As our new mission statement underscores, ABFM is committed to the triple aim of improving health, patient experience, and cost-effectiveness—and we believe that family physicians will need to continue to play a major role in this transformation.

As a first step, we must encourage more improvement across broader dimensions of care—not just clinical quality and safety, which are the most common focus today, but also the other dimensions originally identified in the original Institute of Medicine reports—patient-centeredness, timeliness, efficiency, and equity. While the ACO measure set touches on some of these areas, it does not go far enough. We will also need to address the emerging and expensive clinical problems that family physicians are uniquely positioned to address—multimorbidity, behavioral integration, substance abuse, social determinants of health, and fragmentation of care. Care of self is also an area in which many physicians want to address and should be included in options for improvement.

Which measures are chosen is critical. Part of the problem we face is the sharp rise in the number of metrics developed and required by government, commercial payers, and others. As has been well documented by the National Academies⁶, the total number of measures in use today is unknown but large; for example, the CMS Measure inventory alone logs nearly 2,238 different measures to date. Although many of these measures are of high quality and provide valid and useful information, many represent only slight variations of the same target. Furthermore, numerous measures in use today differ enough to prevent direct comparison among the various states, institutions, or individuals.

Thus, as a broader health care system, we will need to focus with intention on fewer, more important metrics; within primary care, we need to focus on measures that matter—measures that capture the unique contribution of personalized primary care. To meet this challenge, ABFM has begun to develop measures that better capture what is unique to family medicine and primary care, such as continuity, comprehensiveness, and patient centered outcomes. Early reports are promising,^8,9 and as new measures are evaluated and taken up by insurers, measuring and improving what we do will become more meaningful to practicing family physicians. Given increasing evidence of the impact of social determinants of health outcomes, we are also working with partners to identify and measure social factors that should contribute to risk-adjustment for core metrics and for payment. As new metrics are approved and adopted by others, we will all need to work together to develop new approaches to improving the care that matters most.

We know that family physicians across the country are doing creative work to improve care for their patients and their communities. We look forward to learning from you about how we can best support your work. It takes a village to improve quality—and to help heal health care.

• © 2019 Annals of Family Medicine, Inc.