Self-assessments can lead to practice improvements, help dermatologists meet MOC requirements
By Ruth Carol, contributing writer, June 01, 2012
Dermatologists have been participating in quality improvement (QI) efforts for decades, but they are increasingly being asked to conduct self-audits of their patient charts. The good news is that these self-audits, also referred to as practice assessments, can take many forms. Dermatologists can address a host of issues surrounding clinical care, peer interaction, and patient satisfaction. The key is to pick a relevant topic and just do it.
“We all need to get comfortable with practice assessments because they will be a mainstay of the future,” said Erik Stratman, MD, chair of the department of dermatology at the Marshfield Clinic and past chair of the American Academy of Dermatology’s Council on Education. “Every doctor wants to provide the highest quality of care possible. But if you’re not measuring where your quality is compared with the ideal state, how can you know if you’re achieving the highest quality of care?”
A self-audit can help achieve that level of quality. The purpose of a self-audit is to determine existing quality gaps and then implement a process or system change that will close the gap and lead to improved patient care. But there is another reason for conducting one. Maintenance of Certification (MOC) requirements call on dermatologists to conduct regular practice assessments as well as a patient and peer communication survey. Additionally, the Federation of State Medical Boards has proposed a Maintenance of Licensure program requiring practice assessments. Fulfilling MOC requirements will most likely fulfill these requirements as well.[pagebreak]
Topics to choose
As part of MOC, the American Board of Medical Specialties (ABMS) has identified six core competencies for quality patient care. They are professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice. These six areas serve as a guide to what the medical community believes is important and they can be used as a framework for choosing a topic, noted Robert S. Kirsner, MD, PhD, vice chairman of dermatology at the University of Miami Miller School of Medicine and chair of the Academy’s Council on Education and Maintenance of Certification.
“The sky is the limit in terms of what you might want to assess,” he said. “Focus on one thing that you are doing, not on what you could be doing.” More importantly, keep it simple.
Start with a very narrow focus; something that is small and measurable and won’t require a team of information systems support, Dr. Stratman concurred. “Don’t try overhauling the entire practice when you’re first getting involved in these assessments,” he advised. “Become comfortable with the process of measuring, implementing changes, and re-measuring. The small success can lead to the next size project.” When choosing a topic, Dr. Stratman said, “Pick an audit area that has relevance to you because the whole point is to identify an area that you might not be doing as well as you hope to, and then you can figure out ways to improve. You don’t want to spend all of your time measuring data that has no relevance to your practice.”
If the focus is biopsies, the dermatologist can determine how often patients are informed of the biopsy results, and care is followed up on. If the focus is medications, the dermatologist can assess how often patients who are prescribed methotrexate, for example, have blood tests to check their liver function. Review a handful of charts going back six months to determine how many patients had lab workups performed and how frequently they received the results. “If patients did not get the results as frequently as you thought, it’s an opportunity to figure out ways to make that happen,” Dr. Kirsner said. Plans to improve care could involve creating a paper or electronic reminder to order blood tests for patients taking systemic medications, a flowsheet that lists how often blood tests are being performed, or a book that lists the patients who require blood tests and dates when the test is ordered, performed, and followed up on.
Dr. Stratman uses simple QI tools to test changes on a small scale. Among them are the Plan-Do-Study-Act, or PDSA, cycle and the Lean Six Sigma’s process of Define-Measure-Analyze-Improve-Control, also known as DMAIC. “These are useful, easy-to-understand tools designed to be very quick,” he said. He is currently using this process in his department to determine how often dermatologists asked psoriasis patients whether they smoked, and if so, whether they encouraged them to quit or offered resources to help them do so. If patients were not being asked, his team tries to identify why not. Is it too time consuming or were team members just uncertain of resources available to help them quit? “With the growing evidence that psoriasis patients who smoke may have a worse burden of disease and cardiac comorbidity, we can impact quality of care by briefly discussing the harmful effects of smoking for psoriasis patients, encouraging cessation, and providing a smoking cessation packet,” he said. Another practice assessment was to determine how many psoriasis patients have a primary care physician. “We found out that 40 percent of our psoriasis patients didn’t have one. That’s alarming because there’s a lot of new information about the risks of these patients having heart attacks and vascular disease — conditions that should benefit by receiving good routine primary care.” By asking this one question, dermatologists can steer their psoriasis patients to getting primary care more purposefully, and thus, improve their quality of care.[pagebreak]
“For dermatologists who just want to perform a self-audit, the process could be less formal and less rigorous,” Dr. Kirsner stated. Those who want to engage in a formal process can participate in the AAD’s Clinical Performance Assessment Tool (CPAT). Modules for this Web-based program include acne, atopic dermatitis, and melanoma; a biopsy module is expected to debut later in 2012. Dermatologists can receive continuing medical education credit for completing CPAT and qualify for extra funding from Medicare for conducting a self-assessment for one year, Dr. Kirsner said. Using the CPAT, the dermatologist typically reviews 10 charts on the specific disease, answers 20 to 25 questions relevant to the condition, and receives a score. Staff can do a lot of the legwork, he noted. Depending on the score, CPAT offers practical tools and/or reading materials designed to improve care. “The design of the CPAT modules was deliberate to be both guidelines-based and to reflect disease states frequently encountered by a broad range of dermatologists regardless of specialty and practice type,” Dr. Stratman said. (For more information on CPAT, visit www.aad.org/education-and-quality-care/aad-professional-education/clinical-performance-assessment-tool-cpat/.)
Additionally, the ABMS boards have developed common standards for institutions that develop and implement QI projects that may qualify for MOC credit. Participants in the Multi-Specialty MOC Portfolio Approval Program include Mayo Clinic, the University of Michigan Health System, and Advocate Physician Partners, among others. As part of this pilot program, the institutions recognize what local quality activities are appropriate for MOC, rather than relying on the specialty societies, Dr. Stratman noted. “This is one way of creating relevant MOC activities at the local level. It’s hard at the specialty-society level to create a single measurement tool that assesses and is relevant to every practice type. What’s relevant to one provider at one institution may be completely irrelevant to another, because systems are different.”[pagebreak]
Providing quality clinical care is not just about picking the right test or making the correct diagnosis, Dr. Stratman points out. It’s also about effectively working with other physicians. “None of us work in a bubble. A big part of the future is looking at how we interface with the system of care. Even if you’re in a solo practice, you’re a part of a larger system of care through the specialists you interact with and the doctors who refer patients to you,” he said. “Many times, errors aren’t made in judgment, but errors are made in communicating the plan.”
Dermatologists can obtain feedback from their peers through the AAD’s peer communication survey. Based on the survey results, they can develop an action plan to improve communication and enhance collaboration of care between physicians. This survey has been approved by the American Board of Dermatology (ABD) to fulfill the MOC Component 4 requirement. (For more information on the Academy’s patient and peer surveys, visit www.aad.org/education-and-quality-care/performance-measurement-and-quality-reporting/aad-measurement-tools/aad-patient-and-peer-surveys/.)
Additionally, quality clinical care is about making sure that the patient understands why a specific treatment is recommended and the patient is on board with that recommendation, Dr. Stratman said.[pagebreak]
When choosing a patient experience topic to measure, it’s important to define what you’re trying to accomplish, noted Thom Schildmeyer, MBA, president of Roseville, Calif.-based Aesyntix Health. “Without a rational reason, staff and the physician will lose interest and patients won’t care.”
The various points at which the patient encounters staff is a good focal point when assessing patient satisfaction, he said. These points include calling in to schedule an appointment, scheduling the appointment, checking in at the front desk, going to the exam room, seeing the dermatologist, paying for services rendered, and receiving follow-up care, if necessary. “Is the staff rude or short on the call? That starts the encounter with a negative impression,” Schildmeyer said. “Is the patient walked to the exam room or just told it’s the third door on the right? Does the medical assistant ask the patient questions to prepare for the physician’s visit? Does the doctor come in and ask the same questions? That may frustrate the patient who has to answer the same questions twice. All of these steps affect the patient’s perception of the outcome.”
If the patient survey results reveal a problem with patient flow, process improvements may involve revamping how patients are scheduled or how the dermatologist works within that schedule, he explained. One solution may be to alternate short, medium, and long appointments, rather than scheduling three consecutive long ones. “Seeing three new patients in a row is probably not a good idea,” Schildmeyer said. Also, if the dermatologist can’t exit the exam room gracefully, he/she can end up having longer appointments than necessary.
“If you have a list of areas to improve, prioritize them,” suggested Sharon Andrews, a consultant with Charlotte, N. C.-based Derm Resources. “Don’t work on several at a time.” Thinking of themselves as patients can help dermatologists develop survey questions pertinent to their patients’ needs. Log any comments or complaints patients make during their visits, including complaints about another dermatologist they saw, as these could be fodder for survey questions. Consider inviting patients to be on an audit team. However, keep in mind that they would have to be educated about HIPAA and sign a confidentiality agreement if they are exposed to private health care information.
Sometimes the clinical and patient experiences overlap, providing opportunities for improvement in both areas. For example, a patient survey that suggests patients do not consistently receive test results can be turned into a practice assessment to determine how to improve the rate of test results being relayed to patients in a timely fashion, Dr. Stratman noted.[pagebreak]
The survey itself should be simple; 10 questions for the initial survey, five for the follow-up one, Schildmeyer said (though, if the survey is being done in part to meet MOC requirements, more questions will be required). If developing a survey, ask patients to rate the various encounters, beginning with the first contact. Were you able to schedule an appointment? Was there a long wait time to schedule the appointment? Regarding staff from the receptionist to those in charge of billing, ask if the individual was friendly, courteous, and helpful. Rate the encounter on a scale of one to five. Regarding the medical assistant (if applicable) and the dermatologist, questions may include: Did he/she listen to my needs? Explain treatment options? Answer my questions? Would I recommend this practice? Many managed care organizations and insurance payers have patient satisfaction surveys that dermatologists can use as a model to develop their own surveys, Schildmeyer said.
Many large institutions also have patient experience surveys that would fulfill the MOC Component 4 requirements, Dr. Stratman noted. Other approved patient surveys include those by Press Ganey, DrScore, and the AAD. (Information about the Academy’s survey is available at www.aad.org/education-and-quality-care/performance-measurement-and-quality-reporting/aad-measurement-tools/aad-patient-and-peer-surveys.) The ABD is expected to have a patient experience survey available in 2012 as well.
Don’t just hand patients a survey, Andrews suggested — ask if they would like to fill one out first. Patients can complete the survey before they leave or return it in a self-addressed stamped envelope. Make sure that the survey is anonymous because “anonymity breeds honesty,” she said, adding that patients can be satisfied even if the desired outcome wasn’t achieved. For a survey that is simply intended to help the practice learn more about its performance and not to meet MOC requirements, Schildmeyer recommended randomly passing out 10 surveys every day for one week per provider. Handing them out in one day offers a snapshot of just that day, whereas extending the timeframe over a week provides a better overall picture, he said. Additionally, some staff will self-select patients, which can skew the results; that’s why soliciting results randomly is so important. Expect to get half of the surveys returned, he added.
It’s important to share the results with staff. This can be done at a routine staff meeting, or if necessary, convene another meeting for all individuals involved in the targeted process, Andrews said. Although one area or department may ultimately address the issue, individuals from different departments can help. But it’s just as important to recognize staff when the survey reveals good results, Schildmeyer said, noting that the number one reason why people leave a job is lack of appreciation. “A patient satisfaction survey allows you to show appreciation to staff for doing well and also gives you a non-emotional tool to help move their behavior if it’s not as efficient,” he said.[pagebreak]
For MOC purposes, two approved practice assessments must be completed during the 10-year cycle. Both a patient and peer communication survey must also be conducted twice during the 10 years; one set by year five and again by year 10. More information about these requirements is available from the American Board of Dermatology at www.abderm.org/moc/requirements.html.
MOC aside, Schildmeyer recommends conducting a patient satisfaction survey once a year, but no more than twice a year. Too many surveys will dilute the effect of them, he warned. A 10-question survey can be conducted annually, with a five-question follow-up survey conducted in six months. “But if you have a problem that’s extreme, you would want to follow-up in 30 days. For example, if the receptionist scores a two on a scale of one to five, one being the worst, you would want to make a change quickly.” That may entail immediately providing customer service skills training or switching duties with another staff member. Determining when to re-measure is based on how inflated the problem is, he said.
Similarly, it may take anywhere from a few to several months to see if the implemented change has improved clinical care, Dr. Kirsner said. Unless the dermatologist is running a melanoma clinic, it might take up to a year to accumulate enough melanoma patients to know whether the QI plan impacted care, Dr. Stratman added. In comparison, it may take only a few weeks to know the same for patients being treated for acne. He recommends conducting one practice-assessment a year, even if it’s not for MOC credit, to get in the habit of picking a measure, implementing a change, and then reassessing the new results after intervening.
Dr. Kirsner concurred. The important thing is for dermatologists to get in the habit of doing practice assessments. “They shouldn’t fear what they find because that’s not the point. The results aren’t held against them. They don’t even have to demonstrate improvement. But hopefully, in the end, self-audits will help them better serve their patients.”
Core competencies for quality patient care
The American Board of Medical Specialties’ (ABMS’) Maintenance of Certification (MOC) process identifies six core competencies for quality patient care. These competencies, first adopted by the Accreditation Council for Graduate Medical Education and ABMS in 1999, are:
Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.
Patient Care and Procedural Skills
Provide care that is compassionate, appropriate, and effective treatment for health problems and to promote health.
Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care.
Practice-based Learning and Improvement
Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their practice of medicine.
Interpersonal and Communication Skills
Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates (e.g. fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).
Demonstrate awareness of and responsibility to larger context and systems of health care. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions, or sites).