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As of 11-10-10

American Board of Emergency Medicine EMCC ASSESSMENT OF PRACTICE PERFORMANCE FREQUENTLY ASKED QUESTIONS (FAQS)

1. What is Assessment of Practice Performance (APP)? Assessment of Practice Performance (APP) is the fourth component of EMCC. It is required for diplomates who are clinically active. APP focuses on practice-based learning and improvement, particularly in regard to patient care, interpersonal and communication skills, and professionalism. 2. Why did ABEM implement APP? The American Board of Medical Specialties (ABMS), the organization that oversees 24 medical specialty boards including ABEM, has implemented a maintenance of certification (MOC©) program for all its specialty boards. EMCC is the ABEM version of MOC. Through the APP component of EMCC physicians demonstrate that they can assess the quality of care they provide against peers and national benchmarks. In addition, they must apply the best evidence or consensus recommendations to improve that care. Patients experience fewer medical errors, better communication and quality clinical outcomes when they choose a board certified physician who participates in MOC. See a list of references. 3. I am already very busy. Will APP add to my workload? ABEM understands that emergency medicine is a demanding specialty. ABEM intentionally designed its APP program to recognize and credit most quality improvement activities that you are already doing. ABEM thinks that there will be minimal increase for most diplomates already engaged in quality activities. 4. I have a colleague in a different specialty. Is he required to participate in APP? All ABMS boards are required to implement an APP program. However, some boards have diplomates with lifetime certificates. Those diplomates are not required to participate. In addition, many boards are phasing in APP, as ABEM is doing, which means that not all physicians have the same current requirements. 5. I have a colleague who is an Emergency Physician who does not appear to have any APP requirements. Is she required to participate in APP? By 2013, all ABEM diplomates who are clinically active will have APP requirements. ABEM is phasing in APP requirements, and some diplomates do not have APP requirements within their current certification period. 6. I remember getting some information about this in the mail and hearing about it at meetings. This looks different somehow. Has anything changed from those mailings? This is the same APP program that ABEM approved in 2005. The perception that the program looks different is because now we are giving each diplomate his or her specific requirements. This may seem different from the general requirements due to the phase-in of the program. 7. Is there a fee for participating in APP? There is no ABEM fee for APP. 8. What are my APP requirements? Clinically active diplomates must begin, complete, and attest to the completion of: · a Patient Care Practice Improvement (PI) activity in years 1 through 4 (of their certification) · a second PI activity in years 5-8 · a Communication/Professionalism (CP) activity in years 1-8 During the phase-in of APP, i.e., in 2010 through 2018, requirements will vary. Diplomates should review their individual requirements through EMCC Online. You will need your ABEM User ID and Password.

9. My APP requirements refer to the first year of certification. How does ABEM define the first year of certification? The first calendar year after diplomates earn or renew certification is considered the first year of certification.

Example #1: a physician took the spring oral certification examination and has a certification date of June 1, 2005. The diplomate's first year of certification was 2006. Example #2: A diplomate took and passed the 2009 ConCert examination and has a new certification date of October 20, 2009. The physician's first year of the new certification is 2010.

10. Do I have to complete APP activities to take my next ConCert exam? Not for now. This may change as ABMS requirements change. One of the ways that the APP differs from the LLSA activities is that meeting the APP requirements is not necessary to take the ConCert exam. However, diplomates must meet APP requirements to maintain their clinically active status. 11. What happens to my APP requirements if I take the ConCert exam early? When you renew your certification by taking the ConCert exam, all of your EMCC requirements renew as well. If you are clinically active, your APP requirements will start and you must begin, complete, and attest to a Patient Care Practice Improvement (PI) activity (years 1-4 of the new certificate), a PI activity (years 5-8), and one Communication/Professionalism (CP) activity (years 1-8). 12. I became certified through the practice pathway. How does that affect my participation in APP? APP participation is not affected by the practice pathway. If you are ABEM certified and clinically active, you must participate in APP. 13. How do I attest to the completion of APP activities? Starting January 1, 2010, diplomates who have a current APP requirement at that time will be able to sign into EMCC, select the Assessment of Practice Performance button from the Quick Links, and complete an on-line form describing the activity they completed. Forms must contain all required information before they can be submitted as complete. See a Sample PI Online Attestation Form and a Sample CP Online Attestation Form. 14. I can see my requirement online, it says "not met", but I don't see a way to attest to completing it. You can only attest to the completion of an activity during the period of time when you have a requirement for that activity. The start and end times of each of your requirements are displayed on your EMCC Online attestation screen. You must be designated as "clinically active" or indicate that you wish to become "clinically active" to attest to an APP activity. 15. How do I complete a Patient Care Practice Improvement (PI) activity? Most organized quality initiatives meet the requirements for PI. Such initiatives might involve PDSA (Plan-Do-Study-Act) or Total Quality Improvement (TQI). Variations of these processes are often found in Lean projects, Six Sigma programs, or Keystone initiatives. Patient satisfaction surveys are part of CommunicationProfessionalism, and generally do not meet PI requirements. PI activities must include the following four steps:

a. Review patient clinical care data from at least ten of your patients. The data must be related to a single presentation, disease, or clinical care process that is part of the Model of the Clinical Practice of Emergency Medicine (EM Model). Frequently used items include core measures and PQRI quality measures. Other measures include door-to-doctor times, total through-put times, and left-without-being-seen frequencies. Group data and data collected through a national, regional, or local practice improvement program in which you participate is acceptable, as long as you have at or around 10 patients on average in the measurement group. b. Compare the data to evidence-based guidelines. Evidence-based guidelines are based on published research subject to peer-review. If such guidelines are unavailable, you may use guidelines set by expert consensus or comparable peer data. Guidelines set by expert consensus are published, accepted, national standards, and guidelines set by peer data are set by individuals who practice in similar circumstances. Even narrowly defined, hospital-specific programs often have some externally reported benchmark.

c. Develop and implement a plan to improve the practice issue measured in Step a. Again, this can be an individual or group improvement effort. d. After implementing the improvement plan, review patient clinical care data from at least ten additional similar patients. This data is used to determine any change in practice performance. See a Sample PI Online Attestation Form.

16. How do I complete a Communication/Professionalism (CP) activity? The communication/ professionalism activity focuses on effective and professional communication with patients. You may use patient surveys, interviews, or focus groups that are administered at the institutional, departmental, or individual level. At least ten of your own patients must be included. A minimum of one physician behavior must be measured from each of the following three categories:

a. Communications/listening, which is described as communicating clearly with patients and other medical staff by listening carefully and couching language at the appropriate level for the listener. b. Providing information, which is described as explaining the clinical impression and anticipated management course to the patient and the patient's family, providing information about tests and procedures, or giving the patient options. c. Showing concern for the patient, which is described as showing respect to the patient and other medical staff, making the patient feel comfortable by asking if they have any questions or concerns, and acting to address their concerns, as well as asking about adequate pain relief. In addition, there should be some consideration (within reasonable limits) of patient preferences. See a Sample CP Online Attestation Form.

17. What is the ABMS Patient Safety Improvement Program and how can I use it to meet ABEM APP requirements? Completion of the ABMS Patient Safety Improvement Program meets the requirements for an APP patient care practice improvement (PI) activity, but diplomates must use their own patients' data. These activities have been approved for AMA PRA Category 1 creditsTM. See more information about the ABMS Patient Safety Improvement Program. 18. How do I know if my APP activities will meet ABEM requirements? If you have followed all the steps listed in FAQ 15 How do I complete a Patient Care Practice Improvement (PI) activity? or FAQ 16 How do I complete a Communication/Professionalism (CP) activity? your APP activity should meet ABEM requirements. 19. Must I use my own patients' data? Yes. Data must be from your own patients. A group dataset that contains data from your patients is acceptable. You should have around 10 patients in both your first and second measurement sample. Performance feedback can be from pooled or aggregate data and does not have to be specific to your own patients. 20. Am I required to submit my data to ABEM? You should not submit any data to ABEM. Your verifier may request to see your data to verify that your APP activity meets ABEM requirements. You may wish to clarify this with your verifier before you being your APP activity. See FAQ 30 How does verification work? and FAQ 32 What happens if my verifier does not completely confirm my APP activities? for more information about verifiers. 21. What standards are available to me for data comparison? Evidence-based guidelines are usually published in peer-reviewed journals. Others standards or measures are established by national quality organizations, major payors (e.g., core measures), and the Centers for Medicaid and Medicare Services (CMS) such as the Physician Quality Reporting Initiative (PQRI) described in FAQ 22.

22. I submit data to the national Physician Quality Reporting Initiative (PQRI). May I use that data for my PI activity? Possibly. PQRI requirements are for measurement only. PI activities must follow all four steps, only two of which are measurement. The other two steps involve comparing your PQRI performance to regional, state, or national performance benchmarks and implementing a plan to improve the performance. An implementation plan could be as simple as regular reporting of the measures. Since the PQRI measures that relate to Emergency Medicine cover clinical processes that are suitable for APP PI activities, you can use PQRI measures if you incorporate them into the full four steps that ABEM requires. The American College of Emergency Physicians (ACEP) has posted a description of PQRI on its website, at the following link: http://www3.acep.org/practres.aspx?id=30492. 23. My institution uses Press-Ganey patient surveys. Will that fulfill my CP requirement? In certain cases, it will fulfill your CP requirement. Since Press-Ganey surveys can be tailored to an institution's specific needs, the surveys might not meet ABEM requirements in some cases. Please review FAQ 16 How do I complete a Communication/Professionalism (CP) activity? to determine if your organization's use of the Press-Ganey survey fulfills the CP requirement. 24. My hospital does not do a patient satisfaction survey. What can I do? If your institution will not be conducting an appropriate patient satisfaction survey in time for you to meet your communication/professionalism APP requirement, you may wish to implement a simple survey process on your own. Please review FAQ 16 How do I complete a Communication/ Professionalism (CP) activity? to see what requirements your survey should meet. 25. My hospital administers a patient survey in the ED, and I know it includes my patients, but the measures reflect the ED as a whole. Do I have to develop a different survey? A survey that measures the ED as a whole is acceptable as long as at least ten of your patients are included, and the survey meets the additional criteria described in FAQ 16 How do I complete a Communication/Professionalism (CP) activity?, is acceptable. A questionnaire must include elements of: 1) communications/listening; 2) providing information; and 3) showing concern. The questionnaire should also include "consideration of patient preferences". 26. Does each physician need to have a different PI project, or can we all do the same one? Each physician does not need to have a different PI project. Group projects are encouraged. If you work on a group project that meets ABEM guidelines during a time when you have a current PI requirement, you will be able to count the project toward fulfillment of your requirement.

For example, you have an ABEM requirement to begin and complete a PI activity between January 1, 2010 and December 31, 2013. You participate in a group PI project in 2011. That project can count toward your current PI requirement.

27. May I report measures done last year? Only if you started the activity during or after the first year of your requirement for that activity.

For example, if you have a requirement to complete a PI activity that starts in 2011, the data you use must be collected no earlier than 2011.

28. May I do extra APP activities now and report them later? You will only receive credit for activities that occur during the requirement periods described in FAQ 8 What are my APP requirements? You must attest to completion of an activity you begin in or after the first year of the requirement for that activity, because the APP component emphasizes continuous improvement.

For example, if you have one PI requirement to complete before your current certificate expires in 2014, you know that you will have another PI requirement to meet during the first four years after you renew certification. If you complete two PI activities now, one of them can count toward your current requirement. The other PI you complete now cannot count toward your requirement that begins after you renew certification. You will need to start and complete a different PI during the first four years after you renew certification.

29. What if I work in three different EDs. Do I have to do this for each of them? You do not have to complete separate APP activities in each of the EDs in which you work. You can focus all your APP activities in one of the three EDs; you can complete distinct activities in different cycles in any of the three EDs; or you can pool data if necessary to acquire a sufficient number of patients. There must be an appropriate person to verify your APP activity within each ED. See FAQ 30 How does verification work? for more information about verification. 30. The online APP attestation form requests verifier information. How does verification work? ABEM randomly selects 10% of attestations for independent verification. When you attest to completing an APP activity online, you must provide the name and contact information for an individual who can independently affirm that you performed the APP activity according to ABEM requirements. This verifier must have oversight or knowledge of practice performance. This could be a Department Chair, the Chief of Staff, a Medical Director, or a practice administrator in a nonhospital setting. See a sample online Verifier Information Form. 31. How will I know when I have met my APP requirement? When you click the submit button on an APP attestation form online, your ABEM record will show that you have met the requirement.

Once you have submitted your activity, ABEM will review your information. ABEM will audit a sample of reports to validate the information. Often, the information will require further explanation. However, if you hear nothing from ABEM it is likely that your APP activity met the ABEM requirements.

32. What happens if my verifier does not completely confirm my APP activities? If ABEM does not receive independent verification of your APP activities, ABEM will work with you to see if another verifier is available. If a solution cannot be found, your clinical status with ABEM will change to clinically inactive. 33. What if I don't improve my performance? As long as you follow the steps ABEM requires for performance improvement, you have met your ABEM APP requirement. 34. What happens if I fail to submit all APP requirements on time? If you miss an attestation deadline or an APP attestation cannot be verified, your clinical activity status with ABEM will be changed to clinically inactive. Completing and reporting an APP activity would change your clinical status with ABEM back to active. 35. Who is considered to be clinically active? Diplomates who can attest to participation in a national, regional, or local practice improvement program that meets ABEM APP requirements are designated as clinically active. Diplomates who do not complete an APP requirement will be designated as clinically inactive. Diplomates may also request to change their clinical activity status to inactive if they do not see patients or do not see a sufficient number of patients to collect the data required to complete an APP activity. 36. Is a clinically inactive diplomate still certified? Yes. Clinically inactive diplomates can maintain ABEM certification by meeting their requirements in the first three components of EMCC, Professional Standing, Lifelong Learning and Self-Assessment, and Assessment of Cognitive Expertise. 37. What are the consequences of being designated "clinically inactive"? ABEM will report diplomates' clinical activity status publicly. 38. I am clinically inactive now, but if I start seeing patients again, how can I change my status to clinically active? After you start seeing patients again, use the APP function on EMCC Online to indicate that you wish to become clinically active. The system will display the APP activities you can complete to become clinically active. Begin, complete, and attest to completion of one of the

displayed activities no later than the deadline indicated. As soon as you have attested to completion of an appropriate activity, your status will become clinically active and you will have APP requirements.

39. I do not see many patients. How can I participate in APP? If you do not see a sufficient number of patients to perform the measures ABEM requires, you will be identified as clinically inactive and will not be required to participate in APP. You should continue to participate in the first three components of EMCC to maintain your certification. 40. I am clinically active, but not practicing Emergency Medicine. Am I required to participate in APP? If the work you do is included in the EM Model and if you see a sufficient number of patients to perform the measures ABEM requires, you may participate in APP and maintain your clinically active status. If the work you do is not listed in the EM Model or if you see too few patients to perform the measures required, your status will be changed to clinically inactive and you will not have any APP requirements. You should continue to participate in the first three components of EMCC to maintain your certification. 41. I am clinically active, but do not work in a hospital emergency department. How do I participate in APP? You may need to create and conduct your own APP activities. The activity you select can be a simple one, provided that you follow the steps ABEM requires. You also have the option of completing the ABMS Patient Safety Improvement Program using your own data to satisfy a PI requirement. There is a fee for this module. See information about the ABMS Patient Safety Improvement Program. 42. How will I know if I have met my APP requirement successfully? When you attest to completion of an APP activity through EMCC Online, it will immediately record that you have completed the requirement and you will see an indication that you have completed the requirement on your screen. If your attestation is selected for verification and cannot be verified, you will be notified. See FAQ 32 What happens if my verifier does not completely confirm my APP activities? In that case, the requirement will revert to incomplete and your status will be changed to clinically inactive.

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