The American Board of Internal Medicine (ABIM) has been making some big changes to its Maintenance of Certification (MOC) program lately, mainly in response to negative feedback from physicians. One of the changes has been to suspend the requirement for MOC Part 4, which included ABIM Practice Improvement Modules (PIMs).

The original aim of Part 4 was to encourage and document physician- and hospital-based efforts to learn from patient data and improve quality. Although many physicians agreed that this type of QI effort was laudable, the requirements for documentation and the oversight by the ABIM were considered onerous. Critics argued that small private practices, academic physicians, and retired doctors should not be regulated as if they were hospitals or large conglomerate practices.

The specific changes to Part 4 — and the ways they will affect your MOC points and certification status — are outlined on an FAQ page on the ABIM website. The bottom line (for now) is that as long as you have earned 100 MOC points (with at least 20 Medical Knowledge points) and have passed the certification exam in the past 10 years, you have met the requirements for certification.

Trends in QI Likely to Continue — Despite Suspension of ABIM Practice-Improvement Modules

Whether you’re practicing medicine in a hospital or a private practice, you were probably working on QI projects before the ABIM required documentation of practice improvement — and, most likely, you’re continuing your QI efforts now that the ABIM has suspended its requirement. The only thing that has changed is that one overseeing body has stopped requiring the extra step of submitting documentation of these projects (i.e., ABIM practice-improvement modules).

QI stretches across medical specialties, of course, and we reached out to Dr. Chén Kenyon, a faculty member at PolicyLab at The Children’s Hospital of Philadelphia (CHOP) and an assistant professor in pediatrics at the University of Pennsylvania, to weigh in. He describes three key reasons why QI efforts are likely to continue:

The culture of medicine is changing. “QI is becoming more and more of a priority,” Dr. Kenyon says, “as measuring care processes and outcomes becomes more ingrained in the culture of medicine. Modifications to payment structures — such as pay for performance, readmission penalties, and lack of reimbursement for care of complications — will help to change the culture, and increasing transparency of quality-of-care metrics to the public will help to facilitate this process.”

Cost savings and quality improvement often go hand in hand. Dr. Kenyon’s experience has shown that “when efforts to improve quality are focused on reducing overuse of services that are either unnecessary or marginally helpful (such as those outlined in the Choosing Wisely recommendations, which are adopted and promoted by many specialties), improvements in care will correspond with cost savings.”

On the other hand, there are scenarios in which effective health care services are underused, and boosting utilization may drive up costs. For example, Dr. Kenyon points out, “Improving screening rates for HIV among high-risk populations or expanding access to new effective hepatitis C therapies may lead to higher costs, at least in the short term.”

Practice improvement data will eventually drive public consumption. “The role of consumers in driving practice improvement is currently limited,” says Dr. Kenyon, “given the lack of transparency between centers. That said, there are now a number of websites that allow patients to compare hospitals and providers with respect to their outcomes on several conditions (for example, Hospital Compare, which is offered on and rates quality at more than 4,000 hospitals). As quality measurement and reporting improve, patients will have better information to make choices about where they should seek non-emergent care.”

Practice Improvement in Real Life

Physicians have been putting a lot of time and thought into improving care through QI projects at their hospitals, rehab centers, and clinics — in real life, not just in theory. To get a deeper look at the type of everyday scenario that could trigger such a project, Dr. Kenyon walks us through a typical case and its implications. This is a pediatrics case, but the lessons from it for QI projects are easily transported to internal medicine — in fact, they could be considered universal.

Let’s say a 9-year-old boy with a history of moderate persistent asthma presents for follow-up after being hospitalized for an asthma exacerbation. During medication review, you discover that rather than using fluticasone as a preventer inhaler, the child has inadvertently been using albuterol twice daily and taking fluticasone when he has a wheeze. The boy and his mother say that he was instructed to take his medications this way when he left the hospital. The same problem has occurred several times before with other patients of yours. The question now is how to prevent this from continuing to happen in your practice.

In a scenario like this, your instincts may not lead you to the best solution. Dr. Kenyon says, “Your first inclination might be to further educate families or create a system to remind them which medication to use in which circumstance. Or you might consider calling the hospital staff to propose a different discharge protocol. But both of these approaches presumes that the potential precipitant that you identified is indeed the driver of the outcome — and that the solution you have generated will improve the outcome. In this case, a far better approach would be to first perform an audit to determine if patients across your practice can recognize and appropriately use their medications. If the problem turns out to be widespread, you can start the process of identifying contributing factors.”

Dr. Kenyon offers two first steps in initiating a QI initiative such as the one in the above case:

  • Assess the extent of the problem. For this, we can ask, “How well does the experience of this patient in front of me represent the experience of other patients in the system?”
  • Understand what is driving the problem. For this, we can ask, “What factors facilitate this undesired outcome or experience, and which ones are most influential?”

He continues, “As we were discussing earlier, physicians will likely undertake this type of QI project (an audit) without a requirement (ABIM practice improvement modules, for example), especially if hospital systems and clinics make it relatively straightforward for physicians to obtain user-friendly data on their practice or performance.”

A clinical scenario like this — a patient who has been taking the wrong medication — is very common and suggests the need for an audit. That said, physicians cannot improve quality by themselves. Dr. Kenyon emphasizes that physicians “need a support system in place to facilitate QI projects, such as personnel dedicated to performing queries of medical records or patient surveys and helping physicians manage improvement efforts.” Clinicians might not always choose the balanced solution unless the institution has the support structure to facilitate QI efforts.

In Dr. Kenyon’s institution and in many others, “This sort of infrastructure is growing and can support the natural desire that physicians have to improve the care they provide and the outcomes of their patients.”

What’s been most helpful to you in starting QI projects? What trends in QI do you see at your institution?