In 2014, newly certified PAs and practicing PAs who had completed their 6-year certification maintenance cycles began transitioning to the new certification maintenance cycles established by the National Commission on the Certification of Physician Assistants (NCCPA). Under this process, PA certification maintenance takes place over a 10-year period comprised of five 2-year cycles. The first four 2-year cycles require PAs to earn credits in two new categories: self-assessment and performance improvement. By the end of the first four cycles, PAs must earn and log at least 40 AAPA Category 1 Self-Assessment CME credits (SA-CME) and at least 40 AAPA Category 1 Performance Improvement CME credits (PI-CME). The fifth CME cycle does not require SA- or PI-CME, instead allowing PAs to choose the type of CME that will best prepare them to attain a passing grade on the Physician Assistant National Recertifying Examination (PANRE).
The category of PI-CME activities was designed as a way to provide PAs with recertification credit for taking the time to think about their practice, specifically in areas that may be in need of improvement with regard to team-based care. A three-stage process — performing a self-assessment, developing and following a plan of improvement, and performing a reassessment to measure the effects of the improvement plan — allows PAs to reflect on ways to improve their practice and gives them the opportunity to consider systemic changes that they might make to improve patient care.
PI-CME credits can be earned by way of the typical online PI-CME module or via two new models: Hospital and Health Systems Quality Improvement, and the Self-Directed Model.
Typical Online Module
The AAPA maintains a growing list of PI-CME activities that have been approved for AAPA Category 1 PI-CME credit. PAs who are not in clinical practice or can’t find a PI-CME activity that is relevant to their particular practice can gain credit through the Johns Hopkins’ Patient Safety Certificate Program. This activity must be accessed through the AAPA’s Learning Central, and all modules of the program must be completed to receive credit.
Hospital and Health Systems Quality Improvement
This request type is now available in AAPA’s online CME application system and is meant to be used by PAs who work in a clinic or hospital that has a quality-improvement department or other access to quality improvement expertise. In this instance, the institution itself applies for approval along with a flat fee for the intended program, and many PAs are able to participate. Benefits of this model are that PAs get to work with other medical professionals (e.g., physicians, surgeons, nurse practitioners, and nurses) to develop a program that will benefit the particular needs of their practice, and the cost for the PI-CME activity is absorbed by the institution.
The Self-Directed Model
AAPA is preparing to launch a new product that will allow PAs to customize their own PI-CME project choosing measures from an online library of measures. This module, the Self-Directed Model, will be facilitated online, and PAs will be able to choose from an online library of approved measures.
PI-CME Process — Three Models to Choose From
According to Eric Peterson, Senior Director for Performance Improvement CME for the American Academy of PAs, there are three separate models for PI-CME.
The first model is the ABC format below, which follows the AMA PI-CME format and describes activities that are designed by a CME provider. That format can be implemented by individuals learners on their own (i.e., PI-CME modules) in three stages.
Stage A is a self-assessment process in which you compare your practice and specific clinical area with national benchmarks and performance guidelines and with the data submitted by other PAs. Basically, at this stage, you are being asked to select a suitable target for improvement, and you are collecting data about performance.
Stage B requires that you evaluate current performance and then develop and follow a plan to improve your practice on the basis of your assessment. For instance, you might make a change in the way you complete a particular process or approach a routine task, or you might create new material for patient education or engage in educational activities.
Stage C is the reassessment stage, in which you measure the effects of your improvement plan or intervention after a suitable period of time and reflection.
The minimum requirement for AAPA Category 1 PI-CME is the completion of at least one quality improvement cycle, although many projects involve repetition of the activity multiple times, and those projects would usually require multiple and sometimes continuous cycles.
The second model is the Hospital and Health-systems Quality Improvement request type, which is currently available in AAPA’s accreditation system and is open to any health care organization to get a team-based workplace project approved.
The third model is the self-directed online option, which permits individual PAs to build their own PI projects by selecting from an approved-measures library.
Pilot Institutional PI-CME Programs
In addition to the three models mentioned above, the University of Michigan Health System (UMHS) and MD Anderson (and now also The Medical College of Wisconsin) are participants in a pilot program, begun in October 2015, that relies on the multispecialty portfolio program infrastructure of the American Board of Medical Specialties (ABMS) to recognize PA participation in institutional projects conducted through the portfolio program. In this model, the AAPA is recognizing the process that is already in place in the pilot institutions for providing adequate oversight of these projects. Pilot projects are not currently available beyond the aforementioned pilot organizations; however, the program may be expanded to other ABMS multispecialty portfolio programs in the near future.
For these pilot program organizations, the institution’s PI-CME program must be recognized by the AAPA as an approved Multi-Specialty Portfolio Sponsor, meaning that the program meets specific criteria and is accountable to the ABMS with regard to the maintenance of program standards.
University of Michigan Health System
UMHS now has a total of six PA-led group projects, according to Marc Moote, MS, PA-C, UMHS’s Chief Physician Assistant. UMHS was the first in the country to implement PI-CME projects conducted within the context of the Multi-specialty Portfolio Approval process in the AAPA pilot program. Their first projects included:
- developing a diagnostic database and electronic scheduling tool (an ongoing project intended to improve patient experience and ease decision making for staff),
- optimizing the timing of prophylactic antibiotics given to patients undergoing cardiac surgery (completed project: they went from 49% improvement to 78% improvement during the course of this project but would love to reach 100% improvement),
- and the use of clinical pathways to improve urological surgery outcomes (ongoing).
According to Moote, there are 275 PAs employed by UMHS, which gives that institution an opportunity to invest in a group that is already there.
“Our first three projects met the PI-CME requirements and were PA-led and run,” said Moote. “But even more importantly, the PI-CME requirements allowed PAs to pick something meaningful to their particular practice and to work together as a group. These projects were not just another requirement — we designed and implemented them to meet all the needs and interests that we care about.”
One of the newer projects at UMHS involved the triage of operative and nonoperative orthopedic surgical patients. Routing patients to the correct clinician means fewer appointments for patients because surgical patients get routed directly to surgeons and nonsurgical patients get routed to PAs. Moote says that the success of this project was due in great part to the good administrative, internet technology, and other departmental support that they have at UMHS.
In other PI-CME activities at UMHS, PAs are working to shorten the amount of time that patients wait to be seen in the temporomandibular joint (TMJ) disorder clinic after being referred by the otolaryngology department, and a project to expedite discharge for inpatients so that they can leave the hospital earlier in the day. Another project involves identifying preoperative patients on high-doses of opioids, as there can be problems with adequate perioperative pain control in that group of patients. The goal of that project is to titrate those patients down to a lower level of opioid dependency before surgery.
Lastly, UMHS is also running a project involving cataloging the insurance information of patients properly with the goal of avoiding the delays in discharge that can occur when there are difficulties getting insurance authorization for discharge medication. Moote says that this project is an excellent example of PAs and physicians working and learning together in the institutional PI-CME model.
“With the institutional PI-CME model, your institution absorbs the cost of one or more cycles of ‘plan, do, check, act’, and the program can be focused on the particular patient care needs of your institution,” says Moote. “Alternatively, you can purchase a typical online module for a price ranging from $100 to $700, but those modules mostly involve chart review, plus the resulting improvement in care may be questionable because the online modules are limited to what society has picked rather than what is directly relevant to your particular needs. Choosing an online module also means using up part of your professional education allowance, leaving less for other expenses, such as conference fees, licensing fees, and additional out-of-pocket costs that PAs must bear.”
University of Texas MD Anderson Cancer Center
Todd Pickard, MMSc, PA-C, Director of PA Practice at MD Anderson Cancer Center in Houston, says that their medical facility also makes excellent use of the institutional PI-CME model. The MD Anderson projects are aimed at improving patient care while maximizing hospital resources.
“The PI-CME process provides avenues for quality-improvement work — a process that works particularly well in institutions that have a quality-improvement board,” says Pickard. “The Center’s departments and divisions identify problems and issues and come up with ways to explore those issues. PAs, nurse practitioners, and physicians participate in the programs, after which the team shows what they learned from the process. We run progressive, collaborative, collegial programs that are AAPA certified. MD Anderson applies the standards necessary so that the PI-CME qualifications will apply to each program.
“Our PI-CME programs also help prepare us for periodic site visits by the Accreditation Council for Graduate Medical Education (ACGME),” says Pickard, “because part of that evaluation involves self-study over a specific period of time.”
MD Anderson is currently running a clinical safety and effectiveness (CS & E) program in surgical oncology. Two consecutive 6-month CS & E sessions are offered per year, permitting 10 to 20 advanced practice providers (PAs and nurse practitioners) per year to take part and learn ways of collecting data, formulating a plan, and using various tools (e.g., fishbone diagrams and run charts) to continuously improve their practice.
The first session involves evaluating the top causes of readmission and then the creation of an improved discharge checklist to address those causes. Project Head Marla E. Weldon, PA-C, who is involved in discharging surgical oncology patients, said that her group is studying the problem of readmission of surgical patients because of nausea and dehydration.
“Surgical patients will not have to pay if they are readmitted within a certain time period after discharge,” says Weldon, “so there is currently a Medicare incentive to reduce readmission rates. My team is tracking data to create a tool to stop patients from being discharged if they have certain symptoms, such as dehydration.”
According to Weldon, the team created a checklist tool with use of data collected from patient readmissions. The tool was effective in alerting the team to the presence of several conditions that might make readmission more likely.
“Patients who had received intravenous administration of narcotics and antiemetics within 12 hours before discharge often came back in throwing up,” says Weldon. “In addition, patients were more likely to be readmitted if they had a heart rate of more than 100 beats per minute at the time of discharge (a possible sign of infection), or if they had a lowered amount of ‘ins and outs’ (an indication that the patient might not be taking in enough nourishment by mouth). We also found it beneficial to do a final inspection of the surgical wound just before the patient left the hospital.”
Weldon says that the project is now going into its second year, and that although they began by collecting the data on paper, they soon moved to entering the data electronically. Although the results from this project were initially very good, they are currently not as great as she hoped they would be; however, the project has served as a reminder to nurses and PAs and is heightening their awareness of these issues.
The second session was an attempt to increase communication and improve dialog between patients’ daytime and nighttime primary care teams.
According to Project Head Lakeisha R. Day, PA-C, over the course of 5 years, verbal communication at this large hospital (140 patients) underwent a transition from verbal only to verbal and electronic. The number of nocturnal providers (advanced practice registered nurses and PAs) had grown from four to 40, and their shift beginnings and endings usually did not line up with those of the daytime providers or the physicians. In addition, it was much more difficult to communicate information to a patient’s physician at night than it was during the day.
A better communication method was needed, as there was no definitive method or means to hand off communication to the next provider. Day took the original evaluation tool created by their director 5 years ago and expanded it, thus implementing a new, comprehensive medical record of information.
By evaluating how the two sets of providers preferred to receive information, the MD Anderson team was able to increase the number of successful handoffs by more than 100%. The Center now uses verbal as well as an electronic method of handoff at the end of shifts. “There has been a great improvement in provider satisfaction since the beginning of this program,” says Day.
Day confesses that she always preferred patient-centered care over research and that she never fully realized the importance of research until she became involved in the PI-CME project. She came to realize that research is actually imperative for patient care, and that group work among the providers involved in a patient’s care is paramount.
How to Earn PI-CME Credit
Many institutions have initiated their own AAPA-approved PI-CME projects, so check with your Chief Physician Assistant to see if there is a program in place that you can join. If your institution does not have a PI-CME program, you can check the AAPA website for programs that accept PAs who are not affiliated with their institution. For more information, see the AAPA’s publication, “Performance Improvement CME: A Practical Introduction & Toolkit.”