How Can Clinical Skills Assessment Become Part of ABMS Board Certification? PDF
Preview How Can Clinical Skills Assessment Become Part of ABMS Board Certification?
How Can Directly Observed Performance Become Part of ABMS Certification? Saul J. Weiner, MD Co-Founder and Principal I3PI September 27, 2016 How are we measuring physician performance in health care? 1. Examining the medical record Query: Were recommended services administered correctly? Were desired outcomes achieved? 2. Asking patients Query: How satisfied were they with the health care experience? 3. Observing it directly Query: Are patients actually getting the care they are reported to be getting and believe they are receiving? Current Sources for Performance and Quality Assessment: Where do we get the data? From the chart: medical and financial data Healthcare Effectiveness Data and Information Set (HEDIS) Examples: Asthma Medication Use , Persistence of Beta-Blocker Treatment after a Heart Attack, Controlling High Blood Pressure, Comprehensive Diabetes Care, Breast Cancer Screening, Antidepressant Medication Management, Childhood and Adolescent Immunization Status, Advising Smokers to Quit From the patient: Consumer Surveys Clinician and Group Consumer Assessment of Health Providers and Services (CG-CAHPS ) Examples: (a) Getting care quickly, (b) Getting answers to medical questions by telephone, (c) Coordination of care, (d) Doctor communication skills, (e) Health promotion and education, (f) Office staff communication skills Assumptions about Performance Measures 1) That documentation is an accurate representation of care 2) That patient satisfaction surveys accurately capture patient experience How do we test these assumptions? Need to actually observe care The Unannounced Standardized Patient (USP). • Like the “mystery shopper” widely used in retail and hospitality industries, but standardized. • Can audio record visit. Uses Checklists Real patients who carry a concealed audio recorder provided by a research or QI team • Not standardized, can’t use checklists. The “Unannounced” Standardized Patient (USP) • Actors trained to consistently and repeatedly simulate a patient with a specific script and interaction behavior • Work incognito: At time of encounter provider unaware actor not a real patient • May audio record encounter, complete post visit checklist • Following visit physician’s note may be downloaded. How accurate is chart abstraction as measure of quality and performance?* • USPs portrayed common ambulatory presentations for which there are explicit quality measurement criteria (e.g. evaluation of lower back pain without comorbidity) • Compared chart abstraction to USP checklists immediately following visit Findings: • Many false negative in chart: USPs reported higher quality care than chart abstractions (i.e. physician provided more necessary care than documented • Many false positive in chart (reported normal cardiac examination but did not auscultate). *Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med. 2000; 108:642-9. USP Research Findings 33% of physical exam findings reported were not conducted 16% of preventive care delivered was not reported <50% of physicians perform fundoscopy or examine feet in diabetics 33% provide no sun protection counseling during a life guard pre- work physical 40% of rheumatologists missed diagnosis of psoriasis because of a failure to examine the skin. 33% of internists neglect to consider hypothyroidism in a patient presenting with constipation, weight gain, heavy menses and poor sleep. Weiner S, Schwartz A. Directly Observed Care: Can Unannounced Standardized Patients Address a Gap in Performance Measurement? Journal of General Internal Medicine. Volume 29, Issue 8 (2014), Page 1183-1187. USPs for Performance Improvement* Captures what happened rather than what was documented. No Hawthorne effect (unaware when being studied)** Incentivizes optimal behavior: Motivates staff to perform well at all times. Intrinsically risk adjusted (“apples to apples” comparisons) Can assess complex decision making USPs are “connoisseurs of care”; may be more reliable then real patients for customer service standards and physician behavior assessment. BMJ article concludes: USPs the “gold standard” for measuring the quality of physician practice.*** *Weiner S, Schwartz A. Directly Observed Care: Can Unannounced Standardized Patients Address a Gap in Performance Measurement? Journal of General Internal Medicine. Volume 29, Issue 8 (2014), Page 1183-1187 **Schwartz A, Weiner SJ, Binns-Calvey A. Comparing Announced with Unannounced Standardized Patients in Performance Assessment. The Joint Commission Journal on Quality and Patient Safety. 2013;39(2):83- 88 ***Luck J, Peabody JW. Using standardised patients to measure physicians’ practice: validation study using audio recordings. BMJ. 2002;325:679. USP Performance Improvement Cycle Step 1: Form a team and identify priorities for assessment: Form a practice improvement team with representation from managers, providers (clinical champions) and support staff, and identify priorities for assessment.
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