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What’s in It for Me? Maintenance of Certification as an Incentive for Faculty Supervision of Resident Quality Improvement Projects Glenn Rosenbluth, MD, Jeffrey A. Tabas, MD, and Robert B. Baron, MD, MS

Abstract Problem Residents are required to engage in quality improvement (QI) activities, which requires faculty engagement. Because of increasing program requirements and clinical demands, faculty may be resistant to taking on additional teaching and supervisory responsibilities without incentives. The authors sought to create an authentic benefit for University of California, San Francisco (UCSF) Pediatrics Residency Training Program faculty who supervise pediatrics residents’ QI projects by offering maintenance of certification (MOC) Part 4 (Performance in Practice) credit.

Approach The authors identified MOC as an ideal framework to both more actively engage faculty who were supervising QI projects and provide incentives for doing so. To this end, in 2011, the authors designed an MOC portfolio program which included faculty development, active supervision of residents, and QI projects designed to improve patient care.

Problem

Graduate Medical Education (ACGME) requirements that each resident “systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement.” To meet this requirement, faculty must possess QI knowledge and skills and be sufficiently engaged to supervise residents’ QI projects.1

Education in quality improvement (QI) presents a new and unique challenge in medical education for students, residents, fellows, and faculty.1 This is particularly true in graduate medical education (GME) because of explicit Accreditation Council for G. Rosenbluth is associate professor, Division of Hospital Medicine, Department of Pediatrics, and director of quality and safety programs, Office of Graduate Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California. J.A. Tabas is professor, Department of Emergency Medicine, and director of outcomes and innovations, Office of Continuing Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California. R.B. Baron is professor, Division of General Internal Medicine, Department of Medicine, and associate dean of graduate and continuing medical education, University of California, San Francisco, School of Medicine, San Francisco, California. Correspondence should be addressed to Glenn Rosenbluth, Department of Pediatrics, University of California, San Francisco, School of Medicine, 550 16th St., Box 0110, San Francisco, CA 94143-0110; telephone: (415) 476-9185; e-mail: rosenbluthg@ peds.ucsf.edu. Acad Med. 2016;91:56–59. First published online June 16, 2015 doi: 10.1097/ACM.0000000000000797

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Outcomes The UCSF Pediatrics Residency Training Program’s Portfolio Sponsor application was approved by the American Board of Pediatrics (ABP) in 2012, and faculty whose projects were included in the

Since 2010, residents in the University of California, San Francisco (UCSF) Pediatrics Residency Training Program have implemented QI projects as part of their continuity practices. When clinic-based QI projects were first implemented, faculty preceptors were concerned and, in some cases, resistant to participate. Increased pressures from program requirements (e.g., increased need for direct observation for assessment) as well as pressure to increase clinical volume had already increased faculty workload. Absent additional financial incentives, our program sought to create an authentic benefit, one which would be recognized and accepted as valuable, to faculty by offering maintenance of certification (MOC) Part 4 (Performance in Practice) credit.

application were granted MOC Part 4 credit. As of December 2013, six faculty had received MOC Part 4 credit for their supervision of residents’ QI projects. Next Steps Based largely on the success of this program, UCSF has transitioned to the MOC portfolio program administered through the American Board of Medical Specialties, which allows the organization to offer MOC Part 4 credit from multiple specialty boards including the ABP. This may require refinements to screening, over­sight, and reporting structures to ensure the MOC standards are met. Ongoing faculty development will be essential.

Approach

Stakeholder identification We identified four major groups of stakeholders: faculty who need MOC (faculty preceptors); institutional education leaders (program directors, education deans, the designated institutional official, faculty in the Deans’ Offices of Continuing Medical Education [CME] and GME, etc.); medical center QI leaders (at both the institutional and local levels); and learners. For faculty who need MOC, active participation in QI projects is one way to fulfill the American Board of Pediatrics (ABP) requirement for MOC Part 4. Clinicians may complete this in a variety of ways, though in 2012, only about 20% of pediatricians fulfilled the requirement through meaningful participation in QI projects in their own practice setting (criteria for meaningful participation vary by project but include both an active role in the project and participation over an appropriate period of time)2; the majority (over 75%) completed online modules.3 Despite outreach and educational efforts, MOC remains a source of concern and perceived burden for many physicians.4

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Institutional education leaders must demonstrate that learners are actively involved in QI to meet program requirements, institutional requirements, and learner milestones. At the same time, they must compel faculty to actively participate by supervising learners. Medical center QI leaders also aim to engage faculty in institutional QI efforts. These efforts can no longer be performed by just a handful of QI experts. Practicing physicians need to be fully engaged. MOC for institutional projects allows faculty QI efforts to align with day-today institutional QI priorities, which is preferable to off-hour practice improvement modules. Learners are obvious stakeholders in that they need to learn QI methodology, and doing so requires the engagement of competent faculty. We sought to change the preexisting “hidden curriculum,” in which many faculty view QI and MOC as a burden,5 in order to reframe QI for learners as part of lifelong learning. A detailed list of stakeholders is presented in Table 1. Solution identification There are many possible approaches to the challenges of both supervising residents in QI activities and providing incentives for doing so. It would have been relatively straightforward to identify a single faculty member to serve as the “physician champion” who supervised all QI projects. However, a recent Association of American Medical Colleges report suggests that all clinical faculty must be proficient in QI, even while certain faculty members are experts or masters.1 In addition, engaging only a small group of faculty leaders runs the risk that residents might view the other frontline faculty as disengaged, and perhaps not view QI as a core tenet of clinical practice. Another approach is to offer credits as modified relative value units (RVUs), sometimes called educational value units (EVUs), as a currency for acknowledging and rewarding the extra work put forth by clinical educators that cannot be captured with clinical revenue. However, there is currently no standard for quantifying the extra effort faculty expend to engage in residents’ QI projects.

Academic Medicine, Vol. 91, No. 1 / January 2016

Table 1 Stakeholders, Their Roles and Contributions, and the Potential Benefits They Receive for Participating in the University of California, San Francisco Pediatrics Residency Training Program MOC Program, Established in 2012 Stakeholder

Roles and contributions

Potential benefits

Dean’s Office of GME

•  G  lobal program oversight •  Approval of projects

Dean’s Office of CME

•  G  lobal program oversight •  Approval of projects •  Administrative support (communication with specialty boards and tracking of MOC projects and credit)

•  C  ommon program requirements are met •  Residents are supervised in systems-based practice activities and meet milestones •  Ability to offer MOC Part 4 (Performance in Practice) credit •  Alignment with clinical and educational missions (support continuing professional development and lifelong learning)

Medical center QI infrastructure

•  Institutional QI data

Program champions

•  P rogram leadership •  Leadership opportunities •  Faculty development •  D  evelopment of novel program •  Approval of QI projects (via Dean’s •  Scholarship opportunities Office of CME)

Local champions (clinical site based and/or program based)

•  O  rganization of local projects •  Faculty development •  Just-in-time coaching

•  A  lignment of local QI projects with institutional priorities •  Engagement of frontline faculty in QI efforts

•  P rioritization and advancement of clinical site QI priorities

Faculty preceptors •  D  elivery of QI curriculum to residents •  Supervision of residents’ QI projects

•  L earn or improve QI skills •  Obtain MOC Part 4 credit

Learners •  Design and implementation of QI (residents, fellows, projects students)

•  L earn or improve QI skills and meet milestones •  Engage in authentic QI projects with faculty supervision

Abbreviations: MOC indicates maintenance of certification; GME, graduate medical education; CME, continuing medical education; QI, quality improvement.

We identified MOC as an ideal framework for supporting active faculty engagement in supervising residents’ QI projects. By developing a system to grant MOC Part 4 credit, we sought to incentivize active engagement with residents’ QI projects as an alternative to fulfilling the requirement by completing online modules or other nonteaching projects.

teaching faculty view MOC as an incentive to precept in the undergraduate medical education environment,7 and the American Medical Association has endorsed a similar approach by approving CME Physician’s Recognition Award Category 1 Credit for teaching.8

The model of using MOC Part 4 credit as an incentive for faculty to participate in the educational mission has been used successfully in other settings. The I-PASS (Initiative for Innovation in Pediatric Education–Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs) handoff study, a multisite initiative to reduce medical errors by improving handoff communication, used MOC as an incentive for faculty who observed resident handoffs.6 Volunteer

In 2011, we initiated discussions with the ABP to identify potential options for granting MOC credit for faculty supervision of resident QI projects. The ABP was extremely supportive and recommended that we become an ABP Portfolio Sponsor. Becoming a Portfolio Sponsor would enable our institution to provide MOC Part 4 credit to faculty who engaged with meaningful participation in a QI activity. Funding for the fees and administrative work

Solution development and implementation

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associated with our MOC portfolio program initially came through the UCSF Pediatrics Residency Training Program, and now comes through the Office of CME. In 2011, we designed an MOC portfolio program which included faculty development, active supervision of residents in systems-based practice (including opportunities for assessment) and in practice-based learning and improvement, and QI projects designed to improve patient care. Using a “train the trainer” approach, all faculty were taught in the Institute for Healthcare Improvement–endorsed Model for Improvement, which uses a plan– do–study–act format. In addition, we offered on-the-fly peer mentorship by a QI leader (G.R.) at our institution. QI projects were chosen by the clinic residents with faculty guidance to enhance authenticity. We wanted to avoid imposing an outside project which might or might not directly relate to gaps in care. QI projects were reviewed by a program champion working with a chief resident, and feedback was sought from residents and faculty at the end of the projects. Faculty provided ongoing support to their residents at monthly 30-minute check-ins and as needed. Our program was unique and innovative in several ways. First, no other organization had specifically designed its MOC portfolio program to grant credit to faculty for supervising residents’ QI projects. We structured our program with oversight through the Deans’ Offices of GME and CME (including our CME Governing Board) and our medical center QI infrastructure (Table 1). We deliberately chose this structure because our training programs are spread across several local medical centers, and we wanted to ensure that we could support faculty at all of our affiliated sites. Additionally, the Dean’s Office of CME had an existing infrastructure for project review and administration of MOC credit. Our program still required local champions to support faculty, but the administrative workload and time commitment were less than what would have been required of a single faculty member providing supervision for all QI projects.

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Outcomes

Initial response Our Portfolio Sponsor application was approved by the ABP in 2012. This enabled us to grant MOC Part 4 credit to the faculty whose projects were included in the application, giving us early success stories to share. Faculty immediately expressed great interest in and appreciation for receiving MOC Part 4 credit. Therefore, we were quite surprised that in the first year of offering credit through the Portfolio Sponsor program, no continuity clinic faculty members took advantage of the opportunity. In fact, two faculty preceptors (one of whom was a local QI leader) chose to complete online modules instead of requesting credit for eligible clinic projects. We had informal discussions with these two faculty members, as well as others, which led us to identify three important barriers which contributed to faculty not taking advantage of this opportunity. First, the standards for participation to earn MOC credit were higher than the standards we had set for the residents to meet in their continuity clinic QI projects, including a longer time frame. We underestimated the degree to which this would be a barrier for faculty. Many faculty already viewed the projects as an “add-on” and did not want to sustain them after the three-month minimum. This barrier was overcome when a second cohort of continuity clinic preceptors approached their MOC deadlines with a self-reported sense of urgency. In the second year, several faculty expressed interest, explicitly stating that they needed MOC credit by the end of the calendar year. It is still unclear to us why the first cohort did not feel the same sense of urgency; however, it may be that additional reinforcement and/or repetition was needed. A second barrier was the need for additional mentorship. Some faculty members who were interested in MOC still lacked the expertise to effectively supervise QI projects. Many faculty members were inexperienced in QI and therefore received mentorship from a QI coach (G.R.). A third barrier was simply the completion of the MOC project application. Despite our attempts to simplify the forms, we found that many faculty requested

additional assistance to frame their MOC projects appropriately. One member of our team (G.R.) served as an informal consultant to provide assistance and feedback in completing the applications, particularly in the development of run charts and the description of the QI project and intervention. As of December 2013, six faculty members have received MOC Part 4 credit for their supervision of resident QI projects. Although this number seems low, it represents about one-fifth of our total continuity clinic preceptors, and because MOC Part 4 is on a five-year cycle, this number is appropriate for any given academic year. We anticipate this program being most attractive to faculty who are due for MOC activities, and the cyclic nature of MOC should create a near-constant demand. At this early stage, evaluation9 by faculty is limited to qualitative reactions to the program, which were uniformly positive. However, on the basis of the assistance provided in creating run charts, we have reason to believe that faculty who met the MOC standards also had greater learning. Our self-assessment is informed by the barriers and responses described above. Institutional alignment Our model has the advantage of providing an authentic, nonfinancial benefit for faculty who contribute to necessary educational programs. Going forward, we must think creatively about ways to support faculty who teach systems-based practice and practice-based learning and improvement. Similar to recognizing clinical educators with CME credit for teaching activities,7 our program rewards faculty for their contributions to underfunded aspects of medical education such as active engagement in supervising residents’ QI projects. The format of this program has the potential to provide greater alignment between the clinical and teaching missions of academic medical centers, and the goals are in direct alignment with the ACGME Clinical Learning Environment Review program, which strives to support learning environments which foster QI activities. On a local level, it has created a greater awareness of institutional QI efforts and an incentive for faculty to take a more

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Innovation Report

active role in residents’ QI projects. Faculty who resisted participating in residents’ QI projects in the past have actively sought out opportunities to participate. Sustainability Faculty must complete at least two MOC Part 4–eligible projects every five years to maintain ABP certification. Therefore, there is an ongoing need for our program to offer MOC credit in this manner. With approximately 30 preceptors each completing two projects every five years, we could have up to 60 requests every five years, or as many as 12 per year if faculty used this as their primary source of MOC Part 4 credit. This number will be higher as the program expands to other clinical settings. To support the project on an ongoing basis, we have identified more concrete faculty and administrative needs. We have two faculty leaders, one supported by the Dean’s Office of GME and one by the Dean’s Office of CME, who review each project both in a preapproval stage (to ensure that the design meets MOC standards) as well as postcompletion. Administrative support for data tracking and monitoring is provided by the Dean’s Office of CME.

MOC portfolio program administered through the American Board of Medical Specialties (ABMS), which enables our organization to offer MOC Part 4 credit from multiple specialty boards including the ABP.10 As the program grows, we may need to refine our screening, oversight, and reporting structures to ensure that faculty’s MOC projects meet the MOC standards set by the ABMS program. Our program places a particular focus on engaging faculty who would not otherwise take an active role in leading QI efforts with residents. Therefore, ongoing faculty development will be essential.1 Acknowledgments: Elizabeth Hanson, MD, designed the initial faculty development program. Matthew Trojnar, Stacey Samuels, and Tymothi Peters provided significant programmatic support through the Office of Continuing Medical Education. Amy Roberts, Kristi Johnson, and Paul Myles, MD, provided significant programmatic support through the American Board of Pediatrics.

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Funding/Support: None reported. Other disclosures: The authors have no conflicts of interest to declare in relation to this manuscript. There was no off-label or investigational use.

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Ethical approval: Reported as not applicable. Previous presentations: Poster presentation at University of California, San Francisco Education Day, April 2014. 9

References Next Steps

Largely on the basis of the success of this program, UCSF has transitioned to the

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1 Headrick LA, Baron RB, Pingleton SK, et al. Teaching for Quality: Integrating Quality Improvement and Patient Safety Across the Continuum of Medical Education: Executive

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Summary of an Expert Panel Report. https:// www.aamc.org/download/309944/data/ te4qexecutivesummary.pdf. Accessed April 17, 2015. Maintenance of Certification Activity Manager. Part 4: QI Project (More Than 10 Physicians). https://abp.mocactivitymanager. org/sponsorgroups/qipa/. Accessed June 4, 2015. Miles PV, Moyer VA. Quality improvement and maintenance of certification. Acad Pediatr. 2013;13(6 suppl):S14–S15. Iglehart JK, Baron RB. Ensuring physicians’ competence—Is maintenance of certification the answer? N Engl J Med. 2012;367:2543– 2549. Arnold GK, Hess BJ, Lipner RS. Internists’ views of maintenance of certification: A stages-of-change perspective. J Contin Educ Health Prof. 2013;33:99–108. Starmer AJ, O’Toole JK, Rosenbluth G, et al; I-PASS Study Education Executive Committee. Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs. Acad Med. 2014;89:876–884. Ryan MS, Vanderbilt AA, Lewis TW, Madden MA. Benefits and barriers among volunteer teaching faculty: Comparison between those who precept and those who do not in the core pediatrics clerkship. Med Educ Online. 2013;18:1–7. American Medical Association. Teaching Medical Students and Residents. http://www. ama-assn.org/ama/pub/education-careers/ continuing-medical-education/physiciansrecognition-award-credit-system/accreditedcme-provider-resources/teaching-medicalstudents-residents.page. Accessed April 15, 2015. Kirkpatrick DL. Evaluating Training Programs: The Four Levels. San Francisco, Calif: Berrett-Koehler; 1994. American Board of Medical Specialties. Multi-specialty Portfolio Approval Program. http://www.mocportfolioprogram.org. Accessed April 17, 2015.

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What's in It for Me? Maintenance of Certification as an Incentive for Faculty Supervision of Resident Quality Improvement Projects.

Residents are required to engage in quality improvement (QI) activities, which requires faculty engagement. Because of increasing program requirements...
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