Thank you all for your tech help, and hello to everyone, welcome to our session called the American Board of Physical Medicine Rehabilitation Expansion of Improving Health and Healthcare Opportunities. I'll just pause on that term because it's a new term and you're going to begin to hear it more frequently, IHHC, Improving Health and Healthcare, so we'll come back to it through the course of this presentation, but I have, I'm one of the directors on the American Board of PM&R, and I have two of my co-directors with me, both Sherry Driscoll, who's the chair of the board, I'm currently the vice chair of the board, and Chris Garrison. So I appreciate them participating in this with me, other than our involvement as directors on the ABPMR, we have no disclosures. And we are going to, through the course of our conversation today, and we do want this to be a conversation, we're a small group, and so we're going to engage a little bit and think about how you might pursue quality improvement work in your scope of practice. What might that look like? So we will break that down by walking through some of the traditional quality improvement processes, some of the framework around it, and then talk about some things that you might have, should have gotten an email about just a couple of days ago, introducing you to some new opportunities to give you credit for IHHC, and then the audience participation part of the discussion. So with that, I'll turn it over to Chris to walk us through. All right, so some of the basics of quality improvement that improves, you know, how you do work in your daily routine, this model, model for improvement, is very simple, but not simplistic. Frankly, it's powerful, powerful enough to create a firestorm of activity back in the 70s when Japanese automakers were using this same model and created a host of changes within the auto industry. This would be an example of simple, but not simplistic. It can solve small problems and can solve big problems. We'll talk a little bit about some of those small problems, and that might very well be the way to go from small problems to big problems. Sorry about that. Okay. All right. So, and this model helps us understand that its application is fairly universal. Auto industry, healthcare, they're pretty different than each other. One manufactures things, the other provides service in a number of different contexts. So the idea is, plan ahead on what problem you'd like to see happen to improve. That's that top element here, and the next is, in that planning, do something about it. In that planning, you change, you decide what you want to do, you pick a metric, and then you do something, then you study how it did, and then you wash, rinse, and repeat. Pretty simple idea, but it's really powerful, and it's hard for us to get our heads around it, believe it or not, because we focus in our world on research, maybe research associated with randomized control trials and the way we traditionally do research. This is perfectly compatible with real research projects. Having said that, it's a bit of a mind shift from how we are trained, so it is not quite obvious when you get down into the details, and we'll talk a little bit about where the opportunities of keys to success and where those keys to success can help you move things along in your real life, because this is very practical, the idea that anything we would want to require inside the American Board of Physical Medicine Rehabilitation for continued certification really, at its core, needs to bring value back to the patients you serve. The better access you have to them, the higher quality of care that you provide, it really is driven toward proving up that we are worthy of taking care of the patients that we wake up every morning and do. The backbone of this quality improvement model is the PDSA cycle, as I mentioned, plan, do something, then measure how you did it, then do it again. Notice you can get on a virtuous cycle where one leads to another, leads to another. Then when you think about the keys to success of this particular model is don't try to boil the ocean. Doing too much is the tendency. I want to improve the, let's say, the quality improvement, deliver quality care inside a rehab hospital. That's way too big. What specifically do you want to do? What elements do you want to improve upon? So the smaller you can get, the better off you can be. Think incrementally. If you drive to a smaller group of metrics of success, then you're able to move that, dovetail that into the next project, into the next project. I do have a saying. If you can do something in a year, you probably can do something in six months. If you can do it in six months, you can probably do it in three. If you can do it in three, you can probably do it in one. If you can do it in one, you might as well do it in two weeks. And if you can do it in two weeks, you can do it in one. An example, just off the top of my head, I'm bringing to mind is that I won 50 bucks from a group of doctors when they said that I specifically could not beat them in preventative care services. As a PM&R specialist, they were primary care doctors. And I said, well, which one do you want to pick? It's not that I'm particularly good. I just use this method, right? And they picked, oh, it was a glorious thing. They picked examining feet. Oh, my goodness gracious, well, that's PM&R all day long, right? If we can stop somebody from getting an amputation, that's ever better. So the intervention was simply take off your shoes. Everybody's shoes are off inside the clinic. Staff instructed them, everybody's shoes come off, right? Had a sign in strategic places, all shoes come off for everybody. I had a little notebook. I wrote that down. And we counted how many times I looked at the feet and documented that. We put that little documentation sheet in the chart. And lo and behold, I get 100% within a week. Because I had opportunity. 20 patients a day. I had 20, I had 40 feet to look at every day. So that's enough in number to actually drive a process change. Now, were there hiccups that I could, at the end of Friday, by Friday, I was chatting it up with my MA saying, where did I slow things down? Where did you slow things down? And then lo and behold, we took another turn at the wheel of PDSA cycle. Simple. I won $50 in two weeks. That's kind of good. Satisfying. So keys to success for a project, specifically, is number one, establish a goal. Make it one goal. And make it smart, right? We'll talk about what a smart goal is. But a smart goal is, in brief, specific, measurable, actionable, realistic, and time bound. Say what you're going to do, put some boundaries around it, and be effective and specific in what you're specifically going to do. And make it a smart goal. And make it one is one way to prevent boiling the ocean, right? Make the measure of success match the goal, right? So let's take an example, before we go into some detail of examples, would be, my goal is to decrease the death from PE in a rehab hospital. Really? Maybe. But there are some details that could be more effective and efficient. Maybe we measure how many DVTs do we reduce. Or maybe how much the adherence to a given protocol inside the hospital could then lead to proper prophylaxis. Now we're getting closer to proper prophylaxis leads to reduction of PE and death from PE, right? So what we do is just kind of keep drilling down and drilling down to a specific measure of success, and you match the goals to it. We'll talk in more detail, but that gives you a sense of how this kind of game is played. And it really can make notable differences in how you do work, right? And understand process. That could be very well be as simple as sitting down with staff in a clinic and say, tell me more about how this process works, and writing it down, step one, step two, step three, step four. And it could be four steps, and that's all you need. Or you could say, let's explore step three, and that could have four steps. And then you do step two out of the second rung, and then you get down to a grander point of process that you can actually make a change over. Linking all three of those together, you pick one change. That one change matches a SMART goal, and that SMART goal goes all the way down to a specific process metric that everyone does all the time. So that gives you a taste of what are those keys to success. So let's take a couple examples, if I may. Let's make sure I got the right one here. Q-care transfers, establishing a goal. Next one is no-shows, making the measures of success match the goal. And inpatient-to-outpatient conversion, knowing a process. Those are examples that have been in my life and have actually been in the lives of physiatrists like yourselves who have done improvement projects that I have reviewed and say, that's pretty cool. Just the process metrics are just slightly different than each other. So the net gain that we have done over the course of, we collectively have done over the course of many years in these process improvement projects, and now transforming them to real practical health care delivery elements, have been remarkable. And I'm just reflecting on what the field has been doing. So let's take the first one, Q-care transfers, establishing a goal. Specific, measurable, achievable, relevant, realistic, time-bound. Knowing that acute care transfers were a notable part of the interest, but is that sufficient? Do we want to stop acute care transfers? My mind goes to the notion of, is that a specific thing? Is it specific enough? And is it actionable enough? Or can we drive a little bit more deeply into, what are the underlying causes to acute care transfers? We all probably sit in rehab hospitals and review acute care transfers. We probably couple them with peer review, because we think that the physician is the underlying opportunity for decreasing acute care transfers, when in fact, it may very well not be a specific activity of a physician that improves acute care transfers. It might be a physician behavior. It might very well be a nurse behavior. It might be something not recognized across two or three elements. So when we think about acute care transfers, it could be, where did those acute care transfers come from? When did they happen? Again, getting more specific. When they happen, do they happen within the first two or three days? Or did they happen mostly over time, smattered throughout the rehabilitation process? One could say, we're choosing poorly at the front end for the former. And for the latter, we're missing something in recognizing. The phrase I often use in that category is, we saw it coming, but it hit us out of nowhere. The idea is that we just were not seeing the right metric of success to turn the tide on acute care transfers. So when you dig more deeply, what were the recognition points in this example? Well, it was choosing wisely, we were doing well. However, we were seeing a number of different spikes over the last six months of pulmonary issues rising through the occasion. We had concurrent levels of turnover associated with nursing staff and a couple of turnovers in young speech and language pathologists. And they had not made a connection to do the proper screening throughout the rehabilitation course to decrease aspiration risk. So very process oriented. So our goal was to decrease acute care transfers. But more importantly, our goal was to actually improve a process, the checklist that nurses and speech and language pathologists did at the time of admission. That then would translate to the decreased risk of aspiration three, four, five, six, one week later. So a lagging indicator, acute care transfers. A leading indicator, one that leads the problem, which would be recognition of aspiration. And the recognition that the underlying cause was the connection that had been lost because of turnover within two categories of employees. So we did that, and then we put time bound around it. How many opportunities were there to actually change this acute care transfers? Well, if we measure the acute care transfers, we have, what, a few per month? So if I can do something in a month, I can do something in a couple weeks. Remember, I drove the goals down to a specific process metric, which would be, did we do the checklist, and was that document in the chart, and did an action happen within the first 24 hours? So we were counting admissions, not acute care transfers. That expanded my N number to quite a bit. So the N number went from, let's say, on average, five or six in a 90-bed rehab hospital, it was five or six a day. So that's five or six opportunities to change the process. So we then decided that we could get realistic information within. This group came to the conclusion, we want to do this in a month. I lost the lobbying for two weeks, but that is the process of give and take within your team. So that was the time basis by which we established the goal. It was a process goal, and it was definitely realistic. We had a checklist already in place, and we just said we are not making a connection between the two. The people in the room were specifically a nurse manager and a floor nurse that travels between the floors, so that she could have continuity between the floors. And be that messenger that we need to get this done on this new admission. And so our acute care transfers were not a relevancy. They just were carried on with the same process that we were measuring. But we were really measuring how many times did we do the checklist. And that was the goal. It matched the process of change, and it was very specific, very realistic, and time-bound, and it did not try to boil the ocean. Because it's such a small group here, questions on that? No? Okay, so this theme will be repeated here. Understand what I did was I took a smaller, a big goal, assuming that that was our goal, and then started pairing it down to more specific and smaller tasks, again, thinking incrementally. That once we got through this checklist, then we would go through another checklist that was equally important, but didn't rise to the occasion on the first turn of the PDSA cycle. So, no shows. How many struggle? How many of you do outpatient work and struggle with no shows? Yeah, pretty much everybody? Yeah, right. Yeah, I wonder why they happen, and why can't we fix them? Yeah. This is a cause and effect diagram. It's a fishbone diagram. There are a ton of cause and effect diagrams that, again, whose opinion is gonna win the day on what are you gonna tackle first? If you got five people in a room, how are we gonna decrease no show rates? Well, you're gonna have five opinions on which is the most important element. I run a, I'm in a spinal cord injury clinic. Clearly, the folks with spinal cord injury can't get up before X period of time and get everything done, so why are we even scheduling them in the morning when they need to have noon or after, and they have transportation barriers, and we have a, this particular clinic has a high density of folks who have challenges in their psychosocial or fiscal arena, and therefore, you can see that, and somebody else might have a different in this one shared clinic. So you can see just how challenging it might be. In our situation, as an example, and again, repeated constantly amongst all of you who provide the PIPs, as we've called them, these quality improvement projects, this is very common. So let's say, long wait time for an appointment, and patient improved. So this would be come out of a back pain clinic, for example. How many patients get better from back pain? Yeah, just a general rule, they get better, unless they don't. And about 10, 15, 20%, depends on the population, don't get better. So it's about decreasing chronicity. So the idea in that situation that you would say, you're waiting too long for appointment, and they're getting better, and those two things are interrelated, right? So because the clinic I work in currently, back pain is not nearly the relevancy. There's something else that might very well be in a situation, is that might take care of a vulnerable population, both medically and psychosocially, and that vulnerable population has limited access to communication by which we would give reminders. We were, when we were sitting in a room, we actually sat in a room with everybody and said, we wrote these all up in this fishbone diagram. And we started circling, what are the relevant drivers of a particular no-show rate? It was total consensus and total discussion-based. I didn't have a whole lot of data because I knew what the data existed because I've been down this pathway before. We all have. It is changes one month to the next, one quarter to the next, and the like. So as a result, we came to consensus that this population at this moment in time, we needed to find new ways to access them and engage them. And we certainly didn't need to start two days before when the phone calls went out. So two days was way too late. I just remembered that I have an appointment and it's two days from now and I really can't make it. Whether that phone call happened, there was not an actionable moment when that phone call was happening two days before the appointment. So that was an irrelevancy, the way we were doing it, because we were just wasting time and it was not going to change the way we were doing things. So we needed to have a multiple, so what we decided, we have a multiple engagement process that fit the bill and it actually started inside the referral source. So the first phone call was not to the patient. The first phone call was to the referring clinic and it wasn't to the doctor. It was to the staff. And the staff then called the other staff and asked, how's this patient been getting here? And got more detail about this particular patient. That took a longer runway of work to be done, but we won the day quite a bit because that became a nice little driver of all the rest. So we didn't have to do the just-in-time phone call to remind folks to come in because in that vulnerable population, it was an irrelevancy. We needed to understand what was the source of opportunity to engage that patient and that source of opportunity came in the form of calling the referring clinic and get an understanding of what the process was. So that then started decreasing time as the appointments drove and then as we started seeing this improvement, we saw the workload actually improve as the day of arrival came, day of the appointment that is. So again, the point of this is measure the success matches the goal. You want the metric of success. The metric of the success was not did you do a phone call and did you talk to the patient two days, three days before? That answer was always yes, whether it did or did not happen because we're not standing over them every day and we're gonna trust our staff to do that. But we knew that was relatively ineffective to whatever degree and it matched the sniff test for us. That is to say, this was a vulnerable population. So why would we expect them to pick up the phone? They got other stuff to do in their daily lives to get up and do work and do things. So that just made sense to us in the population for that moment in time. So that's how we measure. That's how one example of how you pick a metric of success and the metric of success was simply consensus driven while we got in a room together and hashed it out and before we left, we knew the task was to get a metric of success chosen. So it was engagement. So before going on, questions on that? All right, last one here. Inpatient outpatient conversion. This is a relatively recent one in my world and I've sifted through others that are doing similar things. Most of the time, this is again, a population that has ongoing needs in a rehabilitative world in an outpatient setting after they finish their rehabilitation stay. One of the main metrics of success that is supporting this kind of clinic is shaving off a few days off the inpatient rehabilitation stay if we can have a soft place for them to land. And so that had high motivation for this inpatient to outpatient conversion because the inpatient folks, be them docs, case managers, therapists, nurses, they had very little interest in what was happening after people depart but the conversion had everything to do with the notion of how you get this inpatient outpatient conversion. So dovetailing what we had done before with this vulnerable population of engagement. If that referral or that patient came from inpatient, then we had a better opportunity to turn the crank again. And that turning of the crank was in the form of, what are the drivers of how we might have that conversion? We went to that same fishbone diagram but in this case, we had to dig more deeply after we'd come to consensus and that consensus was not the diagnosis on admission, not even the discharge circumstances. Frankly, it was about the performance of team conference in a discharge checklist that happened the last team conference and the conference right before it, right? And if we were worried that the team conferences were too short and we had a short stay, I really didn't care about it. My statement to everybody was, I really didn't care about those folks. They'll come if they need us and they're not the most vulnerable, needy folks that need longitudinal care. So didn't try to boil all the ocean, just those targeted team conferences that match up with the highest vulnerable need that we were providing value back, right? And so checklist, discharge checklist was the metric of success that then drove a number of different elements. Now, what is a process? Why we're engaging the process is that the team conference checklist, if I said there were three, we have like five or six rotated team conferences in any given part of the week and three of them I went to because they had the populations that were the most vulnerable and we had the most interest in. And I watched those team conferences unfold and I go, wow, y'all are all different than each other, right? So the idea was I mapped out each one of those processes, showed it to the docs and the other members of the team conferences and got unity across a checklist that was gonna be driven in front. So the checklist was in front of every single person in the team conference and that was the intervention in only three teams. So I didn't worry about any other teams, just these teams to have a checklist and then concurrent with that, one of the docs in one of those team conferences ends up changing the way they do their templating. Once they changed their templating, interesting enough, that was a second metric that was serendipity that I did not see, but it was of great value ahead of time. And so that doc volunteered to change the template and let's see how it rolls and sure enough, it rolled just as well as the discharge checklist. Again, we're driving to a process, driving to detail, driving to metrics that you can measure more rapidly that then scale up to greater value. So for example, team conference checklists drive straight into more vulnerable people being inside a clinic, particularly when it was coupled with the previous project that was targeting no-show rates or supposedly targeting no-show rates. Questions on that? No? All right. So last little bit here. We see that the improvement model might've been applied. Don't blow the ocean. It's very simple, but not simplistic. It can solve big problems and solve small problems. It's a near universal application and the key element here is what are your opportunities? So this would be a time where we kind of talk about what the opportunities you guys have. We're a small enough group. We kind of knew that this was gonna happen to be so we can be more thoughtful about having a dialogue as Dr. Johns talked about that we can start a dialogue here and see where those opportunities exist in your world right now. Okay? Okay. Yeah, so I'm gonna walk through a few more things and then we'll come back to this. So start thinking about your own individual practices and where those opportunities exist and where you might start to nibble around the edges and look at key drivers. So for those who are not in training, you're probably familiar with this. This is a screenshot from the ABPMR website that looks at what's involved with continuing certification and what's involved and required during each five year cycle. So I'm not gonna cover every component of this, but the bottom bar says quality improvement project. And so there's one project that's been required every five year cycle. So this again is what we're evolving now into calling IHHC credit one every five year cycle. One opportunity for that is still to do a quality improvement project. That is absolutely going to be nuts and bolts about how we make our own practices better, how we impact health systems, how we improve care for our patients is looking at quality and trying to drive that in the ways that Chris was just describing. So for any folks who are still in training in the room, it's important to know that as we talk about this, there is an allowance to do what's called bank a project, bank an IHHC credit. So that it's something that's done during training that will meet that requirement during the first five year cycle. So everything that I'm gonna be referring to is potential bankable IHHC credit. So looking at what have been called PIPs, practice improvement project, performance improvement project, or QI project, quality improvement project, all are really the same thing. And there's a tool on the abpmr.org website that you can walk through and it will ask you questions about your practice and do essentially what we're gonna try to help you with today for any who want to kind of engage at that level. To say, what's the setting in my practice? What's the patient population? And there's always the opportunity to design a project on your own, but this will walk into potentially one of the currently available 22 templates that are on the website to say, here's a project you can think about and really kind of walk you through that, making this easier, accessible. This is not the highest level research project, though that's an opportunity as well. And there are some great QI research projects that are done out there. So this next point that I put on here is to let you all know that as a board of directors and as our board staff, we recognize that there are projects that do require more than one person to work on. Just with the scale, the scope of the project, it just takes more than one person to really drive change and to figure this out and collaborate. It's not every project, but some do. So right now, through our process, each individual who's on that group project has to submit their own project into the website, into the system, and each gets kind of evaluated and determination is made about, does it meet criteria, et cetera, individually. We are working to improve that. We don't have a timetable on it yet, but we understand it's important for many reasons. And one of the overarching reasons is just to reduce burden. This isn't about burden. It's not about asking any of us, because we're all doing this, the same thing. We're all doing QI projects. We're all submitting things into the same database and forms that you all are. So we want to make it so that a group can submit it once, and there will be some way to attest to the fact that, yes, I was a participant in this, and it will be evaluated once, and each individual on that project can get credit for it, with some degree of attestation that says, I was a member and I helped in this way. Here's how I contributed to this project, these types of things. So more to come on that. In addition to those projects, those templates that are available through the ABPMR website, and what I'm walking through right now, it's not new information, but for some, you might not have been exposed to it. You just think, I've got to do a QI project. Here are some options that have been available and are still available. So there are some pre-formatted or templated projects that are available and free for members through the AAPMNR. There are also three pre-formatted projects that are free for AANEM members through the AANEM site. There is the ABMS Portfolio Program, which I almost hesitate to say this, but I think from a PMNR standpoint, there hasn't been great uptake into this. I think some other specialties, there's been significant uptake. Some institutions that maybe many of you practice at have these portfolio programs in place. My personal experience is there's just not a lot of uptake and participation from PMNR physicians on this, but it is an option. Other things. So through the National Committee on Quality Assurance, so it's a patient-centered specialty practice recognition. So if your practice has this designation, that can qualify. That can earn you this IHHC credit. Again, these are not new things. They have been available and still are available. A practice accreditation in musculoskeletal ultrasound-guided interventional procedures. So this is through the American Institute of Ultrasound Medicine. So it's an accreditation process, and part and parcel of that accreditation is there is a QI component. So we recognize that, and just having that accreditation checks the box. You don't have to submit what that QI work was. We know, we reviewed what's required by this organization, by this accrediting body, and we wanna recognize that, reducing the burden on diplomates. So coming back to this term IHHC, where does this come from? So you may be familiar with the fact that the American Board of Medical Specialties, several years ago now, went through a really extensive stakeholder analysis, a lot of conversations, surveys, focus groups, et cetera, that they called the vision for the future commission. And what they developed were new standards for continuing certification that went into effect January 1st of this year, this calendar year, 2024. So in that, they rephrased this to improving health and healthcare. So it broadens this, it broadens the opportunities that are available. Still QI is certainly part of that, and that's always gonna be core, but it allows us to consider some other things that might not have been traditional QI work. Another thing that they asked and really required in these new standards is that each member board align requirements with members' practices. What are folks doing on a day-to-day basis, and what IHHC work might we all already be doing and be required to do as part of our daily workflow, or our leadership roles in our institution, or in our practices? And then how can we align that in a way that, again, lowers the burden on each of us to continue to do the work, but to get credit for what we're already doing? And then the last thing that they emphasize is recognizing that we all come to this with varying degrees of expertise and interest, and that there may be a need to teach and equip folks with the skills and knowledge and comfort, such as what Chris was just doing, but in a more formal way even, and I'll circle back on that. So, in the email that many of you got earlier this week, whether you had time to read it yet or not, you have been exposed to some of this. I'll just walk through some of these things. So, this was actually announced last year, but it's in the announcement and it's officially on our website. For annual meetings such as this and the AAP meeting in the spring, for folks who are presenting quality improvement posters at either of these two Specialty Society meetings, that will be reviewed for approval without having to submit that again through the ABPMR system. So, we're working behind the scenes to operationally make this easier on both organizations, but we wanna take that burden off of the folks who are doing those posters and submitting and doing the work. So, I think that's a significant improvement. Yeah. Nice. Don't stand up. I'm too lazy to stand up. Every author can use this, if there's three authors on the poster, all three, assuming that they all agree. Yes. Yes, similar to a group project. It's all your author on the poster. Right. Now, at some point, and we've had some discussion about this and we haven't landed on the exact answer, but at some point you could get carried away with this and say, well, I'm gonna put all 12 of our residents on this one QI project. Yes, there are certainly quality improvement projects that are of that scope and scale, but if the quality improvement project is about taking shoes off in a clinic, no offense, that's probably not 12 people that you needed to do that work. So, it's gotta make sense and it might be that we come back and just ask a clarifying question to say, great project, can you help us understand your roles? That's true. No. Yes. What do you think? So, okay, no thanks. Yeah. I mentioned the ultrasound accreditation. So, this is another accreditation that embedded within it is QI, it's quality improvement. And it's through the AANEM, it's their electrodiagnostic lab accreditation. This is for the initial accreditation and not re-accreditation because at least from what we've learned from them, the re-accreditation part for this accreditation does not require that ongoing kind of quality improvement or quality assurance, that type of thing. But the initial accreditation does meet criteria for IHHC. So, it's simply a matter of submitting that accreditation letter and your role in it and attestation of your involvement in that work, done. For those who are in academic programs, either for residency programs or ACGME fellowship programs that require program evaluation committee and clinical competency committee, involvement for at least three years on either of those committees, earns that IHHC credit. Baked into that is an evaluation of the residents, their learning, establishing new learning programs, individualizing it, looking at the program itself, how are we working to improve, all of these things that it's all QI work. So, for those, it's simply an attestation letter that can be downloaded from the website to the program director to say, yes, this person has served in that role and for three years. Similarly in that second one that they, let's say you're on it for 10 years, one or the other, can you use it twice? Yes, yeah, because you're going to continue to evolve and the residents themselves are gonna change, the needs of the program are gonna change, the learning that needs to be done. So, that's an ongoing quality improvement process. So, there's no limitation on that. Right, so your five-year cycle where you will actually earn that credit will be at the end of that three years. So yes, but right, yeah, or yes, it ends in that next three, in that next five-year cycle. Sorry, that's displaying kind of backwards. For those who participate in CARF or the outpatient version for CARF and the subspecialty programs within CARF, again, those accreditation and reaccreditation, as you know, require quality improvement work. They require program, you know, outcome measures that you're working towards. Similarly, for joint commission at the inpatient rehab hospital level and for the disease-specific certified programs, the specialty programs within that, there are program outcome measures that you're working towards and improvement models, both for the initial and the reaccreditation or recertification. So the medical leaders of these programs can earn that IHHC credit with an attestation letter that says, I was involved in this QI work as a medical leader for this accreditation or reaccreditation cycle. So it's not submitting the projects that led to that or looking at the details or submitting it into the forms through submittable through the website. It's submitting that letter, just an attestation letter and the accreditation letter. If it's within your current cycle, yes. We are also recognizing that significant work is done at the ABPMR level to improve health and healthcare. And it takes a lot of volunteer work, including the directors on the board, but all of the item writers and examiners and vignette writers and senior reviewers and longitudinal assessment writers. And as part of that, there is constant work and improvement cycles and feedback, better item writing, better examination delivery to, again, to continue to elevate the work that we do, to elevate what board certification means and to hold certain standards. So recognizing that serving in those volunteer roles for a minimum of three years will earn that IHHC credit. So going back now to the statement that I made about recognizing that diplomates have varying levels of knowledge and expertise about quality improvement. This is the last area that kind of ironically is actually the first area that we actually approved when we were looking at expansion. Because I think this is a really important thing, because we heard from so many diplomates that just say I'm intimidated by QI work. I don't understand QI work. And they just have this too, I don't know. I don't know what they're picturing. But that's why we want to demystify all of that. So we now have a great tool through the longitudinal assessment and especially the LAPMR article-based questions that beginning in 2025, you can opt in to selecting as one of your articles each year a quality improvement developmental article so that you can learn about quality improvement work and processes. And if you select that article for four years and answer those questions, that will earn IHHC credit for that five-year cycle. Now that one, you can only do once every other year. Because the idea is you're going to take those skills now that you've learned and actually do something with them. So for that next five-year cycle, the idea is you take that and actually do hopefully a QI project, because now you're better equipped to do that. So that's, you call it developmental, you call it formative, something to help people shore up their skills, be reminded of maybe what they knew at one point in their career, those types of things. Yeah. And with that, I've labeled it as questions, but this is where we do want to just kind of open the floor, see what's on your mind either about these new opportunities or to help you, as Sherry will maybe guide us here, think about your practices. And let's start breaking these down a little bit. Yeah. Question? Go ahead. Yeah. Is the microphone on? Okay. Hello. Is it on? Okay. It is. So I came to this session, I think, last year. I am not in clinical medicine anymore. I'm actually in public health. And I am having a hard time determining what would to be considered acceptable in this role. I have a vast amount of responsibility. I work for the Alabama Department of Public Health, and I'm one of the medical directors there. And I'm over several different bureaus. So I'm having a hard time parsing down out of everything I'm doing, something to focus on. And again, that would be acceptable in PM&R. I will say the, I think, the most relevant two bureaus, two of the three bureaus that I'm over are home and community services. We're one of the very last states that have home health that's offered through the state. And we work, we take about 90% of the Medicaid population in the state of Alabama. And the second one is the Bureau of Health Provider Standards. And we are the regulatory agency that surveys. So essentially, we're the JCO, but for non-deemed hospitals, ESRDs, home health hospices, clinical laboratories, et cetera. So that's just a part of it. Like, how do I parse down what I do? And then, like, managing, like, 100 people into, like, okay, this is a project that is, you know, quality improvement. I know. You are boiling a lot of oceans. Yeah. Yeah. Sherry? I love that you've asked this question. I don't know if this is on. Yeah, maybe it is. I love that you've asked this question because we hear it in a variety of different forms by people who are not necessarily in clinical practice, be it from educators, administrators, or people who are just sort of even a little adjacent, insurance, whatever. Yeah. My guess is there are probably 50 things that you do in any given day that could apply here. Our goal, and I think the ABMS goal with this whole thing is, gosh, you guys, you are on the front lines. Go try to fix something. We have so many things that need fixing. Go try to do something good in the world. I mean, that's sort of the way I look at it, the bottom line. So in your daily life, you're probably trying to fix a lot of things. And so there's not really, we don't have a big lofty goal like, okay, well, if you, so in your role, if you're in charge of 100 people, we want you to make sure that all those 100 people do a certain thing. I would ask you, what's important to you in your daily life that you would like to fix a little bit that applies to healthcare in some way, shape, or form? Teaching it, providing it, sharing it, whatever, and just do a little PDSA cycle. And maybe you already have 20 times last week. I don't know. Try to find a problem that you want to fix that you care about. Try to see if there's something measurable about it. Try to fix it. Remeasure. Think about what you might do the next time to make it even better. Okay. And you made a comment in your question that you said that would, I think, and maybe I'm not going to state this as you did, but what I heard you say was that it's related to PM&R. This doesn't have to be about PM&R. It's improving health and healthcare. Okay. So if it's access to, you know, hemodialysis for ESRD patients. Okay. Great. All right. It can be anything. Yeah. All right. Got it. It could be, so one of the things you mentioned was you do some surveys. Yes. Well, maybe the surveys need to be a little bit more efficient. Good Lord. We're actually having a boot camp for our surveyors coming up in two weeks. I grabbed the mic. Yes. To help with this, we're, and I don't, I can't necessarily say that this would be something that's measurable because it's going to take some months, but one of the things we're going to be talking about is efficiency. We're trying to see what's taking them so long. Part of it is because they're going out with like 24 plus complaints on one survey, but, okay. This is helping. So Chris has a saying that I hope he's about to say right now that I love that, the three things. Oh, so you have a spaghetti sauce challenge, right? I'm in the spaghetti sauce aisle of the grocery store, and I don't know which one to pick, right? They're all going to taste reasonably good. So make a, make a stab at what you want to pick, right? So second thing is, yes, maybe do something that saves a life, saves one life in Alabama. Maybe saves one dollar in Alabama. Maybe saves one minute or one hour in Alabama by one person. Okay. That would be save a life, save some time, save some money. If you can do one, that's great. Two, that's better. Man. Three, it's a home run, right? It's not quite a home run, three, right? So you get the point, maybe. And so a couple things that might help you notably is that how you pare that down, that's one way. Then you might consider what are, what is the most important thing to you? And what is the most actionable thing? So laundry list of important things, pick the, rank them, and pick the top three. And then of those top three, which are the most actionable, right, then in that group of people that might touch that particular metric or that particular area, get them in a group. You don't, if it's 100 people, don't pick 100. Yeah. Then pick some rainmakers in that 100 people. The people you know that if they talk to another person, they're going to be influential in the 100. Okay. Get them in the room and build a fishbone diagram on one of, on a consolidated specific area. Okay. And something will pop. Okay. Thank you all. You're welcome. I might add one more comment because if you're doing something that's maybe as you see it, maybe more peripheral to PM&R or you mentioned like the efficiencies of the surveys. If you're submitting that to me as a reviewer, I may not be familiar with that. That's not something that's really core to most of what PM&R physicians do. It's important for you and it's important for the state of Alabama, absolutely. But just as you described that, just an extra line or two to connect the dots for me as a reviewer to say, how does this improved efficiency tie into, you know, the thing that you were actually trying to get to? Got it. Who else has a question? I'm wondering if, in the audience, if anyone has IHHC credit due within the next year? And for the couple others of you who haven't spoken yet, do you know what you're doing yet? Do you have a plan for how you might get the credit? So, I do have a saying around that too, is hope a really good strategy? Right, do you feel that it turns a corner on something related to how something you do or somebody else in your influenced world improves saving a life, saves some time, or saves some money? Yes. There you go. So you should have a high level of confidence that it would then be selected, right? And I'm only speaking that letting everyone else hear that you probably don't need to hope. It probably sounds like it's a good project. And such a project, you know, can still earn that IHHC credit. It may just be that it has to be submitted, you know, on the back end. I know. I know. Good. I'll add another comment as you think about potential projects and areas of practice for improvement. When you do that first step of planning, and you think you may have a, you know, opportunity for improvement, and you say, well, how often do I already have patients take off their shoes and examine their feet? And I'm just going to study that for a week. And at the end of that week, you realize 100% of the patients, you've had their shoes off and you've documented that you've inspected their feet. There's no room to improve there. And I would encourage you then to look to another area of your practice that you do need to spend a little bit of time on to improve. Because submitting a project that says, I was at 100%, I'm going to keep doing what I'm doing, and I'm still at 100%, that's not a quality improvement project. It's great, and it's good work. Keep doing it. But I'm confident that there's some other area of practice that could use some improvement. Were you going to follow up on that? Yeah. Go ahead. So for example, a timeout before an epidural steroid injection, or quite frankly, any injection. So if you do injections and you've got 100% for the past six months on timeouts in the epidural suite because things are going tight, well, do you do a timeout in every single procedure you do inside the clinic area? That is perfectly on inbounds. But inside that 100% in epidural, if you don't want to do something in that clinic for procedures, you could consider the next step of what the value stream of a checklist brings to the table of a point of before the injection. Do you have a confirmation that they're not on blood thinner before you stick a needle in? Well, if you don't, and you haven't counted it, it might be a good idea. And that's the next... That's how you turn the cycle. When one seems to have petered out, then you go to the next turn of the cycle within the same relative domain. That's how you get leverage out of one project to the next project to the next project. You're just taking that same set of skill sets and moving them into another domain that is parallel or aligned with. So my thought with the last few minutes is that I'd like to lob out a couple of ideas for you two and have you react to whether or not you think that an idea for a QI project would be okay or not. First one, first idea. I feel like I would really like to learn a little bit more about a certain neuromuscular condition so that I can take better care of them in the clinic. Would that work? I read 10 papers. That's my goal. Will you accept that? You can earn CME, and that's another part of continuing certification. So it's very valid to continue to try to improve knowledge, but I would not consider that a QI project. Chris? In a word, or a couple of words, knowing something doesn't improve something. Knowing something improves things. Okay, my next idea then, if you're not going to take that one, is that I think it would be a really good idea if we had a multi-specialty clinic for kids with Down syndrome at my institution, and we don't. And I'd like to start one. Does that mean you do start one, or you'd just like to start one? I would like to start one, and I will start one. And starting one is my project. And my outcome is getting a clinic up and running. Then I would ask you to submit your outcome, which is when that clinic is operational, so that then you can study it to say what works, how could I continue to improve this. It would be similar to several projects that we've seen coming out of the pandemic where people have said, pre-pandemic, I didn't have telemedicine access in my clinic. And so I could not see patients. They had no access to care. I have now stood up the ability. I've tried out different systems. I'm now using X system, and a certain percentage of my patients are now seen by telehealth. Similar to what you're saying, in my mind, is I've stood up this clinic. I've now seen X number of patients over this time period, and that's the first turn of the cycle. Now I'm going to say, how can we continue to improve this, and how can we improve care, and maybe study better outcomes? I'd answer a little bit differently, so that I don't think you need to wait until to turn that crank to get said clinic up, because remember, it might take a year or two or something to stand up a clinic in some bureaucratic system. The Mayo Clinic doesn't have any bureaucrats in it. Nope. It's okay. So that should be easy for you then. So then there are a series of steps that you could do that ultimately lead to said clinic being launched. Therefore, boiling the ocean would be clinic. Doing something that advances the cause of said clinic, justified by the presence of a clinical need that you would then have all sorts of Olmstead County data to support why that clinic would be valuable, right? And so then you turn the crank early. So it's not necessarily the metric of success, like clinic is kind of like death from PE. You know, if you wait for death from PE, you're just going to wait a long time, because it takes... Not all DVTs load up into a PE, and not all PEs load up into a death. So that'd be my thoughts. Okay. My next thought is... Okay. That's fine. Maybe what I really want to do is, I'll just switch hats a little bit, and I think what I'd really like to do is improve staff retention of our physical therapists. Can that be my project? I think that's, in my mind, the start of a project. And then as you would do with anything where you've identified a need, so let's say you know your retention is X percent right now, it's 85%, and you want to improve that to 95% over the course of six months. And then pulling together a group, looking at what we think those causes are, what are the key drivers, and then which piece of that might you start to address, and that to me starts a project. And then you're going to study it at whatever time frame that you've set, three months, six months, and if it wasn't successful, then you look at the next measure, and then you continue to turn the crank. So yes, I think that's a very reasonable project, because staff retention we know is going to continue to build on expertise, you're not going to have to train up new staff, there's productivity, there's patient access, all kinds of things. Do you get tired of boiling the ocean all the time? Right? It's exhausting. It is exhausting, right? So a similar answer, but don't boil the ocean. I could say, maybe in your mind, don't know, don't let me put words in your mouth or thoughts in your brain, but the notion of, what in the heck is a doctor doing anything with staff retention? That's trying to stay in your lane, young lady. Well, no, that's simply a bad idea. That would be like saying, doctors in a clinic shouldn't engage their MAs with respect and thoughtfulness, right? I think you should. And that would, in fact, make their retention improve. So I bet you, doctors in engaging therapists in a thoughtful way may be one among a host of drivers that will improve outcome that you would like. I would counsel you also that the staff turnover may very well come in quarterly lumps, so that may not be your best metric of success. So I think we are about at time, so before Sherry throws us another curveball, I just want to thank you all for your time and attention and thoughtful input and comments and questions. And thank you to Sherry and Chris for your participation and leadership and with that we will be adjourned. Thank you.

American Board of Physical Medicine and Rehabilitation

healthcare improvement

quality improvement

PDSA cycle

Sherry Driscoll

Chris Garrison

real-life examples

continuous learning

patient care

professional development