ABIM PIM Sample Attestation

The following ABIM PIM Attestation and Impact statement is intended to serve as a guide for cardiologists who have participated in D2B wishing to claim ABIM PIM points. These answers were those actually submitted by Dr. Henry H. Ting from Mayo Clinic Rochester.

Established Continuous Quality Improvement Program
   You must complete all 4 items of the following attestation, including at least five measures used in your quality improvement program. Next, complete the questions that follow in the "Experience and Observations" section.
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ATTESTATION
1. I hereby attest that I have significantly participated in and contributed to this established continuous quality improvement program. Specifically, I personally reviewed and reflected on the five performance measures (listed below) collected as part of this program.
Performance Measures:
      1. Percent of STEMI patients (nontransferred) with door-to-balloon < or =90 minutes
      2. Percent of STEMI patients when the ED physician activated cardiac cath lab
      3. Percent of STEMI patients when the cath lab is activated with single call
      4. Percent of STEMI patients when patient departed ED <30 minutes after activation
      5. Percent of STEMI patients where D2B data is reviewed with staff within 48 hours

2. I Participated In (must check at least one):
the design of the quality improvement activity
implementation of the quality improvement activities or interventions
maintenance of the continuous quality improvement program
a quality improvement team working with other healthcare professionals

3. I applied this continuous quality improvement program to my own clinical practice or the clinical practice of my healthcare institution and was involved with the continuous quality improvement program for at least 3 months. Yes, I agree with this statement.

4. I understand that the American Board of Internal Medicine or an appointed agent may review the specifics of my involvement in this continuous quality improvement program.
Please type your name in the box below which will serve as your electronic signature for this attestation.
Signature

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EXPERIENCE AND OBSERVATIONS

1. Enter the source of your data: Mayo Clinic STEMI Protocol and Database

2. Enter the method used for data collection (check all that apply):
        Electronic medical record audit
        Paper-based medical record audit
        Claims data
        Patient survey
        X       Other

3. Provide a brief summary of how your organization's practice initiative or your medical society's practice module or project helps you in continuously improving your performance.
The Mayo Clinic STEMI protocol for nontransferred patients presenting to the Saint Marys Hospital Emergency Department was implemented in May 2004 and decreased the median D2B from 98 minutes to 62 minutes. We actively work with ACC and CMS to monitor our structural, process, and outcome measures for quality in STEMI care.

4. What are your reflections on the quality measures? How well do you think they measure important aspects of care within this condition or practice attribute? The D2B time measure is a very important and relevant process measure that directly correlates with survival and outcome in STEMI patients. The other 4 performance measures are quality improvement tactics which help to achieve D2B <90 minutes reliably.

5. What was your and/or the organization’s plan to improve performance on the baseline measures?
We implemented these major tactics to improve D2B: Acquire ECG <10 minutes for all chest pain patients; ED physician activates the cath lab without cardiology approval and with a single call; Cath Lab is fully operational in <30 minutes; Prospective data collection of time and clinical variables; Concurrent review and feedback for each case.

6. Why did you and/or your organization choose this approach? Did you and your organization consider other approaches (please describe)?
We chose a multidisciplinary approach and involved all stakeholders including the ED, CCU, Cath Lab, Emergency Communication Center and allied staff in planning and execution. The communication and coordination of care and team-based approach were very important for our quality improvement initiative.

7. What, if any, tools and/or resources were used to bring about improvement? What, if any, changes occurred in the behavior of the clinical team to support the improvement?
All physician and allied health providers committed to making process and system changes to improve D2B in the best interest for the care of our patient. We developed a web-based data collection and reporting tool to provide immediate feedback. The technology for single call activation was implemented.

8. What problems were encountered in implementing the improvement, and how were these barriers overcome? We determined that an ECG with new ST-elevation or presumed new LBBB does not represent a true STEMI in 9% of the activations. These included other diagnoses including apical ballooning, myocarditis, pericarditis, and aneurysm. Our ED and cardiology physicians were anticipating and expecting this finite rate of false positives.

9. What did you learn about your practice process(es) or system(s) of care when making the changes? We were able to significantly improve D2B from 98 to 62 minutes by critically examining and redesigning our processes, systems, communication, and coordination of care. The planning and communication phase were very valuable as this made the actual execution relatively easy and smooth.

10. What do you believe are the benefits to your patients of these changes? What are the benefits to you of these changes? We have tracked outcomes including 30 day mortality and this has also decreased to 3-4%. We have extended our protocol for STEMI care to patients presenting to regional community hospitals.

11. What are your next steps to improve quality in your practice?
Focus on outcome measures and what factors contribute to improved outcomes such as outpatient compliance with medications and participation in cardiac rehabilitation.

12. What are your reflections on examining your or your organization’s initial performance and resulting improvement?
The Mayo Clinic STEMI protocol and quality improvement initiative is a model for QI that can be applied to many other disease states.