ABEM’s Assessment of Practice Performance (APP)

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altIt seems that every time we comply with a regulation someone moves the finish line. Well, don’t blame the American Board of Emergency Medicine (ABEM). ABEM answers to a greater being, the American Board of Medical Specialists (ABMS)

How to remain in compliance with part 4 of ABEM’s board cert. maintenance process


It seems that every time we comply with a regulation someone moves the finish line. Well, don’t blame the American Board of Emergency Medicine (ABEM). ABEM answers to a greater being, the American Board of Medical Specialists (ABMS), who, in 2000, approved a plan to require continuous professional development in their Board certification processes. They named this the “ABMS Maintenance of certification (MOC).” By 2006, all of the specialty Boards that were members of ABMS (e.g. ABEM) had received approval for their MOC plans  and are currently in the implementation phase.

Although I have heard many of our colleagues curse ABEM and express their frustration over this process, things could actually be worse. Where their infrastructure for providing attestations via their web site can be a bit confusing, the actual requirements for demonstrating the two components of MOC, patient care practice improvement and professionalism and communication, are fairly easy to perform and somewhat eloquent. In fact, compared to the complexity of the plans devised by other specialties, we should be thanking ABEM for creating a workable solution.

To maintain your ABEM Board certification, you must fulfill the four components of “Continuous learning” set forth by the ABMS. The first is licensure and professional standing. If you have an unrestricted license, you’ve passed step one. Step two is Lifelong learning and self-assessment (LLSA). If you keep up with your LLSA articles and take the annual, open book quiz, you’re half way there.  Remember to keep track of how many you will be required to take to qualify for your Concert exam. If you take one less than required, you’ll have to take the initial qualifying examination (formerly known as the initial certification examination); complete two less and you get to start all over again, taking the qualifying examination and your oral boards. Step three is termed “Cognitive expertise.” ABMS refers to this as demonstrating your specialty-specific skills and knowledge. This is assessed by taking your ConCert examination. Finally, part four is assessment of practice performance (APP): Demonstrating your use of best evidence and practices compared to peers and national benchmarks.  We have grown to accept parts one, two and three. So, what is the magic to complying with four?


First, when do we have to comply? Some confusion was created last January when ABEM sent out notices announcing the process for complying with part four, APP.  Although they reported attestations would be accepted in 2010, this requirement actually doesn’t begin until 2011. During each ABEM Diplomate’s ten-year certification cycle, two attestations must be made, regarding the patient care practice improvement component. These attestations must be made by, but not after, years four and eight, while complying with the professionalism and communication component only requires one by year eight. So, what is an attestation? An attestation is simply a statement affirming you have complied with the requirement.

The required components of the attestations, as you navigate from one screen to the next, include naming the program you participated in, listing the dates of program involvement (make certain the dates submitted within and not outside of the attestation period), reporting the location of the program, including whether it was local, regional or national and answering a series of questions, in drop down boxes and toggle buttons, asking specific questions pertaining to the program goals and design.  

How does ABEM define a practice improvement (PI) activity and what exactly are we attesting to? Well, here is exactly what they say:

“A PI activity must include the following four steps:


1. Review patient clinical care data from ten of your patients.  The data must be related to a single presentation, disease, or clinical care process that is part of the Model of the Clinical Practice of Emergency Medicine (EM Model) for example
clinical care processes
feedback from patients that relates to the clinical care given
outcomes of clinical care
access to care such as time for through-put, left without being seen, etc.
Group data and data collected through a national, regional, or local practice improvement program in which you participate is acceptable.

2. Compare the data to evidence-based guidelines.  Evidence-based guidelines are based on published research subject to peer-review.  Only if such guidelines are not available, you may use guidelines set by expert consensus or comparable peer data.  Guidelines set by expert consensus are published, accepted, national standards, and guidelines set by peer data are set by individuals who practice in like or similar circumstances.

3. Develop and implement a plan to improve the practice issue measured in Step #1.  You may plan for an individual or group improvement effort. 

4. After implementing the improvement plan, review patient clinical care data from ten additional patients with the same presentation, disease, or clinical process as the first patient data review.  Use this data to evaluate whether clinical performance has been improved or maintained.”

Resist the temptation to over think this. Quite honestly, almost every ED in the country performs some form of acceptable PI work. One of the easiest and ubiquitous is the assessment of core measures. Remember when you hated them? Blood cultures prior to antibiotics for pneumonia. Antibiotics within 6 hours of presentation, etc., etc. Now, your hard work and the data your hospital and/or group have been collecting will actually serve a purpose for your benefit. This is just one example. However, many, and probably most, ED quality initiatives will meet the above requirements.  This includes operational assessment of performance metrics such as door to doctor, patients left without being seen, etc.

Is anyone’s patient satisfaction being assessed? If so, you have probably already complied with the professionalism and communication component (below is ABEM’s description of this component)? The attestation addresses similar verification questions as did the PI component. The following is an example of this from ABEM’s web site.

“The communication / professionalism activity is designed to help ensure that diplomates communicate with patients in an effective and professional manner.  You may use any formal method of assessing communication skills including patient surveys, interviews, or focus groups, administered at the institutional, departmental, or individual level.  At least ten of your own patients must be included.  A minimum of one physician behavior must be measured from each of the following three categories:
1. Communications/listening, for example:
Communicate clearly with patients and other medical staff by listening carefully and couching language at the appropriate level for the listener
2. Providing information, for example:
-Explain the clinical impression and anticipated management course to the patient and the patient’s family
-Provide information about tests and procedures
-Give the patient options
3. Showing concern for the patient, for example:
-Show respect to the patient and other medical staff
-Make the patient feel comfortable by asking if they have any questions or concerns and act to ad
dress their concerns
-Ask the patient about adequate pain relief”

You’re almost done. However, with most attestations, there is an audit mechanism to verify actual compliance. Near the end of your attestation, you will be asked to name a verifier, the person who will be available to verify the information you have provided in your attestation. This could be your Quality Director, Medical Director or hospital Chief Medical Officer. However, make certain that individual will accept this responsibility and if they leave, that this responsibility is reliably forwarded to their successor. ABEM will audit 10% of attestations.

There is one exemption to this process. If you are not clinically active for any reason, you can fulfill APP and maintain your board certification by changing your status from clinically active to clinically inactive.  When you become clinically active again, you can switch your status back, and the APP requirements will be applied to your web page. There is no penalty for changing your status and this does not negatively impact your board certification status. Just log in; click the EMCC online link and then the large rectangular “Assessment of Practice Performance” icon. The top of the next screen will ask you if you want to change your status and the bottom of the page will show your APP attestation requirements.

Although the ABEM APP online process is not particularly intuitive, with a little background information, it shouldn’t take you long at all. I hope this guidance will help you navigate your way to a successful attestation.


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