Performance Improvement

As noted by the American Medical Association (AMA) Performance improvement (PI) activities describe structured, long-term processes by which a physician or group of physicians can learn about specific performance measures¹, retrospectively assess their practice, apply these measures prospectively over a useful interval, and re-evaluate their performance. To award AMA PRA Category 1 Credit for PI activities, providers must:

• Establish an oversight mechanism that assures content integrity of the selected performance measures. These measures must be evidence based² and well designed (e.g., clearly specify required data elements, data collection is feasible). PI activities may address any facet (structure, process or outcome) of a physician’s practice with direct implications for patient care.
• Provide clear instructions to the learner that define the educational process of the PI activity (documentation, timelines, etc.) and establish how they can claim credit.  Validate the depth of physician participation by a review of submitted PI activity documentation. Providers may award credit to physicians for completing defined stages of the PI activity.  When requested, supply specific documentation of such credit to participating physicians.
• Provide adequate background information so that physicians can identify and understand the performance measures that will guide their PI activity, and the evidence base behind those measures.  Providers may deliver this education through live activities, enduring materials or other means.  Providers must ensure that participating physicians integrate all three stages described below to develop a complete, structured performance improvement activity.

Stage A: Learning From Current Practice Performance Assessment
Assess current practice using identified performance measures, either through chart reviews or some other appropriate mechanism. Participating physicians should be actively involved in data collection and analysis.

Stage B: Learning From the Application of PI to Patient Care
Implement an intervention based on the performance measures selected in Stage A, using suitable tracking tools (e.g., flow sheets).  Participating physicians should receive guidance on appropriate parameters for applying an intervention and assessing performance change specific to the performance measure and the physician’s patient base (e.g., how many patients with a given condition, seen for how long, will produce a valid assessment?).

Stage C: Learning From the Evaluation of the PI Effort
Re-evaluate and reflect on performance in practice (Stage B), by comparing to the assessment done in Stage A. Summarize any practice, process and/or outcome changes that resulted from conducting the PI activity.

Assigning Credit for PI Activities
Physicians may be awarded incremental AMA PRA Category 1 Credit for completing each successive stage of a PI activity. Incremental credit for PI activities should be awarded as follows:

• Five (5) AMA PRA Category 1 Credits can be awarded for the completion of each of the three stages (A, B and C). Completion of the full PI cycle is not required.
• Providers may design PI activities so that physicians can enter at any of the three stages. Providers that do so must design a mechanism by which physicians who enter after stage A can document their completion of work equivalent to that described for the earlier stages.
• Physicians completing, in sequence, all three stages (A – C) of a structured PI activity may receive an additional five (5) AMA PRA Category 1 Credits, for a maximum of twenty (20) AMA PRA Category 1 Credits. This credit allocation acknowledges the best learning is associated with completing a well conceived PI activity.

¹ A clinical performance measure is a mechanism that enables the user to quantify the quality of a selected aspect of care by comparing it to a criterion. (Institute of Medicine, 2000).

² Evidence based medicine is “the integration of best research evidence with clinical expertise and patient values.” Sackett DL, Strauss SE, Richardson WS, et al. “Evidence-based medicine: How to practice and teach EBM.” Second edition. London: Churchill Livingstone; 2000.