Written on July 23, 2011 by Ava Gwynn
Neonatal intensive care units around the country are participating in quality programs to improve care for the most vulnerable babies, todays Informed Patient column reports.
But the quality-improvement movement is at the center of a dispute between some neonatologists and the American Board of Pediatrics, with the doctors protesting requirements that they demonstrate meaningful participation in quality-improvement activities as part of the boards certification maintenance process. The rule applies to doctors who are to be newly certified, or were due to be re-certified anytime after 2010.
The board has approved ten quality-improvement programs around the country that qualify for the process, including one sponsored by the large for-profit Pediatrix Medical Group which employs physicians who care for about 20% of the infants in hospital NICUS. Other programs include the Vermont Oxford Network, which is currently working with about 900 hospitals, the California Perinatal Quality Care Collaborative and state collaboratives in Ohio, North Carolina and Tennessee.
In March, neonatologists at 69 academic medical centers around the country published a letter in the online e-Journal of Neonatology Research, protesting that quality-improvement programs cant adequately reflect individual professional performance, and warning that most clinicians will participate in accredited projects simply for the purpose of maintaining certification, taking time away from more important professional activities.
The rules, they added, put some academic and smaller private-practice neonatologists at a disadvantage relative to those participating in corporate-based collaboratives, those whose institutions can afford to participate in costly national network collaboratives or those few who can participate in state network collaboratives.
The latest issue of the journal includes an online survey of 165 doctors, published by editor-in-chief Phillip V. Gordon, chair of the neonatology unit at Tulane School of Medicine and lead signer of the letter. The survey found the vast majority of respondents didnt think the new certification maintenance requirement would make the practice of neonatology safer, didnt think the quality-improvement portion assessed performance and didnt think the ABP was responsive to the needs of neonatologists.
Gordon tells the Health Blog he and other physicians who signed the March letter dont believe the ABP program is adequate to assess skills, and that it takes up time and money doctors dont have. He suggests an alternative such as a more traditional continuing medical education program with a secure online self- test. We are being asked to jump through hoops to keep the public happy but all this is doing is taking time away from the bedside, Gordon says. People are angry.
ABP President James A. Stockman says the group welcomes feedback, and declines comment on the survey. But he points out that credit for participating in an approved quality-improvement activity is only one pathway that is approved to meet the requirements. Neonatologists can also complete an individual practice improvement module, such as one designed to increase breast milk feeding or hand hygiene, he notes. In addition, individuals or groups of physicians can measure and improve their care and submit these efforts for credit without going through an institutional sponsorship.
Stockman also takes issue with the idea that physicians cant be judged by how well they do in team quality-improvement efforts. Other medical boards also encourage participation in quality improvement for certification, he notes, and outcomes in the NICU are clearly dependent on team care, he says, with multiple doctors working alongside nurses, respiratory therapists and other clinicians. And as for protests about the corporate-sponsored QI initiatives, such as those of Pediatrix, they are of uniformly high value or they would not have been accepted for credit by the board.