Currently, the American Board of Medical Specialties, which oversees the MOC process for its 24 member boards, is already accepting CME credit awarded for completion of PIMs in other disciplines. The American Board of Internal Medicine, for example, offers PIMs in areas such as asthma, chronic kidney disease, diabetes, hypertension, preventive cardiology, and communication.In addition, at least one major insurance carrier is using PIMs as a criterion for additional physician recognition.

AAOS Now

Published 6/1/2012
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Stuart J. Fischer, MD

PIM Development Is Underway

Performance Improvement Modules are last phase in Maintenance of Certification™

What are Performance Improvement Modules (PIMs)? They are a new way for us as orthopaedic surgeons to assess what we are doing in practice. Additionally a PIM can be part of a performance improvement continuing medical education module (PI CME) that enables us to receive CME credit for this process. The PIM relates to the chart review process while the PI CME module ties the PIM to CME. And we can do it without leaving our offices.

PIMs are a series of steps in which we document a number of cases with the same diagnosis, evaluate the results, and then make changes based on our findings. For example, a hand surgeon may look at his or her treatment of distal radial fractures, a joint reconstruction surgeon at knee osteoarthritis leading to total knee arthroplasty, and a pediatric orthopaedist at the treatment of osteochondritis dissecans.

The concept of performance improvement for CME credit was first approved by the American Medical Association (AMA) in 2004. It involves the following three stages:

  • current practice performance assessment
  • application of performance improvement to patient care
  • evaluation of performance improvement

Currently, 5 AMA PRA Category I CME credits™ are awarded for each of the first two stages of the process and 20 credits are awarded for completing all three parts.

PIM activities
The AAOS has established a Performance Improvement-CME (PI-CME) project team, chaired by Kenneth J. Koval, MD, to develop modules.

A PIM/PI-CME summit sponsored by AAOS and the American Board of Orthopaedic Surgery (ABOS) was held in Rosemont, Ill., in June 2011 to discuss plans for coordinating the PIM/PI-CME process among orthopaedic subspecialties. The goal is to create practice-based learning that would be reflected in part IV of the Maintenance of Certification™ (MOC) process, which requires evaluation of performance in practice. The process would be standardized and easy to use.

“The Academy can assist the specialty societies in preparing their PIMs and also assist in preparing topics that involve multiple specialties,” said Dr. Koval.


PIMS are a way to assess current practice, apply improvements, and evaluate performance.

How PIMs work
As envisioned, orthopaedic PIMs would be web-based and allow participants to enter and save data as they work through the process.

The first stage of a PIM record includes data on factors such as the following:

  • history of injury
  • co-morbidities
  • prior level of function
  • associated injuries or conditions
  • physical examination
  • radiographic findings
  • classification of the fracture or disease
  • surgical decision making
  • surgical technique
  • associated procedures and complications
  • postoperative results and complications

It is anticipated that surgeons would enter data from at least 10 cases with a minimum 6-week follow-up. The second part of the process involves review of data, identification of areas that need improvement, development of an improvement plan with timelines for completion, and documentation of improvement.

During this time, surgeons would also participate in an educational activity(ies) related to the performance improvement. This might include journal CME, online material, or attendance at courses.

In the final stage, surgeons perform a second chart review on a new series of cases with the same diagnosis as the first series. Results between the first two series are compared and participant surgeons then evaluate the results to determine what improvements have occurred since implementation of the plan.

Orthopaedic PIMs
The first series of orthopaedic PIM/PI-CME modules is currently being developed. A prototype PIM for carpal tunnel syndrome has been created by the American Society for Surgery of the Hand and is now being tested. It is anticipated that this will be used for recertification in hand surgery.

Another module, Distal Radius Fractures—Operative Treatment, has been developed by the AAOS PI-CME Project Team. Two additional modules, Achilles Tendon Repair and Glenohumeral Arthritis, are currently being developed and are based on AAOS Clinical Practice Guidelines.

The following modules are either in the planning or writing stage:

  • hammertoe
  • supracondylar humerus fractures
  • proximal humerus fractures
  • Dupuytren’s disease
  • ankle fractures
  • clavicle fractures

Once modules are written, they must meet 10 essential steps outlined by ABOS and then be tested for usability. A clear timeline for implementation has not yet been established.

As noted in the PIM/PI-CME Summit, a standardized format among all orthopaedic specialty societies has yet to be designed. According to Dr. Koval, “It has to be a standardized process that can be incorporated into everyday practice. The PIM should incorporate questions about the decision making process of the treatment being considered.”

PIMs will be one way to fulfill the self-assessment requirement for MOC. Although PIMs are not mandated, they may be submitted for MOC Part II credit. The goal is to give surgeons the opportunity for more practice-based learning.

PIMs may also be used to satisfy part of the performance in practice requirement. According to Shepard R. Hurwitz, MD, executive director of ABOS, “PIMs will complement the case list in the future but not replace it. PIMs should make it easier for surgeons because information comes from their own practices. At the same time that they are reviewing and evaluating their performance, they are getting CME credits and credit toward Maintenance of Certification.”

Dr. Hurwitz also notes that PIMs may have benefit outside the certification process. “We are giving surgeons a way to show a hospital or insurer that they are involved in a quality assessment program.”

He predicts that in the future, surgeons who participate in a registry may be able to link the case data to a PIM. However, before this occurs several issues must be addressed.

For more information on MOC, visit the ABOS website (www.abos.org) or call 919-929-7103.

Stuart J. Fischer, MD, is the Communications Cabinet liaison to the Council on Education, associate editor of the AAOS patient information website OrthoInfo.org, author of 100 Questions and Answers about Hip Replacement, and a member of the AAOS Now editorial board. He can be reached at 3pindoc@attglobal.net