In 1970 – a time that Kent Shoji, MD, FACEP, jokingly refers to as the “Paleolithic era” of his career – there was no formal Board Certification process for physicians in Emergency Medicine.
Dr. Shoji remembers working with a surprisingly broad array of doctors in the emergency room (ER) of a small community hospital for many years. Then in 1979, the American Board of Emergency Medicine began a formal certification process for emergency physicians. “After that, there was a quantum leap in the knowledge base and capabilities of candidates,” Dr. Shoji said. “The subjective and objective data bears this out – that any patient can go to almost any ER today and receive high quality care.”
This dynamic is a major factor behind Dr. Shoji’s support of the ABMS Program for Maintenance of Certification (ABMS MOC®). He said quality improvement (QI) projects designed to meet MOC requirements have literally saved lives at his own facility: Providence Little Company of Mary Medical Center (PLCMT), in Torrance, Calif., where he serves as an Emergency Medicine specialist.
In one QI project, Dr. Shoji and his colleagues reduced door-to-physician time for patients entering the ER from as long as 60 minutes to an average of 26 minutes. In another, the time it took for patients with chest pain to receive an electrocardiogram (EKG) dropped from approximately 30 minutes to four minutes, on average. Higher acuity patients are now seen by a physician immediately, and their labs and other tests are ordered within minutes. That’s because another QI project resulted in a physician being stationed in the ER waiting room at all times. Previously, a triage nurse worked alone.
“Emergency Medicine is such a dynamic field; it’s always changing,” Dr. Shoji said. “There’s a lot of variability in medicine and, of course, in patient cases themselves. And there is variability in the way individual physicians practice medicine. The QI projects help us standardize processes and tighten the bell-shaped curve of practice patterns.”
A patient in her late 40s recently benefited from those QI projects when she came to PLCMT’s ER, which admits approximately 75,000 patients a year. While gardening, she started to have shoulder pain, he explained. The patient came to the ER where she was immediately given an EKG, which revealed that she was having a heart attack. Within approximately 40 minutes, the patient was in surgery having a stent placed. “That kind of process improvement definitely has led to better patient outcomes,” Dr. Shoji noted.
Another patient came to the ER with abdominal pain, including nausea and vomiting. “Abdominal pain could be caused by a number of things,” he said. “We ordered an EKG right away, which showed he was having a heart attack— an acute inferior myocardial infarction. Those are the cases that are rare – the ones you don’t want to miss.”
Dr. Shoji and his staff also have opened up an observation area for high-risk patients. “If you have a 35-year-old man come in with chest pain and you rule out a cardiovascular event, it’s still best to proceed carefully,” he said. “We keep patients in this category under observation for twenty-four hours.”
An added benefit of these and many other QI projects is that patient satisfaction scores have risen significantly, Dr. Shoji added.
“I think Maintenance of Certification, in general, has initiated the process for doing more clinical and process improvements,” he said. “You can talk about plans in committees. But until there’s a process in place that enables you to identify, dissect, and improve the problem, and measure the results afterward, you don’t change behavior. In the long run, it’s a much better way to deliver patient care.”