20th Anniversary Report: 1996 – 2016 · affiliate that addresses these professional...

20th Anniversary Report : 1996 – 2016

imq.org • Improv ing Healthcare Qual i ty Through Educat ion and Eva luat ion

William H. Goodson, III, MDChair, Board of Directors

Institute for Medical Quality

Aprofession is a group entrusted by society

to do three things: 1) maintain a body of

knowledge that is important to society;

2) teach that knowledge to perpetuate

the profession; and 3) assure the quality

of services provided by the members of the profession.

To be a profession, physicians must lead in all three of these

tasks. If physicians relinquish any of these roles, we cease

to be a profession.

For 20 years, the Institute for Medical Quality (IMQ)

has been the California Medical Association (CMA)

affiliate that addresses these professional responsibilities.

By commitment to quality - independent of advocacy -

IMQ demonstrates to society as a whole that physicians

can be trusted to work for quality care for everyone.

The physicians who lead, oversee, and participate in IMQ

programs contribute personal time far out of proportion

to their symbolic stipends because, as individuals, they

value the mission of IMQ. They are respected physicians

in their communities, and their participation in IMQ

demonstrates commitment both to the care of patients

and to the maintenance of their profession.

When I explain IMQ to my friends, I surprise them

by explaining the Corrections and Detentions Programs.

Inmates eventually return to live among us, and illnesses

untreated during incarceration become a burden and

source of disease for all of us. When we oversee care

for inmates, we demonstrate to society our professional

commitment to treat the illness independent of who

has the illness.

This same commitment to universal quality of

care underlies our programs in Ambulatory Surgery,

Continuing Medical Education, Physician Leadership,

and yes, remedial Ethics Training.

It is my honor to be the fifth chairman of the Board

of Directors of IMQ and to work in partnership with

our CEO, Jill Silverman, MSPH - and her outstanding,

professional staff - as she takes IMQ into the next phase

of our development.

IMQ MISSIONThe Institute for Medical Quality’s (IMQ) mission is to be an innovative leader in improving the quality of care provided to patients across the continuum of health care by encouraging, developing and implementing programs which effectively measure and improve the quality of care provided to people in California and beyond.

MESSAGE FROM THE CHAIR

“They are respected physicians in their communities,

and their participation in IMQ demonstrates commitment both to the care of patients

and to the maintenance of their profession.”

“

Jill K. Silverman, MSPHPresident & CEO

Institute for Medical Quality

Inst i tute for Medica l Qual i ty • 2016 20th Anniversary Report

Twenty years ago, CMA formed IMQ to

improve healthcare quality through direct

physician involvement in evaluation and

education. Experienced and talented

physicians came together from throughout

California to participate as surveyors, educators, peer

reviewers, committee and Board members. Thanks to

the selfless contributions of hundreds of volunteers, along

with a talented and hard-working staff, IMQ has grown

from a few core programs to a thriving national entity. As

we celebrate 20 years of success, we recall many early IMQ

programs which helped us reach our current position.

In 1996, CMA transferred to IMQ the CME Accreditation

and Certification programs, the Hospital Survey Program

(CALS), the correctional health accreditation program, and

a program to participate in the surveys of Ambulatory care

facilities. In its first months, IMQ submitted a proposal

to the California Department of Corporations to survey

health plans, and for four years, IMQ surveyors reviewed

California health plans, assuring that they complied with

state requirements for patient safety. In 1998, IMQ also

established the first accreditation program in the United

States for Independent Review Entities. IMQ’s invitational

summit on the independent/external review process, along

with IMQ’s study, funded by the California Healthcare

Foundation, on the effectiveness of external review for

patients in California, identified opportunities to improve

this important mechanism for assuring that patients were

not denied access to clinically indicated care.

In 1996, IMQ established its own ambulatory surgery

accreditation program , which now operates nationally,

and anticipates receiving recognition from the Centers

for Medicare and Medicaid Services this year. IMQ’s

Correctional Accreditation Program has expanded its

services to include Title 15 reviews and systems consultation.

The CME Accreditation Program, which until 2009

enabled Audio Digest to grant CME for its materials, has

expanded its educational offerings and outreach to CME

providers, and helped them integrate cultural and linguis-

tic competence into their programs. Although the end of

CMA/IMQ physicians participating in the licensure and

accreditation surveys of hospitals (CALS) is a huge loss for

hospitals and medical staffs, IMQ continues to guide medi-

cal staffs through a range of peer review, consultation, and

tailored educational programs.

As IMQ enters its third decade, I am proud and confident

that ever increasing numbers of patients and health care

systems and professionals will look to IMQ for guidance

and assurances regarding quality care. I am grateful for the

honor of working with so many innovative and dedicated

professionals who join me in enthusiastically anticipating

our next decade of improving health care quality.

IMQ VISIONThe Institute for Medical Quality will be a nationally recognized authority for evaluating and improving health care quality.

CHANGING VIEWS, SAME GOALS 20 YEARS OUT

“Thanks to the selfless contributions

of hundreds of volunteers, along with a talented and

hard-working staff, IMQ has grown from

a few core programs to a thriving national entity.”

– 1 –

Kevin C. Reeder, MPAAdministrator Corrections & Detentions Health Care Program

Robert Spencer, MDChairCorrections & Detentions Health Care Committee

“The IMQ correctional survey program is based on integrity and knowledge.

It provides facilities with direction and expertise for providing appropriate

and humane services to their inmates. IMQ is the cornerstone in health care

for the future of Corrections.”

Ernest Williams, MD, Past Chair Corrections and Detentions

Health Care Committee


While most patients can switch doctors or hospitals if they are unhappy with their health care, inmates in correctional facilities have no choice. Inmates who leave jails with infectious diseases carry those diseases back to their communities. Through accreditation, consultations, and Title 15 surveys, IMQ helps correctional facilities provide constitutionally adequate and regulation-compliant health care services, protecting inmates, their

families and their communities.

1989: First Accreditation – Marin County

1992: Wooden vs. The County of Shasta The US Court of Appeals, Ninth Circuit recognizes CMA/IMQ accreditation standards as meeting a

constitutional level of health-care services for inmates, and the survey process as a valid tool in measuring compliance with the standards.

1996: First Consultation - San Bernardino County

1999: 15th county completes the accreditation process

2001: First Title 15 Inspection – San Mateo County

2003: 25th county completes the accreditation process

2010: Title 15 Contract – San Diego County

2015: 5th county enters into Title 15 Contract

2016: Adult Inmate Medical Services (AIMS) Contract – Alameda County Assist the AIMS Panel in fulfilling its charge to independently assess the delivery of medical services to inmates in the Alameda County correctional system.

CORRECTIONS AND DETENTIONS HEALTH CARE PROGRAM

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20011989 1992 1996 1999 2003 2010 2015 2016

Strong independent oversight and rigorous standards help assure that outpatient facilities offer safe, high quality health care. Since its inception, IMQ’s Ambulatory Accreditation Program has been recognized by the Medical Board of California as an approved accrediting body for outpatient facilities. Increasingly, other state regulatory bodies are recognizing IMQ’s program, such as Kansas, Nevada, and Oregon. IMQ uses a survey process grounded in peer review. Well-trained surveyors (physicians, nurses, and health care facility administrators) with relevant practice experience provide facilities a practical, meaningful, and cost-effective method for improving the quality of health care. We anticipate that the program will be recognized by CMS this year.

1997: Medical Board of California approval

2005: Kansas Bureau of Health Care Facilities approval

2007: Oregon Medical Board approval

2010: Nevada Bureau of Health Care Quality and Compliance approval

2011: First facility accredited in Nevada

2012: First facilities accredited in Oregon, Kentucky, Texas

2013: First facility accredited in Minnesota

2014: Ambulatory facility consultation in Mexico City, Mexico

2014: Program credentials first surveyor in Oregon

2015: First facilities accredited in Michigan and Hawaii

Inst i tute for Medica l Qual i ty • 20th Anniversary Report : 1996 – 2016

AMBULATORY ACCREDITATION PROGRAM

Victoria Samper, MSVice PresidentAmbulatory Programs

Neal H. Shorstein, MDChair Ambulatory Care Review Committee

“We chose to work with IMQ over other national accrediting

organizations due to its responsiveness, professionalism, and dedication to patient safety.”

Wilbur Hah, MD, Owner, Beauty MD, Texas

“Our interactions with IMQ support staff and clinical surveyors have been

extremely positive. Their goal is not only to audit

but to educate.”

Marjorie Newman, MD, Assistant Medical Director Sansum Clinic, California

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20111997 2005 2007 2010 2012 2013 2014 2015

Jena Resner, MDAdministratorCME Accreditation Program

K.M. Tan, MDChairCME Steering Committee

“By helping CME Providers provide relevant, unbiased programs,

IMQ strengthens the educational foundation which helps physicians

provide great care to their patients.”

K.M. Tan, MD, Chair CME Steering Committee


CME provides lifelong learning for physicians, with the ultimate goal being better care for patients. IMQ (in affiliation with the California Medical Association), is the Accreditation Council for Continuing Medical Education’s (ACCME) designated California accrediting agency. This means that IMQ accredits organizations

and healthcare providers within California to offer meaningful CME to physicians.

IMQ accredits about 250 organizations in California, Nevada and Alaska to offer about 7,500 CME activities per year. This provides physicians with vastly more learning opportunities. CME helps physicians provide care that is consistent with current best practices, is compliant with laws and regulations, and is void of conflicts of interest.

IMQ accredited organizations provide about 42,000 hours of education, involving 400,000 physician interactions and 170,000 non-physician learner interactions, each year.

Through Joint Providership with IMQ, several non-accredited entities offer CME credit for their educational activities.

IMQ provides CME credit for numerous CMA activities, such as the Western Health Care Leadership Academy and OMSS Educational Programs.

IMQ also directly provides CME and recently received a Six Year Accreditation with Commendation, attesting to

the outstanding quality of IMQ’s CME educational activities.

CONTINUING MEDICAL EDUCATION (CME) ACCREDITATION PROGRAM

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CONTINUING MEDICAL EDUCATIONCME CERTIFICATION PROGRAM

IMQ’s CME Certification Program tracks and verifies that individual physicians have the required number of qualified CME credits to maintain licensure. This program reduces physician time, stress and hassle because the Medical Board of California (MBC), which audits physician compliance, accepts IMQ verification of CME credits as evidence of compliance.

Each year, IMQ tracks certification for almost 5,000 physicians.

➢ The Certification service brings peace of mind by verifying that each activity reported qualifies for credit toward renewal of licensure. IMQ ascertains that every reported provider is accredited, and navigates the complicated qualifications for AMA-recognized activities such as teaching, publishing articles, and much more.

➢ While CME providers might provide physicians with a calendar year transcript of their activities, only IMQ tracks and allocates CME according to each individual’s two-year relicensing period, which differs according to the physician’s birthday month.

➢ The CME Certification reporting process has been upgraded to make reporting easier for physicians. They now are able to report, view, and print an official transcript of their activities online 24/7.

➢ Although MBC audits about 10% of physicians each year, physicians using IMQ’s Certification Program do not need to worry about an audit because the MBC accepts IMQ verification as evidence of compliance.

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“The CME Certification service from IMQ gives me great peace of mind. Taking just a few minutes each year, this service assures that I meet my

CME obligations to the Medical Board.”

Barbara R. Paul, MD

“You should know that I (and other Docs too) have been delighted with

your work and responses to our queries and issues ... Thanks.”

Jerry Hughes, MD, FACEP

“The IMQ Certification Program and everyone at the IMQ ... in the course

of documenting my CME activities has been very helpful and very responsive.”

Larry Stuart Deutsch, MD

IMQ uses educational programs to improve the practice of medicine. IMQ’s programs address topics ranging from leadership and conflict resolution to infection control and the use of data to enhance quality. Since 1996, IMQ has offered 315 educational programs, with a combined total registration of 17,641 attendees. IMQ continues to be a trusted source of guidance for thousands of healthcare professionals.

Medical Staff Leadership Conference (formerly the IMQ PreCALS Conference) Gives Medical Staff Leaders current information on patient safety, regulatory requirements, effective data usage, quality systems and the evolving healthcare delivery environment.

IMQ Professionalism Program Developed to comply with the requirements established by the Medical Board of California, IMQ’s Professionalism course has helped hundreds of physicians and pharmacists understand the legal and ethical dilemmas they have faced and provided excellent resources as well as follow-up interactions to help them avoid future problems.

On-Line Courses To make continuing medical education more easily and conveniently accessible, IMQ offers a broad range of courses on-line. They are available 24/7 and are updated frequently.

Ambulatory Workshops Helps facilities prepare for the accreditation process, and in doing so, enhance their systems of care delivery.

CME Essentials Explains the fundamentals of planning and evaluating a CME activity to help new CME

professionals succeed.

CME Annual Provider Conference By providing annual updates regarding changes in CME requirements and practices, strengthens the effectiveness of California’s CME community.


EDUCATIONAL PROGRAMS

ABOUT THE AMBULATORY WORKSHOP

“Very informative. After attending this workshop,

I no longer feel so intimidated by the [accreditation] process.”

Cori Good Premier ENT, California

ABOUT THE CME ANNUAL PROVIDER CONFERENCE

“I always come away from the conferences with a list of new learnings to implement and

re-energized to build our program.”

Ann Engwer Dignity Health, California

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Numerous IMQ programs have been made possible through funding from foundations and government organizations. Each has helped IMQ serve its mission. These have included:

The California Endowment Supported IMQ in creating standards and helping CME providers integrate Cultural and Linguistic

Competence into their educational offerings (2006 – 2010).

The Physicians Foundation Funds the IMQ/PACE Stepping Up to Leadership Conference, an interactive two day training which

uses case studies, videotapes, and group exercises, as well as didactic presentations, to help physicians strengthen their skills in communicating, handling disruptive or impaired professionals, and collaborating with others. Almost 500 medical staff professionals have participated in this program offered in 2011, 2012, 2014, and 2016.

Physician’s Institute Funded the REMS Grants in which IMQ worked with CME providers to offer a series of coordinated

trainings on Risk Evaluation and Mitigation Strategy (REMS) for opioid medications. 1,155 learners participated in these trainings from 2014 – 2015.

The Governor’s Office on Emergency Preparedness Provided grants to make the Child Abuse Prevention Center’s (CAP) online course on recognizing and

reporting child abuse available to healthcare providers free of charge. To date, almost 700 providers have participated in this course (2015 – 2016).

W. M. Keck Foundation: This planning grant enables IMQ to bring together many emergency medicine experts to develop

fundable strategies for reducing wait time and improving patient outcomes in Emergency Departments in LA County (2015 – 2016).

GRANT FUNDED EDUCATION AND RESEARCH

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ABOUT STEPPING UP TO LEADERSHIP

“One of the best and most useful

leadership conferences. It gave us the practical tools

we need as medical staff leaders. I strongly recommend all medical staff leaders, department chairs,

and hospital leaders attend this outstanding conference.”

Sarada Mylavarapu, MD Past Chief of Staff, Fountain

Valley Regional Hospital & Medical Center

Leslie Iacopi, MBAAdministrator Medical Staff Services Programs

Donald S. David, MD, FACGChairMedical Staff Services Steering Committee

ABOUT JUDICIAL REVIEW PANELS

“IMQ provides invaluable services to medical staffs, empowering physicians to take a leadership

role in ensuring patient safety and quality.”

Donald S. David, MD, FACG, Chair Medical Staff Services Committee

“When medical staffs utilize this unique IMQ service, the peer review hearing process speeds up

immeasurably, providing better service to the physician and the hospital.”

Greg Abrams, JD


For almost 40 years, CMA/IMQ physician surveyors participated in the accreditation and licensure of California acute care hospitals. While IMQ’s participation in surveys ends April 30, 2016, IMQ continues to help hospitals and medical staffs provide high quality care through a range of peer review and consultative services. Since 1996, IMQ has performed dozens of these services.

Medical Staff Consultations Help medical staffs or individual departments improve systems of care. Each program is custom

designed, offering specific guidance which is timely and relevant. Consultations often focus on areas such as effectively implementing quality measurement, peer review, and credentialing and privileging.

Peer Reviews IMQ offers both an on-site review of a physician’s pattern of care and off-site patient chart review.

By providing independent, qualified physicians, IMQ assists hospitals in determining the quality of care provided by a physician. This is particularly helpful when the number of physicians practicing in the same specialty or sub-specialty on the medical staff is deemed insufficient to perform objective peer review, or when physicians practicing in the same specialty or subspecialty feel they may have a conflict of interest.

Judicial Review Panels By providing independent physician panelists to serve on judicial review panels, IMQ enables hospitals

and other healthcare organizations to complete judicial reviews in a more timely manner and without conflict of interest. This provides a more fair process for physicians.

MEDICAL STAFF SERVICES

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Edward A. Chow, MDAnthony F. Chong, MD, FAAFPDustin CorcoranWilliam H. Goodson, III, MDLee H. Hilborne, MD, MPHScott R. Karlan, MD, FACSJeffrey G. Klingman, MDJohn A. Kusske, MDSharon L. Levine, MDWilliam A. Norcross, MD

Barbara R. Paul, MDRobert A. Reid, MDJill K. Silverman, MSPHCora M. TellezEdie E. Zusman, MD, FACP, FAANS, MBA

Liaisons David H. Aizuss, MDSue U. Malone

Gifford Boyce-Smith, MDToni J. Bayer, MDTom J. ElkinDonald E. FelsingerRichard S. Frankenstein, MDJohn C. Lewin, MD

Rosalio Jimenez Lopez, MDRichard B. Rabens, MDK.M. Tan, MDScott R. Weingarten, MD, MPHJill K. Silverman, MSPH

Founding Board of Directors (1996)Richard O. Ashby, MDRonald Bangasser, MDMelvin C. Britton, MD, FACPRemo A. Cerruti, MDJoseph Dunn, JD

Lucian L. Leape, MDWilliam G. Plested, III, MDLeslie R. SchlaegelBarry M. Straube, MDRobert M. Takamoto, MD

Other Board Members through the years Current Board of Directors (2016)

Inst i tute for Medica l Qual i ty • 2016 20th Anniversary Report

2015 IMQ BOARD OF DIRECTORSAbsent: William G. Plested, III, MD; Barbara R. Paul, MD; Dustin Corcoran; and Liaison Sue U. Malone

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IMQ STAFF

Absent: Leslie Iacopi, MBA and Eva Melendez

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20th Anniversary Report: 1996 – 2016 · affiliate that addresses these professional...

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