Performance Improvement CME

As a CME professional I have to ask myself, am I ready to facilitate or carry out performance improvement CME initiatives? Do I have a deep understanding of what is required to make performance improvement efforts successful and sustainable? Do I have the skills necessary to lead or participate in PI CME efforts?

CME is being held accountable for demonstrating impact on physician competence, or performance, or patient outcomes. One form of CME particularly well suited to meet this mandate is “Performance Improvement CME” (PI CME).

At the end of Stage A of a PI CME effort all the physicians know is where they stand in their practice compared to selected performance measures and sometimes their peers. As a CME Provider I can award 5 CME credits to them for developing that understanding. But then what? You know what I think. I think mastering the Toyota A3 report as a problem solving approach may be one set of skills that would serve me well to be sure a PI CME effort is done effectively and help me feel comfortable in awarding PI CME credit to physicians engaged in PI CME initiatives. I like the A3 problem solving approach for three reasons

First, it is brief and graphic in nature. The approach is called A3 because they use they use one a one page legal size piece of paper – called A3 in other parts of the world – to capture and communicate a performance improvement opportunity. It forces the team working on the improvement effort to be clear and concise in describing and communicating about the problem and the solution throughout the effort.

Second, the key elements of A3 problem solving are very powerful and fit well into the values I think most physician scientists value.

* It values objectivity. My observation on any improvement need is going to be inherently subjective. As will the observations of others involved in the improvement effort. However, discussing the various viewpoints on an improvement need makes these perspectives explicit. As the team collects objective information about the situation biases, assumptions and misconceptions can be resolved in a more objective manner.
* It is results and process oriented. Results are not valued over process. Both process and results are important. We clearly don’t want a process that doesn’t achieve the desired results. Nor do we don’t want a poor care process even if we approximate the outcomes we want to achieve. We want results that come from effective and efficient care processes.
* It requires that we synthesize, distill, and visualize all of the salient information required to understand the improvement need and a potential solution. A picture may indeed be worth a thousand words. Using an A3 piece of paper to present an improvement problem and a proposed solution requires careful synthesis, a logical distillation of the information required to understand the problem, and an ability to graphically show people exactly what we are talking about
* It requires internal consistency and coherence. One part of the A3 report must flow logically to the other sections of the report.The diagnosis of the problem is consistent with the real improvement theme.The root cause analysis emanates from an analysis of the current situation.The proposed solutions address the root causes analyzed. The solutions implemented put the suggested remedies in place.
* The follow-up plan tests the results against the desired outcomes established earlier in the process. Logical, coherent, consistent.
* Finally it takes a systems approach. It requires that I know the purpose of the course of action we decided to take:that I understand how the course of action furthers my organizations priorities and goals; and that I have knowledge of how the solution fits into the lager picture and affects other parts of my organization or the health care delivery system.

Third, it is built on sound processes utilizing effective improvement tools. Underlying the steps involved in an improvement effort is the proven Plan, Do, Check Act (PDCA) process. The planning phase may take as much as two thirds of the time of the entire improvement effort. There is no skimping at this stage in the process.

Let’s assume it is your CME Committee charged with oversight responsibility for approving PI CME activities for CM E credit. What do I want my CME Committee to know as they consider approving a PI CME activity for CME credit?

* I want my CME Committee to know the physicians involved in the effort can actually describe the performance problem in a clear and concise manner. In short, they should know what is going on the practice setting so they can describe what is actually going on. This is their picture of the current situation. Without this they the CME Committee won’t know how much progress was made in resolving the problem as part of the improvement efforts.

* I want my CME Committee to know the physicians have some very specific idea(s) about why the situation exists by identifying the root cause(s). Why is this effect happening? And then looking at that cause as an effect, why is this effect happening? Doing this exercise up to five times will help get to the root cause(s) of the performance problem and not just the symptoms of the problem.

(NOTE: Engaging diligently in these two planning efforts will lead to a much deeper understanding of the performance problem and the potential causes that need be addressed by countermeasures.

* I want my CME Committee to know the physicians involved in the effort have examined all the potential causes of the performance problem and made a conscious decision about which of those causes (if any) are amenable to an educational resolution. After all, I am a CME professional. Education is my stock in trade. But if there doesn’t appear to be an educational solution required to resolve of the performance problem that doesn’t mean I have to turn away from the issue. That means, as a CME professional, I have to expand my effort and find non-educational solutions. And that will likely require partnering with others in my setting. Together we need to identify the root cause(s) that can be addressed that will resolve the performance issue. CME professionals should take ownership on the performance issues they identify and stay with them until they are resolved or given to someone who is committed to taking ownership and resolving the problem.

* I want the CME Committee to know what the physicians think the future situation should be after they implement the improvement initiatives.

* I want my CME Committee to know what countermeasures the physicians intend to implement in the practice setting to resolve the performance problem. What are they going to do to change the current situation in an effort to lead to the desired situation?

* I want my CME Committee to know that the physicians involved in the improvement effort can articulate an implementation plan to guide their improvement efforts. Who is going to what and when to get to the desired improvements? (Stage B)

* I want my CME Committee to know the physicians involved in the improvement effort have an effective plan in place to evaluate the improvements made during the project. (Stage C)

* I want my CME Committee to know if approvals are required to make the changes that gaining these approvals is built into their improvement effort.

* I want my CME Committee to know the physicians involved in the improvement effort have a plan to secure buy-in from of all parties that will be affected by the improvements

* I want my CME Committee to know that there is a follow-up plan that includes a description of steps they will take to standardize the improvements in their practice setting made as a result of the effort.

PI CME initiatives using an A3 process will be effective, produce lasting improvements in the delivery of care, improve patient health outcomes and truly be CME activities that matter. This is CME the CME Committee will have no problem in awarding 20 credits.

The AMA three part approach to offering CME credit for involvement in performance improvement CME is deceptively simple. Three stages. Stage A requiring the physician to engage in some sort of data based assessment of his or her practice using identified performance measures through chart review or another appropriate mechanism. Stage B requiring the physician learns from an intervention based the performance measures used in the first step. Stage C requiring the physician to re-evaluate and reflect on performance in practice (Stage B) by comparing the outcomes achieved with the assessment done in Stage A. Then the physician summarizes any practice, process and/or outcome changes that resulted from their participation in the entire process.

ABC. Simple as can be. But is it? That may depend on how far the physician goes in an attempt to really understand the practices they are engaged in that show a disparity between their current practice and the recommended practice provided in the “identified performance measure”.

What does the physician really know when looking at his or her performance data compared to that of expected performance provided in an identified performance measure? They know one thing. How their performance stacks up against an identified performance measure. That’s it. Nothing more. That is not enough to develop an effective intervention to close the gap between their practice and the practice suggested in the identified performance measure. That requires a much deeper understanding of what is going on in his or her practice that is yielding the observed outcomes.

The temptation at this stage of a PI CME project is to assume we have an answer. We’ll throw some CME at it. Usually that answer is based on well intentioned opinions but not on valid or reliable information. Basing a PI CME intervention on well intentioned opinion(s) about how to “fix” something and not on data that lets you know exactly what is going on in the practice is likely to result in a short term fix but not a sustainable change in the practice setting. So what will surely happen? Things will gradually drift back toward where they were when the initial assessment was done. That is not performance improvement. That is treating symptoms and not causes. That should not be how the CME provider wants PI CME to be conducted in their setting.

Here is a serious question. How many CME professionals currently have the skill set required to facilitate PI CME efforts? My observation is a few but not nearly enough. With the changes in the CME environment making CME and performance improvement synonymous this will have to change. I have some ideas about the skill sets that CME professionals will have to acquire to be effective in PI CME. More on that in a later posting.

For many years physicians have been asked, even required, to participate in formal CME activities and use the credits earned from that participation to retain their medical license, maintain practice privileges, be accepted as part of third party payer panels, and as an attestation to the public that they are staying current in their field. While formal CME has its place among the learning resources physicians should access to help them in their efforts to maintain their competence and improve their performance, there are much more reliable forms of CME to depend on to assure the care a physician s providing is leading to good patient outcomes. These are is Performance Improvement CME (PI CME) and Practice Based Learning.

I recently did a podcast with Norman Kahn, MD, Executive Vice President and Chief Operating officer of the Council of Medical Specialty Societies focused on PI CME. There appears to be a convergence of interest in PI CME that may soon make PI CME the dominant form of learning across a physicians career. You might find this brief conversation with Dr. Kahn very informative. Click here to listen.

If , in the coming years, PI CME emerges as the “New CME” , it will change the CME profession. It will change how physicians approach learning in their own care environments. The importance of consensus on medical evidence supporting clinical decisions will be critical. Physicians will engage in evidence based learning that provides the highest probability to impact the care they provide their patients. And they will have data from their practice to show how well it is working with their patients.

Thoughts?

During the recent meeting of the National Task Force on CME Provider/Industry Collaboration Dr. Norman Kahn, Jr., Executive Vice President and Chief Executive Officer of the Council of Medical Specialty Societies made a compelling presentation on “The Important Role of CME in Impacting Patient Care”. In the presentation Dr. Kahn gave 12 reasons why the field of CME should move to “Performance Improvement CME.”

1. Physicians can actually show improvements in quality measures in their practices.
2. Evidence-based clinical practice guidelines actually move from “dust covered shelves” into real practice.
3. Physicians will be involved in CME activities that actually improve patient care, countering recent criticisms of CME that doesn’t change practice.
4. PI-CME is worth a lot of CME credit per activity, decreasing the burden on physicians to meet required CME credits.
5. PI-CME is expected to qualify for Maintenance of Certification Part IV credit in all specialties.
6. PI-CME is designed to qualify for Maintenance of Licensure, as MOL, is implemented each state soon.
7. PI-CME enables physicians to be eligible for Pay for Performance in many programs currently, and more to come (CMS-PQRI, CO, NC, PA, others). .
8. PI-CME is what practices will report when public reporting is required.
9. CME providers will be a part of, if not leading, change that is coming anyway.
10. PI-CME creates a “Culture of Improvement” in medical practice, where physicians are continually measuring and improving the care they deliver, with documented improved outcomes.
11. PI-CME fulfills the two primary tenets of professionalism: putting patients first (outcomes) and voluntary self regulation (minimizing external regulation).
12. PI-CME may mitigate against threatening government inquiries into CME (Senate Finance and Aging Committees recently.

Perhaps one of the most compelling gains suggested by Dr. Kahn for physician participation in PI-CME was “improved quality of care within one year”. Most PI-CME initiatives will last less than one year during which time physicians will be engaged assessing the care they deliver, measuring against national benchmarks, comparing their performance with peers and documenting improvement over time.

I recently did a podcast with Dr. Kahn where we discussed PI-CME. You might find it interesting. Click here.

The ACCME considers CME as being synonymous with practice-based learning and improvement.

* Activities are linked to practice-based needs (Criterion 2)
* Content of CME matches the scope of the learner’s practice (Criterion 4)
* Measurements of change in competence, performance or patient outcomes will be available (Criterion 11)

The ACCME requires that all CME be directly involved in performance improvement. That doesn’t mean all CME providers have to offer learners education designed to meet the AMA format of PI-CME. But accredited providers are required to show a report of the evaluation data and information about changes in physician learners’ competence, performance and/or patient outcomes.
All accredited CME providers are now required to be squarely in the health care quality improvement business. To be effective we must:

* learn improvement “science”.
* understand the tools used in improvement initiatives.
* find partners to work with that are in the health care quality improvement business.
* create cultures of improvement in our own CME operations.
* Transform our overall CME programs into improvement focused operations.

Will CME lead, follow, or get left behind? If CME is ineffective in this challenge someone will supplant us and do do the job.