Performance Improvement CME

A thought.

There is a need for serious conversation about what we mean by PI CME and what is required of PI CME to have any lasting impact in improving the delivery of healthcare. It is no longer enough simply to consider how physicians learn – an emphasis promulgated by the adult educators (and I am one) far too long. While an understanding of how physicians learn is important, it is not enough. The end product of learning – knowing- is not enough. Physicians know how to do far more than they actually do in providing care.

The more important question is where physicians learn. Physician learning takes place at three levels. First, it occurs in the physician-patient interaction where care is being provided. Second, it occurs in the organizational systems and work processes that comprises practice settings. And third, it occurs in the socio-political-economic systems that frame healthcare delivery. These are each sub-systems of our larger, very complex healthcare system. Change occurring in one subsystem requires change in other subsystems. That is how systems work.

If structured in a way that acknowledges learning occurs in these subsystems PI CME can have a major role in effecting change in physician competence and performance in complex health systems. I believe this. I also believe that CME professionals need to understand improvement theory and the tools used to effect improvement in complex health systems. PI CME offers the CME professional a way to add tremendous value to their organization. We need to step up and take advantage of this opportunity.

Let me start by revealing a personal bias – KNOWING IS NOT ENOUGH. Physicians know a lot of things they could be doing to care for their patients but those things don’t get done. We know a lot of things that can make CME more effective but we don’t do them.

Think about it. PI CME activities are basically projects. Projects are specific and targeted in application. The approach or method you select depends on the problem or issue being addressed. The focus of the AMA approach to PI CME is on learning projects. You know, Stage A -measure your practice, Stage B – learn from your practice, and Stage C – re-measure your practice. Get it done. Get 20 credits and its over. Not a bad thing. The question I ask is whether this is enough to effect permanent change in patient care.

There is a second important part of thinking about improvement. It is a more comprehensive process or system-focus dealing with how an organization gets things done. Results of improvement efforts in these organizations are directly influenced by the organization’s culture. Without changes in HOW care is provided – translated HOW the healthcare team does its’ work – permanent changes in patient care are not likely to happen. Improvement initiatives in organizations with a process and systems focus throughout the organization make improvement a part of the fiber of the organization.

In a system and process focused organization it is expected that every person from the top down and the bottom up be concerned about meeting their organizations core mission. What if that core mission of a practice was “Providing Every Patient the Right Care at the Right Time Every Time the Patient is Seen”. Or “Perfect Patient Care”.

In the United States, we tend to jump to solutions. We are project focused people. We don’t often confront culture directly, either because we think it is too big a mountain to climb, or we believe there is no need. Projects present a shorter, more manageable path to short term progress. See a problem – solve a problem without regard to how that solution may affect the parts of an organization. In fact, these solutions may create more problems down stream in the organization irritating more people and perhaps driving up costs to the organization as a whole.

So here is my bottom line for this diatribe. Doing PI CME initiatives outside of a “Culture of Improvement” is most likely to yield short term non-sustainable improvements. The challenge to the CME provider? How can we begin to effect a culture change in our healthcare system? How do we help move PI CME from being solely project focused efforts to include efforts that develop physicians who can integrate systems thinking into their practice settings?

For permanent change to occur in the practice of medicine there must be a change how the work of patient care is done. Performance improvement and systems based thinking are two sides of the same coin. KNOWING IS NOT ENOUGH.