Performance Improvement CME

Are You Systematically Engaged in Performance Improvement in Your Continuing Medical Education Operation?

My brother has worked industry for over 30 years. Many of those years he has been directly engaged in improvement initiatives. Now, in his own business, he works with many types of enterprises, including healthcare, helping them identify and engage in ways to improve their operations. He also teaches these skills to students in a business college in the Midwest.

In training situations he is fond of asking those in attendance, “How many of you had a perfect day at work yesterday? A day in which everything went perfectly where there were absolutely no problems, no issues, zero hassles”. You know, not one person has ever raised their hand saying that was my day. Then he asks this, “How many of you went to work yesterday with the intention of doing a bad job?” Again, no one raises their hand. Then he asks, “How many of you are engaged in a conscious effort to improve or start improving something that went wrong at work yesterday?” Again there are no hands raised. What does this say about how we approach our work? Everyday we can count on something going wrong. We do not go to work everyday intentionally to do a bad job. Yet, everyday we do nothing systematically to improve our work world.

Our customers, those we serve in CME, are required to engage in improvement efforts to earn CME credit. They have to be engaged in efforts to improve their capability to practice (competence), their actual performance, or the health status of the patients they care for. As an ACCME accredited provider we have to measure those improvements.

Most CME providers I talk to are not engaged in a systematic, sustainable, repeatable effort to improve their own CME operation. What better place to learn how to develop improvement skills in our customers than to engage in improvement efforts in our own CME operation?

Here is an invitation. My brother (the one I mentioned earlier) is going to work with me on this. We are looking for five people interested in learning, and then participating in a four month pilot test of a systematic sustainable, repeatable approach to improving their CME operation. It is also an approach you can teach physicians to use in PI CME or any improvement initiative in their practice setting. We will learn this approach by participating in a series of four one hour discussions on Go To Meeting. No charge to you. After the orientation, we will use a page created Facebook to communicate our progress, ask questions, share experiences, and, ultimately share our outcomes. If you would like to participate in the pilot project contact me at ctlassoc@mindspring.com.

I firmly believe that if we adopt this approach to improvement we can transform a CME operation, we can provide physicians an effective approach to improvement efforts in their practice, and we can generate data demonstrating that our CME program is a strategic asset in our organization.

The American Medical Association has approved a framework physicians can use to engage in performance improvement and earn CME credit. The framework is useful but guidance for how to engage in effective performance improvement initiatives that will result in sustainable change is missing in the framework. In fact, the simplicity of the model may be a disservice to the physician wanted to engage in effective performance improvement efforts. But there is a solution. The solution is to adopt a nationally accepted standard for the implementation of PI CME initiatives. I think is a good idea.

There is a good argument to be made for encouraging the medical profession to adopt a standard approach to performance improvement and PI CME. With all physicians engaging in a standard approach to PI CME a coherent, common transferable set of skills is established that facilitates effective problem solving, encourages effective communication within and across practices and institutions, and fosters the transfer of innovations shown to improve the delivery of patient care.

A standardized system of performance improvement would contain the following elements:
• A logical thinking process
• Objectivity
• Value for results as well as process
• The synthesis of ideas, distillation of issues, and visualization of processes
• Alignment with organizational and professional development goals
• A coherent approach to problem solving that could be applied consistently across all problem solving tasks
• A systems viewpoint
Most approaches to performance improvement encourage an approach where results are achieved through a process and utilization of tools that:
• Considers context
• Engages all the effected parties in an improvement effort
• Describes actual performance
• Defines desired performance
• Assesses the gap between current and desired performance
• Finds root causes
• Selects effective countermeasures
• Implements countermeasures
• Monitors and evaluates performance
• Standardize improvements

If you are familiar with the core of many improvement systems you know this process is rooted in the classic Plan, Do, Study, Act approach to improvement. This is a scientific approach to problem solving that healthcare providers are expertly trained to carry out.
 
Physicians can approach a PI CME activity the same way they approach treating patients. They use the same skills used in a basic clinical decision making process with their patients. The difference is that they are looking at the practice and not at an individual patient. In a PI initiative they will take a history and physical assessment of a part of their practice related to an issue of concern to determine the current situation; they will gather additional information to establish the root cause of the problem to get at the most likely the cause for not meeting desired performance standards; they will make a diagnosis based on these data; they will prescribe a way to resolve the problem; and then check for the effect of the treatment.

This process is almost a direct parallel to the steps taken in a performance improvement initiative. What is called for is a simple, logical approach to PI CME that every physician in the country can use to engage in performance improvement with the healthcare team. Such an approach exists. It is the standard approach used by Toyota manufacturing that every employee is trained to use. It is called “A3 Problem Thinking”. A3 thinking is a powerful approach to problem solving that creates a structure to implement the PDCA cycle. It requires those involved to engage in efforts to develop a deep understanding of a problem or opportunity, leading to insights on how to address the area of concern. It is an objective, data based, collaborative approach to improvement that can be taught to every healthcare professional on the care team. It will lead to a culture of improvement that is required to foster continuous quality improvement.

The A3 approach to problem solving can easily become the national standard guiding performance improvement CME.

I think CME providers adopting this approach to PI CME on a national basis will produce a CME provider with practical skills valued by the healthcare system, add value to our organizations and our physician constituents, and position the CME provider as a major player in the bridge to quality in healthcare.

I have started a training program for CME providers designed to introduce A3 thinking and its application to PI CME. Those of you interested in learning more about this can contact me by e-mail at ctlassoc@mindspring.com or post a response to this blog.

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.

The AMA guidelines on Performance Improvement CME require that physicians assess their current practice using identified evidence based performance measures. A good start. After the assessment they know where they stand on the measures compared to their peers and national standards. Then they are encouraged to do an intervention based on the performance measures assessed in their practice. But what? How will they know what practice behaviors to change that will reduce the variation in the performance in their practice compared to national standards? What performance behaviors have kept them from meeting the expectations of the standard? Knowing this gets to the heart of PI CME.

Should we encourage the physician participating in a PI CME initiative to engage in a dialogue in the practice setting around what is the right thing to do to meet expectations? Seems to me that might require gaining a deep understanding of what is actually going on in the practice. That understanding will help the physician comprehend the real nature of why the performance in their practice is not meeting expectations. They can analyze alternative causes and develop an understanding on how to “work” the practice to select reasonable countermeasures to improve the situation. Permanent change is not likely to come from a physician authority based management model. Permanent change will come from a “responsibility based” management model in which every person involved in any aspect of the care being examined understands how their effort effects the current outcomes and how any proposed countermeasures will impact the desired outcomes.

Simply taking recommendations from guidelines and trying to apply them in practice, as important as that is, without a fact based understanding how the context in which the care is being provided impacts the care, may not result in lasting performance change. As CME providers are we ready to take this one on? We have a great opportunity to facilitate a “Culture of Change” in practices engaged in PI CME, We need to help physicians understand how to look at performance, how to understand why they are getting outcomes less then what they want, and how to “work” the practice to the place where desired outcomes are the new standard in that setting.

Do we have the skill set to do that or do we need to develop that skill set? Not a rhetorical question.

If you have been following this blog for a while you know I have a particular interest in “Performance Improvement CME”. Recently I have done several podcasts with CME professionals engaged in providing PI CME to their constituents. One striking outcome is being reported almost universally in these efforts. When physicians or groups of physicians engage in an effective PI CME initiative they not only make significant changes in their performance , they report they are learning a systematic approach to improvement they can replicate in other improvement efforts.

Not one of the CME providers I talked with indicated this was an outcome they intended. But to me this is an outcome as valuable as the intended performance changes in patient care. CME providers are teaching skills that are transferable to many different improvement interests. Perhaps we should consider physicians gaining this skill as an intended outcome of our PI CME efforts. It does mean we have to be very deliberate in teaching “improvement science” which may require some professional development of our own.

What do you think?

Listen to this conversation with Beth Mullikin, MS, Outreach Program Manager for the Office of Continuing Professional Development in the University of Wisconsin School of Medicine. If you are interested in PI CME I think you will find it very informative. Beth has a number of resources used to monitor PI CME initiatives and she is willing to share them. You can contact her at eamullikin@wisc.edu.

Each year the Alliance for Continuing Medical Education recognizes outstanding work in our field. This year the award for a “Great Idea” selected by the Medical School Member Section went to the Jefferson Medical College. The program was titled “Accelerating Best Care in Pennsylvania”. Under the direction of Jeanne Cole, MS, Director of CME at the Jefferson Medial College and Alexis Skoufalos, EdD, Assistant Dean for Continuing Professional Education in the Jefferson School of Population Health and in collaboration with Baylor this project was effective in changing some significant practices in two Pennsylvania Community Hospitals.
I recorded a conversation with Jeanne and Alexis about the project. For those of you interested in finding ways to effectively link CME and improvement efforts you’ll want to hear about this project. Go to my podcast.

You can also find more information about the project by linking to a presentation made at the 2009 meeting of the Alliance for Continuing Medical Education. Click here.

There are several articles in the July 2008 issue of the American Journal of Medical Quality regarding the project.

Project Overview Article
Accelerating Best Care in Pennsylvania: Adapting a Large Academic System’s Quality Improvement Process to Rural Community Hospitals Ziad Haydar, Julie Gunderson, David J. Ballard, Alexis Skoufalos, Bettina Berman and David B. Nash American Journal of Medical Quality 2008; 23; 252. Available online at http://ajm.sagepub.com/cgi/content/abstract/23/4/252

Hazleton Article
Accelerating Best Care in Pennsylvania: The Hazleton General Hospital Experience Andrea Andrews and Anthony Valente American Journal of Medical Quality 2008; 23; 259. Available online at http://ajm.sagepub.com/cgi/content/abstract/23/4/259

Meadville Article
Meadville Medical Center’s Experience With the Accelerating Best Care in Pennsylvania Project: Lessons Learned and Future Directions Sarah J. Dickey and David E. McNamara American Journal of Medical Quality 2008; 23; 266. Available online at http://ajm.sagepub.com/cgi/content/abstract/23/4/266

Let me know what you think.

For years CME professionals have been told that principles of adult learning should be followed in providing CME activities to physicians. We have been encouraged to use instructional strategies that will facilitate or support the physician as learner. Well, PI CME is nearly a perfect fit with what we have been urged to do.

The basic principles of Andragogy are:

1. Adults need to be involved in the planning and evaluation of their instruction
2. Experience (including mistakes) provides the basis for learning activities.
3. Adults are most interested in learning subjects that have immediate relevance to their job or personal life.
4. Adult learning is problem-centered rather than content-oriented.

In practical terms, andragogy means that instruction for adults needs to focus as much on the how to present information as the content being taught. Strategies such as case studies, role playing, simulations, and self-evaluation are most useful. Faculty is prompted to adopt a role of facilitator or resource rather than only lecturer or grader.

Enter PI CME.

To participate and claim credit for PI CME:

1. Physicians are required to “be involved in the planning and evaluation of their instruction.”
2. The physicians practice (experience) is the basis for PI CME initiatives.
3. Physicians choose improvement initiatives that “have immediate relevance to their job”.
4. PI PI CME activities are “problem-centered rather than content-oriented.”

Could there possibly be a better format for the continuing education of physicians? In PI CME learning is focused on how care is provided. PI CME has the potential to change the way medicine is practiced in specific settings. Patient care will improve in settings engaged PI CME. CME providers offering PI CME focus on strategies that facilitate learning in real care settings. They are resources not “lecturers”. Doesn’t get any better than this.

Want to heed the call of the CME “gurus” to do effective CME? Do PI CME. Bring to life the principles of Andragogy.

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.