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 ACCME requires that all CME be directly involved in improvement. Accredited CME providers are required to measure change (improvement) in physician competence, performance or patient outcomes. 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. What does this mean? It means CME providers are  expected to be integrally involved in health care quality improvement. I think the best way to learn how to be effective in this improvement environment is to adopt a “culture of improvement” in our own CME operations.   We should:

• adopt a systematic, sustainable, repeatable approach to  improvement;
• use the tools employed in  improvement initiatives to improve our own CME operations;
• expect that every person in our own CME operation is engaged in targeted improvement efforts;
• transform our overall CME programs into improvement focused operations.

We must learn these skills.  We must integrate a systematic, sustainable, repeatable approach to improvement in our CME operation. As a result of our own improvement efforts the CME operation will be well positioned to  become an effective strategic asset in many efforts designed to improve  health care delivery.

If you are interested in learning a approach you can use to acquire or hone your improvement skills contact me at ctlassoc@mindspring.com.

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.