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CME, QI, & Transfer of Practice. David Price, MD Director of Education, Colorado Permanente Medical Group Clinical Lead, Education, KP Care Management Institute Associate Professor, Family Medicine, UCHSC Chair-elect, American Board of Family Medicine SACME March 2007. Problem #1

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slide1

CME, QI, & Transfer of

Practice

David Price, MD

Director of Education, Colorado Permanente Medical Group Clinical Lead, Education, KP Care Management Institute Associate Professor, Family Medicine, UCHSC Chair-elect, American Board of Family Medicine

SACME March 2007

David Price, MD

SACME March 2007

slide2

Problem #1

  • US expenditures on health care lead the world
  • The quality of US healthcare is “mediocre” (#37 in overall quality) (IOM)

David Price, MD

SACME March 2007

slide3
Problem #2: Overall, only about half of recommended care is delivered

McGlynn et al, 2003

David Price, MD

SACME March 2007

slide4
Problem #3
  • Despite years of trying, traditional CME doesn’t fix this

David Price, MD

SACME March 2007

slide5
Why Might Physicians Engage in CME?
  • Some don’t!
  • Requirement (board, credentials, license)
  • Food
  • Stipends (for employed physicians)
  • Networking
  • Intellectual stimulation

David Price, MD

SACME March 2007

slide6
Why Might Physicians Engage in CME?
  • Keep up/verify current practice
  • Desire to learn new things
  • Desire to solve current problems (reflective learning)
  • Desire to improve

David Price, MD

SACME March 2007

slide7
Why Might Organizations Support CME?
  • Disseminate new information
  • Support new initiatives (organizational initiatives, new services/products)
  • Address public/regulatory concerns
  • Enhance public image
  • Improve quality

David Price, MD

SACME March 2007

slide8

External factors affecting CME

David Price, MD

SACME March 2007

slide9
CME in context
  • Physicians practice as part of a system (even in solo practice)
  • Systems are composed of multiple interconnected parts with some autonomy

David Price, MD

SACME March 2007

slide10

Variables in adoption of evidence

(conceptual framework)

  • Evidence
  • Manner of facilitation
  • Context (including the system in which one practices)

Kiston A. Harvey G, McCormack B. Enabling the

Implementation of evidence-based practice: A conceptual

Framework. Qual Health Care 1998;7:149-58

David Price, MD

SACME March 2007

slide11
Background
  • Perspectives vary in different system parts
    • Resources
    • Context of Care
    • Barriers and incentives
    • Accountability
  • Interventions that address only the physician (as 1 point in a system) unlikely to lead to sustained practice change

David Price, MD

SACME March 2007

slide12

Premise

  • CME as part of a system or organization can:
  • Help identify new perspectives
  • Help “educate” multiple stakeholders
  • Assist the organization in a multifaceted approach toward improvement.
    • Help identify “leverage” points (Senge) for organizational improvement

David Price, MD

SACME March 2007

slide13

Objectives

  • Describe key principals from 3-4 different models of QI, organizational change & diffusion of successful practices
  • Relate these key principals to the processes used in developing, implementing & evaluating CME Programs.

David Price, MD

SACME March 2007

slide14

Reflection questions

  • What major initiatives are going on in your organization (or the organizations of your customers) right now?
  • What major CME programs are on your plate right now?
  • Do they match?

David Price, MD

SACME March 2007

slide15

Who are Your Sponsors?

  • Have you explicitly talked with your sponsor(s) about how they see CME helping them achieve the goals of the(ir) organization?
  • Have you ever explicitly talked with your sponsor(s) about how CME can help them with specific initiatives?

David Price, MD

SACME March 2007

slide16

Models

  • PDSA
  • Rogers’ Diffusion of Innovation
  • The tipping point/Complexity Theory
  • PRECED/PROCEED

David Price, MD

SACME March 2007

slide17

CME Process vs. QI Cycle

David Price, MD

SACME March 2007

slide18

Using the PDSA Model

  • What Stage is a QI initiative in?
  • How can your needs assessment help plan the QI initiative?
  • What CME format(s) integrate with the “do” phase?
  • How can CME evaluations support the “study” phase?
  • What f/u CME activities can support the “act” phase?

David Price, MD

SACME March 2007

slide19

Characteristics of Innovations that spread

  • Trialability (adaptability)
  • Advantage (relative to current system)
    • Plsek add Evidence-based
  • Compatability
  • Observability
  • From E. Rogers
  • Sponsorship (from Price)

David Price, MD

SACME March 2007

slide20

Using Rogers’ model

  • See article with list of questions

David Price, MD

SACME March 2007

slide21

Who Adopts Innovation?

From Rogers

David Price, MD

SACME March 2007

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How innovation spreads

David Price, MD

SACME March 2007

slide23

Complexity Theory (PIsek)

  • Organizations are complex adaptive systems (complex web of relationships)
  • Individuals often have choices whether to change
  • Universal agreement on need to change is rare
  • Agreement often lacking about effects of proposed change

David Price, MD

SACME March 2007

slide24

Complexity Theory (PIsek)

  • Most change happens in “zone of uncertainty”
    • About need for change
    • About results of change
  • Change happens over time, at different speeds in different parts of the organization, with lots of experimenting
  • Small local changes may have ripple effects
    • “butterfly effect”, “stone in the pond”

David Price, MD

SACME March 2007

slide25

Using the Tipping Point and Complexity Theory

  • Where/who are the early adopters?
  • WIIFT (why might they want change?)
    • Creative desire
    • Dissatisfaction w/status quo?
  • What CME format will best reach this audience?
  • Who should the faculty be?
  • How can early adopters serve as facilitators in future CME (train the trainer)?

David Price, MD

SACME March 2007

slide26

PRECEDE/PROCEED

  • Personal factors (PRECEDE)
  • Environmental factors (PROCEED)
  • Precede/Proceed model, Green and Kreuter

David Price, MD

SACME March 2007

slide27

PRECEDE

  • Predisposing factors
    • knowledge
    • attitudes
    • skills
    • beliefs

David Price, MD

SACME March 2007

slide28

PRECEDE

  • Reinforcing factors
    • discuss data
    • recognize incentives and disincentives

David Price, MD

SACME March 2007

slide29

PRECEDE

  • Enabling factors: tools
    • “just in time” information recall
    • scripts
    • handouts
    • patient education
    • patient self-care

David Price, MD

SACME March 2007

slide30

PROCEED

  • Policy implications
  • Regulations
  • Organizational initiatives/other factors

David Price, MD

SACME March 2007

slide31

Using PRECEDE

  • How will your CME program address attendee knowledge, attitude, skills, & beliefs?
  • What reinforcing factors will be used after the CME program?
  • What enabling factors can be provided at the CME program?

David Price, MD

SACME March 2007

slide32

Using PROCEED

  • How can policy implications of proposed changes (in regulations) be addressed in your CME program?
    • Allow attendees to discuss/brainstorm with each other, share ideas and learnings
  • How can discussions at CME programs provide feedback to those setting policy, regulations, or directing organizational initiatives?

David Price, MD

SACME March 2007

slide33

Effectiveness in changing practice (Cochrane, 2002)

  • Minimal
    • Didactic lecture, mailed unsolicited materials
  • Moderate
    • Audit & feedback delivered by opinion leaders or peers
  • Relatively strong
    • Reminders, academic detailing, multiple interventions

David Price, MD

SACME March 2007

slide34

Additional Factor in Successful Spread (Kaiser Permanente Care Experience Council)

  • Challenge/compelling problem
  • Source champion (innovator) willing to help in source transfer
  • Lead implementer has high level of trust in source champion
  • Strong physician champion
  • Steering committee with multiple stakeholders

David Price, MD

SACME March 2007

slide35

Additional Factor in Successful Spread (Kaiser Permanente Care Experience Council)

  • Project manager for practice transfer
  • PDSA/phase-in
  • Physicians/staff dissatisfied with status quo
  • Performance/financial gap
  • Trusted opinion leaders
  • Evidence it worked elsewhere

David Price, MD

SACME March 2007

slide36

Additional Factor in Successful Spread (Kaiser Permanente Care Experience Council)

  • Strong support senior management
  • Effective clinical leadership
  • Credible/persuasive data to support start up
  • Coordination across departments
  • Planned sustainability from the outset
  • “WIIFM” – perceived ability to reduce external threats

David Price, MD

SACME March 2007

slide37

Additional Factor in Successful Spread Sheldon TA et al. BMJ 30 Oct 2004

  • Effective use of communication channels (including personal)
  • Interconnectedness of the network
  • Extent of promotion efforts by agents of change
  • Commitment to/systems for managing process of change

David Price, MD

SACME March 2007

slide38

Additional Factor in Successful Spread Sheldon TA et al. BMJ 30 Oct 2004

  • Proactive assessment of local costs & implications of implementation
  • Culture of consensus
  • Clinician involvement in process

David Price, MD

SACME March 2007

slide39

Which Model to Use?

David Price, MD

SACME March 2007

slide40

CME as a means of translating evidence into practice

  • Attitudes and beliefs
  • Knowledge: components of good care
  • Skills to make changes that result in improvement
  • Systems: processes to facilitate change/overcome barriers

David Price, MD

SACME March 2007

slide41

“Knowing is not enough…”

“Knowing is not enough; we must apply Willing is not enough; we must do.”

David Price, MD

SACME March 2007

slide42

Price D. Continuing Medical Education, Quality Improvement, and Organizational Change: Implications of Recent Theories for 21st Century CME. Medical Teacher 2005;27(3):259-68

David Price, MD

SACME March 2007