CME, QI, & Transfer of Practice

1. 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

2. 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

3. Problem #2: Overall, only about half of recommended care is delivered McGlynn et al, 2003 David Price, MD SACME March 2007

4. Problem #3 • Despite years of trying, traditional CME doesn’t fix this David Price, MD SACME March 2007

5. 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

6. 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

7. 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

8. External factors affecting CME David Price, MD SACME March 2007

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Models • PDSA • Rogers’ Diffusion of Innovation • The tipping point/Complexity Theory • PRECED/PROCEED David Price, MD SACME March 2007

17. CME Process vs. QI Cycle David Price, MD SACME March 2007

18. 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

19. 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

20. Using Rogers’ model • See article with list of questions David Price, MD SACME March 2007

21. Who Adopts Innovation? From Rogers David Price, MD SACME March 2007

22. How innovation spreads David Price, MD SACME March 2007

23. 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

24. 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

25. 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

26. PRECEDE/PROCEED • Personal factors (PRECEDE) • Environmental factors (PROCEED) • Precede/Proceed model, Green and Kreuter David Price, MD SACME March 2007

27. PRECEDE • Predisposing factors • knowledge • attitudes • skills • beliefs David Price, MD SACME March 2007

28. PRECEDE • Reinforcing factors • discuss data • recognize incentives and disincentives David Price, MD SACME March 2007

29. PRECEDE • Enabling factors: tools • “just in time” information recall • scripts • handouts • patient education • patient self-care David Price, MD SACME March 2007

30. PROCEED • Policy implications • Regulations • Organizational initiatives/other factors David Price, MD SACME March 2007

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Which Model to Use? David Price, MD SACME March 2007

40. 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

41. “Knowing is not enough…” “Knowing is not enough; we must apply Willing is not enough; we must do.” David Price, MD SACME March 2007

42. 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