Employing Adult Education Principles to Tackle Performance Improvement Challenges
Welcome to today’s webinar!Please take a moment to answer the poll question below.Boston University Slideshow Title Goes Here How many people are participating in this webinar at your location today? 1 2 3 4 5 6 7 8 9 10 or moreWelcome to today’s webinar!Please take a moment to answer the poll question below.Boston University Slideshow Title Goes Here What member section do you belong to? Hospital/Health System Medical School Medical Specialty Society State Medical Society Federal Health Care Education/Government Health Care Education Association Pharmaceutical Medical Education and Communication Company OtherEmploying Adult Education Principlesto Tackle Performance Improvement Challenges Lara Zisblatt, M.A. July 12, 2011 2:00 – 3:00 pm ET
PresenterBoston University Slideshow Title Goes Here Lara Zisblatt, M.A. Assistant Director Continuing Medical Education Boston University School of Medicine 7/8/2011DisclosuresBoston University Slideshow Title Goes Here Lara Zisblatt has nothing to disclose with regard to commercial relationships and is not selling a technology, program, product, and/or service. 5 7/8/2011Competency Area 2.1Boston University Slideshow Title Goes Here Use evidence based adult learning principles to guide the practice of CME 6
7/8/2011ObjectivesBoston University Slideshow Title Goes HereFollowing this session, you will be better able to: Describe how adult education principles inform the practice of Performance Improvement (PI) CME Use adult learning principles in the planning of effective PI CME activities Employ adult education principles to confront PI CME challenges 7 7/8/2011Experience in PI CMEBoston University Slideshow Title Goes Here Began planning first PI Initiative in 2004 First initiative was launched in 2006 To date we have planned and implemented 18 activities, some that have lasted for a few years Clinical areas have included: Adolescent Vaccinations Depression Attention Deficit Hyperactivity Disorder Diabetes Asthma Obesity Chronic Obstructive Pulmonary Disease Osteoporosis Coronary Artery Disease Urinary Incontinence 8 7/8/2011Models for PI CMEBoston University Slideshow Title Goes Here 2 National PI CME Initiatives completed, 1 ongoing, 1 in planning phase (COPD, Depression, Type 2 Diabetes, Obesity) Online, distance education 3 completely self-directed, 1 on BUSM-directed schedule 3 small regional PI CME Programs (2 CAD and Overactive Bladder) Connected to an annual meeting 11 local PI CME Programs (Adolescent Vaccination, ADHD, 7 COPD, 2 Obesity and Osteoporosis) Providers complete all stages of the PI CME activity during their regularly scheduled practice meetings or grand rounds 9
Example of Outcomes from a LocalCOPD PI CME Activity 100% 96% 98%Boston University Slideshow Title Goes Here 94%100% 90% 85% 81% 79% 77% 82% 80% 75% 76% 74% 68% 70% 60% 60% 60% 50% 50% 38% 40% 30% 21% 20% 15% 9% 10% 0% Influenza Vaccine Intervention Rehabilitation Initial Spirometry Pharmacology Pneumococal Long-Term Saturation Assessment Spirometry Oxygen Pulmonary Smoking Oxygen Repeat Smoking Vaccine Pre-Intervention Post-Intervention Statistically significant improvement seen in initial spirometry, repeat spirometry, pulmonary rehabilitation, flu vaccination, and smoking assessment 7/8/2011The ChallengeBoston University Slideshow Title Goes Here How do we motivate clinicians to engage in and complete a performance improvement activity? 11 7/8/2011Malcolm Knowles – Father of Adult Ed6 Assumptions about Adult LearnersBoston University Slideshow Title Goes Here 1. Have a Need to KnowHelp the clinician-learner identify the gap between where they are now and where they want to be. 2. Are Self-Directed PI CME is self-directed and allows for clinicians to choose their own interventions and design their own action plans. 12
7/8/20116 Assumptions about Adult LearnersBoston University Slideshow Title Goes Here 3. Bring a Lot of Experience to the Learning Environment Acknowledge this, incorporate it, employ it in the planning of the educational interventions – give them practical tools to use. 4. Are Ready to LearnAdult clinician-learners will be in various stages of readiness to learn and change. PI CME can help them move through this process. 13 7/8/20116 Assumptions about Adult LearnersBoston University Slideshow Title Goes Here 5. Have a Real-life Orientation to Learning Adults learn best when new information is presented in the context of real life – PI CME is embedded in the “real-life” practice setting. 6. Are Motivated to Learn Internal motivators are the most potent. 14PI CME Strong Basis in Learning TheoryBoston University Slideshow Title Goes Here Not just about outcomes data Performance Assessment addresses the issue of clinicians inability to accurately assess their own practice (Davis, 2006) The serial and active nature of PI CME have been shown to be effective in improving performance (Grimshaw, 2001, Davis, 1999) 15
Behavioral Basis for PI CMEBoston University Slideshow Title Goes Here PI CME is based on Edward W. Deming’s industrial and statistically driven model for quality improvement: Plan, Do, Study, Act The idea is to look at the data from patients, examine the system of practice, and make a change to improve care If we had total control of the practice environment, we could implement an intervention that would automatically change behavior 16More to PI CMEBoston University Slideshow Title Goes Here But we don’t have total control of the environment Clinician involvement in improvement is crucial To Err Is Human expressly states that the IOM is “not…pointing fingers at caring health care professionals who make honest mistakes.” (Institute of Medicine, 2001) Many have wondered: where are the clinicians? PI CME is a great way to promote clinician involvement 17Why clinicians participateBoston University Slideshow Title Goes Here “I figured I could learn more” “Great if we could take an organized look at this” “Clinically significant...it seemed like it was an area where we had a lot of room to improve” “We could really...help our patients” “I’ve been always somebody who likes to improve” “Many hours of CME didn’t hurt” “My job is QI and organization of improvement for diabetes care and so I thought it was interesting” 18
7/8/2011How Theory Can HelpBoston University Slideshow Title Goes Here We don’t have the answer to the retention problem for online PI CME programs Local activities where practices complete each stage as a group Physician champions and buy-in from the leadership are key Theories can help identify gaps in your planning Theories can give meaning to your planning choices 19Learning ParadigmsBoston University Slideshow Title Goes Here Behaviorists (Skinner, Pavlov): Stimulus-response. All behavior caused by external stimuli (operant conditioning). All behavior can be explained without the need to consider internal mental states or consciousness. Humanists (Maslow, Rogers): Learning is a personal act to fulfill one’s potential. Social Cognitivists (Bandura): People learn from one another, via observation, imitation, and modeling. 20Behavioral Learning TheoriesBoston University Slideshow Title Goes Here The teacher can help institute interventions that lead participants to respond appropriately Insert changes to the environment to precipitate improvement without additional burden on clinicians Electronic reminders Standing orders Data collection by Medical Assistants Stage A and Stage C act as reinforcement of positive and reminder of negative behaviors Yet - provider involvement and motivation is important Difference between PI and QI Clinicians need to believe in the change to make it happen 21
Humanistic Learning ParadigmsBoston University Slideshow Title Goes Here How can you make the education more personal? We found that those who were used to looking at data found the individual chart review process personalized the process, making it more meaningful But what else could make the experience personal? 22 7/8/2011Example of from the practiceBoston University Slideshow Title Goes HereInterviewer: would you ever want to go to a model just for ease of it to look at it through epic or doyou think keeping this piece of it?Physician: I think keeping the individual chart reviews? I think they are always going to bevaluable. Um you know…as we get further and further into an EMR would we be able to replicateevery single thing…I don’t know, um I don’t know, um but I think looking yourself I think looking, Idon’t know. I just found it to be really helpful. Looking at a patient that I know that I have knownfor 10 years, who has COPD and realizing I don’t know, what, that they really could’ve usedpulmonary rehab and I had never suggested it. And I think that is very valuable. And its differentfrom getting a piece paper spat out saying number who could have used it and numberwho…cause you know, cause you feel like you are letting this particular patient down. That’spowerful.Interviewer: yeah a little bit of the emotional tugPhysician: Well, yeah, because when you are doing chart reviews if you are a primary care docwhose been in practice for any amount of time you are really reviewing individual…you know thesepeople, right, so….I think, I think it has value from that perspective. Even if you could do itcompletely out of the computer. 23Social Cognitive Learning ParadigmsBoston University Slideshow Title Goes Here How can you create an environment for online learning programs where participants can observe and model appropriate behavior? The chart audit form itself can identify appropriate behaviors How else can you encourage interaction so that participants can observe appropriate behavior? How can you give participants the ability to try out behavior? 24
7/8/2011Example of from the practiceBoston University Slideshow Title Goes Here Interviewer: How did that make you feel when you saw that data? Were you just…what was your attitude towards seeing that gap in practice? Nurse: Well, I probably said okay nice, interesting to know how can I incorporate something. I did show that first audit to doctor and I showed him what it said toward the national average and recommendation umm what it says what you should do so um I didn’t feel it as a critique against our work no. Interviewer: mhum mhum Nurse: if we call critique constructive criticism Interviewer: mhum mhum Nurse: What it was geared to be Interviewer: Yep Nurse: Since it was a performance improvement program Interviewer: mhum mhum, yes [laugh] Nurse: [laugh] it was for us to identify was is the gold standard, right? Interviewer: mhum mhum Nurse: and What you should strive for to improve the quality of care for your patients Interviewer: and then so when you showed it to your doctor when did you decide to do that, were you always planning on doing that Nurse: I did it after I printed it off and looked at it and said sean I did this program I told you about that I was going to do and this is the result of my first audit this is what it says and he goes ohh interesting 25Boston University Slideshow Title Goes Here 26Incorporating Humanist Learning TheoryBoston University Slideshow Title Goes Here Motivate through Feeling: Emails with cases and other descriptions to help participants become emotionally involved in the program. Emphasize that the charts represent real patients. Don’t always focus on the final percent. Promote Mindfulness: Open Action Plans can ask probing questions that promote reflection about practice and how to implement change. A coach can call participants to encourage reflection about practice. Encourage Transformational Learning: Learners not threatened by negative feedback. Can use this as a transformational experience. 27
Incorporate Social Cognitive TheoryBoston University Slideshow Title Goes Here Observe others Performance data from peers Modeling through videos demonstrating positive behaviors, like motivational interviewing and best practices Instructors as Mentors Teleconferences and office hours can help encourage one-on-one time with participants and faculty Social Interaction Discussion boards, open teleconferences, meet-ups Encourage clinicians to participate as a group 28Boston University Slideshow Title Goes Here Humanism Approach EnhancedKnox’s Proficiency TheoryBoston University Slideshow Title Goes Here Knowledge Attitude Skill Leads to improved performance
Proficiency Theory - Knox - 1990Boston University Slideshow Title Goes Here Examined CME participation applying adult education principles. Recommendations: Employ testimonials, success stories and human interest stories to encourage participation Portray benefits Recruit an entire practice State discrepancies between current and desired proficiencies 31Knox - 1990Boston University Slideshow Title Goes Here Build in opportunities for positive feedback and success along the way – to build proficiency and sense of self-efficacy Include examples of how others used ideas Build in variety and measures of progress “harness encouraging influences and deflect discouraging influences” Encouraging influences - MOC, PQRS, QI 32“Deflect discouraging influences” (Knox)Boston University Slideshow Title Goes Here Address barriers whenever possible Consider number of chart reviews – process, performance, outcome measures Time commitment Lack of knowledge about PI CME process 33
7/8/2011 Self-Determination Theory – Theory of Motivation Boston University Slideshow Title Goes Here A framework for the study of motivation (Deci and Ryan) Intrinsic and extrinsic motivation How social and cultural factors can help or hurt motivation 34 7/8/2011 Motivation Intrinsic Extrinsic Boston University Slideshow Title Goes HerePositive Desire to help patients Increased Pay Wishes to improve job skills Promotion Love of learning/curiosity Recognition Personal development Performance evaluation Desire to close clinical gap Popularity/fame Licensing/certification requirements Demonstrated competencyNegative Fear of failure Failure to achieve recertification and/or re-licensure Failure to demonstrate competence Poor opinion of performance by peers and/or patients 35 7/8/2011 Motivation – How PI Can Respond Intrinsic Extrinsic Boston University Slideshow Title Goes Here Positive Providing better care – gaps in care Pay-for-Performance become personalized and motivating (payers, CMS) Clinical relevance to patient Board MOC approval population State licensure Provide feedback through chart Joint Commission – summary OPPE Compare to peers Supervisor Compare to national benchmarks /organizational Provide opportunities for reflection requirement Possible career advancement 36
7/8/2011 SummaryBoston University Slideshow Title Goes Here Using theories and frameworks can help you make decisions on what auxiliary components you can add to your PI CME activities Use theories and frameworks to make your case to funders, collaborators, and participants 37ReferencesBoston University Slideshow Title Goes Here Aparicio, A., & Willis, C. E. (2005). The continued evolution of the credit system. Journal of Continuing Education in the Health Professions, 25(3), 190-196. Brennan TA. Physicians professional responsibility to improve the quality of care. Academic Medicine. 77 : 973 2002. Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence - A systematic review. Jama-Journal of the American Medical Association, 296(9), 1094-1102. Deming EW. The New Economics for Industry, Government, Education. Cambridge, MA: MIT Center for Advanced Engineering Study, 1982. Duffy, F. D., Lynn, L. A., Didura, H., Hess, B., Caverzagie, K., Grosso, L., et al. (2008). Self- assessment of practice performance: Development of the ABIM practice improvement module (PIMSM). Journal of Continuing Education in the Health Professions, 28(1), 38-46. Epstein et al. “Self-Monitoring in Clinical Practice: A Challenge for Medical Educators.” The Journal of Continuing Medical Education in the Health Professions. 28.1 (2008): 5-13. Goulet F, Gagnon RJ, Desrosiers G, Jacques A, Sindon A. Participation in CME activities. Canadian Family Physician. 1998;44:541-8. Grimshaw JM, Shirran L, Thomas R, et al. (2001) Changing provider behavior: an overview of systematic reviews of interventions. Med Care 39:II2–II45. 38ReferencesBoston University Slideshow Title Goes Here Holmboe, E. S., Meehan, T. P., Lynn, L., Doyle, P., Sherwin, T. & Duffy, F. (2006). Promoting Physicians Self Assessment and Quality Improvement: The ABIM Diabetes Practice Improvement Module. The Journal of Continuing Education in the Health Professions, 26(2), 109-119. Knox, A. “Influences on Participation of Continuing Education.” Journal of Continuing Education in the Health Professions, 10(1990) 261-274. McHugh, E. “Awareness of Performance Improvement Activities.” Medical Meetings Magazine. 37.1 (2007) Cover. Ryan, R. M., and E. L. Deci. "Intrinsic and Extrinsic Motivations: Classic Definitions and New Directions." Contemporary Educational Psychology 25.1 (2000): 54-67. Print. Simpkins, J; Divine, G; Wang, MQ; et al. “Improving asthma care through recertification - A cluster randomized trial.” Archives of Internal Medicine. 167:20 (2007): 2240-2248. Shershneva, M. B., Mullikin, E. A., Loose, A. S., & Olson, C. A. (2008). Learning to collaborate: A case study of Performance Improvement CME. Journal of Continuing Education in the Health Professions, 28(3), 140-147. Staker, LV. (2003). Teaching Performance Improvement: An Opportunity for Continuing Medical Education. Journal of Continuing Education in the Health Professions, 23(1) S34- S52.
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