Performance Improvement – Enhancing the Educational Grants Process with Quality Measurement Tuesday, May 12 8:30 am – 12...
Identifying the Value of Performance Improvement  for CME William A. Mencia, MD VP, Medical Affairs Med-IQ Disclosure Info...
What is Performance Improvement CME?
What is PI? <ul><li>AMA definition </li></ul><ul><ul><li>“Performance improvement (PI) activities describe structured, lon...
What PI-CME  is Not ? <ul><li>Systems or quality improvement alone </li></ul><ul><ul><li>There must be physician involveme...
Quality CME <ul><li>Needs driven, learner-centric </li></ul><ul><li>Evidence-based curriculum  </li></ul><ul><li>Evidence-...
Why PI? <ul><li>Updated ACCME Criteria call upon providers to  </li></ul><ul><ul><li>Plan content to address identified ga...
History of PI-CME <ul><li>AMA Taskforce on PI and CME – 2001 </li></ul><ul><ul><li>Integrating CME and QI </li></ul></ul><...
What are the Driving Forces  Behind PI-CME? <ul><li>Maintenance of Certification (MOC) and the Medical Licensing Boards </...
Is PI-CME the Future of CME? <ul><li>“ Yes!” </li></ul><ul><ul><li>Norman B. Kahn, Jr., MD </li></ul></ul><ul><ul><li>Exec...
Establishing the Foundation for  PI-CME
PI-CME – Opportunity for  Aligning Common Goals <ul><li>Quality improvement </li></ul><ul><li>Patient safety and systems i...
Meeting ACCME Expectations <ul><li>Level 1 </li></ul><ul><li>Analyzes changes in learners </li></ul><ul><li>Conducts a pro...
ABMS Six Core Competencies <ul><li>Patient Care  – Provide care that is compassionate, appropriate and effective treatment...
ABMS Six Core Competencies – Relevance to PI <ul><li>Systems-based Practice  – Demonstrate awareness of and responsibility...
ABMS Maintenance of Certification <ul><li>Level 1 – Licensure and Professional Standing </li></ul><ul><ul><li>Hold a valid...
Structure of an AMA PI-CME Activity
Performance Improvement Process
What are the Steps for PI-CME? <ul><li>Three-step process </li></ul><ul><ul><li>Stage A </li></ul></ul><ul><ul><ul><li>Ass...
PI-CME Physicians need to be actively involved in the data collection  and analysis Need to see how they compare not just ...
Basic Principles for Improving Patient Care
Stakeholders in Healthcare Delivery <ul><li>Patients </li></ul><ul><ul><li>Expectations and needs from the healthcare syst...
Five Stages of Physician Learning <ul><li>Recognize need for learning </li></ul><ul><ul><li>Am I treating my patients corr...
Five Stages of Physician Learning <ul><li>Engage in learning </li></ul><ul><ul><li>How does this information relate to my ...
Application to Practice <ul><li>PI-CME can develop authentic learning experiences </li></ul><ul><ul><li>Directly related t...
PDSA Cycle Act –  adopt the change Plan  a change aimed at improvement Do  – carry out a change Study  the results of what...
Focus of QI and PI Adapted from Addleton RL. Role of CME Professional in PI-CME. 2008. Standardize the improvement;  re-st...
Performance Measures Performance Measures: Whether or how often a  process  of care or  outcome  of care occurs AMA Perfor...
Types of Performance Measures <ul><li>Process measures – physician’s control </li></ul><ul><li>Ordering lab tests appropri...
Designing a PI-CME Grant Request
Basic Requirements of a PI Grant <ul><li>Addresses real educational needs </li></ul><ul><li>Communicates a clearly identif...
Additional Requirements of a PI Grant <ul><li>Performance measures must be well defined and evidence-based </li></ul><ul><...
Additional Requirements of a PI Grant <ul><li>Identifies the learner “how-to” –   </li></ul><ul><ul><li>Educational interv...
Accreditation Requirements <ul><li>Must meet multiple requirements </li></ul><ul><ul><li>ACCME </li></ul></ul><ul><ul><li>...
Collaboration <ul><li>Defines roles and expectations of the various stakeholders / collaborators in the PI-CME activity </...
New Sources of Need <ul><li>Physician self assessment of </li></ul><ul><ul><li>Knowledge, skills, current practice behavio...
New Approach to Objectives <ul><li>Traditional learning objective </li></ul><ul><ul><li>Identify barriers that prevent pat...
New Levels of Outcomes <ul><li>Performance measures </li></ul><ul><ul><li>Process (physician or system) level </li></ul></...
Barriers to PI-CME
Barriers to PI-CME <ul><li>PI-CME is a fairly new format that is not well known or understood by learners or faculty </li>...
Physician Barriers to PI-CME <ul><li>Time </li></ul><ul><li>Complexity </li></ul><ul><li>Lack of understanding </li></ul><...
Provider Barriers to PI-CME <ul><li>Staff training/understanding of PI requirements </li></ul><ul><li>Infrastructure requi...
Overcoming Provider Barriers  to PI-CME <ul><li>Keep physicians engaged through all three stages </li></ul><ul><ul><li>Cre...
Thank You!
Discussion Questions
What are the differences to PI-CME in the various provider settings?
What are realistic expectations in terms of outcomes for PI-CME? Does it vary by provider type?
What do you consider to be the core components of a PI-CME grant request? Provider perspective? Supporter perspective?
How many providers here have written a PI-CME grant request? How many have been funded?
How many supporters here have funded a PI-CME grant request? Single or multisource?
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  • CBI Grants West 2009 PI_Enhancing Grants

    1. 1. Performance Improvement – Enhancing the Educational Grants Process with Quality Measurement Tuesday, May 12 8:30 am – 12:00 pm San Diego, California
    2. 2. Identifying the Value of Performance Improvement for CME William A. Mencia, MD VP, Medical Affairs Med-IQ Disclosure Information: Dr. Mencia works for Med-IQ, an organization accredited by the ACCME as a provider of certified CME activities. Med-IQ receives commercial funding in support of the development of its CME activities.
    3. 3. What is Performance Improvement CME?
    4. 4. What is PI? <ul><li>AMA definition </li></ul><ul><ul><li>“Performance improvement (PI) activities describe structured, long-term processes by which a physician or group of physicians can learn about specific performance measures, retrospectively assess their practice, apply these measures prospectively over a useful interval, and re-evaluate their performance.” </li></ul></ul>
    5. 5. What PI-CME is Not ? <ul><li>Systems or quality improvement alone </li></ul><ul><ul><li>There must be physician involvement at each stage </li></ul></ul><ul><li>Knowledge improvement </li></ul><ul><ul><li>Specific to the practice, not a measure of simple knowledge change </li></ul></ul><ul><li>Time-based </li></ul><ul><ul><li>Credit awarded based on completion of each stage </li></ul></ul>American Medical Association.
    6. 6. Quality CME <ul><li>Needs driven, learner-centric </li></ul><ul><li>Evidence-based curriculum </li></ul><ul><li>Evidence-based educational methods </li></ul><ul><li>Focus on clinically-relevant objectives </li></ul><ul><li>Goal to enhance: </li></ul><ul><ul><li>Professional competence </li></ul></ul><ul><ul><li>Practice performance </li></ul></ul><ul><ul><li>Patient outcomes </li></ul></ul>AAFP Foundation.
    7. 7. Why PI? <ul><li>Updated ACCME Criteria call upon providers to </li></ul><ul><ul><li>Plan content to address identified gaps in knowledge, performance and patient outcomes </li></ul></ul><ul><ul><li>Measure changes in competence, performance or patient outcomes </li></ul></ul><ul><li>PI-CME places practice behavior under the microscope to make measures of performance the currency of the activity </li></ul><ul><ul><li>Clinical decisions are reviewed in the context of each learner’s own practice </li></ul></ul><ul><ul><li>Creating self-awareness of gaps in performance (compared to guidelines and peers) provides crucial motivation for learners to change </li></ul></ul><ul><li>Performance Measures are derived from published guidelines and evidence-based medicine </li></ul><ul><ul><li>Ensures objectivity and balance for the activity </li></ul></ul><ul><li>American Board of Medical Specialties shifting focus from traditional CME to Maintenance of Certification (MOC) </li></ul><ul><ul><li>Self-assessment activities necessary for MOC </li></ul></ul>
    8. 8. History of PI-CME <ul><li>AMA Taskforce on PI and CME – 2001 </li></ul><ul><ul><li>Integrating CME and QI </li></ul></ul><ul><ul><ul><li>Providing evidence-based medicine </li></ul></ul></ul><ul><ul><ul><li>Measuring baseline performance </li></ul></ul></ul><ul><ul><ul><li>Access to educational interventions </li></ul></ul></ul><ul><ul><ul><li>Reassessing performance </li></ul></ul></ul><ul><ul><li>Changing the paradigm for teaching </li></ul></ul><ul><ul><ul><li>Moving away from linear models (“one-and-done” and knowledge-based education) </li></ul></ul></ul><ul><ul><ul><li>Elimination of time-based credit </li></ul></ul></ul>Davis N. NIQIE. 2008.
    9. 9. What are the Driving Forces Behind PI-CME? <ul><li>Maintenance of Certification (MOC) and the Medical Licensing Boards </li></ul><ul><li>AMA PI CME credit </li></ul><ul><li>ACCME Requirements </li></ul><ul><li>Joint Commission/QI requirements </li></ul><ul><li>Third party payers </li></ul><ul><li>Learners </li></ul>
    10. 10. Is PI-CME the Future of CME? <ul><li>“ Yes!” </li></ul><ul><ul><li>Norman B. Kahn, Jr., MD </li></ul></ul><ul><ul><li>Executive Vice President, Council of Medical Specialty Societies </li></ul></ul>2007 CMSS CME Summit.
    11. 11. Establishing the Foundation for PI-CME
    12. 12. PI-CME – Opportunity for Aligning Common Goals <ul><li>Quality improvement </li></ul><ul><li>Patient safety and systems improvement </li></ul><ul><li>Physician-led initiatives </li></ul><ul><li>Maintenance of certification </li></ul><ul><li>Licensure requirements </li></ul><ul><li>ACCME requirements </li></ul><ul><li>ACGME competencies </li></ul>American Medical Association.
    13. 13. Meeting ACCME Expectations <ul><li>Level 1 </li></ul><ul><li>Analyzes changes in learners </li></ul><ul><li>Conducts a program-based analysis on the degree to which the CME mission of the provider has been met </li></ul>Accreditation Council for Continuing Medical Education. <ul><li>Level 2 </li></ul><ul><li>Identifies, plans and implements the needed or desired changes </li></ul><ul><li>Changes or improvements are underway </li></ul><ul><li>Impacts of program improvements are measured </li></ul><ul><li>Level 3 </li></ul><ul><li>Integrates CME into improving practice (16) </li></ul><ul><li>Utilizes non-education strategies (17) </li></ul><ul><li>Identifies factors that impact on patient outcomes (18) </li></ul><ul><li>Addresses barriers to physician change (19) </li></ul><ul><li>Builds bridges to other stakeholders (20) </li></ul><ul><li>Participates with system for quality improvement (21) </li></ul><ul><li>Influences the scope and content of interventions (22) </li></ul>
    14. 14. ABMS Six Core Competencies <ul><li>Patient Care – Provide care that is compassionate, appropriate and effective treatment for health problems and to promote health. </li></ul><ul><li>Medical Knowledge – Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care. </li></ul><ul><li>Interpersonal and Communication Skills – Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates. </li></ul><ul><li>Professionalism – Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations. </li></ul>
    15. 15. ABMS Six Core Competencies – Relevance to PI <ul><li>Systems-based Practice – Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care. </li></ul><ul><li>Practice-based Learning and Improvement – Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their practice of medicine. </li></ul>
    16. 16. ABMS Maintenance of Certification <ul><li>Level 1 – Licensure and Professional Standing </li></ul><ul><ul><li>Hold a valid, unrestricted medical license </li></ul></ul><ul><ul><li>CME hours </li></ul></ul><ul><li>Level 2 – Lifelong learning and self assessment </li></ul><ul><ul><li>Educational and self-assessment programs </li></ul></ul><ul><li>Level 3 – Cognitive expertise </li></ul><ul><ul><li>Pass a secure test </li></ul></ul><ul><li>Level 4 – Practice performance assessment </li></ul><ul><ul><li>Demonstrate use of best evidence and practice compared to peers and national benchmarks </li></ul></ul>
    17. 17. Structure of an AMA PI-CME Activity
    18. 18. Performance Improvement Process
    19. 19. What are the Steps for PI-CME? <ul><li>Three-step process </li></ul><ul><ul><li>Stage A </li></ul></ul><ul><ul><ul><li>Assessment of each physician’s current practice using identified evidence-based performance measures through internal chart review, other means </li></ul></ul></ul><ul><ul><ul><li>Feedback to physicians compares their performance to national benchmarks and when possible, to the performance of peers. </li></ul></ul></ul><ul><ul><li>Stage B </li></ul></ul><ul><ul><ul><li>Participate in an intervention based on the performance measures assessed in the practice. Create a learner-specific implementation plan based on the initial self assessment AND the education </li></ul></ul></ul><ul><ul><li>Stage C </li></ul></ul><ul><ul><ul><li>Re-evaluate performance in practice including reflection and summarization of outcome changes resulting from the PI CME activity and implementation plan </li></ul></ul></ul><ul><li>Physicians completing all three components may claim a total of </li></ul><ul><li>20 credits as adopted by AMA and AAFP </li></ul>
    20. 20. PI-CME Physicians need to be actively involved in the data collection and analysis Need to see how they compare not just pre/post, but also versus their peers and national standards
    21. 21. Basic Principles for Improving Patient Care
    22. 22. Stakeholders in Healthcare Delivery <ul><li>Patients </li></ul><ul><ul><li>Expectations and needs from the healthcare system </li></ul></ul><ul><ul><li>Active or passive participants in their own care </li></ul></ul><ul><li>Physicians </li></ul><ul><ul><li>Self assessment of current knowledge/practice </li></ul></ul><ul><ul><li>Structured external assessment of current knowledge/practice </li></ul></ul><ul><ul><li>Improvement process (PDSA or similar) </li></ul></ul><ul><li>Systems </li></ul><ul><ul><li>Practice/systems assessment of performance </li></ul></ul><ul><ul><li>Continuous improvement through planned change </li></ul></ul>Adapted from Addleton RL. Role of CME Professional in PI-CME. 2008.
    23. 23. Five Stages of Physician Learning <ul><li>Recognize need for learning </li></ul><ul><ul><li>Am I treating my patients correctly? </li></ul></ul><ul><ul><li>What are the latest standards of care? </li></ul></ul><ul><li>Search for learning resources </li></ul><ul><ul><li>Where can I find the information that I need? </li></ul></ul><ul><ul><li>How to determine what is important? Applicable? </li></ul></ul><ul><ul><li>What is the experience of others in this area? </li></ul></ul>(Moore, Cervero, & Fox, 2007: Moore, 2007).
    24. 24. Five Stages of Physician Learning <ul><li>Engage in learning </li></ul><ul><ul><li>How does this information relate to my practice? Patients? </li></ul></ul><ul><ul><li>What is the evidence base to support this information? </li></ul></ul><ul><li>Try out what was learned </li></ul><ul><ul><li>How to apply information to practice? </li></ul></ul><ul><ul><li>What results am I finding? </li></ul></ul><ul><li>Incorporate what was learned </li></ul><ul><ul><li>How do I make this a permanent part of my practice? </li></ul></ul><ul><ul><li>What systems need to change? </li></ul></ul><ul><ul><li>What training is required for staff? </li></ul></ul>(Moore, Cervero, & Fox, 2007: Moore, 2007).
    25. 25. Application to Practice <ul><li>PI-CME can develop authentic learning experiences </li></ul><ul><ul><li>Directly related to the learner’s practice </li></ul></ul><ul><ul><li>Assist in identifying barriers to practice (process or outcomes) </li></ul></ul><ul><ul><li>Identify solutions </li></ul></ul><ul><ul><li>Apply / assess solution in practice </li></ul></ul>
    26. 26. PDSA Cycle Act – adopt the change Plan a change aimed at improvement Do – carry out a change Study the results of what we learned P Plan D Do A Act S Study
    27. 27. Focus of QI and PI Adapted from Addleton RL. Role of CME Professional in PI-CME. 2008. Standardize the improvement; re-start the cycle Institutionalize improvement, re-start the cycle Act Re-measure to assess improvement Assess the impact of the plan Study Implement the interventions identified to improve performance Implement the plan on a pilot basis Do Identify evidence-based measures relevant to the identified practice problem Identify a problem and develop the plan for improvement Plan Performance Improvement (System and Individual) Quality Improvement (Process & System) PDSA Cycle
    28. 28. Performance Measures Performance Measures: Whether or how often a process of care or outcome of care occurs AMA Performance Measurement Coordinating Council.
    29. 29. Types of Performance Measures <ul><li>Process measures – physician’s control </li></ul><ul><li>Ordering lab tests appropriately (eg, lipid, A1C) </li></ul><ul><li>Performing specific examinations (eg, foot exam) </li></ul><ul><li>Monitoring, follow-up visits, referrals </li></ul><ul><li>Outcomes measures – patient level </li></ul><ul><li>Maintaining patient at goal (eg, A1C < 7%) </li></ul><ul><li>Medication adherence </li></ul><ul><li>Prevention of complications of disease </li></ul>AMA Performance Measurement Coordinating Council.
    30. 30. Designing a PI-CME Grant Request
    31. 31. Basic Requirements of a PI Grant <ul><li>Addresses real educational needs </li></ul><ul><li>Communicates a clearly identified educational goal </li></ul><ul><li>Aligns educational design/format(s) with the educational goal </li></ul><ul><li>Establishes evaluation mechanism to assess impact on physician performance or patient outcomes </li></ul>
    32. 32. Additional Requirements of a PI Grant <ul><li>Performance measures must be well defined and evidence-based </li></ul><ul><ul><li>Can refer to any area of a physician’s practice (system, process, outcome) </li></ul></ul><ul><ul><li>Must have a direct impact on patient care </li></ul></ul><ul><li>Clearly defined oversight mechanism to ensure integrity of the assessment of the selected performance measures </li></ul><ul><li>Identifies the PI “how-to” – defines how the provider will establish the PI process for the learner </li></ul><ul><ul><li>Process for stage A, B, and C </li></ul></ul><ul><ul><li>Timeline </li></ul></ul><ul><ul><li>PI requirements (minimal standardization) </li></ul></ul>
    33. 33. Additional Requirements of a PI Grant <ul><li>Identifies the learner “how-to” – </li></ul><ul><ul><li>Educational intervention </li></ul></ul><ul><ul><ul><li>Evidence-based support of the selection of performance measures </li></ul></ul></ul><ul><ul><ul><li>Enhances learner identification and understanding of the importance of measures </li></ul></ul></ul><ul><ul><ul><li>Live/enduring activities; other means </li></ul></ul></ul><ul><ul><li>Improvement recommendations </li></ul></ul><ul><ul><ul><li>Tools, documentation, resources </li></ul></ul></ul>
    34. 34. Accreditation Requirements <ul><li>Must meet multiple requirements </li></ul><ul><ul><li>ACCME </li></ul></ul><ul><ul><li>AMA PRA Category 1 Credit TM </li></ul></ul><ul><ul><li>AMA PI criteria </li></ul></ul>
    35. 35. Collaboration <ul><li>Defines roles and expectations of the various stakeholders / collaborators in the PI-CME activity </li></ul><ul><ul><li>Design/needs/data perspective </li></ul></ul><ul><ul><ul><li>Specialty society / association </li></ul></ul></ul><ul><ul><ul><li>Healthcare system </li></ul></ul></ul><ul><ul><ul><li>Managed care organization </li></ul></ul></ul><ul><ul><ul><li>Physician groups/practice communities </li></ul></ul></ul><ul><ul><ul><li>Third-party payer(s) </li></ul></ul></ul><ul><ul><li>Other process-based collaborators </li></ul></ul>
    36. 36. New Sources of Need <ul><li>Physician self assessment of </li></ul><ul><ul><li>Knowledge, skills, current practice behavior </li></ul></ul><ul><li>Practice profile </li></ul><ul><ul><li>Chart audits, registries </li></ul></ul><ul><li>Quality improvement data </li></ul><ul><ul><li>Health system </li></ul></ul><ul><ul><li>Payers </li></ul></ul><ul><ul><li>Overall practice performance </li></ul></ul><ul><ul><li>Individual performance </li></ul></ul>Davis N. NIQIE. 2008.
    37. 37. New Approach to Objectives <ul><li>Traditional learning objective </li></ul><ul><ul><li>Identify barriers that prevent patients with diabetes from achieving A1C goals </li></ul></ul><ul><li>Performance objectives </li></ul><ul><ul><li>For patients with A1C levels above 7%, prescribe appropriate lifestyle, non-insulin, or insulin therapy and re-assess A1C every three months </li></ul></ul>
    38. 38. New Levels of Outcomes <ul><li>Performance measures </li></ul><ul><ul><li>Process (physician or system) level </li></ul></ul><ul><ul><li>Outcome (patient) level </li></ul></ul><ul><li>Based on actual patient data versus self-reported change </li></ul><ul><li>Stronger predictor of practice change and impact on patient health </li></ul><ul><li>Insight into development of future CME-based interventions </li></ul>
    39. 39. Barriers to PI-CME
    40. 40. Barriers to PI-CME <ul><li>PI-CME is a fairly new format that is not well known or understood by learners or faculty </li></ul><ul><li>Multistep process requires not only initial recruitment but enduring commitment to keep learners engaged in the process </li></ul>
    41. 41. Physician Barriers to PI-CME <ul><li>Time </li></ul><ul><li>Complexity </li></ul><ul><li>Lack of understanding </li></ul><ul><li>Resources needed </li></ul><ul><li>Self-directed </li></ul><ul><li>Data collection (tedious) </li></ul>
    42. 42. Provider Barriers to PI-CME <ul><li>Staff training/understanding of PI requirements </li></ul><ul><li>Infrastructure requirements to support data collection, analysis, learner experience </li></ul><ul><li>System to validate physician participation at all stages of PI in order to award appropriate credit </li></ul><ul><li>Creating a meaningful PI activity for the physician </li></ul><ul><ul><li>What will make it worthwhile – credit? </li></ul></ul><ul><ul><li>How to make physicians want to participate? </li></ul></ul><ul><ul><li>How to create meaningful practice change? </li></ul></ul><ul><li>Generating funding to support PI initiatives </li></ul>
    43. 43. Overcoming Provider Barriers to PI-CME <ul><li>Keep physicians engaged through all three stages </li></ul><ul><ul><li>Create a meaningful program </li></ul></ul><ul><ul><ul><li>Build interest and understanding among physician community </li></ul></ul></ul><ul><ul><ul><li>Strong clinical content, evidence-based </li></ul></ul></ul><ul><ul><ul><li>Selection of performance measures that are relevant </li></ul></ul></ul><ul><ul><li>Description of PI process – keep it simple </li></ul></ul><ul><ul><ul><li>Create an initial experience that doesn’t “scare them off” </li></ul></ul></ul><ul><ul><li>Employ a “hybrid model” combining traditional CME offerings with option to participate in PI-CME </li></ul></ul><ul><ul><li>Provide continuous support to the learner </li></ul></ul><ul><ul><li>Reminder communications </li></ul></ul>
    44. 44. Thank You!
    45. 45. Discussion Questions
    46. 46. What are the differences to PI-CME in the various provider settings?
    47. 47. What are realistic expectations in terms of outcomes for PI-CME? Does it vary by provider type?
    48. 48. What do you consider to be the core components of a PI-CME grant request? Provider perspective? Supporter perspective?
    49. 49. How many providers here have written a PI-CME grant request? How many have been funded?
    50. 50. How many supporters here have funded a PI-CME grant request? Single or multisource?

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