CBI Grants West 2009 PI_Enhancing Grants

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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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