A Warmer Welcome to Quality Improvement

Without meaning to or wanting to, most of us involved in the work of helping healthcare professionals learn about quality improvement (systematic improvement) have been making it more difficult than it needs to be for those new to our field.

It is possible to provide a much more welcoming introduction to Quality Improvement. It is all the more important that we do so now that QI is required by medical specialty boards, by the ACGME of residency and fellows programs, and by the Joint Commission.

What can we do?

- We can demystify improvement science as rapidly as possible. We can invite those new to QI to go through a rapid, self-assessment inventory that lays out in straightforward, down to earth language what we are talking about.

- We can encourage those who go through this sort of self-assessment to identify first what they already know about QI and what they already are able to do (what they bring to the party). We should explain that much of what they already do in their clinical work and in the way of clinical reasoning just needs to be applied here, in QI work, to the processes, procedures and systems in their particular practice settings. The only difference is that here you "think of the practice as your patient" (Ogrinc and Headrick).

- We can also encourage those new to improvement work to identify those aspects of QI with which they would appreciate some help. We should make it clear that they don't have to know it all in order to embark on meaningful and productive improvement efforts.

- And, of course, we can help them to identify other things they would like to learn more about. 

When the individuals and teams we are coaching begin to work on various phases of improvement initiatives, they and those of us supporting them should be in a much better position to consider what sorts of resources, resource people, experiences and/or structured activities might prove especially useful for them. Our role should be to help clinicians identify and build on their existing strengths while at the same time encouraging them to seek out the help they need and to learn more about those things they want to know more about or to be able to do next.

UNLEASHING INITIATIVE - An Overview

I have supported the learning and improvement efforts of people in many different settings and with many different levels of education. Surprisingly, there are a number of things that seem to be important for everybody, despite such differences. This is particularly important when it comes to encouraging and fostering the development of initiative.

1. First of all, most people are innately curious. The trouble is most schools have a way of dulling and discouraging that curiosity and with it the native propensity to take initiative that is present in all of us. By the third grade most learners have been conditioned into passivity. They have learned what it means to be considered "a good learner" in our society. A "good learner" knows what the teacher wants him or her to learn, is willing to do it on schedule (when the teacher wants him or her to learn those things), and how the teacher wants him or her to learn. And a good learner demonstrates what has been learned in ways that are most comfortable for the teacher, not the ways most natural and appropriate for the learner.

2. If we want to unleash a good deal of the repressed curiosity and initiative that is there in every learner and worker, we need to find ways to reverse this process, that is, ways to de-condition people, ways to help them re-discover their curiosities and passions. We need to help the people we work with identify their skills, their values, their preferences, their passions and their sense of direction and purpose. This is how we can best help them go where they want to go rather than where we want them to go. This is how we can best help people tap their own deepest motivations.

3. An important part of helping people discover or better articulate their personal sense of direction is to help them develop a better appreciation of their particular strengths. And side by side with that growing appreciation, they need to be encouraged to develop the habit of leading from strength. This way of work needs to be applied to whatever task or project or major goal they are working on. And leading from strength should be applied just as routinely to the learning they need and want to do in support of such efforts.

4. Only with this sort of foundation is it possible to help people see if they can connect with externally proposed tasks, projects, and assignments, or with the curricula and/or requirements of a particular course, training, or continuing professional development activity - in a genuine way.

5. We need to help people set and learn how to set for themselves achievable and measurable goals and objectives. The odds for success should be high, particularly for people who have been discouraged by a good deal of failure. Actually, 90% success (10% stretch) seems to be a good mix for most of us.

6. Encouraging workers/learners/patients to negotiate and training them how to negotiate the important details of projects they are working on is an essential ingredient in the mix when preparing people for lives characterized by a high degree of self-management and a great deal of initiative. This should include learning how to negotiate the criteria by which their success will be assessed. And that, in turn, should be followed by active participation and collaboration in the continuous formative and summative evaluation processes associated with such activities.

7. Learning experiences are most powerful when they are characterized by reciprocal interactions and a great deal of true dialogue. Reciprocal learning is where teachers/supervisors/colleagues and learners are learning from and with one another. It is a two way street. "True dialogue" [Freire] is where both or all participants expect to learn from and with one another, are willing to be changed by the interaction and where participants anticipate creating new knowledge together, not just the sharing of "existing" knowledge. The craft of the educator/leader, here, is knowing how to consistently and reliably create conditions that facilitate these sorts of reciprocal, truly dialogical learning experiences.

I have found these things equally relevant to supporting the work, improvement efforts and learning activities of high school drop-outs and doctors...and so many others.

Lack of a clear distinction between action and learning is deliberate. We should seek to unleash initiative in every sphere of human endeavor. Encouraging, supporting, and expecting it everywhere will reinforce it everywhere.

Mark

PRACTICE IMPROVEMENT VS. RESEARCH

If you've been involved in some sort of practice improvement initiative in recent years, it is likely you have learned how frustrating it can be to submit an improvement project you propose to undertake to an "Institutional Review Board" (aka the 'IRB' Committee). And you would find it difficult to believe that the profession of medicine had identified 'practice-based learning and improvement' as a critical competency area which all physicians now need to master.

This is because many of the requirements and criteria IRB's rightly apply to research projects don't fit improvement projects. What it all comes down to is that research projects are almost always proposing to change the standard of care. Whereas improvement projects are usually trying to implement the prevailing standard of care (as laid out in national guidelines or similar protocols) in a better, more effective way. Many times, what is going on in an improvement project is an alteration in procedures, organization of care and/or systems - some sort of process.

The effectiveness of an improvement effort can and should be evaluated. But this kind of "research" is usually substantially different from the kind of research appropriate for the clinical trials of new medications, new medical procedures or other new and/or improved standards of care.

For example, requiring consent forms could be viewed as overkill for many improvement initiatives. On the other hand, compliance with HIPPA guidelines is probably just as important, particularly if there is the possibility that those conducting the improvement effort will want to publish what they learn from their work.

Moreover, most IRB committees haven't been staffed at a level that would allow them to deal with a large number of submissions on an ongoing basis. As a result, even if there is some kind of partial exemption granted, the review process may significantly delay the start of an improvement effort.

Routine initiation of thoughtful improvement efforts is something we are coming increasingly to associate with sound practice. This is something we want all clinicians to do all the time. But the growing IRB logjam will almost certainly impede and discourage the very sort of activities that leaders in the health professions are putting so much effort and resources into fostering via education and certification programs.

We need to begin to draw sharper and better distinctions between clinical research and practice improvement. There should be two, entirely separate committees reviewing these two different kinds of activities. They should have their own criteria, their own procedures and their own timelines. This is essential if we don't want to see required review committees discouraging improvement initiatives or the sharing of improvement successes and failures by reflective practitioners.

The two committee approach has been implemented here and there. But widespread implementation of this approach has been retarded for fear of loss of funding and/or accreditation of one kind or another, or even fines. There are committees studying the problem. But prompt and unambiguous action at the national level is required, if leadership in healthcare wants to send the right signal to clinicians... namely: "We really are serious about wanting you to incorporate clinical systems improvement into your practice, and we intend to make it feasible for you to do so on an efficient, effective and timely basis."

Equity and Balance in CE Funding

In another post, I suggested that those of us in the field of continuing professional development might do well to look at five other kinds of bias and not just the bias that can be introduced as a consequence of commercial support for a CE activity. In this post I want to suggest a broader perspective on the funding of CME.

I don't think it is necessary to limit the debate about CME funding to the two extreme options most frequently advanced of late: either accepting or not accepting commercial support. I think there are certainly other, more reasonable and more equitable formulas and systems for funding CME/CPD activities that we could, in good conscience, work to bring about?

• Equity - For one thing, I think it is time that we consider supporting a more “equitable" fee structure for those participating in formal continuing professional development activities in the field of healthcare. At the moment, physicians are asked to pay lower fees (or no fees) for most of their continuing education activities when compared with the fees other healthcare professionals are asked to pay for activities of similar duration. This in spite of the fact that physicians are much better compensated than others in healthcare. It is universally understood that this is a direct consequence of the high level of resources made available by commercial firms for activities provided to those wielding the "prescribing pen."

Wouldn't it be fairer and create some much needed leverage of a sort useful in beginning to alter the funding mix for healthcare continuing professional development activities, generally, if physicians were asked to pay at least as much as their colleagues for comparable activities. Physicians should expect to pay a reasonable fee that relates realistically to the total costs incurred by the sponsoring organization to provide the activity. To the extent that commercial funds and/or other funds are made available to support continuing professional development activities, these should be pooled and expended in such a way as to subsidize and thus lower the fees charged for all such activities in a given geographical region or organizational setting.

• Better Balance - I have a second suggestion to be combined with the first. It would further reduce the impact of commercial support on CPD activities. And it would keep the cost of continuing education modest (thereby preventing cost from becoming a barrier to participation by any group of healthcare providers).

I propose we seriously consider recommending that support for all such activities would come from three approximately equal sources: 1/3 from participating healthcare professionals, 1/3 from public and/or non-profit sources and 1/3 from pharmaceutical and/or device manufacturing sources. We should explicitly limiting commercial support to something like one-third of total activity costs. This type of limitation would ideally be applied on a program-by-program basis. Less desirable would be applying it to the programmatic portion of a CE provider’s entire annual budget.

Asking both physicians and the government to pay their fair share of the cost of healthcare CE, right along side commercial entities, seems like an especially appropriate suggestion at this particular moment, when we are doing our best to piece together a major package of healthcare reforms here in the USA.

6 Kinds of Bias in CME/CPD

This post is one of a series of posts adapted
from an article published in the newsletter of the
Association for Hospital Medical Education, Summer, 2006.

Three years ago, there was a discussion concerning “CME
Plus” on the listserve of the Society for Academic CME.
What was being proposed was a special designation for
CME activities put together without any commercial
support. Since then there has been a good deal of heated
discussion about commercial support and whether or
not medical schools, among others, should accept any
commercial support whatsoever for the continuing
medical education activities they sponsor.

That discussion left me thinking that there is a good
deal more we should be talking about besides
commercial support if those of us involved in supporting
the continuing professional development of
healthcare professionals truly wish to reinvent our
profession.

What I talked about when this piece was first published
seems more relevant than ever, today. So what follows
is an example of how I think we might broaden and
deepen such discussions, and question some long held
assumptions.

There are five additional, potential sources of bias that
need to be monitored by CPD professionals and
accrediting bodies if we intend to get serious about
reducing bias in continuing medical education /
continuing professional development activities.

[In future posts I'll get into a couple of CME/CPD funding
issues (equity and better balance), point out the need
to better distinguish the difference between practice
improvement initiatives and clinical research
(attempts to help providers meet or exceed
the current standard of care vs. initiatives that
attempt to alter the current standard of care), and
say something about the problem with trying to
move gradually from time-based credit to a system
of performance-based assessment.]

Bias
Let's take a closer look at concern about bias. What I
would very much like to know is this: Why is the
potential influence of commercial support the only kind
of bias we seem to care about and monitor? Isn't it obvious
that we are ignoring several other important potential
sources of bias?

• Clinical bias is the tendency of some instructional
faculty to make certain recommendations out of
habit more than anything else. This is less work than
wading through conflicting studies that attempt to
assess new approaches which may or may not prove
to be better than “what we’ve always done.”

• Researcher bias is the tendency of some
instructional faculty to see their area of research
expertise under every rock.

• Treatment bias is reflected, for example, in the
disproportionate emphasis on medication-based
modalities in CME/CPD activities, generally. Many
would argue that this is an appropriate focus.
But shouldn’t we find a way to support more
balanced representation of pharm and non-pharm
approaches to clinical care when the prevailing
standard of care encourages application of
multifaceted (often multidisciplinary) treatment
strategies for so very many conditions, and when
new evidence strongly suggests that consideration
be given to effective nonpharmaceutical and/or
complementary approaches to treating patients
with given conditions? If this is so, we
should begin to regularly ask instructional faculty if
they have adequately considered and included nonpharm
modalities and not just medications, devices and/or
surgical procedures.

• Reimbursement bias is catering, implicitly, to
prevailing patterns of reimbursement when they are
at variance with evidence-based best practices and/
or powerful cost-benefit considerations.

• Research methodological bias (possibly better
termed ‘disciplinary norm bias’) might be inherent,
for example, in the widespread practice of basing
clinical recommendations on short term trials
wherein a new medication is only compared with
a placebo and not also required to go head to
head with existing, well established alternatives.
Should we consider encouraging a much higher
evidence rating for therapeutic approaches when
the evidence of their effectiveness is based both
on comparisons with placebo and on comparisons
with competing alternatives, when these exist?
Aren’t we uncomfortable with the idea that so many
decisions at the moment, are made at every level of
the healthcare system (from PCP to the FDA), on
the basis that something new is apparently better, if
only marginally yet statistically better, than nothing?

Well that's it. What about all these other kinds of bias?
What do you think?

Mark