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Changing Health Care Provider Performance: the role of effective CME

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Title: Slide 1 Subject: Case Study Author: AAMC User Keywords: Overview Siegel Gale Last modified by: AAMC User Created Date: 4/6/2007 1:01:39 PM Document ... – PowerPoint PPT presentation

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Title: Changing Health Care Provider Performance: the role of effective CME


1
Changing Health Care Provider Performance the
role of effective CME CPD National Coalition
for HP Education in Genetics, September 2011
invisible
  • Dave Davis, MD
  • Senior Director, Continuing Education and
    Improvement
  • Association of American Medical Colleges

2
An outline many questions, little time
  • What are CME and CPD? Why are they invisible?
  • The Does CME Work? question the in- vitro
    perspective
  • Does CME work in the real world? - a look at
    the in-vivo, clinical care gap and its
    relationship to the world of genetics education
  • So What? Recommendations to a thoughtful
    genetics audience guidelines for the use of CME
    CPD

3
Question 1
  • Some definitions
  • What do we mean by CME CPD?
  • .by the terms diffusion, implementation?
  • .how have we changed in our thinking?
  • Later.what is knowledge translation/implementatio
    n science?

4
What do we mean by CPD and CME?
  • educational materials
  • formal CME lectures, small groups, courses
  • outreach visits
  • opinion leaders
  • patient-mediated strategies
  • audit/feedback
  • reminders
  • (paper, computerized, interactive, etc)
  • comprehensive, QI- or practice-based
    interventions
  • web-based tools, PDAs
  • (borrowed from EPOC, Cochrane Collaboraitve)

5
How have we changed?
6
What do we mean by?
  • Diffusion distribution of information and the
    practitioners natural unaided adoption of
    policies and practices
  • Dissemination communication of information to
    clinicians to improve their skills
  • Implementation putting a guideline in place,
    involves effective communication, overcomes
    barriers by administrative and educational
    techniques
  • (after Lomas)...

7
Question 2
  • Does CME (CPD) Work?
  • The In Vitro Question
  • (The Sackett question)

8
Database of Physician Education Change
www.rdrb.utoronto.ca
  • The Research and Development Resource Base
  • - educational, clinical health services
    literature
  • supported by the
  • American medical Association, the North
    American CME organizations, Royal College of
    Physicians and Surgeons of Canada, the University
    of Toronto and the Association of American
    colleges
  • Now 25,000 studies

9
  • 12 metropolitan areas, roughly 30 conditions
    studied, gt6,000 patient records examined
  • Substandard care noted in 45 of clinical areas
    (of this, 46 underuse 11 overuse)
  • Little variation by region or by type of
    condition (chronic, acute), socioeconomic status
  • Notable gaps in care in depression, alcohol
    abuse, diabetes care (about 45), pneumonia
    (39)
  • Better care (gt50 compliance with
    recommendations) noted in hypertension, cardiac
    care, but just
  • NOTE the inviible care gap (undiagnosed,
    undetected e.g., smoking cessation, obesity
    counseling, care gap is HUGE)

www.rdrb.utoronto.ca
www.rdrb.utoronto.ca
10
1) About educational interventions Changing
Physician Performance - a systematic review of
the effect of CME strategies JAMA
1995274700-705

11
The effect of formal CME - conferences,
symposia, rounds, meetings, lectures
  • Effective
  • Interactive Lecturing
  • Sequenced Sessions
  • Accurate needs assessment
  • Successful education has three elements
    predisposing, enabling, reinforcing
  • Not so Effective
  • Didactic Teaching
  • One-time only sessions

12
Other findings
NEW Multiple methods effect uncertain print
materials (simple messages) may not be so bad
after all consider the message and consider the
setting
13
2) and about the learner-clinician
  • age
  • motivation
  • (dis)incentives
  • experience
  • time
  • environment
  • training
  • Emphasis on knowledge
  • Inability to detect needs, evaluate performance
  • ?self-directed learning
  • ?critical appraisal
  • The Pathman Model
  • awareness of a guideline, practice innovation,
    change
  • agreement with the innovation or guideline
  • adoption trying out the new practice,
    irregularly
  • adherence abiding by the new practice on all
    appropriate occasions
  • Pathman, 1996

14
The self-assessment question
Davis co., JAMA 20062961096-1102
15
Of 20 comparisons..
  • 13 demonstrated little, no or an inverse
    relationship between self and external
    assessment
  • Examples learning needs, EBM skills, simulated
    knee injections
  • Note inverse relationships between confidence
    noted by Leopold (knee injections), Fox (OSCE
    misperception) and Parker (knowledge-based FP
    exam)
  • 7 demonstrated a positive relationship
  • Examples cultural-linguistic competencies,
    global performance with dementia patients,
    comfort with psycho-social issues in family
    medicine


16
Just in case we miss the point of 20
comparisons of self-assessments with external
assessments

17
3) About aligning the learner and educator the
Pathman-PROCEED model stages
Methods/ Stages Awareness Agreement Adoption Adherence
Predisposing
Enabling
Reinforcing
18
3) About the cumulative effect of CCME/CPD
Despite the quality of the evidence of CME, it
appears to be effective in the acquisition and
retention of knowledge, skills, behaviors, and
clinical outcomes AHRQ EB report, Feb
2007 ACCP, CHEST, 2009
19
Question 3
  • Does CME/CPD work in the real world? In the
    world of effectiveness? Why or why not?
  • The In Vivo Questions
  • The Clinical Care Gap
  • Overuse
  • Underuse
  • Misuse
  • Chassin, 1998

20
The clinical care gap
Ideal, evidence-based practice
clinical care gap
clinical care gap
Current practice
21
(No Transcript)
22
What causes the gap? The evidence-to-practice
puzzle
The clinician
The evidence/guideline
The educational delivery system
  • Health Care
  • System issues
  • Patient
  • Team members

23
No time
No, Thursdays out. How about never-is never good
for you?
24
Information management is like having your mouth
to a firehose David Naylor, President,
University of Toronto
25
What causes the gap?
The clinician
The evidence/guideline
the educational delivery System and knowledge
translation/ implementation science
  • Health Care
  • System issues
  • Patient
  • Team members

26
An emerging field one concept, two terms
  • Knowledge translation is the effective and
    timely incorporation of evidence-based
    information into the practices of health
    professionals in such a way as to effect optimal
    health care outcomes and maximize the potential
    of the health system
  • Adapted from the Canadian Institutes for Health
    Research definition, 2001
  • Implementation Science is the scientific study of
    methods to promote the systematic uptake of
    research findings and other evidence based
    practice into routine practice thus to improve
    the quality and effectiveness of health care and
    services. ..adapted from the NIH, USA

27
Question 4 How do CME and CPD play a role in
genetics genetics education ?
28
The guideline process evidence-to-action
Consideration of clinician learning style, needs
The goal effective implementation
Evidence/message Development
Implementation
Effective CME/PD
29
How an we use CME/CPD in evidence/message/guidelin
e development in genetics?
  • Recommendation 1
  • Guideline Development/adaptation
  • Consider CME/CPD in any evidence development
    process from learner and educational
    perspectives (for example, guard against
    knowledge overload, consider already-held
    knowledge)
  • secure buy-in involve the end-user in guideline
    development/adaptation
  • employ adult learning principles in guideline
    statements (format, spacing, language)
  • consider recommending effective educational
    strategies in the guideline itself

30
.educational issues to consider within the
guideline, evidence itself
  • compatibility
  • complexity
  • cost
  • relative advantage
  • accessibility
  • format
  • patency of evidence, process of development
  • opportunity trial-ability

31
One attempt to fix the Message The Guidelines
Advisory Committee, Ontario (now the Center for
Evidence-based practice)
  • Joint body of the Ontario Medical Association and
    the Ministry of Health and Long term Care,
    Ontario
  • Chooses a topic area reviews all guidelines in
    that area scores them by the Cluzeau/AGREE
    instrument
  • Mounted them on a website
  • Quick, 30 second synopsis
  • Clear language
  • Appropriate format
  • Parallel patient synopsis
  • The apple-score

32
How an we use CME/CPD in genetics education ?
  • Recommendation 2
  • Include CME/CPD in any guideline implementation
    strategy
  • Consider the learner
  • - mode of current learning
  • - stage of awareness-adherence at which
    clinician-learners exist
  • b) Consider effective educational strategies

33
The CPG implementation toolkit
  • Formal CME
  • Lectures, workshops, small groups
  • Informal education
  • Audit/Feedback
  • Reminders
  • Policy, CQI administrative techniques
  • Print
  • Patient Strategies
  • Multiple Strategies
  • MM conferences
  • Quality-based rounds
  • Journal Club
  • Team training
  • Handover/off rounds

34
How can we use CME/CPD in genetics education?
  • Recommendation 3
  • Consider CME/CPD in a staged fashion, depending
    on stage of adoption of information, by
    individuals, groups use appropriate educational
    strategies

35
Example 1 a new guideline describes the use of
a new disease screening test..
Methods/Stages Awareness Agreement Adoption Adherence
Predisposing Print material, Lectures, Conferences Academic detailing, Media Interactive sequential sessions
Enabling Small groups, opinion leaders Pt. education, workshops, opinion leaders
Reinforcing Reminders, audit/feedback Reminders, audit/feedback
36
Example 2 many primary care providers fail to
use a simple genogram when taking patient history
Methods/Stages Awareness Agreement Adoption Adherence
Predisposing Print material, Patient education and advocacy
Enabling Small groups, opinion leaders Pt. education, workshops, flow charts
Reinforcing Reminders, audit/feedback Reminders, audit/feedback
37
Example 3 a national campaign a project of the
Association of American Medical Colleges
  • Launch, June 2011
  • Tools, resources, and support for AAMC members
  • Collaborative learning sessions
  • National Faculty Development Initiative
  • Roughly 250 med schools teaching hospitals
    participating
  • www.aamc.org/bestpractices

38
  • Participating medical schools and teaching
    hospitals have committed to

  • Teach quality and patient safety to the next
    generation of doctors
  • Ensure safer surgery through use of surgical
    checklists
  • Reduce infections from central lines using proven
    protocols
  • Reduce hospital readmissions for high-risk
    patients
  • Research, evaluate, and share new and improved
    practices.
  • This list of commitments will grow over time.

39
The Pathman-PROCEED model applied to AAMCs BPBC
campaign
Methods/Stages Awareness Agreement Adoption Adherence
Predisposing Emails, Conferences, Media Group work at meetings, conference calls
Enabling Learning collaboratives, workshops, Web-tools, webinars
Reinforcing Reminders, audit/feedback, Awards Reminders, audit/feedback
40
How can we use CME/CPD in genetics education?
  • Recommendation 4
  • When considering further research implications,
    add those related to changing physician health
    professional performance relative to CME/CPD
    interventions, staging and learning

41
And a few final last words
  • Large and growing body of evidence about the
    effect of CME/CPD now imbedded in models of
    change- no longer an invisible (and ineffective)
    intervention
  • Huge clinical care gap, no less so in genetics
  • Considerable support for consideration of CME/CPD
    practices and principles based on best
    evidence.

42
Daves contact info
  • ddavis_at_aamc.org
  • www.aamc.org/initiatives/CME/ae4Q
  • www.rdrb.utoronto.ca
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