Using Continuing Education to Effect
Change within Your Organization
Jennifer Hurley, CPHRM, CCMEP
Chief Operating Officer at ELM Exchange, Inc.
Risk Management/CE Overlap
ELM's mission is to be a leading provider of proactive, effective
healthcare risk management and patient safety programs. … In
pursuit of this mission, ELM develops or jointly-sponsors/coprovides continuing education activities that stress the role of the
healthcare professional in anticipating, recognizing and
managing risk to prevent patient injury.
• ELM Exchange, Inc. is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
– Accreditation with Commendation
• ELM Exchange, Inc. is accredited as a provider of continuing
nursing education by the American Nurses Credentialing Center's
Commission on Accreditation.
– Accreditation with Distinction
Learning Objectives
• Describe how to apply adult learning
fundamentals to motivate medical staff.
• Discuss barriers to the effective use of
continuing education.
• Discuss the role of continuing education as a
tool to effect change within an organization.
• Identify interventions that will minimize
barriers and promote patient safety in an
organization.
Format/Agenda
• Findings from AHA’s Physician Leadership
Forum’s white paper on Lifelong Learning:
Physician Competency Development
• Theories of adult learning as they apply to
healthcare CE
• ELM’s CE planning process
• Summary of Institute of Medicine of the National
Academies’ Best Care at Lower Cost: The Path to
Continuously Learning Health Care in America
• Feedback/Q&A
AHA’s Physician Leadership Forum
Lifelong Learning: Physician Competency Development
• In 2007, the Institute for Healthcare
Improvement determined that improving
healthcare delivery in the US requires a
focus on three areas:
– Improving the experience of care
– Improving the health of populations
– Reducing per capita costs of healthcare
Source: Combes J.R. and Arespacochaga E., Lifelong Learning Physician Competency Development. American Hospital
Association's Physician Leadership Forum, Chicago, IL. June 2012
"Experience of Care"
•
A gap exists:
– Patient is passive, subordinate, without voice/vote or knowledge
– Providers/front line have the power, knowledge and resources
•
•
HCAHPS [Hospital Consumer Assessment of Healthcare Providers and
Systems] survey is one of many initiatives designed to force improvement
on this issue
“In an era in when hospitals compete for patients by boasting the latest
clinical technology, the most prestigious physicians and impressive
amenities, patient satisfaction is most influenced by human factors,
especially superior service-related communication skills between
hospital staff and patients, according to the J.D. Power and Associates
2012 National Patient Experience StudySM released today.” (Source: J.D. Power
and Associates, 9/4/2012)
Source: Combes J.R. and Arespacochaga E., Lifelong Learning Physician Competency Development. American Hospital
Association's Physician Leadership Forum, Chicago, IL. June 2012
"Health of Populations"
• Obesity in US population sits at 34% and growing1
– Obesity-related health conditions expected to account
for more than $549 billion in healthcare costs in 2030
when hits 42%1
• Baby boomer population
– Palliative and geriatric care demands peak in 10 yrs
• Cultural diversity
1Source:
CDC, http://www.cdc.gov/obesity/
"Per Capita Costs"
• Defensive medicine
• Pay for performance/other “incentives”
– “A looming 2% cut in Medicare reimbursement
triggered by the failure of Congress to forge a
deficit-reduction plan will wipe out 767,000 jobs
across the economy through 2021, according to a
new study released today by the American
Medical Association (AMA) and 2 other groups.”
(Source: Medscape Medical News © 2012 WebMD, LLC, 9/12/2012)
• Medical malpractice
• Generational differences
Sidebar: Excess Costs
AHA concludes new competencies required:
•
•
•
•
Leadership training
Systems theory and analysis
Use of information technology
Cross-disciplinary training/multidisciplinary teams (incl.
respecting one another)
• Additional education around: population health management,
palliative care/end of life, resource management/medical
economics, health policy and regulation
• Interpersonal and communication skills; Less "captain of the
ship" and more "member/leader of the team," empathic
care/customer service, time management, conflict
management/performance feedback, understanding of
cultural and economic diversity, emotional intelligence
Conclusions
• “Continuing medical education can offer a unique opportunity for
rapid response to emerging gaps in training given that accreditation
is renewed yearly.”
• “Ongoing review of emerging professional practice gaps and the
underlying competencies can serve to make continuing medical
education well suited for a rapid response to emerging problems.”
• “Increased availability and simplicity of attaining continuing medical
education credit for involvement in practice/hospital-based
improvement projects and efforts around systems-based practice
should be considered.”
• “Embracing the use of evaluation and tools to improve within the
scope of practice evaluation and continuous improvement efforts
should be considered.”
Source: Combes J.R. and Arespacochaga E., Lifelong Learning Physician Competency Development. American Hospital
Association's Physician Leadership Forum, Chicago, IL. June 2012
Andragogy
The education of adults
Andragogical Model
•
The andragogical model is based on several assumptions that are different
from those pedagogical model2:
– The need to know: adults need to know why they need to learn something before
undertaking to learn it.
– The learners' self-concept: Adults have a self-concept of being responsible for their
own decisions, for their own lives. They have a deep-seated need for autonomy.
– The role of the learners' experiences: Adults of the come into an educational activity
with both a greater volume and a different quality of experience from that of youths.
– Readiness to learn: Adults become ready to learn those things they need to know and
be able to do in order to cope effectively with their real-life situations.
– Orientation to learning: In contrast to children's and youth's subject-centered
orientation to learning, adults are life-centered (or task-oriented or problem-centered)
in their orientation to learning. Adults are motivated to learn to the extent that they
perceive that learning will help them perform tasks or deal with problems that they
confront in their life situations.
– Motivation: Adults are responsive to some external motivators (better jobs, promotions,
higher salaries, and the like), but the most potent motivators are internal pressures
(the desire for increased job satisfaction, self-esteem, quality of life, and the like).
2Malcolm
Shepherd Knowles, Elwood F. Holton, Richard A. Swanson, The Adult Learner: The Definitive Classic in Adult
Education and Human Resource Development, Gulf Publishing Company, Jul 1, 1998
Process for Planning & Implementation
Continuing Education
D.L. Sokol, Pleased But Not Satisfied, self-published, 2007
PLAN
• Isolate a professional practice gap (difference between current and
ideal practice)
• Identify the target audience (who can be empowered to make a
difference?)
• Reveal the underlying educational needs (the competencies, skills
•
or knowledge of the target audience contributing to the gap)
Decide on the best intervention (based on attributes of the target
audience, educational needs and available resources)
• Make a case for why the learner needs to know (gap) – The Need to
Know/Motivation
• Select a method that allows the learner to engage on their own terms –
Self-Directed/Autonomy
• Make sure the learner is able to feel connected to the subject matter –
Orientation to Learning/Role of Learner’s Experiences/Readiness to
Learn
EXECUTE
• Engage/qualify content experts
• Develop the learning objectives, content and a method of
analyzing efficacy directly correlated to the objectives
– CME = activities must be designed/evaluated to change competence,
performance and/or patient outcomes
– CE = activities must be designed/evaluated to change knowledge, skills
and/or practice
• Reason: Make a case for why the learner needs to know (gap) – The
Need to Know/Motivation
• Empower: Select a method that allows the learner to engage on their
own terms – Self-Directed/Autonomy
• Real World: Make sure the learner is able to feel connected to the
subject matter – Orientation to Learning/Role of Learner’s
Experiences/Readiness to Learn
• Conduct the intervention
MEASURE
• Assess your performance in bringing
about change using the efficacy data
generated from the activity
• Return on investment
CORRECT
• Investigate deficiencies in learning
objectives vs. efficacy evaluation
– Now you have a new gap and you start the
process all over again
Sidebar: Finding Money to Fund a Program
for Risk Management
• Insurance entities
– Captives
– Carrier
– Reinsurer
• Operating budget (tie to CME/CE goals)
• Grants (tie to quality)
Potential Gap in Next Ten Years
•
Obesity in US population tops 40%?
–
•
Baby boomer population
–
•
Generational differences; younger generations seek greater work-life balance, work fewer
hours, gain less experience over time as predecessors
Nursing shortage
–
–
•
Palliative and geriatric care demands peak
Millennials and Gen Y in leadership roles
–
•
Obesity-related health conditions account for ~$400 billion in healthcare costs 1
Average age of today’s nurse is 49 years
Nursing school attendance is low
Pay for performance, non-payment for HACs/HAIs, readmissions, etc.
Fewer, less experienced nurses/physicians to care for more
complex patients under financial pressure to perform.
According to the CDC obesity study in 2006
1
Changing Course
• Encouraging treatment of causes, not just
symptoms – empathic care/emotional intelligence
• Establish nursing/physician/risk leadership
development programs to mentor today’s recent
graduates to build leadership skills and ability to
direct integrated teams/facilitate systems-based
practice
• Plan for specialized services and equipment
needs over the 10-year span
• Provide education and tools to promote
compliance with rules and regulations
Institute of Medicine of the National Academies
Best Care at Lower Cost: The Path to Continuously
Learning Health Care in America
• "Narrow-minded rejection of scientific evidence is rarely
encountered today in medicine, yet the American health care
system imposed significant institutional, economic, and
pedagogic barriers to learning and adapting."
• A paradox exists, "...learning and adoption that are
maddeningly slow--as with hand washing---coexisting with
overly rapid adoption of some new techniques, devices, and
drugs, with harmful results."
• "The system needs to learn more rapidly, digest what does
and does not work, and spread that knowledge in ways that
can be broadly adapted and adopted. This report offers a
roadmap for accomplishing this to benefit patients and
society."
Institute of Medicine of the National Academies, Best Care at Lower Cost: The Path to Continuously Learning Health Care in
America, The National Academies Press, Washington, DC, 2012.
Industry Comparison
“Consider the impact on American services if other industries routinely operated in the
same manner as many aspects of health care:
• If banking were like health care, automated teller machine (ATM) transactions would
take not seconds but perhaps days or longer as a result of unavailable or misplaced
records.
• If home building were like health care, carpenters, electricians, and plumbers each
would work with different blueprints, with very little coordination.
• If shopping were like health care, product prices would not be posted, and the price
charged would vary widely within the same store, depending on the source of
payment.
• If automobile manufacturing were like health care, warranties for cars that require
manufacturers to pay for defects would not exist. As a result, few factories would
seek to monitor and improve production line performance and product quality.
• If airline travel were like health care, each pilot would be free to design his or her own
preflight safety check, or not to perform one at all.”
Institute of Medicine of the National Academies, Best Care at Lower Cost: The Path to Continuously Learning Health Care in
America, The National Academies Press, Washington, DC, 2012.
The Imperatives
“Clinicians and health care staff work
tirelessly to care for patients in an
increasingly complex, inefficient, and
stressful environment.”
– flood of innovations/technology to blame, but
we can leverage technology to also create
efficiencies
Conclusions: The Imperatives
•
•
•
•
Diagnostic and treatment options are expanding and changing at an accelerating
rate, placing new stresses on clinicians and patients, as well as potentially impacting
the effectiveness and efficiency of care delivery.
Chronic diseases and comorbid conditions are increasing, exacerbating the clinical,
logistical, decision-making, and economic challenges faced by patients and clinicians.
Care delivery has become increasingly fragmented, leading to coordination and
communication challenges for patients and clinicians.
Health care safety, quality, and outcomes for Americans fall substantially short of their
potential and vary significantly for different populations of Americans.* The growth
rate of health care expenditures is unsustainable, with waste that diverts major
resources from necessary care and other priorities at every level--individual, family,
community, state, and national.
* Recent studies have reported that as many as 1/3 of hospitalized patients may
experience harm or an adverse event, often from preventable errors (Classen et al.,
2011; Landrigan et al., 2010; Levinson, 2010)
Conclusions: The Imperatives (cont)
• Advances in computing, information science, and connectivity can
improve patient-clinician communication, point-of-care guidance, the
capture of experience, population surveillance, planning and
evaluation, and the generation of real-time knowledge--features of a
continuously learning health care system.
• Systemic, evidence-based process improvement methods applied in
various sectors to achieve often striking results in safety, quality,
reliability, and value can be similarly transformative for health care.
• Innovative public- and private-sector health system improvement
initiatives, if adopted broadly, could support many elements of the
transformation necessary to achieve a continuously learning health
care system.
Barriers
• Clinicians report moderate to high levels of stress, feel there is not
enough time to meet their patients' needs, and find their work
environment chaotic (Burdi and Baker, 1999; Linzer et al., 2009;
Trude, 2003).
• ...they struggle to deliver care while confronting inefficient workflows,
administrative burdens, and uncoordinated systems.
• ...overwhelmed by the sheer volume of initiatives currently under
way to improve various aspects of the care process, initiatives that
appear to be unconnected with the organization's priorities.
"Significant change can occur only if the environment,
context, and systems in which these professionals practice
are reconfigured so that the entire health care infrastructure
and culture support learning and improvement."
The Path
“The path to achieving the vision of a
learning health care system entails
generating and using real-time knowledge to
improve outcomes; engaging patients,
families, and communities; achieving and
rewarding high-value care; and creating a
new culture of care.”
Conclusions: The Path
• Despite the accelerating pace of scientific discovery, the current
clinical research enterprise does not sufficiently address pressing
clinical questions. The result is decisions by both patients and
clinicians that are inadequately informed by evidence.
• Growing computational capabilities to generate, communicate, and
apply new knowledge create the potential to build a clinical data
infrastructure to support continuous learning and improvement in
healthcare.
• Regulations governing the collection and use of clinical data often
create unnecessary and unintended barriers to the effectiveness
and improvement of care and the derivation of research insights.
• As the pace of knowledge generation accelerates, new approaches
are needed to deliver the right information, in a clear and
understandable format, to patients and clinicians as they partner to
make clinical decisions.
Conclusions: The Path (cont)
•
•
•
•
•
Improved patient engagement is associated with better patient experience,
health, and quality of life and better economic outcomes, yet patient and
family participation in care decisions remains limited.
Coordination and integration of patient services currently are poor.
Improvement in this area will require strong and sustained avenues of
communication and cooperation between and among clinical and
community stewards of services.
The prevailing approach to paying for health care, based predominately on
individual services and products, encourages wasteful and ineffective care.
Transparency of process, outcome, price, and cost information, both within
health care and with patients and the public, has untapped potential to
support continuous learning and improvement in patient experience,
outcomes, and cost and the delivery of high-value care.
Realizing the potential of a continuously learning health care system will
require a sustained commitment to improvement, optimized operations,
concomitant culture change, aligned incentives, and strong leadership
within and across organizations.
In conclusion: “The nation’s health and
economic futures—best care at lower cost—
depend on the ability to steward the
evolution of a continuously learning health
care system.”
Institute of Medicine of the National Academies, Best Care at Lower Cost: The Path to Continuously Learning Health Care in
America, The National Academies Press, Washington, DC, 2012.
Opportunity for Improvement
• Did this presentation follow its own advice?
– Reason: Make a case for why the learner needs
to know (evidence of gap) – The Need to
Know/Motivation
– Empower: Select a method that allows the learner
to engage on their own terms – SelfDirected/Autonomy
– Real World: Make sure the learner is able to feel
connected to the subject matter – Orientation to
Learning/Role of Learner’s
Experiences/Readiness to Learn
Q&A
• Questions? Comments?
• jhurley@elmexchange.com
• 303-223-2622, x303
It is not the strongest of the
species that survives, nor the
most intelligent that survives. It
is the one that is the most
adaptable to change.
- Charles Darwin