Not your Grandma’s CME

using continuing professional

development to meet patient,

quality improvement and system

needs

Dave Davis, MD, FCFP

Visiting Professor, Mohammed Bin Rashid University, Dubai, UAE

Professor Emeritus, University of Toronto

formerly Senior Director, Continuing Education & Performance Improvement, AAMC

Some questions

1. What’s the clinical care gap? Why does it matter to medical education? To quality?

2. What causes it?

4. Are there forces driving quality and education to align?

5. What global forces support this movement? (a snapshot)

5. So what? The real purpose of CME

Framing questions

1. What’s the clinical care gap? Why does it matter to (continuing) medical education? To quality?

2. What causes it?

3. Are there forces driving changes globally?

4. How can we do this?

5. So what?

Current practice

Ideal,

evidence-based practice

The clinical care gap….

Evaluating Competency (Using Miller’s Pyramid)

While overall we might think

we’re doing well, there is

another story…...

The clinical care gap

Life expectancy: 2012

Maternal mortality, 2013,

WHO Observatory

HIV AIDS

Zika Virus

Rx Opioid use, US data 2012

Dartmouth Atlas 2010

The peculiar case

of American low

back pain

Country-country comparisons

The care gap: the metaphorical

view

"the burden of harm conveyed by the

collective impact of all of our health care

quality problems is staggering" Chassen et al., 1998

Other framing questions

1. What’s the clinical care gap? Why does it matter to medical education?

2. What causes it?

4. Are there forces driving quality and education to operate more closely together?

5. How can we do this?

QI/PS educational innovations

Specialty Board and other innovations

AAMC’s e4Q initiatives

5. So what? How can we measure change?

What causes the gap?

The evidence-to-practice puzzle

What causes the gap?

The evidence-to-practice puzzle

Evidence: a snapshot

CPGs

Problems with guidelinesTACO

trialabilityacceptabilityadoptabilityadvantage

compatibilitycomplexity

costobservability

CPGs

NGC currently contains >3,000 individual guideline summaries

What causes the gap?

The evidence-to-practice puzzle

the Continuum: what we know“Traditional” Student

PremedicalMedical

School

Residency and

FellowshipsPractice

Life-Long

Learning

© 2009 AAMC. May not be reproduced without permission.

Some traits may be

characterologic,

testable at admission

EBM, self directed

learning can be

taught, modeled and

assessed

We know lots about

effective teaching,

problem-based

learning, flipped

classroom

We do at best only a modest job of training our physicians to practice in current and developing systems

Note especially, Systems-based practice and Practice-based learning & improvement; QI/patient safety issues

What causes the gap?

The evidence-to-practice puzzle

What causes the gap?

The evidence-to-practice puzzle

What do we think of when we think of ‘CME’?

CME

regulations

Specialty

requirements…

..

FRAMING CME and the

Clinical Care gap:

1977:

Does CME work?

Referrals

revenue

reputation

registrations

Does CME work?

Does CME

change

physician

behavior?

Health care

outcomes?

Problem #1 & 2: not knowing or heeding the research in CME

Physicians and others not self-aware: objective needs assessment, performance feedback important; learning is staged

Knowledge necessary but not sufficient for change; didactics lousy at changing performance by themselves

‘CME’ > conferences; = practice-based tools (reminders, audit-feedback, protocols & training)

Effective education possesses three characteristics: predisposing, enabling and reinforcing strategies

…………Cochrane reviews, AHRQ/EB reviews, others

What works in standard continuing education? Interactivity and sequencing

Problem #3: thinking that CME is just lectures

Other framing questions

1. What’s the clinical care gap? Why does it matter to medical education? To quality?

2. What causes it?

3. Are there forces driving change in CME/CPD?

4. How can we do this?

5. So what? How can we measure change?

The Reports

Integrated

CME/CPD

Forces for change

Framing questions

1. What’s the clinical care gap? Why does it matter to medical education? To quality?

2. What causes it?

3. Are there forces driving quality and education to operate more closely together?

4. How can we do this?

5. So what? Lessons for the future….

The tipping point

No Change Change

UsualCare

Accre

dita

tion

Inertia Change

The tipping point

AAMC’s e4Q initiatives

ae4Q – aligning

and educating

for quality

What this??

What does ae4q do?

Educational Process

• Use of quality metrics in planning and assessment

• Use of evidence based interventions (including HIT, team training, staff development)

Organizational Alignment of CME and GME, QI/PI initiatives, practice plans, electronic health records, faculty/staff development, credentials…

On-line Resources, Community of Practice

Teaching

Hospital

Staff

dev’tQI/PI

UME/

GME

Faculty

Devel’t

EHR

Health

system

data

Accreditation,

other input

What are the

sites doing?

organizational

alignments

Region

ae4Q achievement pyramid

To come: HSR/QI/CME scholarship; regional (ACO)

facilitation; linkages with financial leadership

markers of readiness, alignment; resources; community of practice;

ae4communiQUEs; webinars

Champions; organizational MOC; new organizational alignments; educational improvements; process improvements,

(even) patient care improvements

Academic

medical

center

Joint

products

In

development

What are the

sites doing?

Changing rounds

OR: use relevant quality metrics to drive rounds planning

Using rounds as a platform to promote QI learning and discussion

• Take a standard QI topic and teach during rounds sessions

• Apply a QI theme and/or local metrics to a case discussion

• Use a QI-proficient clinician to comment on the case

NOTE: M&M improvement rounds

Review Quality

data

Select set, benchmark

Plan rounds

Implement rounds

Repeat, integrate

Anther example: the Health Quality Matrix applied to M&M/Improvement conferences

Bingham et al, JQ&PS,

2005

Summary - the goals of AAMC’s e4Q initiatives: Facilitating change in academic medical centers

Capacity building: individual (Te4Q) and

organizational, educational (ae4Q) strategies

Other framing questions

1. What’s the clinical care gap? Why does it matter to medical education? To quality?

2. What causes it?

3. Are there forces driving quality and education to operate more closely together?

4. How can we do this?

5. So what? How can we infuse health care outcomes into curricula across the continuum?

Not your grandma’s CME/CPD

“The future is here; it’s just a little patchy, is all….”

T

Current picture Possible Future

More

effective

Not your grandma’s CME

Less Effective

Didactic Education with little follow-up, reinforcement

Education unlinked to observable metrics

Inadequate team training

Poor/little linkage between QI/PS, education and research

Clinical topics not focused on system needs

Use CME/CPD as an intervention linked to quality metrics, organizational goals.. NOT just lectures

Think of its major messages – e.g., cost/value, shared decision-making,

Change the name?

1) Rethink CME

2) Start small: Change CPD planning: from this…

Isn’t ID always

the third

Tuesday?

I heard Jane XXX at a

recent meeting; she

was GREAT!

Don’t you have a friend at

SABC company who

could support this?

Isn’t it Joe’s

turn to speak

this month?

What are we doing

here? I thought the

AA planned rounds..

….to thisWhat are the

clinical

problems

we’re trying to

solve here?

How do we know it’s

a problem? What kind

of data are there?

What are the barriers to

solving them? What about

a systems-based

approach? We’ve had

enough of the one-offs

How can we

use education

to solve it?

What types of education? How

could we deploy them? What

else could we do?

3) Consider aligning Faculty Development, GME, CME

4) Foster scholarship: quality, health services, knowledge translation plus med ed/CME research

5) Consider an active, integrated presence for CME/CPD in the region/system

Faculty development/

CME/CPD

(P)GME

UME

A culture of quality

6) put what we know together; plan strategically for

the use of CME; the Pathman/PROCEED model Davis et al, BMJ, 2003

Methods/

Stages

Awareness Agreement Adoption Adherence

Predisposing

Enabling

Reinforcing

Future #7: apply what we know about effective education across the continuum

“Aspiring” Student

PremedicalMedical

School

Residency and

FellowshipsPractice

Life-Long

Learning

© 2009 AAMC. May not be reproduced without permission.

EBM, self directed

learning can be

taught, modeled and

assessed…so can

quality/safety

Didactics lousy about

effective educationat

changing performance;

experiential, feedback-

based learning more

effective; predispose;

enable; reinforce learning

Note: the flipped

classroom

Physicians and others not self-aware: objective needs assessment, performance feedback important

Use stages of learning (awareness, agreement, adoption to adherence) to systematically plan for CME/CPD

Your grandma’s CME The New

CME/CPD

Format Everything

Target Audience

Content Focus

Location

Support

Outcomes

Clinical Integration

All health professionals

Quality of care gaps

Point of Care

Multiple sources; system-based

Patient and Process changes

CPD integrated into practice

References

Uemura M et al, Enhancing quality improvements in cancer care through CME activities at a nationally recognized cancer center.

J Cancer Educ. 2013 Jun;28(2):215-20. doi: 10.1007/s13187-013-0467-z.

Pingleton S et al, Acad Med October 2013

Davis, N et al Acad Med, October 2013

Bingham et al, JQPS, December 2005

Visit us www.aamc.org/ae4q; www.aamc.org/te4q

and….

AMEE CPD SIG (Special Interest Group)

Do you want to know more about the work of the Committee and AMEE in the area of CPD?

Are you interested in joining the CPD SIG which will be in place soon?

Contact:

Lawrence Sherman (meducate@gmail.com)

Jane Tipping (jane.tipping@utoronto.ca)

Or AMEE (Amee@dundee.ac.uk)

Thanks,

Dave Davis, MD, FCFP

dave.davis@mbru.ac.ae