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/co- provides 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 Study SM 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 growing 1 –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 1 Source: CDC, http://www.cdc.gov/obesity/
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
Andragogical Model The andragogical model is based on several assumptions that are different from those pedagogical model 2 : –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). 2 Malcolm 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%? –Obesity-related health conditions account for ~$400 billion in healthcare costs 1 Baby boomer population –Palliative and geriatric care demands peak Millennials and Gen Y in leadership roles –Generational differences; younger generations seek greater work-life balance, work fewer hours, gain less experience over time as predecessors Nursing shortage –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. 1 According to the CDC obesity study in 2006
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
"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. Institute of Medicine of the National Academies Best Care at Lower Cost: The Path to Continuously Learning Health Care in America
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 – 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
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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