Professionals in healthcare, continuing medical education, and quality and performance improvement all want basically the same things: expanded knowledge, reduced errors, minimized costs, and improved health outcomes. The problem is that the differences in where each group is coming from — science, education, engineering, and business — can make it difficult for everyone to work together to get where they want to go.

The Indiana University School of Medicine and CME Enterprise, Carmel, Ind., both Accreditation Council for CME-accredited providers, wanted to develop a collaborative model that would enable all participants, regardless of background, to share a common understanding that will lead to demonstrable performance improvement.

To do it, the organizers decided to bring a total-quality-improvement-management process that has proven vital to the success of many manufacturers to wider use in healthcare. Called “A Bridge to Quality: Engaging Continuing Education and Quality Improvement Professionals in Health Quality Improvement,” the initiative also would provide practical tools to improve healthcare quality. IUSM and CMEE pilot-tested the initiative in 2009 at a workshop held at IUSM. This year they are bringing it to four new academic health centers, and repeating the workshop at IUSM.

Manufacturing Better Care

The partners in this initiative chose Lean Six Sigma — a combination of Lean and Six Sigma process improvement systems — because the LSS combination is one of the most successful methodologies for eliminating waste and variation. Lean methodology, which originated in the Toyota Production System, uses cross-functional teams guided by business-improvement objectives to reduce overall lead times by eliminating waste in processes. Six Sigma, developed by Motorola and now used by Fortune 500 companies including Honeywell and General Electric, aims to reduce defects by reducing variations in processes. Together, the two methodologies work to identify and eliminate activities that don't add value to the work-flow process. LSS builds upon the more commonly used quality-improvement Plan-Do-Study-Act, or PDSA, cycle that statistician William Deming originated in the 1950s by adding techniques designed to identify customer need, reduce wasteful practices, and apply a statistical approach to calculate and remove defects.

LSS QI methodologies, the partners decided, would be a good fit for healthcare organizations. They involve a systematic analysis of internal processes, are easy to implement, can achieve both short- and long-term results, are sustainable across an organization, and can gain approval and participation from physicians and other healthcare professionals. LSS's cross-functional team approach also can help reduce costs and eliminate inefficiencies by breaking down the silo mentality that is endemic to the healthcare industry, and providing tools that can be applied to a wide variety of therapeutic areas.

IUSM, which has been involved in a number of initiatives to incorporate QI methodologies throughout its system, either internally or in partnership with other entities, has firsthand knowledge of how well LSS can work. One of its partnerships involved implementing 32 LSS healthcare programs in Indiana hospital systems; 25 of the systems were able to sustain the majority of the project's goals.

CME Enterprise has been training its staff in LSS principles, procedures, and tools since 2006 and has seen dramatic improvements in efficiency and productivity in its own operations, including the critical educational areas of needs assessment, instructional methods, evaluation, and outcomes.

IUSM and CMEE decided to develop a train-the-trainer initiative that would provide LSS methods and tools to engage clinicians in systems improvement and create a sustainable model of healthcare QI. The model also could track improved performance on key quality indicators such as HbA1c testing for diabetic patients or low-density-lipoprotein cholesterol screening for patients with cardiovascular conditions, providing data on what does and does not work so the initiative can continue to evolve. As Zev Winicur, PhD, CMEE manager of assessment services, says, “For us to provide healthcare workers with effective tools they can implement within their own clinics, we need more data on which improvement methodologies lead to better patient outcomes.”

The author, Charles M. Clark Jr., MD, associate dean for continuing medical education at IUSM, and Winicur headed the educational design of the initiative, with assistance from LSS specialist Deanna Suskovich of Ancerra Corp. and CMEE activity manager Tiffany Harazinova, CCMEP. Pfizer provided funding for the pilot workshop. The second, five-center phase has garnered more than $500,000 in support from Pfizer, Ortho-McNeil Janssen, Genentech, Sanofi-Aventis, and AstraZeneca.

Assessing Clinician Needs

Before designing the initiative, the partners identified the barriers that hold healthcare organizations back from implementing a systems-wide QI strategy. Physician involvement is key: If the physicians aren't involved in the QI initiative, they aren't likely to implement it in their practices. Even though systems-based practice is one of the six core competencies required for maintenance of certification, the 2003 Commonwealth Fund National Survey of Physicians and Quality of Care found that only one-third of responding physicians had engaged in QI activities.

Clark says, “We know that many, if not most, of the problems in patient safety and the quality of healthcare result from deficiencies in the system or microsystem in which care is delivered, yet most physicians are ill-equipped to address system problems.” Part of the difficulty may be that physicians usually aren't trained to understand how their actions affect the system in which they practice. Nearly a third of respondents to the Association of American Medical Colleges 2007 Graduation Questionnaire reported inadequate training in QI.

The culture of medicine, with its emphasis on individual performance, also seems to work against the concept of shared, systemwide responsibility. Collaborative environments are scarce due to a competitive healthcare environment that can at times push productivity ahead of quality of care. Physicians may actually look upon the collection of quality-of-care information in their practice as threatening to their autonomy, says Clark.

Physicians also are concerned about how clinical performance data will be used, and whether a systems redesign will make their work more complex and time-consuming. They wonder about the scientific rigor of system-improvement methodologies, and are skeptical of their organization's commitment to a QI initiative, especially considering that fewer than 40 percent of healthcare QI initiatives successfully make the transition to long-term practice.

However, as Clark points out, physicians also are increasingly being asked to address deficiencies in the quality of their practices. They can no longer afford to look askance at externally mandated QI methodologies. The IUSM/CMEE initiative aims to dispel or address these concerns, and encourage physicians to participate in systemwide improvement initiatives, as well as teach all participants how to create and nurture collaborative environments.

Assessing CME/QI Needs

CME professionals generally have little or no training in QI, so the responsibility for it has rested elsewhere in healthcare organizations. Likewise, QI professionals generally have had little or no training in CME and so often don't understand how the two can work together to accomplish QI goals. The partners recognized that, although CME interventions can be integrated with QI to close performance gaps, both CME and QI professionals need to make a concerted effort to study the parallels and differences between CME and QI, either through simple communication or through shared learning.

Next Page: The Pilot Takes Off