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

Thus, the first step in the train-the-trainer approach was to educate CME and QI professionals in LSS methodologies, providing a high-speed bridge that would link both disciplines and target organizational change to where it is most needed within the organization.

The train-the-trainer approach identified the early adopters of organizational change who could in turn become champions to influence others. The partners expect that about half of workshop participants will go on to conduct at least one follow-up workshop at their own institutions, expanding the pool of trained learners and potential trainers.

Clark notes, “This collaboration requires the leadership and ongoing support of the physicians in the practice. Those involved need to get to know each other and to understand the language and concepts underlying approaches to performance improvement. The initiative we developed was specifically designed to bring the disparate professionals involved in performance improvement together in an activity involving both didactic presentations and interactive workshops.”

The Pilot Takes Off

The pilot train-the-trainer workshop — conducted at IUSM on November 13, 2009 — convened 45 CME/CE healthcare professionals, QI professionals, and clinicians from throughout Indiana in a daylong activity to develop the core curriculum with slides, syllabus, and collateral materials to be used at subsequent workshops that would take place at IUSM and four other academic health science centers.

CMEE's Tiffany Harazinova, who served as activity manager for the workshop, was encouraged to see registration fill up quickly. “We had to cap registration at room capacity and start a wait list. At that point, we knew this was a topic that our target audience wanted to hear more about.” She notes that participation the day of the event was focused and enthusiastic.

Although the workshop received high marks for relevance and practicality, activity planners from IUSM and CMEE decided to modify the curriculum based on feedback and their own observations of participants' interactivity and enthusiasm. In future workshops, they will increase the number of faculty, provide a greater emphasis on Lean methodology, and focus more on the applications that most engaged clinician participants.

“We are trying to balance theory and practice,” says Winicur. “Learners are given a background in Lean Six Sigma theory and tools in the first half of the day and practical applications of Lean methodologies in the second half. When doctors, nurses, and QI specialists do hands-on activities together, they learn that Lean initiatives run the gamut from organizing a medical supply closet to monitoring A1c levels in diabetic patients.”

Moving on to Phase 2

Going forward, in addition to IUSM, the academic health science centers of the University of California, Irvine School of Medicine; University of New Mexico School of Medicine; University of Wisconsin School of Medicine and Public Health; and the University of Arizona College of Medicine-Phoenix, in partnership with Arizona State University, will continue the initiative.

Clark says that the partners selected academic health centers “that were enthusiastic about the concept of the initiative and were willing to assure us of their continuing support of the attendees as they applied the concepts learned in the initiative. The selected centers also were willing to collect the data we would need to evaluate the initiative's effectiveness.”

To help sustain the effects of the workshops over the long term, the initiative's partners are developing tool kits that condense lengthy clinical practice guidelines or standard methodologies. They will post the tool kits on an online Web portal, which also will serve as the mechanism for disseminating, collecting, and analyzing data for the initiative's outcomes research component. Workshop participants will be encouraged to publish their contact information on this Web portal to create a virtual community of practice.

Measuring the Results

The outcomes of the initial workshop at IUSM were measured to Moore's Level 5, performance changes, and that level of outcomes will be measured at the added sites. (See box on page 18 for Moore's seven-level outcomes pyramid.)

A workshop scheduled for late 2010 on the IUSM campus is designed to take the initiative to Moore's Level 6, patient health, by specifically investigating evidence of:

  1. An increase in the number of QI activities at each participating clinic or hospital;

  2. An increase in the engagement of healthcare professionals in QI activities;

  3. An improvement in selected clinical performance measures.

Participants in the IUSM intervention are being recruited from healthcare practices with assistance from Wishard Health Services, a central Indiana health service network of about 20 medical clinics, and the Indiana Health Information Exchange through its Quality Health First program. The partners will survey each participating practice monthly on the number of QI activities initiated that month, the number of its healthcare professionals involved, and the number of patients achieving target outcomes measures.

Winicur explains that the survey will use an interrupted-time-series experimental methodology, which allows a researcher to distinguish the effects of unaccountable variables from planned interventions across time. This allows the partners to differentiate change that stems from QI activities from unrelated causes, while also accounting for the complexity inherent in large healthcare systems, a factor often ignored by randomized controlled trials. IUSM and CMEE will ask practices opting out of the intervention to complete the monthly QI surveys to act as a comparison group. They also will invite learners to participate in the surveys via e-mail. A complementary healthcare LSS outcomes research study, “Researching Implementation and Change While Improving Quality,” has been submitted by the partners to the Agency for Healthcare Research and Quality as an R18 grant.

As noted in the December Medical Meetings' cover story, “If you plan to continue educating physicians and other healthcare workers in this increasingly QI-focused healthcare system … you're going to have to erase some old ways of thinking, planning, and conducting it.” In other words, you need a new direction. The Bridge to Quality initiative aims to help all groups within healthcare organizations head in that new direction together.

Bruce J. Bellande, PhD, FACME, CCMEP, is president of CME Enterprise, an ACCME-accredited medical education and communication company based in Carmel, Ind. He previously served as executive director of the Alliance for CME.

Sidebar: Moore's 7 Levels for CME Outcomes Measurement

  1. Participation

  2. Satisfaction

  3. Learning

    3a. Declarative knowledge

    3b. Procedural knowledge

  4. Competence

  5. Performance

  6. Patient health

  7. Community health

Source: Moore, D.E. Jr.; Green, J.S.; Gallis, H.A. “Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. “Journal of Continuing Education in the Health Professions 29, no. 1 (Winter 2009):1-15