that continuing medical education is undergoing some fundamental changes is becoming ever more apparent. Fading fast is CME as usual, whose mission is to provide a lecture on a topic of interest and judge an activity's success by asking learners if they liked the coffee and doughnuts. The old version of CME is not-so-slowly, but surely, being reconstituted so that it can become a vital piece of the growing healthcare quality-improvement movement. The new form of CME that will be able to actually help make the QI that physicians, insurers and other payers, healthcare systems, legislators, and patients are increasingly demanding? It's called continuous performance improvement, and it's going to rock the CME world.

So said those who participated in the National Institute for Quality Improvement and Education Fall Conference, held in Chicago in September.

No, it won't be as easy as just changing an acronym, but if you plan to continue educating physicians and other healthcare workers in this increasingly QI-focused healthcare system, NIQIE leaders said you're going to have to erase some old ways of thinking, planning, and conducting it.

Quality Improvement Here to Stay

While it's easy to think the pendulum is swinging just temporarily to the quality side, all indications are that QI as a fad is one of the first ideas you need to delete from your mind-set. The Institute of Medicine, in its 1999 “To Err Is Human” report, sparked the public interest when it pointed out that up to 98,000 Americans die in the hospital each year from preventable medical errors, the equivalent of a jumbo jet load full of people crashing daily. When IOM followed up two years later with “Crossing the Quality Chasm,” which makes an urgent call for fundamental change to close the quality gap and asks for a redesign of the entire American healthcare system, it was like throwing gas on the fire.

The organizations that regulate, accredit, credential, and license healthcare practitioners have started feeling the QI heat and are putting some of their own on their members. One of the most influential moves so far came when all 24 member boards of the American Board of Medical Specialties began requiring their HCPs to demonstrate their commitment to lifelong learning, engage in a periodic self-assessment process, and show their competence in areas such as patient care and communication skills, as well as medical knowledge, in order to maintain their specialty board certifications.

According to a presentation by Richard Hawkins, MD, senior vice president, professional and scientific affairs, ABMS, Chicago, at NIQIE, recent revisions to Part II of the maintenance of certification, or MOC, standards include requiring 25 CME credits per year, a third of which involve self-assessment. Part IV of the standards, which involves practice performance assessment, now includes practice assessment and QI, including a registry with learning collaborative, a self-administration module, and quality measurement/improvement. This doesn't mean, however, that any CME that qualifies for American Medical Association PI CME credit will automatically satisfy a board's MOC Part IV requirements. Each certifying board has its own criteria for approving activities for MOC Part IV — just being able to offer PI CME credit for an activity that isn't designed specifically to meet that board's criteria may not suffice.

As Hawkins pointed out, there are lots of other parties interested in physician performance improvement as well. Consumers and payers are considering pay-for-performance, physician report cards, and rating systems. Eric Holmboe, MD, senior vice president for quality research and academic affairs with the American Board of Internal Medicine said that ABIM's MOC program has been incorporated into a number of private-sector reward and recognition programs, including those of Aetna, Cigna, and Humana.

Quality organizations such as the Agency for Healthcare Research and Quality, the AQA (formerly known as the Ambulatory Care Quality Alliance), National Quality Forum, and the National Committee for Quality Assurance are also focusing on CPI, as is the federal government in the form of the Centers for Medicare and Medicaid Services. As Atul Grover, MD, PhD, FACP, FCCP, chief advocacy officer, Association of American Medical Colleges, Washington, D.C., showed, the government is beginning to tie reimbursement to the quality, not just the volume, of care provided. A case in point is the CMS Physician Quality Reporting Initiative's recent decision to provide financial incentives to physicians and systems that report on their use of quality metrics.

Of course, the Accreditation Council for CME is making adjustments to this new quality focus as well. In 2006, it revised its accreditation criteria to reflect the growing trend. The aim is to frame CME outcomes in “improvement of competence, performance, and patient outcomes rather than just “'learning,'” said Barbara Barnes, MD, MS, associate vice chancellor, continuing education and industry relationships, University of Pittsburgh; vice president, sponsored programs, research support and CME, University of Pittsburgh Medical Center; and chairwoman, ACCME board of directors, at NIQIE.

For example, Level 2 now asks the provider to incorporate into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners, where the prior version wasn't specific about the needs, nor did it mention practice gaps. And while the criteria didn't previously ask for more than some kind of evaluation (hence the coffee-and-doughnuts questions), Level 3 now demands that CME activities are designed to change competence, performance, or patient outcomes.

Those who want to achieve “accreditation with commendation (six years) must comply with criteria for mission, educational design, evaluation, and Standards for Commercial Support as well as requirements for engaging with the environment,” Barnes said during her presentation at NIQIE.

Like it or not, the participants at the NIQIE conference emphasized, the healthcare quality movement is gaining momentum, as is the concomitant shift from CME to continuous performance improvement.

As NIQIE board member Jack Kues, PhD, assistant senior vice president for continuous professional development, University of Cincinnati Academic Health Center, said after the conference: “Quality is going to be the focus of healthcare reform; CME will not survive if it cannot adapt.”

Get Out of Your Silo

People have been talking for years about the need to get out of the CME silo and collaborate with others. It may be cozy, but silos get the red pencil. As Don Moore, PhD, director, division of CME; director of education and evaluation, graduate medical education; faculty associate, Office of Teaching and Learning in Medicine; and professor of medical education and administration, Vanderbilt University School of Medicine, Nashville, said, “It's about coordinating a different set of resources than it has been in the past.” That means coordinating with quality-improvement professionals and instructional designers to develop effective continual performance-improvement approaches. To receive AMA PRA Category 1 credit for a CPI activity, physicians must complete three phases: They must compare their performance to national benchmarks, identify gaps and improve practice, and measure their performance over time. They get five credits for each phase they complete, and another five for completing the whole set.

“Clearly the most important, and most difficult, part is to develop a collaborative relationship with whomever is doing quality improvement in your organization, or in the case of a medical education company, the organization you're working with,” he said.

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