If continuing education providers want to create change, they need to understand the intricacies of the system they and their learners work in.
If there was one message to walk away with after the Alliance for Continuing Medical Education's Annual Meeting in New Orleans in January, it was that continuing medical education can be a key driver in an organization's move toward performance improvement. But healthcare-related organizations are complex entities that can take a lot of time and effort to turn around. To make change happen that will improve outcomes, CME providers have to learn how to collaborate with departments including informatics and quality and performance improvement, as well as the individual docs and their healthcare teams.
While this is easier said than done, it can be done. So said David Price, MD, and George Mejicano, MD, at a session they presented at the Alliance annual meeting. Price is director of education, Colorado Permanente Medical Group; medical director, Permanente Federation Education Program, Oakland, Calif.; and professor, family medicine, University of Colorado at Denver Health Sciences Center. Mejicano is associate dean for continuing professional development; director, office of Continuing Professional Development; and professor, internal medicine, University of Wisconsin School of Medicine and Public Health. Here's what they had to say.
CME is nested in complex adaptive systems, said Mejicano. Even solo physicians work in systems, all of which consist of many interconnected parts. When the CME office acts as a part of a system, rather than as its own entity, it can identify new perspectives and barriers to change that can move the entire organization forward.
But first, CME providers need to understand the system they're in and its many moving parts. The people in the various parts of an organization get to make their own decisions about when, where, and how fast to adopt a change, said Price. Each piece of the system can view the proposed change differently, depending on the resources available to it, the barriers and incentives it faces, and its level of accountability to the results. Rarely do all parts of an organization agree on the need to change, nor on the schedule for its implementation, said Mejicano and Price.
You have to forget about fixing just one link in the chain — that analogy doesn't work for these systems, said Mejicano. That means that interventions that aim to change only a physician's behavior most likely won't lead to a sustained change in practice systemwide. However, small changes can ripple out as different pieces of an organization begin to experiment locally. That's why you have to identify the networks that connect various people and departments. “They may not be what you think they are,” said Mejicano. You may think everyone is talking to everyone else in an orderly fashion, but when you look at actual interactions, some of the connections you would assume are there may not be, while others you wouldn't expect may be strongly in place. You have to find out where the connections actually are, he said.
One problem CME providers run into is a language barrier: CME providers speak CME, PI practitioners speak PI, and docs speak “medicalese.” To be effective change agents, CME providers “have to speak the language of their stakeholders,” said Price. Take “learning objectives,” for example. Why not call them something that would make more sense to your stakeholders, such as “performance expectations,” since these are statements of what you expect your learners to be able to do when they walk out the door? Mejicano offered another example: “Don't call a handout a ‘non-educational strategy.’ Call it a handout.”
It's important to talk their talk when it comes to departmental functions as well. While the CME and quality improvement processes have very different names for their various segments, the underlying concepts are pretty similar. For example, the QI cycle's “Plan, Do, Study, Act” lines up right alongside the CME model, with the needs assessment and objective setting being the “plan,” implementation the “do,” evaluation the “study,” and follow-up the “act.”
Once everyone understands the parallels, it's easier to talk about how your needs assessment can help plan the QI initiative. Can the gaps you uncover during your needs assessment process help to better plan the QI initiative? Which educational format would best accomplish the “Do” phase? “The more you can incorporate [CME factors into the QI cycle], the more likely your initiative will take off,” said Price.
Most organizations focus their change efforts on those who appear to need it most: The people who score in the bottom 20 percent when it comes to making a change in behavior. If you want to be successful, forget about them: They have already demonstrated that they will be resistant to your efforts to make them change.
“Concentrate your efforts on those who are dissatisfied with the status quo and interested in doing new things, the early adopters, not the laggards,” said Price. Mejicano added that who those early adopters are may vary from idea to idea. What CME intervention is best for that audience? Who should the faculty be? How can early adopters become facilitators in future CME?”
The tipping point comes when 10 percent to 20 percent begin to implement the change. That's when “it takes on a life of its own,” said Mejicano.