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					CME, QI, & Transfer of
                David Price, MD

Director of Education, Colorado Permanente Medical Group
 Clinical Lead, Education, KP Care Management Institute
Associate Professor, Family Medicine, UCHSC         Chair
         -elect, American Board of Family Medicine

                  SACME March 2007
Problem #1
• US expenditures on health care lead the
• The quality of US healthcare is “mediocre”
  (#37 in overall quality) (IOM)
  Problem #2: Overall, only about
  half of recommended care is

McGlynn et al, 2003
Problem #3
• Despite years of trying, traditional CME
  doesn’t fix this
Why Might Physicians Engage
in CME?
• Some don’t!
• Requirement (board, credentials, license)
• Food
• Stipends (for employed physicians)
• Networking
• Intellectual stimulation
Why Might Physicians Engage
in CME?
• Keep up/verify current practice
• Desire to learn new things
• Desire to solve current problems (reflective
• Desire to improve
Why Might Organizations
Support CME?
• Disseminate new information
• Support new initiatives (organizational
  initiatives, new services/products)
• Address public/regulatory concerns
• Enhance public image
• Improve quality
External factors affecting CME
CME in context

• Physicians practice as part of a system (even
  in solo practice)
• Systems are composed of multiple
  interconnected parts with some autonomy
Variables in adoption of evidence
(conceptual framework)

• Evidence
• Manner of facilitation
• Context (including the system in which one
             Kiston A. Harvey G, McCormack B. Enabling the
         Implementation of evidence-based practice: A conceptual
              Framework. Qual Health Care 1998;7:149-58

• Perspectives vary in different system parts
   • Resources
   • Context of Care
   • Barriers and incentives
   • Accountability
• Interventions that address only the physician
  (as 1 point in a system) unlikely to lead to
  sustained practice change

CME as part of a system or organization can:
• Help identify new perspectives
• Help “educate” multiple stakeholders
• Assist the organization in a multifaceted
  approach toward improvement.
   • Help identify “leverage” points (Senge) for
    organizational improvement

• Describe key principals from 3-4 different
  models of QI, organizational change &
  diffusion of successful practices
• Relate these key principals to the processes
  used in developing, implementing &
  evaluating CME Programs.
Reflection questions

• What major initiatives are going on in your
  organization (or the organizations of your
  customers) right now?

• What major CME programs are on your plate
  right now?

• Do they match?
Who are Your Sponsors?

• Have you explicitly talked with your
  sponsor(s) about how they see CME helping
  them achieve the goals of the(ir)

• Have you ever explicitly talked with your
sponsor(s) about how CME can help them with
specific initiatives?

• Rogers’ Diffusion of Innovation
• The tipping point/Complexity Theory
CME Process vs. QI Cycle
Using the PDSA Model

• What Stage is a QI initiative in?
• How can your needs assessment help plan the QI
• What CME format(s) integrate with the “do” phase?
• How can CME evaluations support the “study” phase?
•What f/u CME activities can support the “act” phase?
Characteristics of Innovations
that spread
• Trialability (adaptability)
• Advantage (relative to current system)
     Plsek add Evidence-based
• Compatability
• Observability
                                  From E. Rogers
• Sponsorship (from Price)
Using Rogers’ model

• See article with list of questions
Who Adopts Innovation?
                         From Rogers
How innovation spreads
 Complexity Theory      (PIsek)

• Organizations are complex adaptive systems
  (complex web of relationships)
• Individuals often have choices whether to
• Universal agreement on need to change is rare
• Agreement often lacking about effects of
  proposed change
 Complexity Theory               (PIsek)

• Most change happens in “zone of uncertainty”
  • About need for change
  • About results of change
• Change happens over time, at different speeds
  in different parts of the organization, with lots of
• Small local changes may have ripple effects
  • “butterfly effect”, “stone in the pond”
 Using the Tipping Point and
 Complexity Theory
• Where/who are the early adopters?
• WIIFT (why might they want change?)
  • Creative desire
  • Dissatisfaction w/status quo?
• What CME format will best reach this audience?
• Who should the faculty be?
• How can early adopters serve as facilitators in
  future CME (train the trainer)?
• Personal factors (PRECEDE)
• Environmental factors (PROCEED)

          Precede/Proceed model, Green and Kreuter

• Predisposing factors
  • knowledge
  • attitudes
  • skills
  • beliefs

• Reinforcing factors
  • discuss data
  • recognize incentives and disincentives

• Enabling factors: tools
  • “just in time” information recall
  • scripts
  • handouts
  • patient education
  • patient self-care

• Policy implications
• Regulations
• Organizational initiatives/other factors

• How will your CME program address attendee
  knowledge, attitude, skills, & beliefs?
• What reinforcing factors will be used after the
  CME program?
• What enabling factors can be provided at the
  CME program?
• How can policy implications of proposed
  changes (in regulations) be addressed in
  your CME program?
  • Allow attendees to discuss/brainstorm with each
   other, share ideas and learnings
• How can discussions at CME programs
provide feedback to those setting policy,
regulations, or directing organizational
Effectiveness in changing
practice (Cochrane, 2002)
• Minimal
  • Didactic lecture, mailed unsolicited materials
• Moderate
  • Audit & feedback delivered by opinion leaders or
• Relatively strong
  • Reminders, academic detailing, multiple
Additional Factor in Successful
Spread (Kaiser Permanente Care Experience Council)
• Challenge/compelling problem
• Source champion (innovator) willing to help
  in source transfer
• Lead implementer has high level of trust in
  source champion
• Strong physician champion
• Steering committee with multiple
Additional Factor in Successful
Spread (Kaiser Permanente Care Experience Council)
• Project manager for practice transfer
• PDSA/phase-in
• Physicians/staff dissatisfied with status quo
• Performance/financial gap
• Trusted opinion leaders
• Evidence it worked elsewhere
Additional Factor in Successful
Spread (Kaiser Permanente Care Experience Council)
• Strong support senior management
• Effective clinical leadership
• Credible/persuasive data to support start up
• Coordination across departments
• Planned sustainability from the outset
• “WIIFM” – perceived ability to reduce
  external threats
Additional Factor in Successful
Spread       Sheldon TA et al. BMJ 30 Oct 2004

• Effective use of communication channels
  (including personal)
• Interconnectedness of the network
• Extent of promotion efforts by agents of change
• Commitment to/systems for managing process of
Additional Factor in Successful
Spread       Sheldon TA et al. BMJ 30 Oct 2004

• Proactive assessment of local costs &
  implications of implementation
• Culture of consensus
• Clinician involvement in process
Which Model to Use?
CME as a means of translating
evidence into practice
• Attitudes and beliefs
• Knowledge: components of good care
• Skills to make changes that result in
• Systems: processes to facilitate
  change/overcome barriers
                “Knowing is not
“Knowing is not enough; we must apply
  Willing is not enough; we must do.”
Price D. Continuing Medical Education, Quality
 Improvement, and Organizational Change:
 Implications of Recent Theories for 21st
 Century CME. Medical Teacher

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