Nancy Davis

Selecting educational interventions for knowledge translation

The term “education” has many meanings, although its gestalt shows little effect on the performance of clinicians or the outcomes of health care. This lack of effect is especially true in continuing medical education (CME), where education often implies a large, group-based session held in a

Aligning academic continuing medical education with quality improvement: a model for the 21st century.

The recent health care quality improvement (QI) movement has called for significant changes to the way that health care is delivered and taught in academic medical centers (AMCs). This movement also has affected academic continuing medical education (CME). In January 2011, to better align the CME and QI efforts of AMCs, the Association of American Medical Colleges (AAMC) launched a pilot initiative called Aligning and Educating for Quality (ae4Q). The goal of this pilot was to assist 11 AMCs as they moved to a more integrated model of continuous performance improvement by aligning their quality measurement and improvement with their continuing education endeavors. In this article, the authors describe the development of the ae4Q pilot and the resulting outcomes that have led to ongoing improvements. During the 18-month pilot, AAMC consultants conducted readiness assessments and on-site visits and provided consultation services and Web-based resources based on the AMC’s needs. Following these interventions at each site, they then conducted both interviews with participants and postintervention assessment surveys to measure the impact of the pilot. Findings included demonstrated increases in the alignment of CME and QI, a greater use of quality data in CME design and delivery, and a greater use of CME as an intervention for clinical improvement. Two sites also attributed measureable improved clinical outcomes to their participation in the ae4Q pilot. The AAMC has used these findings to create resources and ongoing services to support AMCs as they pursue efforts to align QI and CME.

The long-term impact of a performance improvement continuing medical education intervention on osteoporosis screening.

Introduction: The purpose of this study is to determine whether a performance improvement continuing medical education (PI CME) initiative that utilizes quality improvement (QI) principles is effective in producing sustainable change in practice to improve the screening of patients at risk for osteoporosis. Methodology: A health care center participated in a PI CME program designed to increase appropriate osteoporosis screening. There were eight 1‐hour educational sessions for this activity over a 9‐month period. Thirteen providers completed all 3 stages of the PI CME program. A variety of other clinicians, in addition to the 13 providers, participated in the educational sessions. Data were collected at the beginning and end of the PI CME activity and at three intervals during the 5 years after the completion of the activity. Results: The percentage of tests for osteoporosis ordered and performed increased significantly from Stage A to Stage C of the PI CME activity and continued to increase after the completion of the PI CME activity. Follow‐up data at 4 and 40 months (for ordering and performing osteoporosis screening) and 49 months (for performing the screening only) reflect the impact of the PI CME activity plus the continuing QI interventions. The percentage of BMD tests ordered continued to increase substantially over the post‐PI CME periods: 4 and 40 months (F(3,46) = 4.04, p < .05). Similarly, the percentage of BMD tests performed continued to increase at 4, 40, and 49 months after the conclusion of the PI CME activity (F(4,55) = 12.55, p < .0001). Discussion: The data indicate that PI CME utilizing QI principles can be effective in producing sustainable change in practice to improve the screening of patients at risk for osteoporosis. Further research is needed to determine the extent to which such changes can be directly attributed to this type of intervention.

Clinical faculty: taking the lead in teaching quality improvement and patient safety

Despite efforts by health professional organizations to promote efforts in quality improvement, patient safety, and cost reduction, the issue remains that US medical schools and teaching hospitals do not have an adequate supply of skilled faculties to lead these efforts. Recognizing this need, an expert, multidisciplinary panel was convened by the American Association of Medical Colleges in 2012 to develop a systematic strategy to build a critical mass of academic health center faculties to lead and implement education in those three areas. In the last year, the American Association of Medical Colleges has launched a national institution-based initiative to train faculty in all clinical specialties, which includes those in obstetrics-gynecology. This comprehensive program consists of interactive experiential learning workshops, web-based resources, a national community of learners, implementation of educational initiatives, and dissemination of outcomes. Those faculties will be invaluable in leading and disseminating educational programs that embed quality improvement and patient safety across the continuum of womens healthcare to all faculty members and residents.

Reconceptualizing continuing professional development to close long-standing quality gaps in palliative care.

Reform is fundamentally changing how health care is delivered in the United States. Increasingly, health care providers are being held accountable for both individual and system performance, making critical reflection, innovation, and care redesign necessary to meet national quality and patient safety (PS) goals and standards. Yet amid this progressive environment, some clinical care areas struggle to make meaningful improvements. One subspecialty experiencing a particularly difficult journey toward quality is palliative care. Palliative care is the treatment of pain, symptoms, and stress caused by serious illness through the combination of patient-centered spiritual, emotional, and medical care. Highlighted in the 2013 Institute of Medicine report Delivering HighQuality Cancer Care: Charting a New Course for a System in Crisis as a subspecialty in need of significant improvement and redesign, improvements in the delivery of palliative care have been only incremental, even as the number of palliative care programs increases. A cursory review of the literature, along with a recent Centers for Medicare & Medicaid Services (CMS) regulatory reform developed to better define and integrate palliative and hospice care, indicates that even a foundational agreement on the appropriate scope and function of palliative care differs from one health system to another. The reason palliative care has so many enduring quality gaps is widely debated. There is certainly no shortage of best-practice evidence, guidelines, or quality measures for palliative care—the National Quality Forum, Center to Advance Palliative Care, and others have developed robust quality and performance measures and evidence-based bundles that provide a clear picture of what effective palliative care looks like—and the research on quality improvement (QI) in palliative care is abounding. Yet like many subspecialties, palliative care operates within a complex care system, and longlasting improvements require trenchant analysis, development, and transformation of care delivery. Furthermore, palliative care is a unique subspecialty in that it explicitly requires many of the nontechnical facilities of medicine, such as patient-centeredness and effective communication. Unfortunately, training in many of the competencies central to palliative care has not been a principal focus of medical education and clinical care, suggesting that significant investment in faculty development is required to meaningfully influence the quality of palliative care. As palliative care struggles to realize lasting improvements, many of the unresolved care gaps may benefit from interventional methods that can consistently promote both technical clinical improvements and the effective employment of nontechnical competencies. This commentary illustrates the potential impact of one of these interventional methods—continuing professional development (CPD; eg, continuing medical education, nursing continuing education)—if it is successfully reconceptualized as a fully integrated vehicle for quality and performance improvement.

Supporting learners in a technology-mediated world

Information and communication technology is pervasive in health care environments. From the smart phones we carry in our pockets to the electronic health records tracking patient data and clinician treatment decisions, digital technologies have become a part of daily practice for many healthcare practitioners. And yet, as educators we do not often make the best use of these technologies in supporting our learners’ transition to clinical practice. This issue of Medical Teacher contains two articles focusing on the use of technology in health professions education and continuous professional development. The articles are based on sessions at the MedBiquitous Annual Conference May 2–4, 2012 in Baltimore, Maryland, USA. MedBiquitous develops technology standards to advance the health professions, and the conference focused on the use of technology to transform health professions education across the continuum (Smothers et al. 2008a,b). The article from Ellaway and colleagues focuses on the use of Electronic Health Records (EHRs) in medical education. The authors reviewed the literature on the intersection between EHRs and medical education, and the results were rather sobering. EHRs are often omitted from or tangential to the medical education experience. When they have been integrated into medical education, the result often lacked the modeling, training, and support necessary for success with both clinical faculty and learners. While there is widespread belief in the benefits of EHRs when implemented appropriately (Committee on Patient Safety and Health Information Technology, Institute of Medicine 2012), systemic change is necessary for these benefits to translate to medical education to adequately prepare learners for practice in EHR-supported practices. The article from Gordon and Campbell focuses on the use of electronic portfolio technology to support the continuing professional development of physicians in Canada. The picture here is more optimistic: building on educational theory, the experiences of portfolios implemented in other educational contexts, and experience with previous professional development efforts, the groundwork is laid for success. The system developed by the Royal College of Physicians and Surgeons of Canada for professional development of its members supports reflection and continuous improvement, while streamlining physician documentation through interoperability with existing systems. Health system technologies and learning technologies serve as important tools in the education and support of healthcare professionals. But their implementation does present a change to workflows, roles, and responsibilities. To succeed, there must be a cultural shift among learners, educators, and their institutions. With appropriate planning and support, we can prepare learners and educators for practice and continuing improvement in a technology-mediated world. We must learn from our collective experiences to develop appropriate and evolving best practices that reflect the context of the complex learning ecologies that define contemporary health professions education.

AJMQ Newsletter Education Committee Update

ACMQ’s first virtual journal club was held on July 21, 2015. Ten members participated in a discussion of The Impact of Tort Reform and Quality Improvements on Medical Liability Claims: A Tale of 2 States by Kenneth D. Illingworth, MD, Steven H. Shaha, PhD, Tony H. Tzeng, BS, Michael S. Sinha, MD, JD, and Khaled J. Saleh, MD, MSc, MHCM, published in the American Journal of Medical Quality, 2015, Vol. 30(3), 263-270. The virtual journal club will be held quarterly. Members are welcome to suggest articles and facilitate discussions. Watch for announcements of upcoming virtual journal club offerings in October and December. See website for dates, times, and featured articles: acmq.org/education/.

Caveat emptor: Judging a book by its cover

This book is part of the British Medical Journal’s “how to” series in medical education. The authors’ primary experience in medical education is in developing and teaching in Advanced Life Support courses. Dr. Davis has vast experience and a PhD in higher education and adult learning theory, while Dr. Forrest is an anesthetist at Leeds General Infirmary and has a master’s degree in medical education. Neither has experience in traditional continuing medical education ~CME!, and the book, while informative in adult learning theory and strategies for higher education, never quite makes the connection to CME. The first chapter is devoted to adult learning theory and does a nice job of presenting background on experiential learning, constructivism, situated learning, group dynamics, and reflective practice. Kolb’s learning styles preferences and Tuckman’s phases of group dynamics ~forming, storming, norming, and performing! are examples of theoretical concepts covered. Interestingly, the longest chapter is the one on lectures. Readers learn components of an effective lecture and how to ask questions in a variety of ways at a variety of levels. Perhaps the most useful chapter for CME as well as other levels of medical education is the one on workshops and discussion groups. Techniques for planning and facilitating small groups are described with useful tips on setup and managing discussion. In the Workshop section, we learn different presentation styles described as “flashers” and “strippers.” Flashers show all the material on one slide, while strippers show one point at a time. The authors provide advantages and disadvantages of both. ~Personally, I tend to be a flasher mainly because I don’t have the technical skills in PowerPoint to “strip”.! The chapter titled “Clinical Teaching” does a nice job of describing the one-minute preceptor, which focuses on the patient rather than the student, and gained favor in undergraduate medical education in the US in the 1990s. The authors go on to describe teaching one-to-one, ward rounds, and opportunistic teaching—all good techniques in undergraduate and graduate medical education, but CME presents few opportunities for their use. The final chapter focuses on e-learning and is fairly superficial, with introductory-level descriptions of design, development, and implementation. There is an innovative section on moderating online discussion. Generally this book seems targeted at undergraduateand graduate-level medical education. Throughout the book learners are called “students” and there is mainly reference to “courses” in a longitudinal, curricular perspective. The only practice-based learning described is for students or “junior physicians,” not practitioners involved in lifelong learning. The annotated bibliography includes no references from the CME literature nor is it cited or referenced in any chapter. There is no mention of the regulation or other challenges in CME today, such as controlling commercial bias. There is no discussion of evidence-based medicine or CME content development, but perhaps that was intentionally outside the scope of this book. I recommend this book for new CME professionals and especially faculty who do not have a formal background in education. The summary of adult learning theory and practical tips for lectures and small group learning are useful. It’s a quick read at only 144 pages and could serve as a useful reference. But the title is misleading. It is much more useful to those whose primary teaching is in undergraduate and residency education. Disclosures: The author reports none.