Employing Adult Education Principles to Tackle Performance Improvement Challenges

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Employing Adult Education Principles
to Tackle Performance Improvement
Challenges
Lara Zisblatt, M.A.
July 12, 2011
2:00 – 3:00 pm ET

Presenter

Lara Zisblatt, M.A.
Assistant Director
Continuing Medical Education
Boston University School of Medicine

7/8/2011

Disclosures

Lara Zisblatt has nothing to disclose with regard to
commercial relationships and is not selling a
technology, program, product, and/or service.

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Competency Area 2.1

Use evidence based adult learning principles to guide
the practice of CME

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Objectives

Following this session, you will be better able to:
Describe how adult education principles inform the
practice of Performance Improvement (PI) CME
Use adult learning principles in the planning of
effective PI CME activities
Employ adult education principles to confront PI CME
challenges

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Experience in PI CME

Began planning first PI Initiative in 2004
First initiative was launched in 2006
To date we have planned and implemented 18
activities, some that have lasted for a few years
Clinical areas have included:
Adolescent Vaccinations Depression
Attention Deficit Hyperactivity Disorder Diabetes
Asthma Obesity
Chronic Obstructive Pulmonary Disease Osteoporosis
Coronary Artery Disease Urinary Incontinence

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Models for PI CME

2 National PI CME Initiatives completed, 1 ongoing, 1 in planning
phase
(COPD, Depression, Type 2 Diabetes, Obesity)
Online, distance education
3 completely self-directed, 1 on BUSM-directed schedule
3 small regional PI CME Programs
(2 CAD and Overactive Bladder)
Connected to an annual meeting
11 local PI CME Programs
(Adolescent Vaccination, ADHD, 7 COPD, 2 Obesity and Osteoporosis)
Providers complete all stages of the PI CME activity during their regularly
scheduled practice meetings or grand rounds

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Example of Outcomes from a Local
COPD PI CME Activity
100% 96% 98%
Boston University Slideshow Title Goes Here 94%100%

90% 85% 81%
79% 77% 82%
80% 75% 76%
74%
68%
70%
60%
60%
60%
50%
50%
38%
40%

30%
21%
20% 15%
9%
10%

0%
Influenza Vaccine

Intervention
Rehabilitation
Initial Spirometry

Pharmacology

Pneumococal

Long-Term
Saturation
Assessment
Spirometry

Oxygen
Pulmonary

Smoking

Oxygen
Repeat

Smoking
Vaccine

Pre-Intervention Post-Intervention

Statistically significant improvement seen in initial spirometry,
repeat spirometry, pulmonary rehabilitation, flu vaccination, and
smoking assessment

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The Challenge

How do we motivate clinicians to engage in and
complete a performance improvement activity?

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Malcolm Knowles – Father of Adult Ed
6 Assumptions about Adult Learners

1. Have a Need to Know
Help the clinician-learner identify the gap between where
they are now and where they want to be.

2. Are Self-Directed
PI CME is self-directed and allows for clinicians to
choose their own interventions and design their own
action plans.

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3. Bring a Lot of Experience to the Learning Environment
Acknowledge this, incorporate it, employ it in the planning of the
educational interventions – give them practical tools to use.

4. Are Ready to Learn
Adult clinician-learners will be in various stages of readiness to learn
and change. PI CME can help them move through this process.

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5. Have a Real-life Orientation to Learning
Adults learn best when new information is presented in
the context of real life – PI CME is embedded in the
“real-life” practice setting.

6. Are Motivated to Learn
Internal motivators are the most potent.

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PI CME Strong Basis in Learning Theory

Not just about outcomes data
Performance Assessment addresses the issue of
clinicians inability to accurately assess their own
practice (Davis, 2006)
The serial and active nature of PI CME have been
shown to be effective in improving performance
(Grimshaw, 2001, Davis, 1999)

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Behavioral Basis for PI CME

PI CME is based on Edward W. Deming’s industrial
and statistically driven model for quality improvement:
Plan, Do, Study, Act
The idea is to look at the data from patients, examine
the system of practice, and make a change to improve
care
If we had total control of the practice environment, we
could implement an intervention that would
automatically change behavior

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More to PI CME

But we don’t have total control of the environment
Clinician involvement in improvement is crucial
To Err Is Human expressly states that the IOM is “not…pointing
fingers at caring health care professionals who make honest
mistakes.” (Institute of Medicine, 2001)
Many have wondered: where are the clinicians?
PI CME is a great way to promote clinician involvement

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Why clinicians participate

“I figured I could learn more”
“Great if we could take an organized look at this”
“Clinically significant...it seemed like it was an area
where we had a lot of room to improve”
“We could really...help our patients”
“I’ve been always somebody who likes to improve”
“Many hours of CME didn’t hurt”
“My job is QI and organization of improvement for
diabetes care and so I thought it was interesting”

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How Theory Can Help

We don’t have the answer to the retention problem for
online PI CME programs
Local activities where practices complete each stage as a group
Physician champions and buy-in from the leadership are key
Theories can help identify gaps in your planning
Theories can give meaning to your planning choices

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Learning Paradigms

Behaviorists (Skinner, Pavlov):
Stimulus-response. All behavior caused by external stimuli (operant
conditioning). All behavior can be explained without the need to
consider internal mental states or consciousness.
Humanists (Maslow, Rogers):
Learning is a personal act to fulfill one’s potential.
Social Cognitivists (Bandura):
People learn from one another, via observation, imitation, and
modeling.

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Behavioral Learning Theories

The teacher can help institute interventions that lead participants
to respond appropriately
Insert changes to the environment to precipitate improvement without
additional burden on clinicians
Electronic reminders
Standing orders
Data collection by Medical Assistants
Stage A and Stage C act as reinforcement of positive and
reminder of negative behaviors
Yet - provider involvement and motivation is important
Difference between PI and QI
Clinicians need to believe in the change to make it happen

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Humanistic Learning Paradigms

How can you make the education more personal?
We found that those who were used to looking at data found the
individual chart review process personalized the process, making it
more meaningful
But what else could make the experience personal?

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Example of from the practice

Interviewer: would you ever want to go to a model just for ease of it to look at it through epic or do
you think keeping this piece of it?
Physician: I think keeping the individual chart reviews? I think they are always going to be
valuable. Um you know…as we get further and further into an EMR would we be able to replicate
every single thing…I don’t know, um I don’t know, um but I think looking yourself I think looking, I
don’t know. I just found it to be really helpful. Looking at a patient that I know that I have known
for 10 years, who has COPD and realizing I don’t know, what, that they really could’ve used
pulmonary rehab and I had never suggested it. And I think that is very valuable. And its different
from getting a piece paper spat out saying number who could have used it and number
who…cause you know, cause you feel like you are letting this particular patient down. That’s
powerful.
Interviewer: yeah a little bit of the emotional tug
Physician: Well, yeah, because when you are doing chart reviews if you are a primary care doc
whose been in practice for any amount of time you are really reviewing individual…you know these
people, right, so….I think, I think it has value from that perspective. Even if you could do it
completely out of the computer.

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Social Cognitive Learning Paradigms

How can you create an environment for online learning
programs where participants can observe and model
appropriate behavior?
The chart audit form itself can identify appropriate behaviors
How else can you encourage interaction so that participants can
observe appropriate behavior? How can you give participants the
ability to try out behavior?

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Example of from the practice

Interviewer: How did that make you feel when you saw that data? Were you just…what was your attitude
towards seeing that gap in practice?
Nurse: Well, I probably said okay nice, interesting to know how can I incorporate something. I did show that
first audit to doctor and I showed him what it said toward the national average and recommendation umm
what it says what you should do so um I didn’t feel it as a critique against our work no.
Interviewer: mhum mhum
Nurse: if we call critique constructive criticism
Nurse: What it was geared to be
Interviewer: Yep
Nurse: Since it was a performance improvement program
Interviewer: mhum mhum, yes [laugh]
Nurse: [laugh] it was for us to identify was is the gold standard, right?
Nurse: and What you should strive for to improve the quality of care for your patients
Interviewer: and then so when you showed it to your doctor when did you decide to do that, were you always
planning on doing that
Nurse: I did it after I printed it off and looked at it and said sean I did this program I told you about that I was
going to do and this is the result of my first audit this is what it says and he goes ohh interesting

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Incorporating Humanist Learning Theory

Motivate through Feeling:
Emails with cases and other descriptions to help participants become
emotionally involved in the program.
Emphasize that the charts represent real patients. Don’t always
focus on the final percent.
Promote Mindfulness:
Open Action Plans can ask probing questions that promote reflection
about practice and how to implement change.
A coach can call participants to encourage reflection about practice.
Encourage Transformational Learning:
Learners not threatened by negative feedback. Can use this as a
transformational experience.

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Incorporate Social Cognitive Theory

Observe others
Performance data from peers
Modeling through videos demonstrating positive behaviors, like
motivational interviewing and best practices
Instructors as Mentors
Teleconferences and office hours can help encourage one-on-one
time with participants and faculty
Social Interaction
Discussion boards, open teleconferences, meet-ups
Encourage clinicians to participate as a group

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Humanism Approach
Enhanced

Knox’s Proficiency Theory

Knowledge
Attitude
Skill
Leads to improved performance

Proficiency Theory - Knox - 1990

Examined CME participation applying adult education
principles. Recommendations:

Employ testimonials, success stories and human
interest stories to encourage participation
Portray benefits
Recruit an entire practice
State discrepancies between current and desired
proficiencies

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Knox - 1990

Build in opportunities for positive feedback and
success along the way – to build proficiency and
sense of self-efficacy
Include examples of how others used ideas
Build in variety and measures of progress
“harness encouraging influences and deflect
discouraging influences”
Encouraging influences - MOC, PQRS, QI

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“Deflect discouraging influences” (Knox)

Address barriers whenever possible

Consider number of chart reviews – process,
performance, outcome measures
Time commitment
Lack of knowledge about PI CME process

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Self-Determination Theory –
Theory of Motivation

A framework for the study of motivation (Deci and
Ryan)
Intrinsic and extrinsic motivation
How social and cultural factors can help or hurt
motivation

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Motivation
Intrinsic Extrinsic
Positive Desire to help patients Increased Pay
Wishes to improve job skills Promotion
Love of learning/curiosity Recognition
Personal development Performance evaluation
Desire to close clinical gap Popularity/fame
Licensing/certification
requirements
Demonstrated competency

Negative Fear of failure Failure to achieve recertification
and/or re-licensure
Failure to demonstrate
competence
Poor opinion of performance by
peers and/or patients
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Motivation – How PI Can Respond
Intrinsic Extrinsic
Positive Providing better care – gaps in care Pay-for-Performance
become personalized and motivating (payers, CMS)
Clinical relevance to patient Board MOC approval
population State licensure
Provide feedback through chart Joint Commission –
summary OPPE
Compare to peers Supervisor
Compare to national benchmarks /organizational
Provide opportunities for reflection requirement
Possible career
advancement

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Summary

Using theories and frameworks can help you make
decisions on what auxiliary components you can add
to your PI CME activities
Use theories and frameworks to make your case to
funders, collaborators, and participants

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References
Aparicio, A., & Willis, C. E. (2005). The continued evolution of the credit system. Journal of
Continuing Education in the Health Professions, 25(3), 190-196.
Brennan TA. Physicians' professional responsibility to improve the quality of care. Academic
Medicine. 77 : 973 2002.
Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L.
(2006). Accuracy of physician self-assessment compared with observed measures of
competence - A systematic review. Jama-Journal of the American Medical Association,
296(9), 1094-1102.
Deming EW. The New Economics for Industry, Government, Education. Cambridge, MA: MIT
Center for Advanced Engineering Study, 1982.
Duffy, F. D., Lynn, L. A., Didura, H., Hess, B., Caverzagie, K., Grosso, L., et al. (2008). Self-
assessment of practice performance: Development of the ABIM practice improvement module
(PIMSM). Journal of Continuing Education in the Health Professions, 28(1), 38-46.
Epstein et al. “Self-Monitoring in Clinical Practice: A Challenge for Medical Educators.” The
Journal of Continuing Medical Education in the Health Professions. 28.1 (2008): 5-13.
Goulet F, Gagnon RJ, Desrosiers G, Jacques A, Sindon A. Participation in CME activities.
Canadian Family Physician. 1998;44:541-8.
Grimshaw JM, Shirran L, Thomas R, et al. (2001) Changing provider behavior: an overview of
systematic reviews of interventions. Med Care 39:II2–II45.

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References

Holmboe, E. S., Meehan, T. P., Lynn, L., Doyle, P., Sherwin, T. & Duffy, F. (2006). Promoting
Physicians' Self Assessment and Quality Improvement: The ABIM Diabetes Practice
Improvement Module. The Journal of Continuing Education in the Health Professions, 26(2),
109-119.
Knox, A. “Influences on Participation of Continuing Education.” Journal of Continuing
Education in the Health Professions, 10(1990) 261-274.
McHugh, E. “Awareness of Performance Improvement Activities.” Medical Meetings
Magazine. 37.1 (2007) Cover.
Ryan, R. M., and E. L. Deci. "Intrinsic and Extrinsic Motivations: Classic Definitions and New
Directions." Contemporary Educational Psychology 25.1 (2000): 54-67. Print.
Simpkins, J; Divine, G; Wang, MQ; et al. “Improving asthma care through recertification - A
cluster randomized trial.” Archives of Internal Medicine. 167:20 (2007): 2240-2248.
Shershneva, M. B., Mullikin, E. A., Loose, A. S., & Olson, C. A. (2008). Learning to
collaborate: A case study of Performance Improvement CME. Journal of Continuing Education
in the Health Professions, 28(3), 140-147.
Staker, LV. (2003). Teaching Performance Improvement: An Opportunity for Continuing
Medical Education. Journal of Continuing Education in the Health Professions, 23(1) S34-
S52.

7/8/2011


PI CME can be a
catalyst for change!

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