How to Use Medical Education as a Tool for Practice Quality Improvement

Alicia Sutton:
Today on Lifelong Learning we are discussing how quality improvement is evolving as it relates to continuing education. Specifically, how can education be used as a quality improvement or QI tool. What does that model look like? Welcome to Lifelong Learning on ReachMD, the channel for medical professionals. I'm your hose Alicia Sutton and with me today is Dr. Lou Diamond. He's President of Quality Healthcare Advisory Group and he also serves as Quality Improvement Education Initiative Chair for the Alliance for Continuing Education in the Health Professions and Alliance is the largest organization of healthcare educators advocating for improvement in patient outcomes through education.

Welcome Lou. We are glad you could join us.

Dr. Lou Diamond:
Than you.

Alicia Sutton:
So give us kind of a big picture here. Talk about what is quality improvement so our learners and listeners can get an understanding of that.

Dr. Lou Diamond:
So in brief Alicia, quality improvement is the set of activities that health professionals and patient engage in to improve the care of both individual patients and patient populations. Patient populations defined as the population in a given practice or a given setting or in a given region or at the state level and it's a set of activities that focuses on identifying what are the standards that need to be followed in the delivery of care to individual patients and populations, what the gaps are. Then taking steps utilizing various tools that facilitate the change in systems and/or the change of behavior of either the patient and their family or the various members of the team so that we achieve maximum positive patient outcomes and to help patients achieve health essentially.

Alicia Sutton:
A set of activities. Are these universal sets? How is that evolving? It must be done differently in different places.

Dr. Lou Diamond:
Well, you're right because at one level, as politics is or healthcare delivery is local, in all healthcare improvement has to be modified to deal with the individual patient population that you're dealing with, the cultural of the settings and the patient population and the environment in which you're working. So we really have to understand the various tools that can be applied and then apply them specifically to the problem that you're dealing with at a local level and then very importantly measure the outcomes of your interventions. It is all local, it does require cultural understanding of the settings that you're working, it requires leadership, and it specifically requires that we apply various tools-no single tool, to the problem that is encountered at a local level.

Alicia Sutton:
Here at the Alliance you are obviously leading the charge on setting up some of those tools. Do you want to talk a little bit about the Roadmap there?

Dr. Lou Diamond:
Yes. Thank you. So the Roadmap is really essentially a very focused initiative to explore the articulation of what is going to be needed to integrate educational tools and techniques and the educators integrate them into the planning and the implementation of various quality improvement initiatives that are done in various practice settings. So it's very focused.

We're not trying to boil the ocean and deal with quality improvement in general but it is focused on that specific aspect of utilizing those educational tools to improve care to influence patients and their families and to provide information to various members of the healthcare delivery team so that they can be appropriately armed with the information and the techniques that they need to utilize to improve care for individual patients and for patient populations.

Alicia Sutton:
Have you seen over the last few years a greater adoption of QI because this is something that is a passion of yours and has been going on for a while but what are you seeing the uptake being on individuals/institutions adopting QI?

Dr. Lou Diamond:
So there's an enormous amount of work going on both at local and national level to facilitate improvement but we've still got a ways to go. The improvement has been much slower than what many of us believe ought to occur. Patients are still being subjected to harms and therapy that is not based on reasonable standards and what their needs are so it's a work in progress really at both the national and local level.

We need to put in place the infrastructure to get that done and some of the infrastructure issues are ready to bold out the health information infrastructure that is occurring as we speak. To provide the kind of educational activities that we are talking about with this particular initiative, the QIE Initiative, and provide the leadership at a local and national level that can facilitate the kind of changes that need to occur. So a lot of work has been done, progress has been made. Some of the progress in some areas has been faster than others but we've got a ways to go.

Alicia Sutton:
You mentioned culture and leadership being among those that have to change. How do you influence those?

Dr. Lou Diamond:
That's one of the most difficult pieces that we have. Leadership is really inherent and some of the leaders that are found at a local level that understand the need for the kind of changes that we are requiring to put in place but also that those individuals have the ability to be able to articulate those needs and facilitate the changes that have to occur both at the patient and family level and at the provider level so that the entire healthcare delivery team at a local level, which includes the patient and the family, can make the kind of changes that they need. The cultural issues really relate to something that is measurable and there are some tools that can measure culture in various organizations. Most of the tools that we currently use are directed at hospitals and those kind of settings.

So we need to modify those tools for other settings like long-term care facilities and physician's office, dialysis units, etcetera. It does require an ability of the entire environment and all of the staff and all members of the team to understand what needs to be done and to facilitate the kind of changes that need to occur and to be open to open dialogue, the identification of areas of tension, so that they can all work together to improve the care. So the cultural issues that we need to imbue in healthcare delivery systems are fundamentally not different from the cultural issues there are required in any number of organizations, the airline industry, or any other industry where the tolerance for error and the tolerance for not being an organization that achieves excellence is imbued in the entire organization.

That's essentially what we're talking about and those kind of attributes in organizations can in fact be measured. So leadership and culture are very important, if you will tools, attributes, requirements, for improving care but others are more measurable such as actually using measures to measure the delivery of care and benchmark them against standards so you can identify what gaps are occurring and then take steps to improve those gaps. So there's no single fix here. It's a complex set of activities that need to be implemented in the various settings and that's what our task is.

Alicia Sutton:
You hear more about new titles on the team such as the Chief Patient Officer, the Chief Experience Officer, the Chief Performance Officer, do you think that's part of that movement to change the culture?

Dr. Lou Diamond:
Yes. It is part of that movement and to be frank with you I'm hopeful that we can move past this phase of the change. What I mean by that is identifying those kind of individuals within an organization is an incredibly important step that we need to take at this phase of our maceration but eventually I would hope that we could eliminate those positions if you will. That everybody on the team is the Chief Patient Officer and everybody has the concern that the best care needs to be delivered to the patient based on what they're needs are.

So yes, you're correct. Those positions are springing up all over the place but I'm personally hopeful that within the next half a decade or so-it's going to take that period of time, that this is just a transitional phase and that everybody on the team is in fact considering the patient as the center of all of the activities and that the patient's families in fact are engaged in every aspect of the care that is delivered to them. Including by the way the aspect that facilitates the measurement of performance and improvement of performance. So it's a needed now, so I don't want to be misunderstood, but it's hopefully transitional.

Alicia Sutton:
You're listening to Lifelong Learning on ReachMD. I'm your host Alicia Sutton and with me today is Dr. Lou Diamond. So Lou, you mentioned politics before and I would agree on your last point about wanting everyone to be the Chief Patient Officer but politics being what they are do you think some of those who might be coming to the table a little more slowly will be driven there by reimbursement models?

Dr. Lou Diamond:
So you're correct. There is a lot of politics still imbued in the entire system. Some of us like to say that healthcare professionals across all of them, physicians, nurses, like to form circles and shoot inwards. So there is a lot of politics between professional groups. There's still a lot of politics, for want of a better way of expressing it, where healthcare professionals continue to refer to patients as them and they, not recognizing that they are in fact us, namely that the healthcare professionals are in fact patients and their families are obviously patients as well. So that gets to your question.

So how do we incentivize the changes that we are talking about? I'm hopeful that we will continue to find ways to use multiple tools to incentivize the kind of changes that we need to implement in the system and what I mean by that is I don't think that the only tool that we ought to be using in the future ought to be focusing on payment and bonuses and financial incentives. We've got to balance that against imbuing in the healthcare delivery team at least the notion of professionalism and that the professionalism actually in and of itself drives the set of activities that provide the right care to the right patient at the right time and for the populations that are under the care of the team.

So there's balance between professionalism and financial incentives is a very important task for us to pursue going forward. Similarly the balance between using measures to measure performance. We ought to be able to, in the future and sooner than later I would hope, balance the use of measures for something for public reporting and utilization of measures for the purposes of using it internally within your own organization to achieve excellence and to improve the care that is needed. So yes, in the short-term we will have financial incentives on the table and relating to that, very lastly, we clearly need to remove the negative financial incentives, the barriers that are financially out there that prevent healthcare teams and patients from achieving the best health that they can possibly achieve.

Alicia Sutton:
So many of our listeners are educators themselves. They may have shared responsibilities for education in an academic center or the provider setting. Where can they go to find more information about these tool sets, other resources?

Dr. Lou Diamond:
Well I'm hopeful that the-firstly, they can go to the Alliance website because the Alliance is in a process of providing tools in an ongoing basis and we do have plans through the development of the QIE Roadmap Initiative to find the resources in the world to provide additional tools but those tools can be found on the Alliance website but there are nay number of sites that can be utilized that provide all sorts of tools that can be utilized by educators. I'm thinking of three websites and three sources that would be very helpful. One is the Agency for Healthcare Research and Quality, AHRQ. The other is the National Quality Forum. That is the kind of center at the national level of accrediting measures for improving performance and finally-but there are others, the IHI, the Institute for Healthcare Improvement out of Boston.

A lot of resources in all three of those websites as are other ones at the Joint Commission as well, the group that accredits hospitals. So there are a lot of resources there and one of the tasks that the Alliance Quality Improvement Roadmap Initiative is going to do is be able to pull some of those resources together in a single site and make it easier for educators and others to access that kind of information and be able to embed those tools and utilize them in the work flow.

Alicia Sutton:
The Alliance's website as at least a baseline, there is ACEHP.org and that stands for the Alliance for Continuing Education in the Health Professions. So check that out, ACEHP.org.

So as we wrap up are there some final thoughts you would like to leave with the listeners about QI, where it's heading, what we can look for?

Dr. Lou Diamond:
Well I guess my final thought would be to say we are making progress. Much progress still needs to be made. It's going to be important for all members of the delivery and improvement team and all professions to find a way to work together in a seamless way. We need to break down the silos between professions that are delivering care to patients and we need to break down the silos between the healthcare professionals and the team and the patient and their families and if we break those silos down and open up the communications, use all the tools that are available to us.

In addition do this is an intricate process, remembering that quality improvement is not an event, it's not a project. It's a continuous process and ought to be considered as that and everybody ought to be thinking about the patient as the centerpiece of what we're trying to get done and take into account what their needs are and what their desires are.

Alicia Sutton:
Lou, thank you very much for your insights today.

Dr. Lou Diamond:
Thank you.

Alicia Sutton:
You've been listening to Lifelong Learning on ReachMD. I'm the host, Alicia Sutton. If you want to download this segment you can go to ReachMD.com or download the podcast on your ReachMD mobile app. Thanks of for joining us.