Outcomes Methodologies in the Changing Landscape of CME
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Transcript of Outcomes Methodologies in the Changing Landscape of CME
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Outcomes Methodologies in the Changing Landscape of CMEChitra Subramaniam, Ph.D
Assistant Dean and Director, Continuing Medical EducationAssistant Director, Center for Educational Excellence
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About Me
Education:• Ph.D in Curriculum and Instruction with a focus on Instructional Technology; Cognate: Measurement and
Evaluation• 10X10 AMIA training in Biomedical Informatics• MS Clinical Biochemistry
Areas of Expertise and its Application:Basic :Curriculum and Instruction
Education Evaluation and Measurement
Information Processing/The learning process
Knowledge Repositories and Instructional Design Systems
Data Visualization
Information/Interaction design; Usability
Applied: Design of Knowledge Systems for Outcomes based Education
Measurement and Evaluation methods; Impact of Learning
Instructional Design Systems; Instructional design strategies, teaching
Integration of Technology in Education
Information Design
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Those who have been influenced!• AO Foundation• American College of Cardiology• American Society for Clinical Pathology• American College of Radiology• CDC, Ministry of Health, Tanzania• National Quality Laboratory Training Center, Tanzania• Pearson Custom Solutions, Pearson Publishing• McGraw Hill• Cengage Learning• Thomson/Delmar Publications• Center for Medicare and Medicaid Services• Council for Exceptional Children, Washington D.C• University of South Florida• University of Central Florida• Lincoln Technical Schools• US Education Corp• City College• Kaiser University• Hernando County School Board• Hillsborough County School Board• IBM, AT&T• Learning Mate, India• Chartered Institute for Professionals in Financial Accounting, U.K• American Society for Clinical Pathology
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Polling QuestionRank the # 1 challenge in measurement and evaluation you face today
1. Concepts are too abstract and cannot be operationalized
2. Data has too much variability
3. Results are mostly subjective. Objective measurements are a challenge
4. The system does not allow for a streamlined approach to measurement
5. None to very few tools available for implementation
6. Accountability is too high- cannot meet expectation
7. Have little or no access to data; not within a health system
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My Perspectives• Outcomes is an afterthought in most organizations both for
education and training. • Strategic and tactical frameworks for achieving outcomes in
most organization is lacking• Lack of clear mapping and alignment of the outcomes
methodology with the instructional design and delivery strategies and learner engagement approaches.
• At a macro-level, the educational program goals do not align with institutional goals.
• The process of learning and factors influencing the learning (individual, group and system level) are not being considered.
• Protocols for programs that include QI/PI, research, collaborative team based learning are not clearly defined.
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A Paradigm Shift in Healthcare
From Here To Here
Individualistic Collaboration
Autonomous Integrated
Scholarly Practical
Expert Centered Focus Patient/Service Team
Hierarchical Distributed
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Healthcare Environment…..Patient Centered
Personalized Care
Diagnosis, treatment, and management- the process
Behavioral, cognitive, social, economic and cultural factors that impact the physical, mental and social well being of a patient
Integrated system- Its about the experience
Micro and Macro level issues
Accountability/Standardization/health outcomes
Health care costs- Sustainability
Motivated, disciplined patientLife Long Learners
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The Challenge
Influencing Factors
Research
Quality Education
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Performance Needs
Learning Needs
Business Needs
Learning Objectives
Application Objectives
Impact Objectives Impact and
Consequences
Application Implementation
Learning and
Confidence
Begin with the End In Mind!
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Business Needs
Job Performance Needs
Learning Needs
Design
Analyze DevelopEvaluationAssessment
Needs Assessments,Evaluations and survey results,Market ResearchNew developmentsAnd trends, Teaching philosophy, goals and vision, situated learning
Objectives/learning outcomes, content, instructional design, assessment measures, supplemental materials, resources, modalities and technology
Formative/Summative evaluations, resources, support services, supplemental materials
Implement
What does that mean?
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SYSTEM NEEDS
Evidence Based Medicine
Quality Improvement
Performance Metrics
Business practices
Delivery Models
Clinical Research
HEALTHCARE DELIVERY
Healthcare Teams
Coordination of Care
Healthcare Disparities
Health Information Technology
Pay for Performance
Life Long Management of
Diseases
CPD/CE
Healthcare Disparities, Episodic to life long treatment, Patient expectations and demands are different, Patients are a part of the team
Learner Centered Education/System Driven Training
Quality
Research Education
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Display knowledge, competence, performance at predefined level/benchmarks
Develop contextual competence, adapt to change, recognize patterns in problems within a context
Adapt to change, find, validate and apply new knowledge
Develop competence further through habits of mind, behavior, and wisdom
Continuously add to knowledge, competence and performance through practice and reflection on experience
Assess “the habitual and judicious use of • Communication• Knowledge• Technical skills• Clinical reasoning• Emotions• Values• Reflection in daily practice”.
Epstein, MR., Assessment in Medical Education, N. Engl. J Med Jan 25, 2007. 356;4
Teacher/Instructor
Facilitator
Coach/Curator
FEEDBACK and POSITIVE REINFORCMENTS
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Polling QuestionsOf the 5 stages discussed at which level do you think your CE activities are designed and measured?
1. Display knowledge, competence, performance at predefined level/benchmarks
2. Develop contextual competence, adapt to change, recognize patterns in problems within a context
3. Adapt to change, find, validate and apply new knowledge
4. Develop competence further through habits of mind, behavior, and wisdom
5. Continuously add to knowledge, competence and performance through practice and reflection on experience
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Performance
Knowledge
Competence
Moore’s Outcomes Levels
Bloom’s levels
Participation, Satisfaction
Performance
Learning- Declarative Procedural
Patient Health
Community Health
Competence
Population Health
KNOWLEDGE
APPLICATION
ANALYSIS
CREATE
EVALUATIONLearner Needs
UNDERSTANDING
Learning FormatsInstructional
StrategiesM & E methods and
tools
Constructive Alignment
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Pre-structural Uni-structural Multicultural Relational Extended Abstract
Quantitative Phase Qualitative Phase
Identify
So simple
procedures
Enumerate
Describe
List
Combine
Do Algorithms
Compare
Contrast
Explain
Relate
Analyze
Theorize
Generalize
Hypothesize
Reflect
The Hierarchy of Verbs
Deep Learning
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Motivation, stress, time constraints, cognitive overload
Metacognition, critical thinking/reasoning, problem recognition
System/Business
Healthcare Consumers
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In case there was a story to tell….
Member Engagement
• At the basic level, any product or service that meets customer needs can derive growth in sales, participation, brand identity and word of mouth.
• Consumption is a form of participation or engagement• Can be measured in money, satisfaction, participation, idea
generation, retention, money invested by customers, number of spin off products.
• Directly links to the professional advancement of the member.
• Product/service level engagement
Educational Value
Activities’ influence on performance, habits and perhaps even outcomes.
Activity integrates into professional practice Activity-satisfaction Activity addresses needs Activity allows for knowledge and skills transfer Format of the activity suitable, convenient and easy to
follow Content relevant to practice and the needs
Return On Investment
A traditional financial measure based on historic data. Trends from financial performance Rate of increase/decrease in revenues Marketing ROI Retention and Acquisition rates
Strategic Effectiveness
Organizational strategy the association chooses to deploy (product leader, most advanced, price leader, cheapest, most customized) based on
o Strategic organizational goalso Member value proposition
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A systems approach to desired resultsFramework for Program planning and Evaluation
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How do you measure quality?
Improvement Tools • Continuous quality improvement (CQI) –
opportunity for improvement exists in every process on every occasion.
• CQI model emphasizes view healthcare as a process and focuses on the system rather than the individual when considering improvement opportunities.
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How do you measure quality?
The FADE Model FOCUS: Define and verify
the process to be improved ANALYZE: Collect and
analyze data to establish baselines, identify root causes and point toward possible solutions
DEVELOP: Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring
EXECUTE: Implement the action plans, on a pilot basis as indicated, and
EVALUATE: Install an ongoing measuring/monitoring (process control) system to ensure success.
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How do you measure quality?
PDSA PLAN: Plan a change or test of how something works.
DO: Carry out the plan.
STUDY: Look at the results. What did you find out?
ACT: Decide what actions should be taken to improve.
Repeat as needed until the desired goal is achieved
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How do you measure quality?
Six Sigma• Statistical measurement methodology designed to reduce
cost, decrease process variation, and eliminate defects• Sigma is a statistical unit reflecting the number of SDs a
given process is from perfection• Steps
• 1. Define – creation of project charter which defines the customer’s needs, project scope, goals
• 2. Measurement – data collection plan• 3. Analyze – data analysis occurs, deviation from standards is
identified• 4. Improve – create solutions and implementation plans• 5. Control – process is controlled by implementing policies,
guidelines, and error-proofing strategies to make reverting to old process impossible.
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Things to consider
• Quality Improvement versus research• QI objective address need of local situation• Research seeks to address problems that will provide
generalizable results• QI can be considered research if:
• the tested intervention involves a deviation from establishedpractices
• individual patients are subject• randomization or blinding is conducted• Participants are subjected to additional risks/burdens beyond
usual practice.
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Quality of Care Measurement
Costly to implement Quality Improvement programs Requires good data and evaluation of costs
Method Purpose Data Requirements
Cost-effectiveness analysis
Comparison of costs and health effects of a QI program vs. usual care
Utilization data for healthcare providersLong-term health benefits to patients
Cost-minimization analysis
Comparison of costs of two programs with identical health benefits
Same as above
Cost-benefit analysis
Comparison of program costs and benefits
Health benefits of programCost of programs
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HealthCare Matrix
Bingham, J. and Doris, Q et al (2006). Using an Healthcare Matrix to assess patient care in terms of aims for improvement of core competencies. Journal of Quality and Patient Safety, Vol 31 (2).
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The Duke Outcomes Matrix
• Practice gap matrix• This is where we started…….• Everything in between……• This is where we are now…….
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Polling Question
Do you use tools to design, develop, implement and measure CE activities?
Yes
No
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Outcome- Increase pneumococcal vaccination rates in patients at high risk (18- 64) and those 65 and greater
Physicians
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Health Educators from the County
Just for us
• Reach out to all seniors and high risk groups through educational sessions within Durham, Wake and Orange Counties
• Communicate the importance of pneumococcal vaccines and the consequences of not obtaining one.
Outcome- Increase pneumococcal vaccination rates in patients at high risk (18- 64) and those 65 and greater
• During home visits for seniors, screen for pneumococcal vaccinations. • Document the screening• Ensure vaccination of seniors who need one and document it.
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Outcome- Improve Quality of Life for HIV patients by empowering them and their care givers
Physicians, researchers, social workers/counselors, nurses and patients
Role Goals Measures
Physicians, Specialists Effectively communicate the need to maintain the treatment regimens.
Emphasize the need for mental, emotional and physical well being and empower the patient to pursue the best treatment that addresses their individual needs.
Work with the care giver team members to support the emotional well being of the patient
Implement evidence based strategies to communicate and build trust and connect with patient
During every patient encounter evaluate patient’s adherence to medication plans.
Assess the emotional, physical, and mental well being of the patient.
Document the assessment
Using coaching techniques, offer suggestions and strategies to enable patient self confidence
Present all available options based on the results of the assessment and discuss their advantages and disadvantages.
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Roles Goals Measures/Indicators
Social Workers Guide HIV patients regarding their legal rights following disclosure of their status.
Serve as an advocate for the patient.
Work with the care giver team members to support the emotional well being of the patient
Implement evidence based strategies to communicate and build trust and connect with patients.
Upon disclosure, inform and document patient’s legal rights using case examples.
List and share all community, state and other resources available to the patient.
Communicate to the physician and other care givers if any changes in the emotional, mental or socio-economic condition is observed.
Follow up with patients on a regular basis to ensure that the support through resources are made available.
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Roles Goals Measures/Indicators
Nurses Follow all protocols during patient encounters
Provide guidance and support related to treatment regiments and their management
Work with the care giver team members to support the emotional well being of the patient
Implement evidence based strategies to communicate and build trust and connect with patients.
Document all patient vital signs, HIV health factors that are evaluated. Assess medication adherence and communicate to the care team appropriately.
Share with the care team any changes observed in the emotional, and physical well being of the patient.
Communicate with patients, physicians and specialists to ensure proper coordination of care.
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Roles Goals Measures/Indicators
Patients Be well informed about the disease, its diagnosis, treatment and management
Contribute to, engage and learn from the broader community
Ask questions of all care givers and communicate concerns and challenges.
Stay motivated and empowered to pursue the best treatment that addresses their individual needs
Participate in educational opportunities offered by the care givers.
Engage in online communities and share/exchange knowledge, experiences and resources.
During visits, clarify concerns and understanding of treatment options.
Participate in activities that lead to empowerment and motivation of oneself to lead a quality life.
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Performance Dashboard
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