PI CME: After Stage A What?

December 9, 2008 at 1:18 am Leave a comment

As a CME professional I have to ask myself, am I ready to facilitate or carry out performance improvement CME initiatives? Do I have a deep understanding of what is required to make performance improvement efforts successful and sustainable? Do I have the skills necessary to lead or participate in PI CME efforts?

CME is being held accountable for demonstrating impact on physician competence, or performance, or patient outcomes. One form of CME particularly well suited to meet this mandate is “Performance Improvement CME” (PI CME).

At the end of Stage A of a PI CME effort all the physicians know is where they stand in their practice compared to selected performance measures and sometimes their peers. As a CME Provider I can award 5 CME credits to them for developing that understanding. But then what? You know what I think. I think mastering the Toyota A3 report as a problem solving approach may be one set of skills that would serve me well to be sure a PI CME effort is done effectively and help me feel comfortable in awarding PI CME credit to physicians engaged in PI CME initiatives. I like the A3 problem solving approach for three reasons

First, it is brief and graphic in nature. The approach is called A3 because they use they use one a one page legal size piece of paper – called A3 in other parts of the world – to capture and communicate a performance improvement opportunity. It forces the team working on the improvement effort to be clear and concise in describing and communicating about the problem and the solution throughout the effort.

Second, the key elements of A3 problem solving are very powerful and fit well into the values I think most physician scientists value.

  • It values objectivity. My observation on any improvement need is going to be inherently subjective. As will the observations of others involved in the improvement effort. However, discussing the various viewpoints on an improvement need makes these perspectives explicit. As the team collects objective information about the situation biases, assumptions and misconceptions can be resolved in a more objective manner.
  • It is results and process oriented. Results are not valued over process. Both process and results are important. We clearly don’t want a process that doesn’t achieve the desired results. Nor do we don’t want a poor care process even if we approximate the outcomes we want to achieve. We want results that come from effective and efficient care processes.
  • It requires that we synthesize, distill, and visualize all of the salient information required to understand the improvement need and a potential solution. A picture may indeed be worth a thousand words. Using an A3 piece of paper to present an improvement problem and a proposed solution requires careful synthesis, a logical distillation of the information required to understand the problem, and an ability to graphically show people exactly what we are talking about
  • It requires internal consistency and coherence. One part of the A3 report must flow logically to the other sections of the report.The diagnosis of the problem is consistent with the real improvement theme.The root cause analysis emanates from an analysis of the current situation.The proposed solutions address the root causes analyzed. The solutions implemented put the suggested remedies in place.
  • The follow-up plan tests the results against the desired outcomes established earlier in the process. Logical, coherent, consistent.
  • Finally it takes a systems approach. It requires that I know the purpose of the course of action we decided to take:that I understand how the course of action furthers my organizations priorities and goals; and that I have knowledge of how the solution fits into the lager picture and affects other parts of my organization or the health care delivery system.

Third, it is built on sound processes utilizing effective improvement tools. Underlying the steps involved in an improvement effort is the proven Plan, Do, Check Act (PDCA) process. The planning phase may take as much as two thirds of the time of the entire improvement effort. There is no skimping at this stage in the process.

Let’s assume it is your CME Committee charged with oversight responsibility for approving PI CME activities for CM E credit. What do I want my CME Committee to know as they consider approving a PI CME activity for CME credit?

  • I want my CME Committee to know the physicians involved in the effort can actually describe the performance problem in a clear and concise manner. In short, they should know what is going on the practice setting so they can describe what is actually going on. This is their picture of the current situation. Without this they the CME Committee won’t know how much progress was made in resolving the problem as part of the improvement efforts.
  • I want my CME Committee to know the physicians have some very specific idea(s) about why the situation exists by identifying the root cause(s). Why is this effect happening? And then looking at that cause as an effect, why is this effect happening? Doing this exercise up to five times will help get to the root cause(s) of the performance problem and not just the symptoms of the problem.

(NOTE: Engaging diligently in these two planning efforts will lead to a much deeper understanding of the performance problem and the potential causes that need be addressed by countermeasures.

  • I want my CME Committee to know the physicians involved in the effort have examined all the potential causes of the performance problem and made a conscious decision about which of those causes (if any) are amenable to an educational resolution. After all, I am a CME professional. Education is my stock in trade. But if there doesn’t appear to be an educational solution required to resolve of the performance problem that doesn’t mean I have to turn away from the issue. That means, as a CME professional, I have to expand my effort and find non-educational solutions. And that will likely require partnering with others in my setting. Together we need to identify the root cause(s) that can be addressed that will resolve the performance issue. CME professionals should take ownership on the performance issues they identify and stay with them until they are resolved or given to someone who is committed to taking ownership and resolving the problem.
  • I want the CME Committee to know what the physicians think the future situation should be after they implement the improvement initiatives.
  • I want my CME Committee to know what countermeasures the physicians intend to implement in the practice setting to resolve the performance problem. What are they going to do to change the current situation in an effort to lead to the desired situation?
  • I want my CME Committee to know that the physicians involved in the improvement effort can articulate an implementation plan to guide their improvement efforts. Who is going to what and when to get to the desired improvements? (Stage B)
  • I want my CME Committee to know the physicians involved in the improvement effort have an effective plan in place to evaluate the improvements made during the project. (Stage C)
  • I want my CME Committee to know if approvals are required to make the changes that gaining these approvals is built into their improvement effort.
  • I want my CME Committee to know the physicians involved in the improvement effort have a plan to secure buy-in from of all parties that will be affected by the improvements
  • I want my CME Committee to know that there is a follow-up plan that includes a description of steps they will take to standardize the improvements in their practice setting made as a result of the effort.

PI CME initiatives using an A3 process will be effective, produce lasting improvements in the delivery of care, improve patient health outcomes and truly be CME activities that matter. This is CME the CME Committee will have no problem in awarding 20 credits.


Entry filed under: CME, CME Certification, CME Issues. Tags: , , .

PI CME. Easy as ABC? Maybe not. Andragogy and PI CME

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