Creative Collaborations in Quality Improvement Modeling

Alicia Sutton:
Today on Lifelong Learning, we're focusing on some innovative ways QI education has been taking shape, with a specific look at one academic medical center and how it uses education as a tool for QI. I'm your host, Alicia Sutton, and with me today is Dr. Chitra Subramaniam, assistant dean and director for continuing medical education, and assistant director for the Duke Center for Educational Excellence at Duke Clinical Research Institute. She's a board member of the Alliance for Continuing Education in the Health Professions, which is the largest organization of health care educators, advocating for improving patient outcomes through education, and she is the chair of the 2014 fall QI Symposium, which is where we are recording this interview. Thank you so much, Chitra, for joining us.

Dr. Chitra Subramaniam:
Thank you for having me.

Alicia Sutton:
Let's look at the, kind of the big picture here about how education facilitates quality improvement. Can you kind of comment on that?

Dr. Chitra Subramaniam:
I think for any kind of quality improvement, whether we're looking at some kind of patient outcome or process outcome or clinical heath outcome, I think education is an integral piece of the learning process and the behavior change that we're anticipating to create the outcomes we need, and I think education has several roles that it can play in different stages of the QI process. I think if you look at research evidence in literature, we talk about education being predisposing, which is orienting somebody to what their issue is, why are we doing this project, why is it important, what's the rush now, and what's the problem and why is it occurring?

So there's education that happens there. Then the next stage when we move on is the enabling phase, where we enable somebody to make the change and help them, which is where your live events, the ways in which we communicate to them and give them the knowledge and the tools to actually make the change and facilitate the behavior to happen that we need to happen. And once you enable that, then there's the issue of sustaining that behavior, which is where there's reinforcement because of education, where we use some of the best practices, like providing feedback, doing self-assessments, and allowing for reflection to happen, and helping people see yes, they've made the change, but where could they improve?

What are they doing right and what are they doing wrong, and providing the feedback and having them sustain that behavior until it becomes practice. So I think education has an integral role in QI, and I think if we are looking at not only creating, learning, and behavior change, but helping people sustain that behavior. Then education should go beyond just the initial dialogue, the conversation, getting together in a room, but I as a practitioner should also have educational materials, resources, and continuous reinforcement and feedback available to me so I can always monitor what I'm doing and maintain consistent behavior that leads to outcomes that we're looking for.

Alicia Sutton:
It sounds like an elaborate ecosystem, so to speak.

Dr. Chitra Subramaniam:
Yes, absolutely, and the timing of the type of intervention you're providing QI is critical as well.

Alicia Sutton:
Can you talk a little bit about different QI models?

Dr. Chitra Subramaniam:
From the education standpoint, I think, I want to speak a little bit from the Duke perspective, if that's okay, things that we have done. The traditional CE kind of activities that we do, the live events and some of the online, they still have a lot of value, but the approach has become-live events, there is more dialogue. There's more participation, and the learner is more an active learner rather than somebody passively absorbing all the information that's given to them. There are new concepts now that we've included, like the flipped classroom where you're preparing all the fundamentals and foundational knowledge and getting oriented to its problems before you actually come to a live event, which is more problem-based, and you're actually having some discussions and deep dives into what the issues are, how do we correct them, where do we go from here.

Those have been successful models, at least for us in our space, of creating the dialogue, the discussion, and getting together, building a community of practice or community of learners who can learn together and continue to sort of provide each other feedback and be a part of this community, this learning community. I think things like-we have done things where in order to provide consistent feedback and resources, there are online communities of learning, virtual communities of learning where physicians and patients who are part of the health care team can actually learn and get educated and also discuss with experts some of the issues that they're facing and get some feedback and reinforcement there.

Research is available to them. We have some models where we do train the trainer, where we invite assistants that are participating in the QI activity along with us. They get invited to Duke, and as a team, they're being trained and we help them with, like, tool, development of tools and resources that they take back to their organization and are able to implement quality improvement intervention and activities. So there are a lot of opportunities for us to think creatively about education and the models for QI, and also to remember the education is one of the many interventions in QI. There are a lot of other things that we need to do because we're now talking of a system-level change, because in order to enable the individual practitioner to make the change, the system has to sort of help with that as well.

So there might be system changes that need to happen in order to help me as a provider to be different than what I was before. So I think there might be some system-level things that we need to look at, process issues that we need to resolve, along with education that we provide is what really creates the change.

Alicia Sutton:
So it sounds like there are some challenges beyond just education. There's challenges obviously with other parts of the system, but can you address some of the challenges that you all face, perhaps at Duke or with any of your partners?

Dr. Chitra Subramaniam:
QI models within the CE community are mostly collaborative models, so there's not one entity that has all the resources and all the skill sets and expertise needed to accomplish sometimes QI. So we always partner, and collaborations bring their own challenges, and when we are scaling a QI effort, the type of partners we pick and resources they have, the infrastructure they have for data collection, what their goals are versus what our goal is. There's a lot of dialogue and a lot of collaborative, sort of facilitative conversation that needs to go on, and bringing everybody on the same page and really discussing what the actual problem is takes a long time. So it's important for each of us collaborating to come with what our interest is rather than what our position is, in terms of what we want to achieve and what we are as an organization, but the goal is really patient care, quality of care.

I think that's a challenge, but it's also sort of a benefit, an advantage if you can pull off a collaboration, because that's wonderful when different people who complement each other can work together and come up with a good outcome. I think that's one of the biggest challenges as well as benefits, and we're trying to figure out what are the models that are successful and how we can get collaboration going on, and it's the time that it takes to make the collaboration work. I think that's a big issue. The other thing is to get the providers, just not the physicians, but the nurses, everybody, participating to understand that this is not one additional task that they have to do, but it's something we have to-it's the right thing to do, rather than, "Why am I doing this," you know, "I already have 20 patients today, I have to do this additional stuff."

So we get that question all the time, and it takes time to help them understand and educate them on why we're doing this and show them their data so they see where they are and sort of get motivated to participate in this. I think in one of our presentations today, there was talk about providers like to see how they are doing compared to their peers, and that's a way of motivating them to participate. So getting the engagement, getting the participation and having providers see value in what, in the QI project, I think, is important.

Alicia Sutton:
Yeah, it sounds like even though those are challenges, they certainly are ones that can be overcome by showing them the benefits of doing that.

Dr. Chitra Subramaniam:
Absolutely, absolutely.

Alicia Sutton:
If you're just joining us, you're listening to Lifelong Learning on ReachMD. I'm your host, Alicia Sutton, and with me today is Dr. Chitra Subramaniam. So you mentioned collaboration. You work with a lot of partners. Can you define for us a couple of outcomes that you've seen with QI, working with these and describe the impact?

Dr. Chitra Subramaniam:
We strongly believe that this QI sort of transformation that's going on in CME and all of the changes that are driving us towards QI, we cannot accomplish all of those just by being one institution trying to do everything. So our philosophy at Duke is to be more open. Let's collaborate, let's get more people in and see what we can do with that. So with that idea in mind, we collaborate within this CE community. We collaborate with _____ (9:04) companies, other hospitals, a lot of different research sites and networks and systems, health care systems, so to accomplish what we want to do. So one example, we are doing a project which is a PICME, which follows the PICME model, the four stages.

Alicia Sutton:
Right, the performance improvement CME.

Dr. Chitra Subramaniam:
Yes, thank you. Yeah, the performance improvement CME, so we have the pre-assessment, the educational phase, the post-assessment, and then the final one, and we actually did something where we went into the practice and we did some research on what are some of the challenges in screening for hep C among primary care physicians. So do they have the knowledge, are they screening well, are they doing the right thing, and if they are, then are they referring the patient to the GI specialist at the right time? We knew that there was some gaps in this, because there was the communication issue, and what was funny was the primary care physician said, "Well, is this my role? Am I supposed to be doing this? I'm not the specialist. The specialist has to really do this."

So there was a lot of quality, I guess, and communication issues that were going on. So we implemented a QI project which was funded, but it was about educating the primary care physicians on the screening requirements and what they need to do, and then how do they then communicate to the GI practitioner at the right time, and we actually went in and did some in-practice research and qualitative research, and the perception that the primary care physicians had of course was, "We're doing the right thing." Well, when we looked at the data, it said something else. So we did interventions and got them together with the GO folks and had-I think the educational intervention here that really worked is for them to come together as a team, hash out some of the barriers, exchange ideas, and say, "Hey, as a team, this is how we could work well."

So the concept of the learner being engaged and actively participating in the conversation and trying to help resolve the problem is an important sort of technique that needs to happen in any educational session within QI. Since then, we've seen a significant increase in the actual screening rates, and then the communication with the GI, and appreciation from the GI specialist on what the primary care physicians do and why it would be challenging for them to actually screen a patient appropriately, because I don't think they even thought that there are challenges that primary care physicians have. So I think it was a good team project getting them to communicate with each other, establishing a protocol, implementing the protocol, and really seeing a change.

Alicia Sutton:
That's excellent, it's a great example, where we're looking at individual change that really does impact the whole system, taking it from the performance improvement of the individual. Have you had enough time to see the impact on patient outcomes yet, or is this a fairly recent initiative?

Dr. Chitra Subramaniam:
It's a fairly recent initiative, and I think we also have results on patient outcomes, but I don't have it with me here, but we do have, because of the screen increase and the communication with GI, that we've seen some significant patient outcomes as well.

Alicia Sutton:
So your work with this conference here, again, with the Alliance for Continuing Education in the Health Professions, and if anybody wants more information, they are located at www.acehp.org. They can find more information. So tell us what you're seeing that's different at this conference. We're seeing a lot more QI in our education, or education in our QI. What are you seeing that's different this year?

Dr. Chitra Subramaniam:
So this is the second year of the conference, very excited to be a part of it. I was a part of the planning committee last year, and then this year took over as chair, and our goal this year was really to sort of continue the dialogue from where we left last year, which was an overview of QI, just introduction to research concepts, introduction to what QI really is, to now taking it to the next level, which is actually sharing practical examples, success stories, and really talking about IPE, which is interprofessional education, and how for the team, by the time kind of education is important in moving the needle in the QI space. Also the patient as a part of the QI team, of the health care team, looking at quality from the patient perspective and seeing how important it is for patient-centered care.

So I think that's different this time is really the dialogue that's happening as to what the techniques are, what the models are, and why we're here and what education can do for QI and some of the techniques that folks have used who have been successful, have used. So I think I'm hoping people will go back with some practical examples, and get a better understanding of what quality improvement is, and what education can do for that.

Alicia Sutton:
That's terrific. So looking out a couple more years, where do you think things will be?

Dr. Chitra Subramaniam:
That's a great question. I think we're going to continue down this QI path. Hopefully we're able to show more outcomes data, to actually show the value of education in this QI process. I think quality improvement starts local, but it is a process to sustain the change, just like learning is a process, and I think education is sort of the backbone of a lot of the things that we're going, but we haven't found a good way of showing outcomes from the education we're doing. So hopefully in the next couple of years, we'll have a lot more examples that will actually show that we as a CE community, we are providing value to improving patient care.

Alicia Sutton:
That's terrific. We look forward to that and hearing more about it in the future. You can visit the Alliance for Continuing Education in the Health Professions online at www.acehp.org. I want to thank our guest Chitra Subramaniam for her insights and for joining us today on Lifelong Learning.

Dr. Chitra Subramaniam:
Thank you.

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