Medical Education as a Solution for a System-Based Problem

By John Ruggiero, PhD, MPA, CHCP, Genentech; Caroline O. Robinson, PhD, Genentech; Michael Lemon, MBA, FACEHP, CHCP, Postgraduate Institute for Medicine; and Robert M. Colleluori, RMEI Medical Education

In recent years, the independent medical education industry has collectively contributed to examining the core tenants of a changing healthcare marketplace— and, importantly, what the role of education is and can be within healthcare today — as is delineated within a recent white paper “Coordinated learning to improve evidence-based care: a model of continuing education for the healthcare environment” (Ruggiero J, Robinson CO, and Paynter N, 2015). The Expanded Learning Model for Systems (TELMS), a framework proposed as the planning and assessment model for learning within healthcare, adds to the many expert voices and case studies from within the CME/CE industry asserting that learning and education are the key mechanisms to drive progress toward the national goals of the Triple Aim. In order to be a catalyst for the improvement of healthcare professionals’ ability and practice to deliver patient-centered care in a context of accelerated knowledge growth, it is critical that continuing education design, implementation and evaluation must address not only learning impact and behavior change at the level of the individual but also at the level of teams, organizations and systems (Ruggiero J, et al., 2015).

In line with this aim, Genentech recently supported a non-small cell lung cancer (NSCLC) continuous medical education initiative provided by Postgraduate Institute for Medicine and RMEI Medical Education. This active learning initiative was implemented in collaboration with several healthcare institutions that aspire to improve their awareness of their own systems-based gaps, a critical step toward quality of care improvement. See Figure 1. The initiative planners from public records identified the gaps addressed in this program, which were used to target potential candidate institutions. Once the institutions that became part of the initiative were made fully cognizant of their gaps, the institution stakeholder(s) encouraged their clinicians to participate in the program’s rounds-styled education and to collectively convert the information into a targeted clinical improvement. This was then captured as data within an updated and visible system report.

Almanac_July16_MedicalEducation_Figure1.PNG

One of these specific rounds activities was titled “Optimizing Patient Care in NSCLC—a Targeted Approach” and was completed in collaboration with MedStar Cancer Network, which is a regionally based healthcare system in the District of Columbia accountable for a sizeable cancer patient population throughout their catchment area of Washington, D.C., and northern Virginia.

The nucleus of a public health concern can be addressed by system-focused education targeted to improve specific outcomes.
Public records available as a result of the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA), indicate that MedStar Cancer Network has a reported quality of care score that rates them as 8 out of 10 for patient survival. More notable is that their attained score for patient safety is 1 out of 10. MedStar is also positioned within the highest risk category for Medicare pa­tients, with an average of 1,300 discharges without a specified care plan in the prior year of measurement. It is interesting to note that in the MedStar patient population, approximately 39 percent of NSCLC patients present similarly. The treatment plans vary greatly as a result of warranted care variations and, more troubling, unwarranted variation in care across patients and care teams. The educational provider researched these data and was able to partner with MedStar to help it become acute­ly more aware of its current public record, improve its knowl­edge about the care variation and—if tied to a knowledge or behavior deficit—discuss how to mend it.

Effectively implementing education within a system requires that the healthcare team focus on system-specific gaps.
The education was designed in the spirit of a flipped-class­room model in which the clinicians completed pre-reading materials prior to addressing illustrated and actual patient cases that centered on the role of anti-epidermal growth fac­tor receptor (EGFR) monoclonal antibodies, EGFR tyrosine kinase inhibitors (TKIs), anaplastic lymphoma kinase (ALK) rearrangements, the frequency of EGFR mutations and—a specific challenge based on the regionally-based and public­ly-reported gaps among this specific healthcare system—the failure to broaden the tested population. Each of the focused rounds sessions within this initiative had an average of 25 participants from a collaborative team of medical oncologists and oncology advanced practice nurses, physician assistants and nurses. This specific activity involved 28 medical oncol­ogists, oncology advanced practice nurse practitioners and nurses, along with a lung cancer team leader who delineated expected and measurable goals as a result of the content that was discussed.

Almanac_July16_MedicalEducation_Chart.PNG

Practical behavior change can translate into clinical impact.
One hundred percent of the 28 learners became more aware of their institution’s public record. This encouraged their leaders to activate the team into analyzing the problem, inves­tigating the reasons for varied care and suggesting resolutions to address these gaps if unwarranted and manageable. While the educational initiative is still active, as are the ongoing outcomes analyses, 40 percent of the audience immediately advanced their knowledge regarding the shared system-level clinical information, resulting from an in-depth discussion of actual case studies superimposed upon the public information and weighted by the regional public health problem associ­ated with the lower relative quality of care scores. Continu­ous monitoring is being done to see how each institution is specifically integrating the direct lessons learned to reduce unwarranted care variation by better evaluating when it is appropriate to provide care plans for patients who are simply discharged as well as by employing testing when appropriate. To accomplish this, the clinical teams have been encouraged to develop and demonstrate a shared engagement with the in­tended goal of methodically and realistically reducing clinical discrepancies within this year.

This example demonstrates not only improvement in the standard measures adopted by the independent medical edu­cation community vis-à-vis scientific knowledge and clinical competence, but also demonstrates the practical impact of a system-focused initiative using the quality of care metrics that have value to the specific healthcare organization. Such mea­sured improvements may include, but are not limited to, be­havior choices as established by validated behavioral economics models that measure improved adherence to evidence-based care options that are currently available to patients.

Reference

  1. Ruggiero JE, Robinson CO, and Paynter N. Coordinated learning to improve evidence-based care: A model for continuing education for the new healthcare environment. Abstract presented at 2016 ACEhp Quality Symposium, September 29, 2015, Chicago, IL.

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