Two Birds and One Stone: Integrating Education and Clinical Redesign to Achieve the Common Mission (#4098) Kelly Caverzagie, MD, FACP, FHM Associate Dean for Education Strategy, UNMC Vice-President for Education, Nebraska Medicine Lois Colburn, Executive Director UNMC Center for Continuing Education
Disclosures Neither presenter has any conflicts of interest to disclose
Objectives
Identify the importance of integrating education and clinical redesign efforts Identify how residency training requirements can catalyze efforts at clinical redesign Develop a business plan to support clinical and educational integration
Outline 1. Changing Landscape of Health Care and Medical Education 2. UNMC and Nebraska Medicine 3. OHPE – Facilitating Alignment 4. OHPE – Business Plan Development 5. Conclusions
OHPE = Office of Health Professions Education
Outline 1. Changing Landscape of Health Care and Medical Education 2. UNMC and Nebraska Medicine 3. OHPE – Facilitating Alignment 4. OHPE – Business Plan Development 5. Conclusions
Changing Landscape of Health Care “Fundamental, sweeping redesign of entire health delivery system.” “Requires changing the structure and processes of the environment in which health professionals and organizations function.”
IOM Crossing the Quality Chasm: A new health system for the 21st century. c2001
Changing Landscape of Health Care
Six Aims for Improvement • • • • • •
Safe Effective Efficient Patient-Centered Timely Equitable
IOM Crossing the Quality Chasm: A new health system for the 21st century. c2001
Changing Landscape of Health Care
Framework that describes an approach to optimizing health system performance
Institute for Healthcare Improvement: The IHI Triple Aim. c.2007
Changing Landscape of Medical Education “Medical education is at a crossroads: those who teach medical students and residents must choose whether to continue in the direction established over a hundred years ago or to take a fundamentally different course, guided by contemporary innovation and new understandings about how people learn.”
Cooke M, Irby DM, O’Brien BC Carnegie Foundation, c2010
Changing Landscape of Medical Education CLER Pathways to Excellence • • • • • •
Patient Safety Health Care Quality Supervision Care Transitions Health Care Disparities Fatigue Management, Mitigation and Duty Hours • Professionalism
Changing Landscape of Medical Education “While the medical education system alone cannot solve all of these problems, ensuring that the nation’s physicians are response to the changing needs and expectations of Canadians is a vital part of the solution.”
Future of Medical Education in Canada Recommendation #3 Recommendation • Create positive and supportive#9 learning and work environments
“Recognizing the complexity of PGME and the health delivery system within which Recommendation #5 it operates, integrate the multiple bodies (regulatory and certifying colleges, • Ensure effective integration and transitions educational institutions) alongand thehealthcare educational continuumthat play a role in PGME, into a collaborative governance structure in order toRecommendation achieve efficiency, reduce #9 redundancy, and provide clarity on strategic directions and decisions.” •
Establish effective collaborative governance in PGME
Sirovich et al. JAMA Int Med; 2014
Bottom Line: Clinical learning environment influences knowledge and judgment
Chen et al. JAMA; 2014
Bottom Line: Clinical learning environment patient care expenditures are reproduced in clinical practice of graduates. Effect persists up to 15 years after graduation.
Asch et al. JAMA; 2009
Bottom Line: Clinical learning environment impacts patient care outcomes. Effect persists up to 15 years after graduation.
Impact on Academic Health Centers Health System Redesign
Medical Education Redesign
• Patient experience • Population Health • Value (high benefit, low cost) • Interprofessional teamwork • Transitions of care • Informatics and data management • Evidence-based standards • Etc…
• New assessment frameworks • New curricular content and structure • New curricular delivery approaches • New learning experiences • Interprofessional education • Emphasis on learning environment • Etc…
Impact on Academic Health Centers Increasing pressure to: •
Demonstrate value in health care delivery
•
Demonstrate value in health professions education
•
Align clinical and educational missions
Small Group Activity #1 At your program, think of an example of an educational redesign. What is the purpose of that redesign? Does that redesign effort align with institutional/clinical (i.e. health system) needs and priorities? How do you know? How could you know?
Outline 1. Changing Landscape of Health Care and Medical Education 2. UNMC and Nebraska Medicine 3. OHPE – Facilitating Alignment 4. OHPE – Business Plan Development 5. Conclusions
Relationship existed between educational units and clinical delivery system Goal is a Health System Leader: Relationship? partnership! “Isn’t that (education) what the University does?” Academic Leader: “What do they (hospital) care about education?”
Why alignment?
Training competent providers requires that they train in competent systems
Partnership is a “win-win” relationship Competent systems cannot exist without competent providers Asch, et. al. JAMA, 2009
Outline 1. Changing Landscape of Health Care and Medical Education 2. UNMC and Nebraska Medicine 3. OHPE – Facilitating Alignment 4. OHPE – Business Plan Development 5. Conclusions
Office of Health Professions Education (OHPE) Who: Small staff (3-4) with key roles to drive strategic areas of focus and facilitate alignment in context of education What: Support, facilitate, prioritize, advocate, partner When: July 2015 Where: Accountable to VP for Education, Nebraska Medicine Why: Facilitate the alignment of Nebraska Medicine, UNMC and its affiliates and partners in context of education
Office of Health Professions Education (OHPE)
How: • Understand strategic needs for all involved
• “Connect-the-dots” between people, programs and resources to help them achieve their goals • Demonstrate value to education and clinical leaders
OHPE Areas of Focus ‘Areas of focus’ were based upon strategic needs, opportunity and potential impact: A. Continuing Education for Health Professionals B. Clinical Quality and Education C. Interprofessional Practice and Teamwork D. Rural / Community Development
OHPE Facilitation – Cont Ed Example Center for Continuing Education (CCE) • Housed within UNMC (i.e. not health system) • Goal: CE to be viewed as a strategic resource (i.e. something to leveraged as opposed to a cost/liability that needs to be tolerated) • OHPE facilitated alignment and integration
CCE Examples of Alignment • Access to health system strategic planning and business priorities • Heart Failure • Geriatric Oncology
• Access to quality data for use in developing focused and/or strategic education • Regularly scheduled series (e.g. Grand Rounds) with refined standards • CCE Director part of health system leadership team
CCE Examples of Alignment • Wide variety of educational opportunities to enhance faculty, staff and resident knowledge, skills and attitudes while improving care: • • • • • •
Sepsis Patient Experience Health Equity High Value Care Milestones and CBME Handheld ultrasound
OHPE Facilitation – Quality Example Nebraska Medicine Quality Office
UNMC Residency Program • Identification of quality need • Trainee and faculty education • Engage in improvement to propose solution
OHPE
• Data Analytics, informatics, expertise • Dashboard development
• Implement identified solutions
Health Literacy
Background Learning
Experiential Learning
Curriculum
Faculty/Staff Development
Interprofessional Teams Enhanced Care Systems
Small Group Activity #2 Using the example that you identified in Activity #1, how might you align efforts at educational redesign with institutional/clinical priorities? What “dots” can you connect in order to achieve that goal? (Hint: think from the perspective of the educator as well as the hospital administrator.)
Overarching National Themes of CLER Theme #3: #1: Clinical learning environmentsvary varyinintheir the environments extent to which they invest approach to and capacity infor continually educating, addressing patient training, andhealth integrating safety and care facultyand members and to quality, the degree program directors in the which they engage areas of health quality, residents andcare fellows in patientthese safety, and other areas. systems-based initiatives.
#2: Theme #4: Clinical Clinical learning learning environments environmentsvary varyinintheir the approach degree to to implementing which they GME. In many clinical coordinate and implement learning environments, educational GME is largelyresources developed across the health care and implemented professions. independently of the organization’s other areas of strategic planning and focus.
CLER Pathways to Excellence • • • • •
Patient Safety Health Care Quality Supervision Care Transitions Health Care Disparities • Fatigue Management, Mitigation and Duty Hours • Professionalism
OHPE and CLER • Facilitate Resident Quality and Safety Committee (RES-Q) • Just-in-time Supervision Monitoring • Health Equity Symposium • Continuing Education as a Strategic Resources
Small Group Activity #3 What imperative can you leverage to help you work towards alignment and achieve your goal?
Outline 1. Changing Landscape of Health Care and Medical Education 2. UNMC and Nebraska Medicine 3. OHPE – Facilitating Alignment 4. OHPE – Business Plan Development 5. Conclusions
Rogers’ Organization Innovation Process DECISION
INITIATION Agenda Setting / Gap Diagnosis
Define your need for change
(Rogers, 2003)
IMPLEMENTATION
Matching
Redefining
Describe how innovation matches your need
Re-define the innovation to stakeholders, restructure organization to fit innovation, communicate
Clarifying
Make roles and tasks associated with innovation clear
Routinizing
Hard-wire: develop business plan, policies, procedures, job descriptions, performance appraisals
Agenda / Gaps Jan – March 2014 Recognize opportunity and establish need Carpe diem! Key Facilitator: CLER site visit in Feb 2014
OHPE - Why Now? Strengths
Weaknesses
• Leadership Support (Chancellor Gold) • Champion with authority • Existing infrastructure for most of desired changes
• Poor coordination between clinical and educational units • Educational silos across continuum • COM only early participant
Opportunities
Threats
• Changes in senior leadership • Changes in organizational orientation • Changes in local health care environment • Timely CLER visit
• “Isn’t that (education) what the University does?” “What do they (hospital) care about education?” • Redundancy and bureaucracy • Turf wars
Matching April – Nov 2014 Sell vision, understand the environment, build relationships with stakeholders Consistent message: Support, facilitate, prioritize, advocate, partner Key Facilitator: Incorporate into UNMC Strategic Plan
Potential individuals to engage Chief Quality Officer (CLER) Informatics (Documentation)
Continuing Education (MOC and quality)
Associate Deans (Educational Programming)
Human Resources (Effective on-boarding)
Chief Financial Officer ($$$)
I/O Psychologists (Organizational Understanding)
Health Services Researchers (Data generators)
Rogers’ Organization Innovation Process DECISION
INITIATION Agenda Setting / Gap Diagnosis
Define your need for change
(Rogers, 2003)
IMPLEMENTATION
Matching
Redefining
Describe how innovation matches your need
Re-define the innovation to stakeholders, restructure organization to fit innovation, communicate
Clarifying
Make roles and tasks associated with innovation clear
Routinizing
Hard-wire: develop business plan, policies, procedures, job descriptions, performance appraisals
Redefining Dec 2014 – Jan 2015 ‘Area of focus’ workgroups established Expand stakeholder network
Key Facilitator: Convergence around common themes
OHPE Areas of Focus A. Continuing Education for Health Professionals B. Clinical Quality and Education C. Interprofessional Practice and Teamwork
D. Rural / Community Development
OHPE Workgroups Broad and multiprofessional representation 58+ individuals 12+ constituencies Total of 6 one-hour meetings
Defined charge
Charge to Workgroups Question #1: Identify opportunities where alignment is desired or needed Question #2: What needs to happen in order to achieve alignment with respect to these opportunities? Question #3: What are the recognized barriers / potential solutions to achieving alignment? What are strategies to overcome barriers? Question #4: What resources are necessary to facilitate alignment?
Clarifying Feb - March 2015 Compile feedback from workgroups to clarify expected services and products of OHPE Justify budget required to build team Key Facilitator: Prior engagement of stakeholders
OHPE – Organizational Structure
Rogers’ Organization Innovation Process DECISION
INITIATION Agenda Setting / Gap Diagnosis
Define your need for change
(Rogers, 2003)
IMPLEMENTATION
Matching
Redefining
Describe how innovation matches your need
Re-define the innovation to stakeholders, restructure organization to fit innovation, communicate
Clarifying
Make roles and tasks associated with innovation clear
Routinizing
Hard-wire: develop business plan, policies, procedures, job descriptions, performance appraisals
Routinizing March 2015 Finalize business plan, complete job descriptions and start hiring Maintain focus areas but accept accountability for specific tasks in the context of education
Small Group Activity #4 Think about your institution or program: a.
What are the opportunities where alignment is needed or desired? (Think about the needs for resident education and needs for clinical improvement.)
b.
What needs to happen in order to achieve alignment with respect to these opportunities?
c.
What are the recognized barriers / potential solutions to achieving alignment? What are the strategies to overcome the barriers? Who can facilitate or hamper the process?
d.
What resources will be necessary in order to facilitate alignment?
Common Mission We are Nebraska Medicine and UNMC. Our mission is to lead the world in transforming lives to create a healthy future for all individuals and communities through premier educational programs, innovative research and extraordinary patient care.
OHPE – Example Business Plan
Outline 1. Changing Landscape of Health Care and Medical Education 2. UNMC and Nebraska Medicine 3. OHPE – Facilitating Alignment 4. OHPE – Business Plan Development 5. Conclusions
Facilitators to Alignment Common missions and common needs Tying OHPE to strategic plans Top leadership is academic focused Engaging all health professions education
Formal leadership roles in both camps
Barriers to Alignment Constant evolution of everything around OHPE Too many initiatives – too many opportunities! Perceived (or real?) redundancy Perceived (or real?) threat to others
Lessons Learned 1.
Use clinical redesign imperatives to your advantage – think broadly to leverage redesign beyond the accreditation standard
2.
Be strategic!
3.
Sell vision, build relationships and understand the environment
4.
Iterative process – identify vision, be flexible and keep working towards that goal
5.
Build trust - be transparent about potential risks/benefits to education and clinical stakeholders
6.
Look for opportunities for alignment
7.
Involve others who have the skill set to help you to succeed
References 1. Institute of Medicine: Crossing the Quality Chasm: A new health system for the 21st century. Washington, DC: The National Academies Press; 2001. 2. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. 3. Cooke M, Irby DM, O’Brien BC. Educating physicians: A call for reform of medical school and residency. 2010. The Carnegie Foundation for the Advancement of Teaching. 4. Weinberger SE, Pereira AG, Iobst WF, et. al. Competency-based education and training in Internal Medicine. Ann Int Med. 2010;153: 751-6.
5. Institute of Medicine. Health Professions Education: Bridge to Quality. Washington, DC: The National Academies Press; 2003.
References 6. Frank JR, Snell LS, ten Cate O. Competency-based medical education: Theory to practice. Med Teach. 2010; 32: 638-45. 7. Caverzagie KJ, Iobst, WF, Aagaard EM, et. al. The Internal Medicine Reporting Milestones and the Next Accreditation System. Ann Int Med. 2013;158: 557-9. 8. CLER Pathways to Excellence: Expectations for an optimal clinical learning environment to achieve safe and high quality patient care. Accreditation Council for Graduate Medical Education. c. 2014. 9. American Medical Association: Accelerating change in medical education initiative. http://www.ama-assn.org/sub/acceleratingchange/overview.shtml. Accessed: 2/26/15. 10. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein A. Evaluating Obstetrical Residency Programs Using Patient Outcomes. JAMA. 2009;302:1277-83.
References 11. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004. 12. Famiglio LM, Thompson MA, Kupas DF. Considering the Clinical Context of Medical Education. Acad Med. 2013; 1202-5.
13. Rogers, E. Diffusion of Innovation. Multiple sources. 14. Using Logic Models to Bring Together Planning, Evaluation and Action. Logic Model Development Guide. W.K. Kellogg Foundation. c.2004.
Questions? Kelly Caverzagie
[email protected] Lois Colburn
[email protected]
Early examples of facilitating alignment A. Clinical Quality and Education –
GMEC and CLER
B. Interprofessional Practice and Teamwork –
Planning for iEXCEL (Interprofessional Experiential Center for Enduring Learning)
C. Rural / Community Development –
Partnerships with Nebraska Health Network (NHN) and Regional Provider Network (RPN)
D. Continuing Education for Health Professionals –
“The Nebraska Ebola Method” on iTunes University
Other opportunities for alignment CME/MOC and quality improvement On-boarding of new trainees (education) and employees (human resources) Tele-medicine and tele-education Patient-centered care (e.g. Health Literacy)
Health Literacy Greater than 1/3 of American adults lack sufficient health literacy People who understand health instructions make fewer mistakes, get well sooner and can better manage chronic conditions Simple strategies to combat health literacy exist Health Literacy Tip Sheet, TMF Health Quality Institute.
10 Attributes of a Health Literate Organization
#2) Integrates health literacy into planning, evaluation measures, patient safety and quality improvement #3) Prepares the workforce to be health literate and monitors progress
Health Literacy Tip Sheet, TMF Health Quality Institute.
OHPE Early Wins Remove Redundancy • Competing leadership development programs
Foster Relationships • Connecting CCE with local / regional partners • Who is across the table?
New Culture • Recognition that someone else may be able to help we are all involved with education and patient care • Integration of strategic plans
The Logic Model
Systematic and visual way to present and share relationships among the resources available to operate a program, activities planned and anticipated changes or results.
W.K. Kellogg Foundation, 2004
Achieving a Common Mission Opportunity to: Improve clinical care Improve educational experience Aligned missions will result in: Better practitioners Better systems of care and training Better care for patients / populations
IOM Competencies for Health Professionals
IOM Health Professions Education: Bridge to Quality. c.2003.
Competency-Based Medical Education CBME is an outcomes-based approach to the design, implementation and evaluation of a medical education program using an organizing framework of competencies.
The International CBME Collaborators Frank et al. Med Teach, 2010
Internal Medicine Milestones
Caverzagie et al. Ann Int Med, 2013
American Medical Association: Accelerating change in medical education http://www.ama-assn.org/sub/accelerating-change/overview.shtml
Imperative for Education Redesign Medical education has not sufficiently responded to: • Shifting patient expectations and demographics • Quality improvement • Use of new technologies • Changing health delivery systems
Summary: Medical education is not meeting the nation’s health care needs Weinberger et al. Ann Int Med, 2010
Efforts at Health System Redesign • Patient experience • Population Health • Value (high benefit, low cost) • Interprofessional teamwork • Transitions of care • Informatics and data management • Evidence-based standards • Others
Efforts at Medical Education Redesign • New assessment frameworks • New curricular content and structure • New curricular delivery approaches • New learning experiences • Interprofessional education • Emphasis on learning environment • Others
Why alignment? WE HAVE THE SAME GOALS!
Clinical and Curricular Integration
Effective integration of medical education with high-performance health care delivery can be enhanced with conventional curriculum development tools applied in unconventional ways. Breakthroughs in clinical care translated into curricular “streams”
Famiglio LM, et. al. Acad Med. 2013