The first five installments of this series  were on the LESS Initiative (December 8th), the Patient-Centered Medical Home(December 15th), the Auditing for quality and safety (January 5th), Team Work (January 12th, and the Philosophical Foundation to SETMA’s Transformation (January 19th).  The goal of this series is to review the core values and functions which have enabled SETMA:

• to connect the past with the present and to prepare for the future (Continuity);
• to illustrate the ingenuity and healthcare transformation which have been central to SETMA’s progress (Creativity), and to allow SETMA
• To sustain the progress of the past, tying it to the needs of the future, enabling SETMA to relentless pursue excellence in patient care quality and safety (Consistency). 

This sixth installment is on sustainability which is a key aspect of healthcare transformation.  Without it, change happens, but doesn’t continue to happen.  Often initiatives begin but shortly are forgotten as another initiative occupies the attention of a provider or an organization.  Maintaining an existing positive change in patient care, while instituting another positive change, is one of the most difficult aspects of excellent healthcare.

The American Medical Association and Sustainability

This tension is what created the American Medical Associates’ (AMA) collaboration with numerous other organizations to produce the Physician Consortium for Performance Improvement (PCPI).  Through PCPI, the AMA designs quality initiative measurement sets which allow physicians, at the point of care, to measure their own performance while seeing patients.  Depending upon how the measures are tracked and measured, PCPI measurement sets were an excellent beginning in sustainability, maintaining over a long period of time a quality improvement effort. 

One of the best aspects of PCPI was that measurement sets involved multiple measures relevant to a singly condition, such as diabetes which had nine unique metrics for the care of a patient with diabetes. 

An addition to PCPI was the AMA’s design of the Performance Improvement Continuing Medical Education (PI-PCE) program.  Historically, continuing medical education occurred in isolated lectures or readings, which attracted provider attention briefly but were often forgotten within a few weeks.  PI-CME activities were designed to address this deficiency in traditional CME. 

What is PI CME?

A PI-CME activity is a process by which evidence-based performance measures and quality improvement (QI) interventions are used to help physicians identify patient care areas for improvement and to change their own performance in the treatment of those conditions. This type of CME activity differs in structure from other CME learning models that may also use Performance and/or Quality improvement data (e.g., live activities, enduring materials).

To produce PI-CME tools, the accredited CME provider develops a long-term, 3-stage process during which a physician or group of physicians learns about specific performance measures, assesses their practice using the selected performance measures, implements interventions to improve performance related to these measures over a useful interval of time and then reassesses their practice using the same performance measures.

The PC-CMI has to consist of the following 3 stages:

• Stage A: Learning from Current Practice Performance Assessment

Assess current practice using the identified performance measures, either through chart reviews or some other appropriate mechanism. Participating physicians must be actively involved in the analysis of the collected data to determine the causes of variations from any desired performance and identify appropriate intervention(s) to address these.

• Stage B: Learning from the Application of PI to Patient Care

Implement the intervention(s) based on the results of the analysis in Stage A, using suitable tracking tools. Participating physicians should receive guidance on appropriate parameters for applying the intervention(s).

• Stage C: Learning from the Evaluation of the PI CME Effort

Reassess and reflect on performance in practice measured after the implementation of the intervention(s) in Stage B, by comparing to the assessment done in Stage A and using the same performance measures. Summarize any practice, process and/or outcome changes that resulted from conducting the PI CME activity.

SETMA’s Experience with PI-CME

SETMA’s entire staff participated in our first PI-CME program in 2010.  We asked the staff of the course, “Why is this course only focused upon five weeks?”   The answer was revealing.  The professor stated, “Because, we think that is as long as we can keep the attention of the healthcare providers.”  To which answer, we responded, “Oh, then you don’t really expect this to make a permanent change in quality and safety but only to show a short-term improvement?”

At this time, SETMA suggested that in order to create sustainability, that the PI-CME project designed need to have a fourth step.  The first three steps were important and appropriate:

1. Evaluate your performance.
2. Direct your study to the areas of poor performance indicated by number one.
3. Re-evaluate your performance after number two to see if there was improvement.

If left at this point however, PC-CME could result in the same problem as seen in traditional CME.  After a while, the provider would, due to other pressures, forget the changes which were previously learned. 

How could this be overcome?  The name CME has been called “Continuing Medical Education” and “Continuous Medical Education.”  Most often, CME looked more like “Episodic Medical Education,” rather than like “continuous or continuing learning.”  During “episodes” of learning, enthusiasm was high, but the pressures of work often distracted the provider and what had been learned and/or what had been determined to be done, was forgotten.

To turn PI-CME into a sustainable change in practice performance and to allow new initiatives to be undertaken without forgetting still valid and important former initiatives, there have to be reminders and on-going measures of that commitment and/or performance. 

To be effective and to remain effective the PI-CME must have a fourth step which is the continual auditing of provider performance with available clinical decision support tools.

Clinical Decision Support (CDS) and Quality Measures (QM)

To be successful these reminders needed to be unobtrusive to the patient encounter and they needed to be completed incidentally to excellent care and they needed not to be the intention of care.  There also needed to be multiple measures for each disease entity being addressed.

More than other changes SETMA made, it was the design of the tracking of quality measures and the inclusion of CDS which made it possible for SETMA continuously to improve the quality and the safety of care which we deliver.

It was this need for sustainability which led to the design of The SETMA Model of Care.  That model has five steps:

1. The tracking by each provider on each patient of the provider’s performance on preventive care, screening care and quality standards for acute and chronic care. SETMA"s design is such that tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the personal provider, nurse, clerk, management, etc.
2. The auditing of performance on the same standards either of the entire practice, of each individual clinic, and of each provider on a population, or of a panel of patients. SETMA believes that this is that this ongoing auditing of provider performance is what is missing from PI-CME.
3. The statistical analyzing of the above audited performance in order to measure improvement by practice, by clinic or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, payer class, socio-economic groupings, education, frequency of visit, frequency of testing, etc. This allows SETMA to look for leverage points through which SETMA can improve the care we provide.
4. The public reporting by provider of performance on hundreds of quality measures. This places pressure on all providers to improve, and it allows patients to know what is expected of them. We believe this is the best way to overcome provider and patient “treatment inertia.”
5. The design of Quality Assessment and Permanence Improvement (QAPI) Initiatives

The piece which is missing from the 3-Stage PI-CME is the ongoing auditing, analysis and reporting of provider performance.  Using clinical disease support and disease management tools, as a 4-Stage, the impact of PI-CME can be perpetuated in a sustainable fashion for an entire career.