Conversation-starter: SQUIRE tool standards as a connection between medical communication organization: ACEhp and AMWA

There are many synergies and resources between the Alliance for Continuing Education in the Health Professions (ACEhp) and the American Medical Writers Association (AMWA), because medical educators and medical writers are all communicators ... which explains why so many of us are members of both. In today's ACEhp webinar (see www.acehp.org/p/cm/ld/fid=367), Jann Balmer replied to a question asking about the role of medical writers in publishing educational outcomes in the quality improvement reporting tool, SQUIRE (as customized by ACEhp), saying that outcomes manuscripts can be enhanced by medical writers and editors because QIE project managers may not be good writers. My colleague, Donald Harting, and I have been discussing potential organizational synergies between AMWA and ACEhp in this regard for over a year.

This is an opportune moment for our memberships to work together: AMWA celebrated 75 years with last week's Annual Conference, which started the very day on which ACEhp launched its custom SQUIRE reporting tool for clinical educational research at the annual Alliance Quality Symposium. This begs the question: What role will professional medical writers and communicators in AMWA play in publishing standardized, SQUIRE-compliant educational outcomes research in the Alliance for CE in the Health Professions custom tool?

Conversation-starter: ACEhp identified a top goal of 2015's Phase II of the Quality Improvement Education (QIE) Initiative as the "Assessment of SQUIRE to generate Case Studies that demonstrate successful integration of Education into QI." Professionals with capabilities in medical education and writing will ideally combine their skills in writing these case studies. Wouldn't you like to author a study that is eligible for later meta-analyses because the study was SQUIRE-compliant?

Extension: There is an inaugural meeting on writing research in the SQUIRE tool at Dartmouth this November 2015. MedBiquitous members, as experts in standardization in medical education technology and reporting, what can you contribute to this conversation? Members of the American Educational Research Association LinkedIn group, what are your thoughts for connecting health education research reporting to more global research agendas? 

I am promoting the SQUIRE tool because of my roles as Co-Leader of the ACEhp QIE Initiative's Building Block on "Nomenclature and Its Adoption" and Research Track faculty. In these roles, I see the needs for developing consistent wording and reporting standards for medical education research. After all, how will we report our achievements and deliberate our challenges in developing and researching CE in the Health Professions if we do not have consistent language to use in the SQUIRE reporting tool? Let's not delay a start in COMMUNICATING among health communicators. Join the discussion! I believe that this is a great opportunity for all health educators, education researchers, and writers to collaborate!

For additional information on these organizations, topics, and events, check out these links (some may have membership firewalls):

- SQUIRE (Standards for Quality Improvement Reporting Excellence) inaugural conference: squire-statement.org/news_events/squire_international_writing_conference/

- ACEhp Quality Symposium: www.acehp.org/p/cm/ld/fid=20 (see also the August 2015 issue of the Almanac: www.acehp.org/p/cm/ld/fid=52, p. 15)

- ACEhp Foundation QIE Initiative: www.acehp.org/p/cm/ld/fid=43

- ACEhp Foundation QIE Initiative's custom SQUIRE tool:

---See Slides 17 - 19 of www.acehp.org/p/do/sd/sid=864&fid=1212&req=direct

---See Webinars at www.acehp.org/p/cm/ld/fid=367

- AMWA 75th Anniversary: www.amwa.org/amwa_anniversary

- MedBiquitous: http://www.medbiq.org/ and new Performance Standard: www.medbiq.org/node/1001

Connect with me! SHBinford@FullCircleClinicalEducation.com or www.linkedin.com/company/full-circle-clinical-education-inc

CS2day: Award-Winning, 9-Collaborator, Performance-Improvement CME With an Outcomes-Based Evaluation Model

I saved the best for the last entry in the Back to School Tweet Fest. The Cease Smoking Today (CS2day) initiative cannot be ignored in a series about effective educational interventions in changing practice and improving quality of health care. An entire 2011 supplement of the Journal of Continuing Education in the Health Professions (JCEHP) reports the complex CS2day educational program and its findings, with six research articles [1-6] and three forum articles [7-9] written by multi-institutional teams among the nine initiative partners. This study was awarded the Alliance for CME (now ACEhp) Award for Outstanding CME Collaboration in 2009 (see PDF pages 15-18 of www.acehp.org/d/do/150), and was presented in a 2012 CME Congress poster (P50: http://www.cmecongress.org/wp-content/uploads/2012/05/CME-Congress-2012-Abstracts.pdf). The study boasts collaboration among universities, professional societies, accredited CME providers, ACEhp presidents and conference chairs, CME directors at academic medical centers, the JCEHP Editor-in-Chief, and other published researchers [1,10] who carefully define the educational program’s framework and collaboration model in the new quality improvement paradigm of CME called for by the Institute of Medicine in 2001 [11].

The CS2day initiative is so big that this blog post cannot feature just one article reporting it. I will focus on the introductory editorial [10] and 2 study articles that focus on (a) developing competencies to assess needs and outcomes [3] and (b) the educational and patient health outcomes data themselves [4]. The medical education expert Donald Moore introduces the supplement and one article therein reports the outcomes data. I hope you will do as Moore recommends, when you question what you can take from articles describing “a huge project with significant funding,” which is to ask, “What are the general principles that I can identify in these articles and how can I use them in my CME practice[?]” [10].

In my previous post, I noted the difficulties of using PI-CME to change patient health outcomes in a condition posing a major public health challenge: the COSEHC study addressed cardiometabolic risk factors and saw performance and patient health improvements. The CS2day initiative faced the same challenge, and happily also reported performance change and a change in patient health outcomes: smoking cessation. Moore nicely summarizes the challenge of connecting Level 5 performance changes among clinicians to Level 7 changes in public health outcomes: “All of us want to improve the health of the public in some way, but our approaches … may prevent us from having the impact that we wish to have. The [CS2day] articles … suggest there might be another approach that we should consider to address the important public health issues that surround but do not seem to be impacted by our CME programs” [10; emphasis added].

The articles in the JCEHP supplement are organized around 4 themes [10], to which I have added themes from the articles: 

a) Collaboration is challenging but worth doing if guidelines are set and a formative evaluation of the collaboration against known success factors is carried out [1,2,5]
b) Best-practice CME includes an outcomes orientation that connects learning and performance objectives from the needs assessment to the outcomes assessment in a valid framework to support content in all educational activities [3-6]
c) A public health focus can lead to development of CME/CEhp activities with a translational or implementation science function that transcends what can happen when education addresses only a practice gap [7]
d) Standards and competencies for CEhp and members of the CEhp profession help initiatives meet the principles and characteristics of the IOM report’s expectations [8,9,11] 

The two featured research articles [3,4] function together as the Methods and Results sections of a typical IMRAD-structured paper, but each is extensive enough to stand alone and inform CEhp professionals. McKeithen et al describe the following: the need for establishing clinical competency statements related to supporting smoking cessation; the clinical guidelines that informed performance expectations; “the 5 A’s” of support for smoking cessation (Ask, Advise, Assess, Assist, and Arrange); the 14 competencies or the 8 performance outcomes measures that fit into the 5 A’s algorithm being assessed; and collaboration of clinical and educational experts on outcomes tools to develop “a comprehensive set of measures at Levels 3 through 6” [3].

The summative outcomes data are extensively reported by Shershneva et al, where “evaluation of a collaborative program” is presented as “translating” the outcomes framework into practice [3,4]. Defining desired outcomes of the program across Levels 1 to 6* was seen as useful in facilitating agreement among stakeholders; guiding the evaluation process; gathering data from multiple activities and collaborators in a central repository; and studying the effects of mechanisms that link education to outcomes [4]. Thanks to effective planning, the researchers were also able to add to the literature on instructional design in CEhp by distinguishing performance outcomes from two groups of activity types: a) live PI activities with either a collaborative or practice-facilitator model and b) self-directed learning PI activities.

Also worth reading are additional insights about using the Success Case Method (SCM) to determine whether and why educational interventions succeed [6]. In CS2day reporting, using the SCM allowed the research team to conclude remarkably confidently, stating, “the PI activities were a primary and proximal cause of improvement in clinical practice” [4]. Moore notes that “the results were impressive: physicians integrated a new guideline into their practices and many patients stopped smoking” [10]. The guideline integrated into practice through the CS2day initiative was a “heavily researched evidence-based practice guideline published by the U.S. Agency for Healthcare Research and Quality,” due to be updated in 2008, the year after this collaborative initiative was begun [1].

Finally, a comment: In CEhp, change data are often seen as valid only when educational and program interventions do not change before activity expiration, nor even when a formative assessment shows changes to be necessary. This attitude can leave participating clinicians with suboptimal educational opportunities and stakeholders in the educational design frustrated. The use of the formative program evaluations that improved the CS2day initiative, with acknowledgements of changes, is in my opinion better than a pure pre/post comparison on an activity where valuable investments are not updated when indicated. If the CME/CEhp profession helps clinicians link medical care to public health through disease prevention, accountability to quality, and more, then educational design should respond to data collected in lengthy and large interventions.

The CS2day initiative is a model study in educational and performance improvement methods for a challenging public health problem. Please read the study articles if you have print or online access to JCEHP, for I have only touched the surface of the initiative's methodology, results, and rationales in the limited confines of this space. 

* Note: In this study, “Learning” was used as Level 3 and included knowledge and clinical skill (competence) measures, while “Performance” including commitment to change (CTC) queries was used as Level 4. Thus Level 5 was “Patient Health Status” and Level 6 was “Population Health Status.”

References cited: 

1. Olson CA, Balmer JT, Mejicano GC. Factors contributing to successful interorganizational collaboration: the case of CS2day. J Contin Educ Health Prof. 2011;31(Suppl 1):S3-S12.
2. Ales MW, Rodrigues SB, Snyder R, Conklin M. Developing and implementing an effective framework for collaboration: the experience of the CS2day collaborative. J Contin Educ Health Prof. 2011;31(Suppl 1): S13-S20.
3. McKeithen T, Robertson S, Speight M. Developing clinical competencies to assess learning needs and outcomes: the experience of the CS2day initiative. J Contin Educ Health Prof. 2011;31(Suppl 1):S21-S27. http://www.ncbi.nlm.nih.gov/pubmed/22190097. [Featured Article]
4. Shershneva MB, Larrison C, Robertson S, Speight M. Evaluation of a collaborative program on smoking cessation: translating outcomes framework into practice. J Contin Educ Health Prof. 2011;31(Suppl 1):S28-S36. http://www.ncbi.nlm.nih.gov/pubmed/22190098. [Featured Article]
5. Mullikin EA, Ales MW, Cho J, Nelson TM, Rodrigues SB, Speight M. Sharing collaborative designs of tobacco cessation performance improvement CME projects. J Contin Educ Health Prof. 2011;31(Suppl 1):S37-S49.
6. Olson CA, Shershneva MB, Brownstein MH. Peering inside the clock: using success case method to determine how and why practice-based educational interventions succeed. J Contin Educ Health Prof. 2011;31(Suppl 1):S50-S59.
7. Hudmon KS, Addleton RL, Vitale FM, Christiansen BA, Mejicano GC. Advancing public health through continuing education of health care professionals. J Contin Educ Health Prof. 2011;31(Suppl 1):S60-S66.
8. Balmer JT, Bellande BJ, Addleton RL, Havens CS. The relevance of the Alliance for CME competencies for planning, organizing, and sustaining an interorganizational educational collaborative. J Contin Educ Health Prof. 2011;31(Suppl 1):S67-S75.
9. Cervero RM, Moore DE. The Cease Smoking Today (CS2day) initiative: a guide to pursue the 2010 IOM report vision for CPD. J Contin Educ Health Prof. 2011;31(Suppl 1):S76-S82.
10. Moore DE. Collaboration, best-practice CME, public health focus, and the Alliance for CME competencies: a formula for the new CME? J Contin Educ Health Prof. 2011;31(Suppl 1):S1-S2. http://www.ncbi.nlm.nih.gov/pubmed/22190095. [Featured Editorial]
11. Institute of Medicine (IOM) Committee on Planning a Continuing Health Professional Education Institute. Redesigning Continuing Education in the Health Professions. Washington, DC: The National Academies Press; 2010. http://books.nap.edu/openbook.php?record_id=12704. Accessed September 17, 2015.

MeSH “Major” Terms for the 3 Featured Articles (common items italicized): 

McKeithen et al [3]: Benchmarking; Clinical Competence; Education, Medical, Continuing/methods; Needs Assessment; Outcome and Process Assessment (Health Care)/organization & administration; Practice Guidelines as Topic/standards; Smoking Cessation/methods; Tobacco Use Disorder/prevention & control
Shershneva et al [4]: Benchmarking/methods; Clinical Competence/standards; Health Personnel/classification; Health Personnel/psychology; Health Personnel/statistics & numerical data; Interprofessional Relations; Outcome Assessment (Health Care)/organization & administration; Program Evaluation; Smoking Cessation/methods; Tobacco Use Disorder/prevention & control
Moore [11]: Benchmarking; Clinical Competence; Delivery of Health Care, Integrated; Education, Medical, Continuing/methods; Interinstitutional Relations; Public Health

Study Design and Paired Comparisons: Individualized Education Fails to Change Practice—Or Was It Only Poor Matching?

We should commend Malone et al for submitting this AHRQ-supported* study [1] for publication when a flaw in its design or execution could be the authors’ main reason for concluding that “the current study was not able to demonstrate a significant beneficial effect of the educational outreach program on [the primary performance outcome measure].” This blog’s “Back-to-School” service campaign did not exclude studies reporting negative outcomes because these studies can potentially inform continuing education in the health professions (CEhp) as much as positive studies can.

CEhp/CME educational proposals, audience-generation strategies, and outcomes reports now specify relevant “target audiences,” recognizing that not all practitioners with a certain degree, specialty, or other professional demographic description would benefit from the same educational activity or design. With this more recent recognition of the importance of targeting specific clinicians and learning about their needs has come greater recognition that many CE participants should not be included in aggregated data. This is even truer in studies with matched pairs, where the step of greatest importance lies in setting match criteria. On September 15th, I discussed an opioids-education study where matching criteria were so stringent that the authors were not able to match certain participants (physicians in the intervention group), and these participants’ data and group assignments were handled nicely and reported clearly in the paper [2] (see post at http://fullcirclece.blogspot.com/2015/09/eight-year-canadian-study-on-opioid.html).

Conversely, the first result listed in this study’s abstract indicates a matching flaw for a study on education on drug-drug interactions (DDIs): “The 2 groups were significantly different with respect to age, profession, specialty, and geographic region.” This finding undermines other benefits to the study, namely, that large samples (19,606 prescribers) were recruited to both groups (educational intervention vs. control) and matched on prescribing volume. Individualized education (also known as academic detailing) was delivered by trained pharmacists as clinical consultants who met with prescribers to “provide one-on-one information … promote evidence-based knowledge, create trusting relationships, and induce practice change.” This study’s performance (behavioral) measure was a reduced rate of prescribing potential DDIs. The prescribing of 25 clinically important, potential DDIs increased more in the intervention group than it did in the control group.

In conclusion, when we look at this presumably negative finding, we are left to wonder whether the educational intervention was not effective—or whether a better matching process might have revealed different results on reducing potential DDIs and improving health care quality and utilization. One could argue that with nearly 20,000 prescribers in both samples, more matching criteria could have been applied without sacrificing so many data points that results would be inconclusive. The study’s design as a retrospective study could also explain recruitment and matching practices. In social sciences research (including educational outcomes research), a core expectation is generalizability of a sample to a population of interest; when reasonably achieved, generalizability lets us apply findings to practical needs and future decisions. 

Recall the study conclusion quoted above: “The current study was not able to demonstrate a significant beneficial effect …” (emphasis added). A secondary analysis with different pair-matching practices might yet inform national initiatives in improving quality while reducing costs through academic detailing, both of which help patients. Now let’s remember to thank Malone, Liberman, and Sun for sharing their data and methods with the healthcare quality and educational research communities in the Journal of Managed Care & Specialty Pharmacy.

* AHRQ = United States Agency for Healthcare Research and Quality

References cited:
1. Malone DC, Liberman JN, Sun D. Effect of an educational outreach program on prescribing potential drug-drug interactions. J Manag Care Pharm. 2013;19(7):549-557. http://www.ncbi.nlm.nih.gov/pubmed/23964616. [Featured Article]
2. Kahan M, Gomes T, Juurlink DN, et al. Effect of a course-based intervention and effect of medical regulation on physicians’ opioid prescribing. Can Fam Physician. 2013;59(5):e231-e239. http://www.cfp.ca/content/59/5/e231.full.pdf+html.
Free Full Text: http://www.amcp.org/JMCP/2013/September_2013/17103/1033.html
MeSH “Major” Terms: Drug Interactions; Drug Prescriptions; Education, Medical, Continuing; Health Education; Physician's Practice Patterns; Prescription Drugs/administration & dosage

Today's Landmark NHLBI SPRINT study results relate to this 2008 PI-CME article by Shershneva, Olson, et al

Today the National Heart, Lung, and Blood Institute (NHLBI) of the United States National Institutes of Health announced the early completion of the landmark SPRINT study into recommended systolic blood pressure, which was led by researchers in my own town, at Wake Forest University School of Medicine. Therefore I am featuring a hypertension performance-improvement CME study by Marianna Shershneva, Curt Olson, and others, whose care is a quality measure in this country and elsewhere.

This PI-CME study was published in 2008, before most educational providers who now have outcomes-reporting capacities were able to study educational outcomes within a clinical context. Marianna Shershneva, M.D., Ph.D., is Building Block Leader for Quality Metrics of the Alliance's Quality Improvement Education (ACEhp QIE) Initiative, and Curtis Olson, Ph.D., has been guiding our field through his influence and tenure as Editor-in-Chief of the Journal of Continuing Education in the Health Professions. With their coauthors, Elizabeth Mullikin and Anne-Sophie Loos, we have a nice study for historical review that might have escaped attention on this day because the article title does not specify hypertension.

Consider this excerpt from the abstract, which lays out the opportunities for quality improvement professionals and clinical educators to work together for better patient care: "Although QI practices and CME approaches have been recognized for years, what emerges from their integration is largely unfamiliar, because it requires the collaboration of CME providers and stakeholders within the health care systems who traditionally have not worked together and may not have the same understanding of QI issues to close performance gaps." This was an observational case study with nine clinicians completing the study, and while we could wish for a larger sample, we should agree with the authors that "PI CME required unprecedented collaboration between CME planners and QI stakeholders to enable change in clinical practice." Let's applaud the effort and enjoy the three core findings that you'll see if you access this article.

This is a FREE article in PubMed Central, and I encourage you to review it for findings on physicians' practice patterns that have bearing on today's news from NHLBI. Thanks to the National Library of Medicine reviewers of articles for their assignments to this article's medical subject headings (MeSH terms), without which this article may not have risen to most noteworthy mention after today's NHLBI news. And by the way, proving the relevance of this sort of work to our nation, this study was also funded by two NIH grants.

References Cited: Shershneva MB, Mullikin EA, Loose A-S, Olson CA. Learning to collaborate: a case study of performance improvement CME. J Contin Educ Health Prof. 2008;28(3):140-147. doi:10.1002/chp.181.
NHLBI. Landmark NIH study shows intensive blood pressure management may save lives: lower blood pressure target greatly reduces cardiovascular complications and deaths in older adults [press release]. NHLBI Website. http://www.nih.gov/news/health/sep2015/nhlbi-11.htm. Accessed September 11, 2015.
Reboussin D, NHLBI, NIDDK, NINDS, and NIA. Systolic Blood Pressure Intervention Trial (SPRINT). NCT01206062. ClinicalTrials.gov Website. https://clinicaltrials.gov/ct2/show/NCT01206062. Accessed Accessed September 11, 2015.
MeSH *Major* Terms: Education, Medical, Continuing/standards; Hypertension/prevention & control; Physician's Practice Patterns; Quality Assurance, Health Care.

3-Hospital Quality- and Performance-Improvement CME Project With Systems Change Support for Diabetes Care, With CE Measure Editor, Derek Dietze

This performance-improvement/continuingmedical education (PI-CME) study by Lapolla and colleagues at three mid-sized, regional hospitals in the United States focused on clinicians’ behaviors that can be documented as “validated metrics of diabetes care” in patient charts.

When you look at this example of a multi-center performance-improvement initiative with educational and institutional change supports, you’ll see that most of the intervention involved obvious reminders of the change initiative and its measures, graphs and data regarding performance trends, and a PI specialist as leader or champion of the campaign in each hospital. Even though the researchers chose hospitals that were willing to invest in change, the following implementation tools and collaborative approaches were incorporated as being necessary to change: "In the design and implementation of this program, we applied recognized PI principles and developed a dedicated working group to evaluate, monitor, and disseminate data, provide timely feedback, monitor outliers, attend to project management details, and maintain support of institutional leadership. We encouraged physicians' engagement by minimizing their time requirements, soliciting their input throughout the initiative, sharing meaningful data, and taking an 'improvement-oriented' approach rather than 'mandating change.'” [Emphases added.]

I wanted to point out the reminder of the American Medical Association’s recommendation of using a three-stage PI-CME structure, “comprising assessment of current performance (Stage A), design and implementation of strategies to improve performance (Stage B), and evaluation of PI efforts (Stage C).” Any outcomes project or program evaluation that sets its goals after educational content and resources are nearly final faces great challenges for later measurement. Permit me to include related content from the May 2015 Almanac article that Erik Brady and I wrote for the series, “Beginner’s Guide to Measuring Educational Outcomes in CEhp”: "A common error in assessment item-writing is the construction of assessment items that focus on a minor or trivial data point found in the content. This practice is particularly common in two cases: first, when assessment items are written from finished content that offers too little material for assessment; and second, when the minimum score a learner needs to request educational credit dictates the number of items on a tool, causing planners to test trivial points in their desperation to hit an arbitrary quota."

Because assessment items are optimally designed to assess how well a learning objective has been met, aligning a learning objective with an assessment item should ensure that your items are focused on the key points of the activity content and that activity content consistently supports learners’ achievement of the educational and performance objectives. Thus when Lapolla et al planned the educational content and reinforcing health-systems supports according to well-established metrics, they made certain that they had all desired outcomes mapped to hospital-specific care gaps before they started. This allowed the research team to provide “timely feedback” and manage the project better at each institution by identifying outliers in the PI datasets. A previously featured article in this month’s “Back to School” Tweet Fest mentioned incorporation of VTE prophylaxis therapies into order sets, and how this was effective. Notably, we see the same in this study: “the PI specialists at all 3 participating hospitals saw marked improvement once order sets included the metrics.”

Look at this article for its insights into quality improvement, implementation science, and educational methods. It is also nicely written and described, with model writing and brevity for a research report—especially remarkable given the number of study authors. Finally, note that Derek Dietze, Editor-in-Chief of CE Measure, participated in this large PI-CME study on improving care practices for diabetes, one of the most challenging epidemiological issues in the United States.

References cited:
Lapolla J, Morrice A, Quinn S, et al. Diabetes management in the hospital setting: a performance improvement continuing medical education program. CE Meas. 2013;7(1):54-60. doi:10.1532/CEM08.12103. doi:10.1532/CEM08.12103. http://www.cardenjenningspublishing.com/journal/index.php/cem/article/view/116. Accessed September 10, 2015. [FREE full text]
Brady ED, Binford SH. How to write sound educational outcomes questions: a focus on knowledge and competence assessments [series: “Beginner’s Guide to Measuring Educational Outcomes in CEhp”]. The Almanac. 2015;37(5):4-9. http://www.acehp.org/p/do/sd/topic=216&sid=811. Accessed September 10, 2015. [Full text]
Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative. Pediatrics. 2011 May;127(5):e1326-32. doi: 10.1542/peds.2010-3282. http://pediatrics.aappublications.org/content/127/5/e1326.full.pdf+html. Accessed September 8, 2015. [FREE full text (Pediatrics final version)] 

Implementation Science Extends Multidisciplinary Education on VTE Prophylaxis at World-Class Children’s Hospital

Let’s continue yesterday's thread with venous thromboembolism (VTE) education in a new patient population: children. In this quality improvement article, Raffini et al point out that while risks of VTE are far lower in children than in adults, children still need clinicians to maintain an appropriate level of suspicion and take action on VTE risk with prophylaxis.

What a nice way to phrase a practice gap and the need to narrow that gap: “VTE prophylaxis for patients at risk is often overlooked in pediatric health care institutions, which provides an opportunity to improve patient care.” Even at the world-class Children’s Hospital of Philadelphia (CHOP) at the University of Pennsylvania, children and adolescents were not receiving an appropriate level of risk assessment and prophylaxis, leading researchers to undertake this four-year quality improvement study.

CME/CEhp initiatives often do not extend into local facilities, but this study used reinforcing methods of implementation science to communicate and support the desired behaviors and tasks. These extended “multidisciplinary educational forums” into patient-care settings. Here’s a summary of the intervention’s rollout of CHOP’s locally established guidelines to “encourage timely initiation of thromboprophylaxis." These interventions included 1) VTE risk assessment in the nursing admission intake forms; 2) a VTE-prophylaxis order set implemented into the computerized ordering system; 3) ICU nurses assessing VTE risk and preventive practice daily during team rounds; 4) trials of various pneumatic compression devices with appropriate sizing for children; 5) acquisition of more compression devices with storage near high-risk areas; and 6) development of a protocol for perioperative nurses to initiate pneumatic compression before surgery for certain patients, later expanded to all inpatient settings.

So was extension of multidisciplinary education into care settings, using methods of implementation science, effective? YES. The study’s primary outcome measure was “compliance with thromboprophylaxis guidelines in patients at risk for VTE.” Clinically meaningful improvements were seen: “Over the 4-year study period, the observed rate of VTE prophylaxis in patients at risk increased from a baseline of 22% to an average rate of 82%, and there were intermittent improvements up to 100%.” Implementation science methods, when added to multidisciplinary clinical education, quadrupled or even quintupled guidelines-based care in an underserved population.    

There’s also a nice feature to point out to those watching IRB “requirements” that peer-reviewed journals increasingly expect of performance-change initiatives: “This project was a quality-improvement activity and exempt from review from the institutional review board at the Children's Hospital of Philadelphia.” The QI initiative was not seen as human subjects research (HSR).

Reference cited: Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative. Pediatrics. 2011;127(5):e1326-32. PMID: 21464186.
See also the ACCP and ICSI guidelines linked from the September 7, 2015 post (http://fullcirclece.blogspot.com/2015/09/pharmacy-education-for-hospital.html)
PubMed: http://www.ncbi.nlm.nih.gov/pubmed/21464186
Free full text (Pediatrics final version): http://pediatrics.aappublications.org/content/127/5/e1326.full.pdf+html
MeSH *Major* terms: Anticoagulants/administration & dosage*; Guideline Adherence*; Patient Selection*; Primary Prevention/organization & administration*; Venous Thromboembolism/prevention & control*
(And for those of you who love MeSH and UMLS, many quality-improvement and program change-related MeSH terms were assigned by NLM but not starred as “major” terms.) 

Pharmacy Education for Hospital Clinicians on VTE Prophylaxis Changed Performance, Bringing Guideline-Adherent Care To Most Patients

Earlier today, I wrote of interprofessional clinical education regarding team communication during cardiac surgery. Now I continue the theme of nonphysician education by highlighting contributions of pharmacy education to patient care, and one that particularly relates to (post)surgical care. While this month’s Back-to-School campaign (illustrating published educational outcomes) mainly features recent articles, this 2005 study by Dobesh and Stacy in the Journalof Managed Care Pharmacy (free full text available) is a worthy read for its contributions to quality care research from the pharmacy perspective and scope of practice.

Venous thromboembolism (VTE and/or DVT, PE) is a great concern among surgeons and other physicians. In fact, the VTE evidence-basedguideline by the Institute for Clinical Systems Improvement (ICSI; Jobin et al 2012) names 10 stakeholder groups—including physicians and pharmacists—as “intended users.” The current article used the 2004 American College of Chest Physicians (ACCP) recommendations. Effectively preventing VTE can dictate the chances of successful outcomes and reduce patient readmission rates for many conditions. Because of the challenges of selecting the optimal anticoagulant agent and dosage for individual patients, pharmacists can clearly collaborate with physicians in making decisions about VTE prophylaxis. The 2012 guideline considered pharmacological thromboprophylaxis with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), fondaparinux, warfarin, aspirin, apixaban, dabigatran, and rivaroxaban—enough therapeutic options to suggest the need for consultation between physicians and pharmacists.  

The pharmacy intervention for nurses, pharmacists, and physicians in the community hospital was traditional in instructional format, involving reinforcing in-service and quality-assurance presentations, as well as newsletters. The educational outcomes assessment method was more notable, using retrospective chart reviews with statistically similar patients before and after the educational intervention (15 months of patient charts before, and 6 months after). Patient chart reviews showed statistically significant and clinically meaningful change in VTE prophylaxis performance in practice. Specifically, both “suitable” and “optimal” prophylaxis increased (P = .006 and P < .0001 respectively), with a fourfold increase in the optimally treated percentage of patients associated with pharmacy education of physicians, nurses, and pharmacists.  

These data show that traditional educational initiatives developed by one health care profession for others can be effective in changing performance, especially when guidelines for practice and risk categories are presented in reinforcing text-based and live formats. This intervention brought guideline-adherent care to 93% of patients with risk, up from 49% before the intervention.  

References cited:
Dobesh PP, Stacy ZA. Effect of a clinical pharmacy education program on improvement in the quantity and quality of venous thromboembolism prophylaxis for medically ill patients. J Manag Care Pharm. 2005;11(9):755-62. PMID: 16300419.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338S-400S. PMID: 15383478.
Jobin S, Kalliainen L, Adebayo L, et al. Venous thromboembolism prophylaxis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012. Available at: http://www.guideline.gov/content.aspx?id=39350. Accessed September 7, 2015. 


PubMed:  http://www.ncbi.nlm.nih.gov/pubmed/16300419
Journal Free Full Text: http://amcp.org/data/jmcp/contemporary_755-762.pdf
MeSH *Major* terms: Health Personnel/education; Heparin, Low-Molecular-Weight/therapeutic use; Inservice Training; Thromboembolism/prevention & control; Venous Thrombosis/prevention & control

Mixed-Methods Study Improves Team Communication After Non-Didactic Interprofessional Education on Cardiac Surgical Crisis

It would be hard to imagine a more crucial setting for effective interdisciplinary clinical interactions than the cardiac surgery operating theater. Stevens and colleagues published this 2012 pilot study on interprofessional education to “sharpen performance of experienced cardiac surgical teams in acute crisis management.”

The educational methods support existing effectiveness research for non-didactic education, incorporating both interactive workshops for an entire care unit and computer-based, crisis-case simulations (whose “high-realism” scenarios improved over time). Researchers found that 82% of the 79 participants recommended repetition of case simulations every 6 – 12 months. Workshop participants identified priorities in “encouraging speaking up about critical information and interprofessional information sharing,” particularly early communication of the surgical plan.

The mixed-methods outcomes assessment methodology is also noteworthy because of its appropriateness to this study of human communications and behaviors during a patient crisis: the structured interviews with study participants added context and insights to the quantitative data that could be gathered from periodic surveys. The surveys that were administered before, just after, and 6 months after the educational activities noted that the “concept of working as a team improved between surveys,” as well as “trends for improvement in gaining common understanding of the plan before a procedure and appropriate resolution of disagreements.” The qualitative arm of the study found that interviewees valued the initiative’s “positive effect on their personal behaviors and patient care, including speaking up more readily and communicating more clearly.”

In the continuing medical education field, we often see the Canadians leading educational research, standards, and innovative methods. In fact, looking only at the U. S. National Library of Medicine’s assignment of Medical Subject Headings (MeSH terms) to this indexed article shows the relevance of this study for medical education methods for promoting competence in decision-making, performance-in-practice change, and quality improvement (see “major” MeSH terms listed below, and others on the PubMed page). One hopes to see a follow-up on this pilot study at the Centre Hospitalier Universitaire de Montréal (Quebec, Canada).  

PubMed:  http://www.ncbi.nlm.nih.gov/pubmed/22502966

MeSH *Major* terms: Cardiac Surgical Procedures/education; Clinical Competence; Critical Care/standards; Education, Medical, Continuing/methods; Patient Care Team/organization & administration

Back to School: See How Clinical Continuing Education Has Improved Health Care Quality – Proven in Peer-Reviewed Journals!

We often hear that there is little evidence of CME’s success in teaching clinicians relevant strategies for better patient care, for changing practice through education, and for connecting with the quality improvement (QI) movement. Witness the current initiatives of the Alliance for Continuing Education in the Health Profession (ACEhp), “Why We Matter” and the 10-year Roadmap and 10 complementary Building Blocks of the Quality Improvement Education (QIE) Initiative. While Davis and others have noted historical effectiveness of CEhp, such as in this 1992 article, later articles by Bloom, Davis, and Ratanawongsa have questioned CME effectiveness (e.g., in 1995 and 2005) and identified reporting inconsistencies that reduce the validity of CME outcomes reports.

It is true that our reporting of CEhp methods and outcomes has need of greater readership and better reporting. Yet CME, performance improvement (PI), interprofessional education (IPE), and education-driven QI projects already have many achievements reported, in both initiative-level outcomes reports and the published, peer-reviewed literature. Going beyond JCEHP, where articles feature methods and case studies for improving clinical education, and CE Measure, which reports on-the-ground initiatives and specific outcomes data, we see that clinical journals and meetings are publishing increasing numbers of CEhp studies. What’s more, reporting of these achievements is certain to grow after the ACEhp QIE Initiative launches its custom version of the SQUIRE tool this month, at September 2015’s Alliance Quality Symposium. The SQUIRE tool, created by the group developing Standards for Quality Improvement Reporting Excellence, will help all of us doing CEhp research design our studies and publish our findings in a standardized manner … for later meta-analyses of into CME/CEhp effectiveness as a mechanism for quality improvement.

Today our goal is to show the past effectiveness of CEhp initiatives in published educational outcomes studies, as we prepare—as a profession—to begin reporting CME and IPE initiatives with greater rigor, and to illustrate the effectiveness of certified clinical education by accredited providers on a greater scale. Therefore, Don Harting, my friend and colleague who specializes in medical education needs assessments, and I have embarked on a “Back-to-School” campaign to highlight published articles where CME, IPE, PI, and QI initiatives worked to change clinicians’ behavior or improve performance in routine, clinical practice. Don featured 15 of our 30 articles on Twitter (@CME_Scout) and his blog from August 17 – August 31, 2015, and I will be posting to publicize another 15 articles at @SHB_CMEedit and this blog from September 1 – September 15, 2015. You can sign up to receive a summary report of the published studies we feature by following fullcirclece.blogspot.com, or find me in person at the Alliance Quality Symposium at the end of September.

We want you to take away these messages from this campaign, so let me encourage you to put yourself in the first person and say these motivational statements:

• I can talk about CEhp initiatives that were effective in improving the quality of health care
• There is evidence in the peer-reviewed literature to prove CEhp effectiveness
• I am ready to read CEhp outcomes studies, to help me learn to prepare my own (if you are not sure you’re ready, check out the 12-article research and statistics series in the ACEhp Almanac, which started in February 2015)
• My group’s CEhp outcomes data do not have to show change to be worth publishing, i.e., it’s okay to publish negative findings because I am a dispassionate researcher of clinical education
• I can find clinical and educational journals to whom to submit my CME outcomes data
• My CEhp work in content and faculty development, instructional design, and outcomes analysis matters

Now don’t you feel better? Not sure? Ready to go? Follow our tweets, read the articles or their abstracts, and then say these points to yourself again. 

Finally, to promote articles showing the achievements of the continuing education profession in improvement health care quality, we have a contest where you can Retweet to Win (see rules) by sharing our featured articles with your network of CEhp professionals. Harting Communications LLC is offering a $100 Amazon gift card as first prize, and Full Circle Clinical Education, Inc, is offering a $50 Amazon gift card as second prize!

Remember to follow us on Twitter @SHB_CMEedit and @CME_Scout so that you can notified via direct message if you win! And tell Don and me whether this service campaign supporting awareness of CEhp effectiveness was helpful to you. 

Good luck, happy reading, and enjoy! 

Best wishes, and thanks for viewing my updates, 

Sandra