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Continuing Professional Development Integration of Formal CME and Quality Improvement Initiatives
How to integrate formal CME and elements of QI?	Previous    Contents    Next

Education in the philosophy and techniques of Quality improvement

To enhance the process of change, formal CME can be used for education in the philosophy and training of QI techniques. Quality Improvement is a young discipline. Implementing will be facilitated if GPs learn about its philosophy, methods and techniques.

Box 3 Germany: training program for moderators of peer review groups Method: in two-day courses general practitioners are trained to lead small group work. Techniques of problem finding, communication in groups, conflict settlement are presented. Additionally the participants learn to document and evaluate quality of care with documentation sheets and videotapes. Training materials and a handbook of instruction (in German) have been developed. Results: crossing the borders of medical speciality, presently about 1,100 physicians in ambulatory care have been trained (and ca. 1,500 other physicians by other providers). Estimated 2,500 quality circles in different medical specialities were established in Germany. Experiences and evaluations show that training of communication skills and techniques of quality improvement is of particular importance for general practitioners to tackle with problems of quality in daily care.

Elements of QI can be used for needs assessment in formal CME

There are different ways to define the needs for CME. One of the key challenges that health professionals face is knowing whether or not their current practice is up to date. Sackett and colleagues (Clinical epidemiology: a basic science for clinical medicine, 1985) refer to this as “the key to continued effectiveness as a clinician”. Needs assessment techniques can be subjective (perceived needs) and/or objective (reflective needs). Several tools exist to help combine reflective or subjective needs assessment methods with use of objective methods, such as measures of competence, performance (for example, external audits), patient management problems, and health outcomes. Review or audit of medical records is a useful method of determining the extent to which our current practice is consistent with evidence-based principles.

QI has developed methods for analysing recorded performance

Data collection tends to be the most time-consuming part of the QI process, but it is essential. To evaluate how well we are doing, it's usually good to compare our own results with somebody else's data. Some methods of evaluating results are shown in the EQuiP handbook on “Tools and methods for QI in General Practice”. One example: Quality circles in primary care (experiences from Germany and Switzerland): Some of the data sources used are case reports, data analysis from charts, practice computers or documentation sheets, as well as video documentation. Other examples are: practice visiting and practice audit (UK, Netherlands, Sweden, Belgium), patient feedback or patient satisfaction (EUROPEP).

QI has developed methods to use evidence based guidelines in formal CME activities

The development of our work by QI is easier when based on solid clinical evidence. To develop a valid and reliable guideline is hard work. Developing, distributing and implementing useful guidelines should be a major challenge for family doctors and their organisations. Guidelines can also provide excellent material for clinical training as well as for CME. There are many experiences from the Netherlands about implementation of the Dutch Guidelines combined with CME-packages linked to the topic of the guidelines. The National CME tutor network in Ireland provides training of key persons to supervise small educational groups performing various QI methods (Box 4).

Data and guidelines give direction to the process of planning actions for improvement.

Box 4 CME-groups with an emphasis on quality improvement (Ireland) Method: CME in small groups involved in peer review, guideline implementation and audit. Groups are led by CME Tutors. These Tutors are local GPs who have been trained as group leaders and educators. Tutors are paid the equivalent of two sessions per week to allow them protected time for their activities. Results: There are 120 small groups distributed throughout the country with an average of 10 members meeting at a local venue on a monthly basis. CME groups are promoted by the ICGP and at local level by individual CME tutors. The ICGP has produced a manual on small group facilitation and organisation. CME tutors attend three residential educational workshops per year to maintain and improve their skills. 90% of Irish General Practitioners are members of the ICGP, and 60% attend CME small groups on a regular basis. Improvement in skills and knowledge e.g. treatment protocols agreed. Supportive environment conducive to mutual support. Inter-referral between GPs encouraged e.g. Minor Surgery, Family Planning. CME tutors have an official ICGP visit every three years to evaluate all aspects of their work. A qualitative study addressing the issue “Does small group CME make a difference” has just been completed. Preliminary results suggest that participants have made changes in their clinical practice as a result of CME.

QI has developed reinforcing strategies enhancing the effects of formal CME activities

Since formal CME activities such as lectures, conferences and educational materials appear to have little impact on practice, better use could be made of other approaches such as practice-based work in small-groups which incorporates the use of patient-specific reminders to health professionals. Dissemination of systematic reviews and evidence-based guidelines could be integrated into the system of CME. Where practices are actively involved in audit, it seems logical to address gaps in practice by linking education programmes to clinical audit. An example of a programme, which has made such links, is the Australian QA and CME Programme (PITERMAN 1995); learning is evaluated by repeating the audit to see whether actual performance has changed.

Box 5 Clinical audit-linking continuing medical education (CME) and practice assessment (PA) Piterman L, Nelson M Department of Community Medicine and General Practice, Monash University, Melbourne, Victoria Method: The Quality Assurance (QA) Program of the Royal Australian College Of General Practitioners has required doctors to engage in practice assessment (PA) activities. Clinical audit is one of these activities and has been used as an assessment tool in the Graduate Diploma in Family Medicine at Monash University, in impact evaluation of educational programs as well as a means of pooling morbidity data for research purposes and peer review. Results: Doctors participating in these audit activities have almost invariably described them as a valuable reflective educational exercise with changes in clinical practice occurring after the audit in a number of instances.

QI and barriers to implementation

Potential barriers to effective practice can be structural (e.g. financial disincentives, limitation of time), organisational (e.g. health care environment: health policies which promote ineffective or unproven activities), individual (e.g. knowledge, attitude, skills), influence of opinion leaders or peer groups (e.g. local standards are not in line with desired practice), patient factors (e.g. demands for care, perceptions/cultural beliefs about appropriate care). The focus of the Cochrane Effective Practice and Organisation of Care Group (EPOC, www.abdn.ac.uk/hsru/epoc/) is on reviews of interventions designed to improve professional practice and the delivery of effective health services, including various forms of CME, QI, informatics and financial, organisational and regulatory interventions that can affect the ability of health care professionals to deliver services more effectively or efficiently.

QI offers methods to evaluate the outcome of formal CME programmes

There are many investigations concerning effectiveness of CME courses. Davis et al (1995) concluded that short (1 day or less) CME events usually bring about little change. Wensing et al. (1998) Review of research on implementing guidelines and innovations in general practice confirms the effectiveness of multi-faceted interventions. Davis et al. (1994) conclude their review of the effectiveness of CME interventions by emphasizing the intensity and complexity of interventions with positive outcomes and the multi-faceted nature of the change process.

Evaluation procedures not only have to check the process of CPD but also the outcome on practice level. Performance indicators are now constructed in a reliable way, which can be used to measure the process and outcome of clinical care.

Box 5 Quality indicators for general practice Method: the team of Martin Marshall, Stephen Campbell, Janny Hacker and Martin Roland developed a well reliable set of indicators for all the major clinical areas. They use a step-by-step procedure reviewing literature, appraisal by expert panels in a two-round data analysis. Results: Quality indicators are defined in 19 major clinical areas. The indicators allow comparisons between practices over time or against gold standards. They facilitate an objective evaluation of a quality improvement initiative.