Column Editor: Natalie Sanfratello, MPH
By Sharisse Arnold Rehring, MD
Shortly after assuming the role of Director of the Department of Medical Education for the Colorado Permanente Medical Group (CPMG), I sponsored an offsite with my department to brainstorm how we could better showcase our organizational value to the C-suite. The following day, my invited guest, the Executive Director of the Kaiser Permanente Institute for Health Research, suggested that we change our name. “Why not call yourselves the Department of Clinician Behavior Change?” I smiled, realizing this would be bold and unprecedented, but the reality is that his suggestion does speak to our departmental mission of striving for performance change and improved patient outcomes rather than a more conventional focus on knowledge acquisition and competency.
In the organization, the Director of Medical Education reports to the Chief Quality Officer, a structure that allows for a natural partnership with population health leaders. Although we reside within quality, our interventions are not always as coordinated as they might be in a perfect world. Since the inception of the CPMG Department of Education in 1997, there have been many iterations of how CE is designed and implemented. We have tested multiple innovative educational platforms such as spaced repetition knowledge-based questions, peer comparison data, e-learning modules, flipped classrooms, podcasts, educational blogs, audience response questions and dissemination of take-home points. Our robust outcomes portfolio has allowed us to assess and study our interventions in such a way that we learn what works, and where we fall short. We have been able to publish many of our findings (references below).
- Daley MF, Reifler LM, Sterrett AT, Poole NM, Winn DB, Steiner JF, Arnold Rehring SM, Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings, The Journal of Pediatrics (2024), doi: https://doi.org/10.1016/j.jpeds.2024.114155.
- Daley MF, Reifler LM, Glenn KA, Cvietusa PJ, Steiner JF, Arnold Rehring SM. Early Peanut Introduction in Primary Care: Evaluation of a Multicomponent Intervention Acad Peds 2022.
- Arnold Rehring SM, Steiner JF, Reifler LM, Glenn KA, Daley MF. Commitment to Change Statements and Actual Practice Change after a Continuing Medical Education Intervention. J Contin Educ Health Prof Spring 2021; 41(2).
- Daley MF, Arnold Rehring SM, Glen KA, Reifler LM, Steiner JF. Improving antibiotic prescribing for pediatric urinary tract infections in outpatient settings. Pediatrics 2020;145(4):1-9
- Arnold Rehring SM, Reifler LM, Seidel JH, Glenn KA, Steiner JF. Implementation of Recommendations for Long-Acting Contraception among Women Aged 13-18 in Primary Care. Acad Peds 2019; 19:572-80.
Our approach is to create a trusted culture of education within the medical home where clinicians learn together. We produce system changes at the point of care to reinforce CE learnings, decrease unnecessary practice variation and make the right thing to do the easy thing to do. We have positioned physician informaticists within the Department of Education to enhance nimbleness and productivity. These system changes may be more typical of QI departments and less commonplace in education but nonetheless, foster sustainability. The reinforcement of communities of practice learning together and adopting change simultaneously is an additional benefit of the educational format.
A key enabler is strong physician educational leadership holding the CE content to a high standard such that learners anxiously await the next offering. High quality education is an organizational investment in the professional development of the work force. The specialty specific physician educator is also a learner in the classroom and designs and moderates each activity, working with subject matter experts to develop the content based on the learner’s perspective. Case-based interactive discussion constitutes at least half of the CE activity, and “canned didactics” are not part of the programming. The education occurs on a predictable schedule over the lunch hour and there are usually 200-300 learners at each activity. Collaboration with nursing and pharmacy education is prioritized through a Trans-professional Learning Collaborative that meets monthly to align team-based education. Investment in the quality of the product and the healthcare team results in widespread engagement in the CE.
An example of this design is an intervention that combined multimodal CE interventions with process improvement strategies. We implemented a new local clinical care guideline for pediatric urinary tract infections (UTIs) aiming to decrease use of broad-spectrum antibiotics and reduce antibiotic duration. Interventions included a hyperlink to the guidelines, development of an electronic health record (EHR) order set and an interactive case-based CME. Longitudinal behavioral nudges included dissemination of “take home points”, spaced repetition knowledge questions, a flipped classroom and dissemination of individual clinician peer comparison antibiotic prescribing reports. The use of first-line antibiotics increased from 43.4% preintervention to 62.4% postintervention (P < .0001) and persisted for the 17 months of the study time period without ongoing interventions. Among children and adolescents 3 to 18 years of age not diagnosed with pyelonephritis, the adjusted proportion prescribed antibiotics for <5 days increased from 26.1% preintervention to 68.6% postintervention (P < .0001). The intervention was associated with an immediate and sustained increase in prescribing and decreased duration of appropriate antibiotics for pediatric UTIs. You can read the full article at the below reference.
- Daley MF, Arnold Rehring SM, Glen KA, Reifler LM, Steiner JF. Improving antibiotic prescribing for pediatric urinary tract infections in outpatient settings. Pediatrics 2020;145(4):1-9
To be honest, we just do what we have learned to do. We have a system that works, grounded in years of evaluation and reevaluation, pivoting when we need to and adopting our strategy to what resonates with our learners. It starts with a robust gap analysis and alignment with organizational key performance indicators, which makes it relevant, thus garnering institutional support. It is outcomes guided, data driven and predicated upon the tenets of adult learning theory and the literature around what makes CE effective. We implement the type of education that creates engagement and striking, sustainable change in performance. I struggle to put our work neatly into one box or another. Is it education? Is it QI? Is it an intersection of the two? Whether education or QI, the end game is the same: create sustainable and meaningful change to improve patient outcomes. In the words of William Shakespeare in Romeo and Juliet, “What’s in a name?. . . .a rose by any other name would smell as sweet.”
Sharisse Arnold Rehring, MD is Director of Medical Education and Pediatric Medical Education, and Clinical Professor in Pediatrics at Colorado Permanente Medical Group in Denver, Colorado.
Natalie Sanfratello, MPH, CHCP is Senior Program Manager – Quality Improvement, Educational Programs, and Contracts, QI Hub Faculty, Barry M. Manuel Center for Continuing Education, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
