>>KOPELOW: I’m Murray Kopelow the CEO of the Accreditation Council for Continuing Medical Education.
>>PHILLIPS: Hello I’m Rosalie Phillips I’m director of the Office of Continuing Education at Tufts University’s School of Medicine and the Executive Director of Tufts Healthcare Institute.
>>KOPELOW: Tell me about the institution that you work in where your professional life is.
>>PHILLIPS: Right. I really have two jobs that are blended into one. One of them is being the director of CME and the office of continuing education at Tufts University School of Medicine. And I’ve been doing that since early 2005. And the other, which has now intersected with that, is since 1995 I have been the director of something called Tufts Healthcare Institute, which was started by Tufts Medical School and Tufts Health Plan to teach doctors and other health professionals about what we now call the general competencies. Things like quality improvement, evidence based medicine, systems based practice, communications. In 2005, we blended those two models so that Tufts Healthcare Institute in a way manages the office of continuing education, so I’m managing myself. And then we report up through the Vice-Dean of the medical school to the Dean of the medical school.
>>KOPELOW: Now, you’re in Massachusetts.
>>PHILLIPS: We are.
>>KOPELOW: And Massachusetts is a complex, complicated healthcare system. There’s multiple institutions. And you operate in that kind of environment.
>>KOPELOW: So, the, we’re here today to talk about a continuing medical education initiative that is really outside the walls of Tufts.
>>KOPELOW: And it’s a regional kind of program.
>>PHILLIPS: Right, right
>>KOPELOW: So, as I understand it started with a regional quality improvement initiative or project that was going on and that you took a leadership role in linking continuing medical education to this project. Is that a fair description?
>>PHILLIPS: Ah, well I just want to modify the quality improvement project that was ongoing. It was really focused on collecting and analyzing and reporting quality data.
>>PHILLIPS: So, it was a piece of quality improvement.
>>KOPELOW: Got it.
>>PHILLIPS: And that group is called the Massachusetts Health Quality Partners it is a collaborative has lots of people at the table from competing organizations and from different stakeholder groups but they stopped at the point of reporting. And I had had conversations with them about whether Tufts CME office and Tufts Healthcare Institute could be their partner and then taking that data into an educational realm to do something.
>>PHILLIPS: something about what they were reporting. But, that idea was in my head.
>>KOPELOW: Of linking CME as sort of an asset to this quality project.
>>KOPELOW: I call it quality improvement but it’s a quality project
>>PHILLIPS: Yes, so it didn’t stop just with the reporting, but there was some follow on when you saw a problem.
>>KOPELOW: OK so was that the end of the project they said sorry not just Tufts
>>PHILLIPS: Well it was just ruminating in my mind
>>PHILLIPS: I also have for a long time since I came out of health care administration particularly in pre-paid groups always thought about improving care and improving practice and wanted to link education to practice improvement.
>>KOPELOW: So, they thought it was an interesting idea
>>KOPELOW: But, were worried about focusing on one partner. So, you were thinking about it while, so, what did you do next?
>>PHILLIPS: Well, what I did next was I actually was talking to you one day and you mentioned that you would like CME to be at the table with quality improvement projects around the country and in a way Murray, that gave me the permission a little bit of a catalyst to go out to some other stakeholders. Like Mass Medical Society which is also a CME provider, to a couple of large practices, some of which did have CME
>>KOPELOW: Sort of like a little coalition of CME people.
>>PHILLIPS: And I started calling people and saying, Would you like to get together to talk about what we could do with the MHQP data and identify some areas that we might work on together? And there was a very positive response from everyone I called at that point.
>>KOPELOW: And did, we at ACCME say well you should call a meeting. Did you call a meeting?
>>PHILLIPS: Yes. [laughs]
>>PHILLIPS: We called a meeting and at that meeting we had a number of stakeholders. I think you were at that first meeting you and Kate were invited and graciously came to be with us. And we had people prepare presentations. What we were looking for, I talked with a couple of people ahead of time to plan it, and what we were looking for was kind of a sweet spot where MHQP data
>>KOPELOW: What’s that stand for?
>>PHILLIPS: Sweet spot! Oh, MHQP, Massachusetts Health Quality Partners.
>>PHILLIPS: The data reporting agency
>>KOPELOW: OK. So, the ones with the data.
>>PHILLIPS: Right. So we were looking for sections of gaps in performance shown by the data
>>PHILLIPS: With potentially malpractice data information
>>PHILLIPS: So we, invited a malpractice insurer
>>KOPELOW: That sort of like adds an incentive to the conversation.
>>PHILLIPS: Correct, right. And then the third circle to help us find the sweet spot was pay for performance incentives. So, we invited somebody from Blue Cross Blue Shield of Massachusetts, who was working on the most advanced level of pay for performance at that time.
>>KOPELOW: So you aligned, so really what you were doing was aligning forces in play, forces in the environment, that were not necessarily parallel, but all pointed at the same thing, the physicians, well, the professionals doing the right thing at the right time.
>>PHILLIPS: Correct. And we were looking as you said before, for ways in which we weren’t just showing gaps for physicians’ inadequate performance, we were looking for incentives. So, one incentive might be you can avoid malpractice claims by improving performance in this area. And another might be pay for performance would reward them through payment if their performance improved.
>>KOPELOW: It’s an interesting matrix of incentives also you’re setting up, it sounds to me. There are incentives for the professional to engage as you’ve just described to do better care, safer from suits more aligned with quality. But, incentives for the coalition to form up.
>>KOPELOW: So that the insurance companies, everybody cares about quality, but insurance companies want the right service to be what’s paid for
>>KOPELOW: The liability carrier wants no claims. So they all have aligned sort of incentives to support this kind of initiative, because of their on some may call it self-serving, but it’s still aligned with quality.
>>KOPELOW: So you had a meeting where they talked about it, I think that talked for a while with the focus of trying to identify this common, what was this common, you called it the sweet spot? What was this convergence of issues that rose up?
>>PHILLIPS: Sure, it popped right up in that first meeting and it was around the patient experience data that Massachusetts Health Quality Partners was measuring and reporting, they measure two sets of data. One is more clinically focused, on things like asthma, diabetes, hypertension and one set is more around the patient experience. And that has to do with communications and coordinations, and so forth.
>>KOPELOW: Which is important right? Because you started off talking about the competencies
>>KOPELOW: Now we’re talking about systems based practice
>>KOPELOW: We’re talking about not just the care but the management of care
>>KOPELOW: And the environment in which the care is delivered is an important part of how quality is measured. And how people feel when they’re finished with care. Right?
>>PHILLIPS: And. Yes. And can have important implications for the outcomes of their care.
>>PHILLIPS: As you will see when I mention what the two gaps emerged the two related gaps that emerged in the coordination arena
>>KOPELOW: And those were?
>>PHILLIPS: And those were, the first was from a questionnaire that goes to patients once a year. In the last twelve months to what extent when you saw your primary care physician to what extent did you feel that that physician was up-to-date and informed about care you got from a specialist?
>>KOPELOW: a physician excuse me a patient perception
>>PHILLIPS: patient perception
>>KOPELOW: of up to dateness of the physician
>>PHILLIPS: Around specialty care. So it’s really a coordination of care issue. And the gap there was 60 percent of patients on average said my physicians always up to date on my specialty care. Forty percent said some gradation of not always. So, the gap of 40 percent seemed very significant.
>>KOPELOW: So the performance measure was about the patient’s perception
>>KOPELOW: And the measurements produced data that said 40 percent of physicians didn’t seem to
>>PHILLIPS: Didn’t seem to know what was up with that patient when they weren’t in their own office.
>>KOPELOW: So that was the professional practice gap from that data, so you said there were two?
>>PHILLIPS: And the other measure
>>PHILLIPS: That popped up for us was test result reporting. And that was patients being asked, If they had a test whether it was blood test, x-ray or any test, in the last twelve months did someone from their physicians office get the results to them?
>>KOPELOW: And presumably the performance rate for that is supposed to be 100 percent.
>>KOPELOW: OK. So, now you’ve got two things in this systems based practice. One is that the patient’s perceptions of the abilities of the physician and the other is an actual performance of the physician’s system, which is the delivery of results.
>>KOPELOW: Those are the two performance areas that you were looking at and you had said you had a 40 percent gap over here what was the gap in the other?
>>PHILLIPS: Thirty percent.
>>KOPELOW: Thirty percent of the patients did not get data?
>>PHILLIPS: Did not, or physicians could say perceived they did not, regardless, they didn’t know
>>KOPELOW: That’s right it’s in the eyes of the beholder
>>PHILLIPS: Exactly. They didn’t know the results of their tests.
>>KOPELOW: And remember this is needs assessment for education this isn’t high stakes evaluation
>>KOPELOW: to say you can staying in practice or you can get reimbursed. This is evaluation and performance measures in the context of continuing medical education or sometimes a little squishy around the edges. But, if you’re one of them that sent nothing, or a physicians whose patients all feel you’re competent that’s important
>>PHILLIPS: Right, right
>>KOPELOW: for that person even though we’re not going to take your license away.
>>PHILLIPS: Right. Right
>>KOPELOW: From an educational perspective and I’m sure your learners will feel that way.
>>KOPELOW: So, you have these two measures then what in your process did you do after these in the discussions or
>>PHILLIPS: After they were identified we talked, even in that meeting, first of all the malpractice data shored up the fact that these two areas could lead to multiple claims I don’t recall the numbers there but
>>KOPELOW: But validated the importance of these two measures
>>KOPELOW: So that made it important for the liability carriers to be still involved.
>>KOPELOW: And in the construct that we were building it also means that that should matter to the physicians cause the physician they want to do quality, but they don’t want to get sued.
>>PHILLIPS: Right, right.
>>KOPELOW: And those things are associated with that. So, now we’ve got sort of you’re building the validity of the collaboration and the project. Now, we’re here to talk about continuing medical education so you must be thinking as this is going on that somewhere there’s a CME, activity project developing?
>>PHILLIPS: Right, right. So, in between that and the CME project developing we did some heavy duty data analysis. Basically in my office because we were aligned with the partnership now we could get the data set from the Massachusetts Health Quality Partners group and looking at it all together we’re able to actually compare practices along these quality lines. And we were able to identify variations in practice. Which is
>>KOPELOW: So, ok. You’re using practice in two different ways.
>>KOPELOW: Variations in practices and identify practices just let me clarify for my own
>>PHILLIPS: OK Practice sites.
>>KOPELOW: That’s what you meant to use it?
>>KOPELOW: So there are varying places where doctors work. Their practices you able to get data about those practices about these two measures
>>KOPELOW: Then you had just said you were able to identify variation between them?
>>KOPELOW: But, also you were able to compare them to these 30s and 40 percentages. OK
>>PHILLIPS: Correct, so it was very important to us that we not just have a statewide average.
>>PHILLIPS: These data are reported to the practice sites so that the sites know themselves what their score is and they’re reported to the public pretty much in terms of like a consumer reports’ two starts, three stars, four stars a relative
>>KOPELOW: They’re not in the percentages
>>PHILLIPS: not in the percentages. So it was really important to us to be able to analyze the data as a set and look to see, Is everyone at 40 percent gap? Or are there some who are doing better and some who are doing worse? Well, we were able to identify one practice that had a seven percent gap on the pcp /specialist coordination.
>>KOPELOW: So that 93 percent of the patients thought they were terrific?
>>PHILLIPS: And one that had a 60 percent gap. So
>>KOPELOW: Forty percent thought that they were ok.
>>PHILLIPS: Correct. So, being able to identify that kid of variation meant two things. One is we could learn from the best practices. So, there’s a CME component that we could identify best practices and ask people from those practices to come to a session and teach all of us.
>>KOPELOW: So when we’re thinking of trying to explore what underlies the gap, knowledge or competence or having systems in place like performance
>>PHILLIPS: Right, right
>>KOPELOW: The strategy that you’re talking about using is seeing those who are doing a best practice sit down with people whose practice is not and let them explore together what success is and what not so successful is
>>KOPELOW: And the idea is not to bring these down to forty percent but
>>KOPELOW: is to see if this if this can be adapted.
>>KOPELOW: Did you actually sit them down together?
>>PHILLIPS: We haven’t done that yet, but what you just said is what the second part of variation meant to us. It meant that there was, it was feasible. We could achieve improvement. If everyone were at the 40 percent level it would be questionable. But, we could potentially bring others up.
>>KOPELOW: OK. So, as you’re thing about the future of your, of designing educational interventions
>>KOPELOW: You have this, this important set of professional practice gaps clearly you’ve got a model, a laboratory model,
>>KOPELOW: For getting gaps because every performance measure that there is you can use this model to translate it to regionalization, individualization and continuing education. So, when you’re thinking now in your mind what other kinds of things that you can do with these data for education what kinds of things are you thinking of?
>>PHILLIPS: You know we were thinking about certainly bring the best practices in to teach others, we were also thinking about team training, and we were thinking about quality improvement training. Have them at a teaching session at a learning session develop their quality improvement plan to take back to their practice.
>>KOPELOW: To their system to their practice.
>>PHILLIPS: Correct. And then have periodic check-ins and how that’s going and
>>KOPELOW: And that’s consistent with the systems based practice model.
>>KOPELOW: You’re not teaching them how to do a lab test and you’re not teaching them how to make a phone call how to communicate a lab test
>>KOPELOW: You’re talking to them about developing and improving their systems to improve
>>KOPELOW: the distribution of information and the manner of presenting themselves in a professional way
>>KOPELOW: But also if patients have the expectation they’re getting lab results and they don’t get lab results the patients are going to say, Well, who am I dealing with here?
>>KOPELOW: Which could be part of the generation of that first performance measure.
>>PHILLIPS: Right right. So, I think of it some times and I talk to physicians about this is helping to diagnose their system.
>>KOPELOW: Good, Yes.
>>PHILLIPS: And if they can diagnose their system they can treat it. And then re-measure it.
>>KOPELOW: part of the way people are taught to to pitch and sell innovation is to use the language that people normally use. And if you build these kinds of constructs and say we’re talking about a making a diagnosis and treatment it resonates with the people who you’re trying to convince of
>>PHILLIPS: So, that was all part of our, is all part of our thinking about the intervention.
>>KOPELOW: Let’s go back to something that you said right at the beginning. Because this has been a very interesting flow of some momentum was created and some progress where you’re at a very exciting place where you can start to develop activities to change practice. I’m interested in that, in that period of time between when you thought that this was interesting and and a little catalytic contact from us and the original sort of negotiations. I’m interested in you as a leader in this context, and it’s hard to figure out what leadership is and define it. What made you think that this would be useful? Both from a, what would be the advantage to you as a professional what would be the advantage to Tufts for the and what when we contacted you when you saw the opportunity as a little bit more of a catalyst what was the glimmer sort of,of interest success that you first saw was the pathway that you took? Can you remember those moments?
>>PHILLIPS: I do remember it and it really wasn’t about me it was about the fact that I in a way always wanted to do this and wasn’t able to do this as an individual organization. Because we did have to coalesce a group of stakeholders in order to make a difference. We might have been able to at Tufts to take those data and apply them somewhere within the Tufts’ system. But, the notion of bringing people together around this very rich validated important data set and improving practice in this state was really an incredible opportunity. It was something that I felt was part of our mission and yet I hadn’t seen a way to get there until you suggested and the CME , the updated CME Criteria really pushed the CME providers in this direction too, to coalesce stakeholders around a particular set of issues.
>>KOPELOW: You know what? That’s interesting. I think that’s a very important message for all to think about reflect on what we’ve done and what we can do. It’s really tough to bring 30 organizations or ten organizations to call a meeting to schedule a meeting to bring them together.
>>PHILLIPS: Right, right.
>>KOPELOW: But, if they’re already a group, they’ve already got some momentum, they’ve already got some shared vision, to get them to start to work on something of interest to you or to be perceived as adding value to their project, I mean that’s one of the things I hear you saying, that they were working on data they had data, and you brought added value to that data. You brought a link to actually improving care in areas that they valued, that they thought were important.
>>PHILLIPS: Yes, although there is still a barrier in terms of coordinating all of this.
>>PHILLIPS: And one of the issues we’ve run up against you won’t be surprised to hear is nobody at that table has the resources now to mount a large scale coordinated intervention. So, we are at the point now having done all this preparatory work and thought about approaches to an intervention and what we need to address in an intervention and thought about that evaluation which I think is so important, but now we’re seeking some grant funding so that we can in fact mount that coordinated it’s not huge scale but large scale implementation project.
>>KOPELOW: right. In closing let me say that a lot of what we do at a national level as leaders in this kind of context at a regional level at a national level at our local institutional level is to try to figure out where the puck is going to be
>>KOPELOW: And don’t you reflect here at this stage when we started this maybe three years ago, two years ago
>>PHILLIPS: Two, two year ago
>>KOPELOW: two years ago we weren’t talking about national health care reform, we weren’t talking about everyone have electronic medical records, we weren’t talking about identifying the problems in the cost of health care delivery and of the patient’s problems and forming coalitions in order to fix those. Now we are. Now we are. And that this program and that this activity and this project is really at the place as a model for what’s being called for from Washington and soon by all the states for Medicaid and the state’s responsibilities. And I think that you will find yourself in a position of being a prototype and a model for things that will happen across the country.
>>PHILLIPS: Sounds good.
>>KOPELOW: Thank you.
>>PHILLIPS: Thank you.
This is a transcript of Assembling a State-wide Partnership to Address Quality Improvement.
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