>>KOPELOW: This is a conversation about communities of practice with some examples of inside institutions, how entities can participate, generate and continue this type of educational activity. I’m Murray Kopelow the chief executive of the Accreditation Council for Continuing Medical Education.
>>DORMAN: I’m Todd Dorman, I’m the Associate Dean and Director of continuing medical education at the Johns Hopkins University School of Medicine and I’m also a professor and Vice-Chair of the Department of Anesthesia and Critical Care Medicine.
>>BERGER: I’m Dick Berger, I’m a Dean of the Mayo School of Continuous Professional Development at the Mayo Clinic in Rochester, Minnesota, where I’m also a professor of orthopedic surgery specializing in hand surgery, and I’m the chair of the division of hand surgery at the Mayo Clinic in Rochester.
>>KOPELOW: We’ve been talking about communities of practice in continuing medical education and in medical education and I’m interested in some examples of communities of practice that can occur inside a health care or inside an educational institution. Todd have you got?
>>DORMAN: I think an ideal example is the tumor boards that exist. That bring specialists across many professional fields. And not only physician specialists, but other health care providers and ancillary support system together to try to leverage all of that knowledge to create the best response for an individual patient. As you know, sometimes it can be difficult to interpret population based data as evidence down to the unique circumstances of an individual patient. And so, bringing this community of physicians and other practitioners together really has quite a bit of power to it.
>>KOPELOW: Now, when we’ve talked about communities of practice up until now, it’s talked about collaboration between entities, between people and communication between, in this kind of educational setting where is the collaboration where is the communication?
>>DORMAN: So, the collaboration is the working together on a particular case and the sharing of knowledge and different perspectives of the different field. And that actually involves that communication between them. I’m realizing that a treatment plan has to be the outcome for a particular patient. And then, potentially a change in a treatment plan for a difficult case. So, you have a radiation oncologist potentially talking about what their perspective of an intervention is, a surgeon talking about a surgical intervention, a medical oncologist talking about those issues, potentially pathologist talking about specific issues of tissue type and tumor type and those implications in a particular patient, then overlaid with that patient’s background medical disorders.
>>KOPELOW: So it’s, you’re really describing a medical health care team. Health care team in the institution working in the pathology lab, in the microbiology lab, at the clinical bedside, the nurses coming together in an educational opportunity as a collaboration and as a community to solve the patient problem.
>>DORMAN: The focus is solving the patient problem. Correct. And in the process there is the shared experience and the shared knowledge across all of the providers that are together.
>>KOPELOW: Interesting. Thank you. Thank you. Dick, an example of a community of practice that would be nontraditional bringing together entities inside an institution that haven’t usually worked together?
>>BERGER: I think I would sight the Institute of Professionalism that’s been developed at Mayo. Professionalism is an entity that’s been difficult to get your arms around. It’s hard to know what professionalism actually is and many people have different definitions, but how to actually evaluate that how do you assess professionalism and how do you teach professionalism. I think we know what the attributes of somebody that behaves in a very professional manner would be, but how to quantify that is difficult. So, we’ve actually embarked on a systematic study of what does professionalism actually mean. How do we actually assess it. And then, finally, how do we teach it. And this goes across all specialties and it permeates beyond the clinical realm as well. It involves professionalism in the way that we carry out the business model, for example, it involves administration. It involves virtually every element that goes into the daily work that we do. Included in this is bioethics, certainly from a very practical standpoint in terms of tackling some of the difficult ethical issues that we have. But, professionalism itself is one that has a definite input into every day of a busy clinical practice.
>>KOPELOW: Now, you’ve described two aspects. One, is that there’s a community of practice of professionalism in your institution, you mentioned administration, the clinical care so, therefore your institution to be professional it is a community of practice. You also alluded to that there’s an educational project or program going on at Mayo that brings together these varying entities that come to bear on creating a curriculum or a plan for an educational enterprise. Could you describe who’s part of that? What entities are part of it? And what they’ve created and what this professionalism in education is like?
>>BERGER: Absolutely. This covers the spectrum of medical education from undergraduate medical education through graduate medical education and continuing medical education. And, so, medical students are introduced into what basic concepts of professionalism are. And at that point they actually begin to experience the mode of teaching that’s, that’s brought about with simulation. This is included in the simulation center activities we have where the students are introduced into scenarios that help draw out the attributes of professionalism that we’re looking for. It’s continuous through graduate medical education, which as we know professionalism is one of the basic competencies that the ACGME has instituted as a requisite for us to address in the training. And we’ve extended this in the same mode then through the simulations into the world of continuing medical education. And on top of that there are programs that are free standing educational activities in professionalism that are carried out annually as well.
>>KOPELOW: Certainly the CME providers are interested in the measurement of outcome with respect to the teaching of professionalism. And, and you’ve got this educational enterprise that’s intervening in undergraduate and graduate and presumably in continuing education, but across that whole spectrum what are you doing about measuring what people are learning or how professional they are or giving them feedback or helping them with self-assessment? Just a range of measurement kinds of things that you might be doing that people could think about using?
>>BERGER: I think that’s been one of the real challenges, because again it goes back to the basic principle: how do you define professionalism in the first place? But, that’s where simulation can really have a strong role, because there are ways of providing immediate feedback to an individual that’s just participated in a real time scenario, in terms of how they performed relative to other standards or to other individuals in their cohort. And they can see themselves and very often there’s a self-assessment process that goes on when you see yourself mirrored in an activity that was in simulation. From the continuing medical education standpoint in terms of the consulting staff we get a lot of feedback from the patient survey that we have that provide a standardized format for patients to provide feedback in terms of the a the approach that their consultant had. Also, from peers, particularly in an anonymous fashion, we get tremendous feedback from 360 degree feedback mechanisms and those are all shared with the consulting staff in terms of a very formal fashion with the annual reviews, for example, of their performance. As well as, a more informal that very often happens amongst colleagues.
>>KOPELOW: You mentioned simulation, were you referring to standardized patients? Were you referring to other kinds of simulation?
>>BERGER: Yeah. It can be any number of formats, standardized patients is an excellent way to do this or scenarios you don’t actually have to have a simulation center. You can have a simulation concept or a simulation suite if you want to call it that where you can actually have a hypothetical situation that you just present to, present to the learner, to the participant and see what their response is. And
>>KOPELOW: A written scenario?
>>KOPELOW: when you say present. And see how they respond
>>BERGER: how they respond.
>>KOPELOW: interact with them in that simulation.
>>KOPELOW: Excellent. Excellent. Todd, we talked before about a community practice inside your institution. Can you give us an example of something outside your institution that it might relate to or just in the community that you know about?
>>DORMAN: Yeah, I think an ideal example would be one of the projects that is pretty far along now and beginning to potentially grow and to become a national project. That was one done between our institution and the Michigan Hospital Association, the Keystone Project. That looked at a host of factors in all of the hospitals in the state of Michigan. So, it included providers of all types, principally those that worked in intensive care units. But, looked at quality and safety parameters and their culture. Evaluated performance related to specific health care outcomes such as cath related blood stream infection and ventilator associated pneumonia. And we tried to leverage the power of expertise as well as the collaborative nature of groups learning from themselves and from each other.
>>KOPELOW: What were the elements of the community, you talked about two hospitals, is that the level of the community? What would you see as the elements of the community?
>>DORMAN: So, the community was the individual ICUs within hospitals. This included then, the institutions themselves and leadership from those institutions to help support the project. It included a community that involved the Michigan Hospital Association and part of its leadership and support. It included individuals from our institution that participated both on the ground and more at a strategic level. It included bringing and leveraging experts in the field of quality safety patient care. And then again cross professional, because the cultural aspects involved individuals that were physicians, nurses, pharmacists, respiratory therapist, and other ancillary health providers.
>>KOPELOW: Now, two things that are important is getting something like this up and running, and then, secondly, keeping the momentum going. I want to talk about both of those. But, what do you see the key features in getting it up and running? Whose idea was it? What need was it trying to meet? How do you see what started it?
>>DORMAN: Well, the need was a patient care outcome that had been recognized across the country as being poor. Principally, cath related blood stream infection. And then a desire to how to effect change in that and the approach employed was one in which the core defect is at the cultural level. The understanding of quality and safety and the principles associated with that particular variable. So, that really drove the beginning of the project. And the need was both recognized by experts in the field as well as by health care providers within the state which is how the partnership was created between those two pools of individuals.
>>KOPELOW: And the momentum, was it, were you just goal, not just goal, but were you goal oriented, you were trying to reduce the incidence of infections and when you reached that it was over and you just kept working to that or was it an ongoing project that needed to be refreshed and re-energized?
>>DORMAN: Great question. And, in fact, that was the power of the collaboration and the shared experience, because those who started to wane in excitement were then lifted up by those in the group that were more excited at that particular point in the juncture. So, this included over a hundred different intensive care units, physician and nursing directors. And clearly people, their motivational levels wax and wane. So, the real power of the collaboration was that the highest level motivators at each point along the way continued to pull everybody with them.
>>KOPELOW: Excellent. Thank you. Thank you. Dick, you gave us an example before of a, of a, with professionalism, units inside your institution coming together that hadn’t usually worked on a common project. Is there another example inside your institution?
>>BERGER: I think one that’s worthy of note is what’s related to what we call the Mayo Health System, which is actually a group of community practices in a three state area, Minnesota, Iowa, and Wisconsin; that have a common communication pathway through the Mayo Clinic, but they’re actually independent practices. And, this is actually a very interesting phenomenon. On their own their leadership in the hospitals and throughout the Mayo Health System, again not directly related to the Mayo Clinic per se, have taken upon themselves a mission of quality improvement for the past several years. And this goes across all the disciplines: from orthopedic surgery to family medicine to pediatrics and various internal medicine entities. And they have embarked upon a systematic process of improving their own practices not only in the hospitals but also in the offices with structured quality programs. And virtually the first 15 minutes of every monthly staff meeting is a review of what quality initiative have been on going what the results are and where they’re going next. So, it’s a systematic approach, again, self-motivated to take on quality issues within these disparate practices that’s virtually the whole spectrum of health care.
>>KOPELOW: And would it be fair to say that the momentum in this one is carried on in the same sort of way that the goal persists to improve quality and to ensure quality. So, it’s always there driving in the direction?
>>BERGER: That’s exactly right. And what’s interesting is that it takes an equal amount of energy and input from not only the consultants, the actual physicians that are practicing, but the support network for that from an institutional standpoint with their hospitals, the practice managers engaged in the process at the same time.
>>KOPELOW: I’ve got a couple of questions we hadn’t talked about, one is how to start one of these up and to know when to stop it? First one is, advice or suggestions about what to do first when you’re getting going? What do you think see is critical features of your two examples of starting up a collaboration?
>>BERGER: There needs to be an identified need first of all. And I think that’s the same thing that we do with any of our educational programs if it’s done properly is to identify, what’s the actual gap that we’re trying to fill. And what is the, what’s the range that the gap affects in terms of the spectrum of potential participants. Is this something that’s limited to just one division or does it go across department lines as well? Once you identify that need I think you very often will find a means to be able to collect the individuals that will engage in this process. You need a champion, somebody that can actually have some organizational skills and knows what the resources are to be able to pull this together. But, I think that the first step the basic step is to clearly identify the need that you are trying to correct. Identify that gap to be able to construct something around.
>>DORMAN: I would agree with those, too. I think that sometimes people think that it takes significant resources to try to do these and go forward. In fact, if you leverage across multiple different providers among partners within the project you can quite often accomplish a lot more than people felt. So, an example in ICU project would be that there was no money to collect global data, but lo and behold if physicians collected a few data points and nurses collected a few data points and respiratory and the institution and risk management and the performance improvement groups then at the end you had a robust database that really was not that resource intensive to get done.
>>KOPELOW: They talk about leadership and leadership being having a vision and recruiting people to that vision it sounds like communities of practice are an example of that. Where the purpose, the goal, is the vision and the work is to recruit people to that vision and then to the process using the community practice to solve that problem to meet that vision. And I think these are two really good examples of ways people can apply this principle inside their institutions. Thank you.
>>BERGER: Thank you.
This is a transcript of Communities of Practice: Strengthening Internal Initiatives (Part 2 of 3).
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