>>SINGER: Hi, I'm Steve Singer. I'm the Vice President for Education and Outreach at the Accreditation Council for Continuing Medical Education. My guest today is Stephen Davidow from PCPI, he's the Director of Quality Improvement. Thanks for joining me, Stephen.

>>DAVIDOW: It's my pleasure.

>>SINGER: Our new requirements for commendation reward a number of things, and one of the areas that is part of the Outcomes category is a requirement that rewards providers that engage in healthcare quality improvement, including being engaged in improving processes of care- system performance. And what I thought would be helpful is for folks that are not familiar with quality improvement, for us to give them a little bit of an introduction of what is quality improvement, what are some of the key concepts and where to start, what's a rationale for how I begin to participate in quality improvement? So, let's first define terms.

>>DAVIDOW: Sure.

>>SINGER: Healthcare quality improvement?

>>DAVIDOW: A lot of different ways you can define quality improvement, but maybe a simple way to look at it is, for some the right care at the right time on the right person. And so we go from a basis of that, but more specifically, when we look at, what I define quality improvement is, really a lot of process improvement methodologies and tools applied to the clinical setting. There has been historically a lot of focus in the quality improvement on a clinical basis where it's the development of clinical guidelines, and so that has a lot of evidence or expert information available to folks, but not necessarily information on how to improve or how to use those wonderful, rich, evidence-based guidelines. How do you implement that in practice? And so we help with that in what we do. So we try to bridge the two.

>>SINGER: So it's cross-cutting. Because it's not only talking about performance and the behavior of people who are working together to deliver care, but it's also talking about the systems in which they operate and their interaction with those systems?

>>DAVIDOW: Yes, absolutely. I think historically, we've looked at quality improvement in a very scientific way, which is great. But I think we haven't often answered the question, "How do we implement improvement?" We have great evidence, we do our laboratory experiments, and when I say laboratory experiments I'm not just talking about what actually happens in a laboratory, but when we test an idea and it can be in a clinical setting with real patients, we're testing things. And we gain knowledge from that, and so that we have the knowledge and we share the knowledge through a variety of ways historically, publications, journals, meetings. And that's all part of the mix. There are actual operational things that we do that's part of process improvement training that we provide, that will help physicians and others actually improve the care that they provide. And so we marry the two together.

>>SINGER: Okay, so several things that you mentioned, it seemed like they're ripe for education.

>>DAVIDOW: Absolutely.

>>SINGER: You talked about methodology, you talked about experimentation, you talked about the idea of the need to translate this evidence-based approach and to start doing it. So, can you tell me... If I'm a CME professional, let's start with the basics of what are some of the tenets of quality improvement methodology and then maybe we can talk about how those get applied.

>>DAVIDOW: Well, I think historically what we've seen in quality improvement in healthcare is a focus on one or two tools from process improvement as opposed to systematic approaches that really look at a continuum. And I think now as healthcare continues to be a complex service that we provide, but also, there's a lot of new incentives to improve care, but a greater understanding of some of the complexities that a systems approach to quality improvement is very important versus using a couple of tools here and there. And for example, there are basically two robust quality improvement methodologies that are used, there are variations on them and people know of certain components of them. But when we talk about doing improvement, we have to start at a place where we recognize that there's a problem first and what the problem is. And then we have to then talk about... We have to understand how that impacts our, ultimately the patient. At the end of the day this is about the patient. And then we go from that to saying, "Okay, what's the root cause of that? Why is that happening and that thing that we don't want to happen, why is it happening?" Then from there, we have to say, "Well, we don't like what we call the current state, the present. Well, how do we go from there to a better improved future state?" So then we have to develop some improvement ideas, we have to test them in an environment before we go widespread.

>>SINGER: So iterative?

>>DAVIDOW: Yes, it's very iterative. It doesn't mean that it's going to be something that you do over three or four years, it means it's something you do over a relatively short period of time, because otherwise you won't sustain the effort, much less get to a place of better improvement. So there are several steps. So there's a stepwise process in using these more robust processes which people may know of as Lean or Six Sigma or some, there's variations on Lean Six Sigma or Lean Sigma, and that's a whole different discussion.

>>SINGER: Right.

>>DAVIDOW: But these are out there and there's tools that are part of it. But there are robust systems that allow us to actually drive improvement.