New generation of CME taking 1st steps

A physician was going about his work when a nurse came up to tell him she'd just done her hand hygiene and had left the water running.

"What she was saying was, 'It's your turn,' " said Michael White, MD, senior vice president of the McKeesport hospital in the University of Pittsburgh Medical Center, who cited this anecdote as an example of how a continuing medical education initiative involving performance improvement has changed the culture at his hospital.

UPMC's hand hygiene project is part of a broader effort at the medical center to combine quality improvement and CME.

CME researchers also are looking at ways to give physicians CME credit for learning done during their clinical practice.

At the University of Florida College of Medicine, a CME pilot program uses handhelds to get scientific-based information into physicians' hands at the moment they are making clinical decisions.

"In the past, we looked at CME and quality improvement as two different activities," said Barbara Barnes, MD, associate dean of CME at the University of Pittsburgh School of Medicine.

Now improving quality is being recognized for CME credit, Dr. Barnes said, and at UPMC, hand hygiene is one of three projects doing this. The others are on combating central line bloodstream infections and antibiotic resistance.

For the 18-month intervention on hand hygiene, a baseline measurement showed that physicians and housekeepers were the worst in compliance. After an initial awareness campaign, the housekeepers improved, but not the doctors, Dr. Barnes said.

Because lack of knowledge was not the issue, the physicians were asked what the barriers were, how they could be encouraged to comply and how nurses could be better empowered to help them.

A one-hour Web-based CME course was required of all physicians employed by the hospital. A new state law requiring physicians to take 10 hours of CME on patient safety also helped participation, Dr. Barnes said.

The doctors' response was that either they didn't have time to wash their hands or that facilities were not readily available. As a result, new sinks were installed, more hand sanitizers were put up and staff were given small dispensers they could attach to their belts.

Dr. Barnes said UPMC also posted reminders, implemented a zero-tolerance policy for noncompliance, used opinion leaders to reinforce the message and published compliance changes in a physician newsletter.

"Seldom does a single intervention change practice," Dr. Barnes said of the multipronged effort.

While Dr. Barnes did not have final statistics on compliance changes at UPMC, Dr. White said the 225-bed McKeesport hospital had seen hand hygiene compliance go from 60% to 95%.

The American Medical Association supports pilots such as the one in Pittsburgh, while the American Academy of Family Physicians has backed a project in Florida that focuses on getting physicians to use a handheld computer to access a database in response to questions that arise during patient exams.

Floyd Pennington, PhD, associate director of CME at the University of Florida College of Medicine, said he expected to get data from 30 to 36 physicians when the pilot, which uses a software program called InfoRetriever, is complete.

So far, reactions have been mixed. A few physicians have reported that they never quite caught on; some reported finding it helpful from time to time; and others found that the technology made a significant difference in how they practiced.

"The intent is that when a question came up, they used the software to help them make a decision," Dr. Pennington said.

The physicians had three sessions to learn the software for a total of 16 CME credit hours. If they used a Web site to get CME credit for the questions they looked up on the handheld computer, they could get another 15 hours of credit. But most didn't take this option, Dr. Pennington said.