Implementation Science and Medical Education Transformation

 From the 4/23/2021 newsletter

Perspective/Opinion

 

 

Implementation Science and Medical Education Transformation

 

 

Jeffrey Amundson, PhD, Michael Braun, PhD, and M. Chris Decker, MD

 

 

Drs. Amundson, Braun, and Decker provide an overview of the basic stages of Implementation Sciences, acknowledging that the process must attend to the people and culture where it occurs …

 

Implementation science - a thoughtful, structured rollout of a new initiative - can help make new programs more successful. In the April 2, 2021 issue of the Transformational Times, Drs. Amundson, Webb, Prunuske, and Kalet discussed the use of implementation science methods in the curriculum transformation process. As we move forward with this change, and with the broader transformation of medical education driven by the Kern Institute, let’s take some time to reflect on implementation science: why it’s important, and what it tells us about how and why to start off right.

 

Why are we talking about Implementation Science?

Successful implementation and maintenance of evidence-based practices for organizational changes or programs are a necessary precondition at Kern for providing successful programs, driving innovation at MCW and elsewhere, and generating scholarship. But there’s no guarantee that merely using an evidence-based practice (EBP) will lead to its adoption. For example, here is a story from Bauer and Kirchner’s (2020) article in Psychiatry Research:

“It was, by all estimations, a successful research effort. We had mounted a randomized, controlled clinical trial across eleven sites in the US Department of Veterans Affairs (USVA), testing an organization of care called the Collaborative Chronic Care Model (CCM) for bipolar disorder versus treatment as usual. Over three years of follow-up, the CCM showed significant positive impact on weeks in mood episode, mental health quality of life, social role function, and satisfaction with care - all at no increased cost to the healthcare system. In parallel, a two-year, four-site randomized controlled clinical trial of the bipolar CCM in the Group Health Cooperative of Puget Sound (now Kaiser Permanente), showed very similar outcomes at minimal cost, compared to treatment as usual. Both studies were published in the same year in mainstream psychiatric journals that are read and respected by mental health researchers, clinicians, and administrators. The CCM for bipolar disorders began to be endorsed by national clinical practice guidelines in the USVA and in Canada, and the bipolar CCM was listed on the US Substance Abuse and Mental Health Services Administration's prestigious National Registry of Evidence-Based Programs and Practices.

And yet, within a year of the end of the studies, none of the 15 sites had incorporated the CCM into their usual workflow. The clinicians who had participated in the CCM went back to their usual duties, and the individuals with bipolar disorder went back to receiving their usual form of care.” (Emphasis added)

Something more than sound evidence is needed for a program to be successful, and implementation science is an approach designed to address the how and the why of getting started right, once the “what” has been defined.

 

What is Implementation Science?

Implementation science is the systematic study and practice of program implementation to increase chances of acceptance, adoption, fidelity, and success. For a new initiative, this means the program is supported and practiced by a broad range of practitioners and stakeholders. It also means the practice of the program adheres to the program’s tenets and dictates. And it means that the program achieves desired outcomes predicted by theory and evidence. Notably, this process involves many similar components of continuous quality improvement (CQI). CQI also involves the continual review of an ongoing program’s implementation, fidelity, and outcomes to adjust the program while it remains in operation.

 

Basic Stages of Implementation Science

There are numerous specific models of implementation, and all identify similar stages of the process. Here are five basic steps to the process of implementation as guided by implementation science.

 

Exploration – Needs, Options, and Partners

The implementation team is responsible for getting the stakeholders and learning environments ready. They explore and research different EBPs to share. This might involve reaching out to other organizations who have implemented similar practices, literature reviews, and mock learning environment experiences to familiarize stakeholders with what evidence-based approach looks and feels like. The implementation team develops needs-assessments to ready stakeholders for the next stage of Installation.

 

Installation - Who, What, When, and How

During this phase, the implementation team identifies human and operational resources that become part of an implementation plan. This plan lays out who will be using the new program, where it will be used, who will be asked to do their work differently. It anticipates necessary training to prepare others for changes and details how the new program will be evaluated.

 

Initial Implementation - Measurement, Meetings, Learning Environment, Support, and Observation

When practitioners use the innovation for the first time, implementation teams help develop competencies required by the EBP, help administrators adjust organization roles and functions, and help leaders fully support the process. During this process, the team is rolling out the implementation plan, sharing EBPs chosen to implement, and displaying and modeling the use of resources.  The team is using valid tools to measure effective EBPs, look-fors (things that represent expected strategies and outcomes), peer support opportunities, plans for observation, and plans for touch-base/how are things going meetings.

 

Full Implementation - How Many People? Fidelity, Good Outcomes, New Standard of Work

During this stage, stakeholders involved are using an effective intervention with fidelity and good outcomes. Notably, expected outcomes should be realistic and aligned with theoretical predictions. The new ways are now the standard ways of work and Implementation Teams ensure that the gains in the use of effective practices are maintained and improved over time and through transitions of leaders and staff. This can involve follow-up meetings with staff, review progress monitoring with educators and administrators to ensure fidelity.

 

Sustainability - Financial and Programmatic

Sustainability planning and activities need to be an active component of every stage. These activities can involve ensuring that the funding streams are established, adequate, and sustainable (financial sustainability, e.g., funding for educators, staff, and administrative time) and ensuring that the implementation infrastructure is established, reliable, effective, and sustainable (programmatic sustainability, e.g., vertical articulation with new stakeholders to identify what worked for which stakeholders).

 

Attending to People and Culture

Another critical dimension for successful implementation in every stage is the people and cultural changes required. Though we may discuss implementation science as a prescriptive way to implement a new program, we would be remiss if we ignored the fact that any change within an organization requires extraordinary commitment and sacrifice from the individuals who are asked to carry out the change and live with the consequences (both good and bad) from the change. These changes will impact personal mattering, professional identity, feelings of purpose, and other emotional elements and must be treated by all with humility, empathy, and compassion. And as organizations learn within the implementation, rate of implementation, which can add to the impact of change, is an important consideration. We look forward to exploring these elements of implementation science in a future article.

 

 

In sum, Implementation Science can help effectively identify and validate a need, strategically plan for change through implementation plans, and provide structure for data collection and reporting on the impact of the change. Engaging employees at all levels (e.g., faculty, staff, learners, etc.) early in the implementation process is key to aligning an EBP with the values and culture of the organization. In future issues of the Transformational Times, we look forward to writing about additional important elements of successful implementation and also about the transformational journey of the MCW curriculum reimagining. Stay tuned!

 

 

Jeffrey Amundson, PhD is a postdoctoral fellow in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

Michael Braun, PhD is a program manager with Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

M. Chris Decker, MD is Chief Transformation Officer and a Professor of Emergency Medicine at MCW. He is a member of the Human-Centered Design Lab, and has leadership roles in the Design Sprint Program and the Transformational Ideas Initiative (TI2) seed grant program for the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

 

‘Take 3’ Question and Answer: Report on a Human-Centered Design Sprint for the MCW Curriculum Re-imagined

 From the 4/16/2021 newsletter

  MCW Curriculum Re-imagined

 

‘Take 3’ Question and Answer:  Report on a Human-Centered Design Sprint for the MCW Curriculum Re-imagined

Dr. Wendy Peltier and second year medical student, Lauren Stippich, share their experience from participating in the first Virtual Design Sprint Workshop on the proposed MCW Curriculum, sharing perspectives through the eyes of a student and senior faculty.

 

The Kern Institute’s Human-Centered Design Lab facilitated a virtual design sprint last week with 77 participants, representing students, faculty, residents and staff from across our MCW community.  Amy Prunuske, PhD, and Travis Webb, MD provided a high-level overview of the key principles of the proposed curriculum, which involves development of learning communities and implementation of longitudinal, case-based and experiential teaching formats for foundational knowledge. The design sprint, led by Karen Marcdante, MD, Chris Decker, MD, and Julia Schmitt, provided an opportunity for participants to work in small groups to provide in-depth feedback on the curriculum proposal. This format ensured that every participant’s feedback was recorded, and all the information  has been qualitatively organized for the Curriculum Steering Committee’s use.   

The curriculum proposal would involve a major shift from our current, ‘2 by 2’ structure of separating basic science course work from clinical rotations. A potential timeline for approval, and detailed summary of background work over the last two years leading up to this proposal was provided. Dr Webb and Pronuske shared, ‘The goal of our curriculum is to produce competent well-rounded physicians who will be excellent clinicians in any specialty and are prepared to practice in the future health care environment’.

They acknowledged the contributions of many in developing this proposal, including Bill Hueston, MD, Jeff Amundson, PhD, and Jennifer Hinrichs.

 

1) What surprised you most about the session?

Lauren:  I was shocked by the high emotion from many of the participants! As students, we only see the ‘end product’ when a curriculum has been implemented, and I did not appreciate all the pre-work and planning that stands behind our course offerings.  It was eye-opening to hear the various worries and hesitations of key faculty for embarking on such a major change in teaching formats.  Frankly, it worried me that some of the comments seemed to go a bit too far, and without recognition for the immense amount of work that went into this workshop and the proposal itself .  This was my first time being part of such a broad group, and I quickly saw how important it will be to have buy-in from all our stakeholders to implement this change.

Wendy:  Must say, I anticipated the high emotions, having been at MCW during  the transition to the Discovery Curriculum, and from my experience with change management.  Hearing the plans for the first time in considerable detail, I was surprised and excited about the spirit behind bringing this new, student-centered approach to adult learning that is explicitly tied to promoting inquiry and innovation in our learners.

 

2) Did you feel your voice was heard?

Lauren:  The small group process really created an authentic, ‘safe space’, to both talk and listen, and we had enough time to review things in detail.  There was a basic science faculty in my group, and I developed an understanding for concerns that previously I did not appreciate even existed.  Some participants complained that the breakouts were too small with only three members each, stating they wanted to hear more opinions, but I understood the rationale behind this.  It is so important to hear all perspectives, and smaller sized groups help to ensure the collected conversations are representative of everyone, not just the most vocal members of a group.  This seems even more important in the virtual setting.  Being part of the workshop planning group, I also saw how the detailed feedback would be gathered, allowing the program leaders to have a full appreciation of all concerns.

Wendy:  My experience echoed Lauren’s.  The more ‘intimate’ breakout sessions created opportunity for in-depth discussion of the guided questions.  It was important to hear both the excitement for a new structure, but also concern and worry over the ‘heavy lift’ involved in implementing such a major change.  A strong theme that came through was need for culture change and to explicitly identify ways to honor educators in our community with protected time and recognition for teaching AND administrative efforts.

 

3) As we reimagine the MCW curriculum, what do you see as important     measures of success?

Lauren:  The new curriculum really excites me, particularly in the thoughtful and deliberate structures that promote student connection and support, as well as the spiral or ‘catch-up’ weeks, where students can take a breath, or refine and review important topics.  As a second year student, I can reflect on what a huge transition it was to enter medical school, and how the 4C Coaching program provided amazing support during this challenging time. I consider my participation in this program the most impactful activity of my M1 year—and I can see how the learning communities and small group activities will help that shine through in the new curriculum.  I would hope that students being more connected, and the environment continuing to be collaborative rather than competitive, despite our large class size, could be key outcomes. After participating in this workshop, I would also hope that all the faculty who contribute to teaching will feel supported, prepared and confident in launching the new changes.

Wendy:  My hope for success would first be a true, institution-wide, commitment to change with resources to manage the transition.  Success will be tied to students and faculty learning together, and for many of us, stepping outside our comfort zone.  The evidence behind the need for change, which is robust, indicates that this will be a much needed and important investment in preparing our graduates for future practice.  This year has certainly been one that highlights the challenges to our profession and current health delivery systems.  To me, training physicians who are prepared to speak up when needed, to care for themselves, and to seek innovation in their daily work, is something to promote and support.

To learn more about the MCW Curriculum Re-imagined and Human-Centered

Design:

1. Discovery Curriculum Exploration Project

2. Human-Centered Design Lab

 

Lauren Stippich is a Wisconsin native currently in her second year of medical school with interest in medical education and the Humanities.  Lauren is a student member of the Human-Centered Design Lab and this was her ‘first dive’ into a curriculum re-design process.  In her free time, Lauren enjoys reading books, time together with friends and a good game of spike-ball.

Wendy Peltier, MD is an Associate Professor of Neurology and Medicine, in the Division of Geriatric and Palliative Medicine at MCW. She is also a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. In her free time, she enjoys yoga, reading books and home-cooked meals by her husband and son.

Entrepreneurially-Minded Learning and Teaching: A Core Element of KINETIC3

 From the 3/5/2021 newsletter

Perspective/Opinion

Entrepreneurially-Minded Learning and Teaching: A Core Element of KINETIC3

 

by Bipin Thapa, MD

 

Dr. Thapa provides an overview of what the KINETIC3 program hopes its participants will learn about the Entrepreneurial Mindset …

 

Teachers and educators do different things, but how often do we stop to consider and “What is the value of what I am doing?” or “What exactly are we trying to create?”

We need to think differently if we are to address these questions.

In medicine and education, we shy away from terms like, “Entrepreneurship” because of the incorrect assumption that entrepreneurs focus solely on monetary profit. But entrepreneurship is more than that. It encompasses ways of creating anything of “value” – and can concentrate on things such as services, scholarships, processes, and quality improvements. It can even focus on experiences.

Academic Entrepreneurship creates sustained value in multiple dimensions that are financially and/or logically stable. It is competitive in the “marketplace”; the “market” here reflects a broader platform that includes, but is not limited to, scientific and peer-reviewed venues. Entering this market requires an Entrepreneurial Mindset (EM). EM is, in essence, a collection of mental habits like attentiveness toward opportunities, focus on their impact, and intent to create value. This learned set of values offers a way of thinking about the world and acting upon what we see. EM empowers the practitioner to question, adapt, think differently, and make positive change; it equips one to identify opportunities and create value in any context.

By building on work borrowed from our Kern Engineering Entrepreneurial Network (KEEN) colleagues, we are deliberately creating an entrepreneurially minded learning and teaching culture in the KINETIC3 program. Our teachers and educators start from the big ideas of why our learners need to learn something and then move to what they need to ask to answer the more important questions. We push them to discern how best they can accomplish the goals. We want them to focus on learning objectives that reflect the tandems of mindset and skillset. That is another offer of value. Our instructional methods must be inclusive and respectful of the differing learning styles of our learners; this is critical to excite every learner. Finally, our assessment methods must be practice-relevant, as we know that assessment drives learning. 

The diagram shows the big picture of how the Entrepreneurial Mindset guides the process from identifying big picture themes through instruction to assessment. 

We believe that by training entrepreneurially minded faculty, we will promote long term institutional change. Having a significant number of KINETIC3 alumni teaching students and residents with techniques built on the Entrepreneurial Mindset, can lead to “good” disruption and new ways of developing identity formation. 

Bipin Thapa, MD, MS, FACP, is an Associate Professor in the Department of Medicine (General Internal Medicine) and Assistant Dean of the Clinical Science Curriculum at MCW. He is a member of the Faculty Pillar and of the KINETIC3 Steering Committee of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

"At the Most Important Crossroads in our Life there are No Signs"

 From the 3/5/2021 newsletter

Perspective/Opinion

"At the Most Important Crossroads in our Life there are No Signs"

 

by Linda Menck, MA

 

Linda Menck, a faculty member in the Kern Institute’s KINETIC3 program, talks about how she employed the entrepreneurial mindset to recast a communications course at Marquette from a tired offering to a creativity powerhouse…

 

After seventeen years of teaching at Marquette University I found myself at the crossroads. My teaching career felt like the plot of the film Groundhog Day. 

 

As a professional faculty member in the Diederich College of Communication, I was assigned to teach the same classes every semester. It was like eating the same breakfast cereal every morning. While students in my classrooms changed, course content remained the same. 

A course I regularly taught was Introduction to Visual Communication (COMM 2100). This was a required course for all majors in the College of Communication but was demoted to an elective after a college core curriculum review. 

I remember thinking this course was destined to die, and the cause of death would be low enrollment. Students with majors in engineering, the sciences, and business administration had no desire or need to learn theories of visual communication or memorize dates and definitions of major art movements. 

This became a personal and professional prefect storm that ultimately motivated me to disrupt and transform my teaching. Consistent with my character, I didn’t ask for permission, but I knew it was time to redesign COMM 2100, and the redesign would need to be of epic proportion. At the foundation of the redesign would be personal passions, what I knew best, and essential skills research indicated our students needed to practice and become capable of applying.

I gathered my markers and faced the whiteboard to mind map my new course. “Mind mapping” is a visualization method I use and teach to promote and practice divergent and disruptive thinking. The central topic of my mind map was COMM 2100 REDESIGN and the initial major branches or connections were creativity, communication, and innovation. 

From the initial branches, twigs began to grow fast and furious. They included entrepreneurial mindset, defining and exploring creativity, building creative confidence, methods for creative problem solving, human-centered design research methods, inclusive and design thinking, disruptive innovation, and the power of storytelling and visualization to present innovative ideas and solutions. 

There were other crucial components to ensure the course would work. It had to be hands-on and grounded in active learning. This meant identifying an environment designed to untether learners from desks. The course needed to be experiential and focused on challenges in our community and the world. Finally, the content had to be collaborative in nature and applicable to students from diverse majors with a variety of skillsets. While planning it became evident this was a red-hot challenge with a whole mess of opportunity. Flying under the administrative radar screen, I created  content, rewrote the course description, objectives, and learning outcomes, and then settled on a new name for the course. Finally, it was time for the reveal. In the Fall of 2014 my new Creativity, Communication, and Innovation course was ready to be put to the ultimate test and judged by the harshest critics, our students. This was my field of dreams. I built it, but would they come? 

Course registration for the semester began and I waited and watched. The result was shock and awe. Within the first two days of registration both sections of the course filled to capacity.

The course continues to thrive and grow. Over time, it has evolved into a course that fulfills a requirement in our University’s new core of common studies, continues to push students out of their comfort zones, and builds their creative confidence. 

When I arrived at the crossroads, I chose to take the transformative route but I never traveled alone. My journey took me across campus to the Opus College of Engineering and the Kern Engineering Entrepreneurial Network (KEEN). I was welcomed, supported, and taught how to integrate entrepreneurial minded learning into my courses with a framework grounded in curiosity, connections, and creating value. 

Continuing on the road led me to MCW and the KINECTIC3 Teaching Academy. You, too, welcomed me. Collaborating with members of the KINETIC3 Advisory Committee to design and teach bootcamp workshops is an exciting new challenge. Your ongoing support transforms me with character, caring, and competence and keeps me from returning to the crossroads. 

The title of this piece is from a quote attributed to Ernest Hemingway. 

Linda E. Menck, MA, is a Professional in Residence in Strategic Communication in the Diederich College of Communication at Marquette University. She is a member of the KINETIC3 faculty. 

Creating Entrustable Professional Activities (EPAs) for Acute Care Pediatric Nurse Practitioner Students

 From the 3/5/2021 newsletter

Perspective/Opinion

Creating Entrustable Professional Activities (EPAs) for Acute Care Pediatric Nurse Practitioner Students

Jill C. Kuester, MSN, RN, CPNP-AC, Katie McDermott, MSN, RN, CPNP-AC, Jennifer K. Pfister, MSN, RN, CPNP-AC, C-NPT, Christine Schindler, PhD, CPNP, and Leslie Talbert, DNP, RN, CPNP-AC/PC

 

EPAs are widely used in measuring the progress of residents in graduate medical education. The members of the Marquette team describe their KINETIC3 capstone in which they adopted an EPA approach to graduate nursing education…

Nursing and medicine go together like peanut butter and jelly. Although distinct, we complement one another. As interdisciplinary teams improve at working together, we have found the ability to gain insights from the more traditional pathways of each other’s endeavors.

The Kern Institute holds a yearlong program known as the KINETIC³ Teaching Academy where the goal is to improve medical education. Character, caring, and competence in medical education are at the center of the program with each participant or group focused on completing a project incorporating these traits.

The five core faculty members from Marquette University’s Acute Care Pediatric Nurse Practitioner (MU ACPNP) program completed a capstone project focused on creating Entrustable Professional Activities (EPAs). Guided by the Code of Ethics published by the American Nurses Association which explicitly states that nurses have compassion and respect for their patients and families, nurses already have a strong reputation for caring. We knew that the KINETIC³ program might offer a different perspective to build upon this foundation.

As nursing has been named the most trusted profession for nineteen years in a row (Gallup), we wondered how this could be operationalized into our graduate level curriculum. EPAs have been widely used in medical education but remain a novel concept in nursing education. The MU ACPNP faculty believed the act of entrustment was well suited to our nurse practitioner students. 

Utilizing this concept from medical education and knowledge gained through the KINETIC3 courses, our group conducted a systematic literature search, synthesized that literature, and created a template to guide development of the individual EPAs. Each member then focused on one of five EPA topics: 

• Reflective practice 
• Leadership identity 
• Holism 
• Social justice 
• Magis - the concept of using talents to strive for excellence 

Each project team member was the designated lead on an individual EPA and drafted the EPA using the template. Iterative cycles of reflection, collaborative review, feedback, and revision were conducted to ensure consensus regarding content, outcomes, and assessment sources. These collaborative sessions were held synchronously, both in-person and virtually, to promote clarity in communication. The final stage of revisions included alignment of language and descriptors used across all five EPAs to promote continuity of content and universality of tone. 

Each EPA includes a succinct action-oriented title followed by a more robust description linked to key literature, as well as a justification statement calling out its significance and impact beyond the walls of Marquette. Each EPA encompassed several nurse practitioner competency domains and described the required knowledge, skills, and attitudes the students must possess for success. Some of the methods of assessment we will use include, but are not limited to, direct observation, critical review and evaluation of projects, reflective journaling, and exit interviews.

As graduate students move into professional practice, our goal is for them to embody the values we espouse as a faculty in alignment with MU’s mission, vision, and core values. EPAs hold the promise of operationalizing the transformation to a competency-based education framework for PNPs by defining a pathway with a common language and clearly articulated ideal outcomes. The KINETIC3 program afforded us the opportunity to learn and work as a team to intentionally develop key strategies to enhance the development of the competent and compassionate nurse practitioner.

Jennifer K. Pfister MSN, CPNP-AC, C-NPT, is a Pediatric Critical Care Nurse Practitioner at MCW/Children’s Wisconsin and a Transport Team Clinical Educator at Children's Wisconsin. She also has a joint appointment at Marquette University where she is part-time faculty within the Acute Care Pediatric Nurse Practitioner program. 

Christine Schindler, PhD, CPNP, is a Pediatric Nurse Practitioner and Advanced Practice Provider Director for Critical Care/Palliative Care At MCW/Children’s WI. She has a joint appointment at Marquette University where she serves as a Clinical Associate Professor and director of the Acute Care Pediatric Nurse Practitioner program. 

Leslie Talbert, DNP, is a Pediatric Nurse Practitioner at MCW/Children’s Wisconsin. 

Katie McDermott, MSN, RN, CPNP-AC, is a Pediatric Nurse Practitioner for Critical Care at MCW/Children’s Wisconsin and has a joint appointment at Marquette University where she is part-time faculty within the Acute Care Pediatric Nurse Practitioner program. She also serves as the Program Director at the Dairy Cares Simulation Lab at Children's Wisconsin. 

Jill C. Kuester, MSN, RN, CPNP-AC, is a Pediatric Critical Care Nurse Practitioner at MCW/Children’s Wisconsin. She has a joint appointment at Marquette University where she serves as Part-time Faculty in the Acute Care Pediatric Nurse Practitioner program.