National Alliance for Physician Competence Discovery Workshop


Creating Movements in Multi-Stakeholder Systems


Context: So far we’ve really focused on the purpose of the Alliance. Now we’re going to segue into a deeper focus on what activities the Alliance undertakes and how it accomplishes these activities in a complex, multi-stakeholder environment. At this point it will be tempting to focus on activities and plans without taking into account the new information that was just presented.

When James Clerk Maxwell was working to discover the principles of electricity and magnetism, the subject was completely obscure. Having little to grasp hold of to make sense of the phenomena, he turned to a metaphor. With his understanding of the principles of hydraulics he asked, “what if electricity flowed like water?” He used the equations of fluid mechanics to help him derive the science of electricity and magnetism. You’re being asked to do something similar in this exercise: apply principles of behavior of ecological systems and the phenomenon of positive deviance to the Alliance’s multi-stakeholder system and the activities that the Alliance has chosen to undertake to support its purpose and mission.

Objective: Based on the new ideas you’ve just heard, what should the Alliance do to accomplish the work implied by the activities described in the Alliance Draft Proposal? (Each group has a different set of activities to focus on.) How can you apply the principles of ecological systems and positive deviance to aid in the fulfillment of the activities? Specifically, how might these principles influence the strategy for each activity, the talent (key players, roles), and execution (methods for getting the multi-stakeholder system to get the work done)?

Process: You may wish to take a few minutes at the start to outline the most important ideas that you heard and see if you can abstract from them some general principles that might relate to this assignment’s objective.

Exchange: At the conclusion of this exercise, you will gather together to listen to the other presenter. Leave your work on your marker board. After the next presentation, you’ll return to this same small group to complete your work.  

Resources: On the following page is a list of the activities and 18-month actions described in the Alliance Draft Proposal. Each small group is assigned one or more of these actions and activities to focus their work on.

Section Three: Activities of the Alliance and 18 Month Work Plan

Groups 1and 2 please focus on these Activities:
Addressing gaps in education, training, licensing, and certification
It will provide a forum through which the various groups composing medicine’s system of self regulation may identify and resolve current and future gaps in the continuum of education, training, licensing and certification.

Strategies to assist physicians in lifelong professional development
It will facilitate sharing of resources and knowledge, thus expediting the development and implementation of strategies to assist physicians in their lifelong professional development.

Demonstrate physician competence to the public
It will be a visible demonstration of medicine’s accountability to the public for the competence of its members.

Groups 3 and 4 please focus on these Activities:
Provide a mechanism for verification of physician competence
The National Alliance for Physician Competence will provide a mechanism for professional verification of physician competence.

Oversee processes that acquire and verify physician competence data
It will oversee the processes used to acquire and verify physician competence data, and inform the public about the quality of those processes and the relevance of the data acquired.

Develop recommendations for interpreting physician competence data
The Alliance will convene physicians, other health professions experts and members of the public to develop recommendations for interpreting physician competence data.

Establish a Trusted Agent data exchange infrastructure
A core function of the Alliance will be to establish and maintain a “Trusted Agent,” i.e., a data exchange infrastructure built upon business principles agreed to by members of the Alliance and owners of existing data repositories. Such an infrastructure will allow data owned by multiple sources to be aggregated and reformatted in ways tailored appropriately for use by individual physicians, by the public and by credentialing bodies.

Groups 5 and 6 please focus on these Activities:
Develop & advocate endorsement of metrics for physician competence (1st 18 months)
Developing and advocating endorsement of appropriate metrics for physician competence throughout the continuum of education, training and practice;

Communicate with stakeholders to support this work of developing metrics (1st 18 months)
Engage in early, widespread and continuous communication with a range of stakeholders to convey the importance of and gain support for this work.

Assignment (part 2)
Creating Movements in Multi-Stakeholder Systems
(part 2)

Context: Another tool to use in innovation is the deliberate overload of information and new models. Many innovators describe a period in the process of “being filled up full,” sometimes to the point of overwhelm. They’re unconsciously searching for something that will yank them out of the familiar and put them into a position where they can see the challenge in a new light. Sometimes it’s overload. While this can feel a bit uncomfortable, just think of it as choosing to go through a rather thorough workout at the gym.

Objective: Return to your small group and continue work on your assignment, now taking into account the new information and models you have just heard and seen.

Process: Before diving into completing the assignment, it might be good to take a few minutes to look specifically for principles from what you’ve just heard that might apply to the solution you’re building. You might also want to take some principles from what you just heard and force them to apply, whether they look like they’re amenable to that or not.  

Exchange: After this assignment we’ll reconvene and you’ll be asked to share the highlights of your work with the other groups.

Resources: The same as for the previous assignment.

Report Outs


Come on in and please take a seat. OK - we have a little bit of attrition here. A couple people are indisposed. Report outs will be about 6 minutes per team. Everyone had the same assignment but each group worked on different activities so please explain that part of it before you go.

Group One
We had the ant hills and Jim coined the phrase of Ali-ants.

We had the ant hills and Jim coined the phrase of Ali-ants.

We talked about restructuring the regulatory bodies. Assessment of competence and acceptance of competence are both issues we face. The assessment of competence that is going on now is rudimentary at this point. There is lots of room for improvement in assessing competence all along the continuum.

We have to deal with the issue of finance in healthcare. We wanted to advocate that the GMP is the core around which we all rally around. The second strategy is how we assist doctors in life long learning.

We wanted to have an EMR that spit out results and we also talked about having personal learning plans at some point.

We got locked into the best practice approach and that had to be re-looked at in light of positive deviance information.

The third topic was to demonstrate physician competence to the public and that would mean we would have to educate the public about competence. In the GMP it has expectations about educating the public about what they should expect from us.

AARP and other media outlets like consumer reports are different places we could use to educate people about competence.

We need to disseminate information that is already available to people. Not many people know that some things already exist. There are already information that people can access but that isn't widely known.

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Group Two

We had the same assignment but we choose to address the entire thing. The first part was to outline the most important ideas we had heard. The ideas we discussed and embraced included the Alliance as a complex system and how it could adapt. We would use the ideas of the speed in which change could happen as one of the signs that adaptability was happening.

We couldn't decide between the horse or the cart - we said we had to create a forum for conversations but we also said we had to look at a framework for identifying gaps in the continuity in education.

We couldn't decide between the horse or the cart - we said we had to create a forum for conversations but we also said we had to look at a framework for identifying gaps in the continuity in education. There should be a review of current curricula and a review of evidence based practice and there should be an identifying of gaps in all of the education system. There should be some inclusion of the physician as well.

Once we identified those gaps we talked about who should be part of the forum for discussing what we came up with. Some of the organizations we identified are: the AAMC, AOA, ACGME, licensing boards, certifying boards, and the joint committee on CME.

We wanted to look for information about the lack of negatives. We thought the Alliance should figure out our processes for the determination of continuing competence of a physician.

We should identify appropriate data around performance and around continuous certification processes. Life long learning was next and there are already some existing mechanisms that could be included there.

This Alliance has done a good job with the GMP. There is one thing that is difficult and that is how to publicize processes and sharing information with payers on competence. How would we publicize how physicians are participating and improving and what level of data would be acceptable for that?

It is challenging and difficult and it's going to be happening anyway - if the Alliance could jump in and figure out something that could be agreed upon that would be a real differentiator.

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Group Three

We had four different areas. Creating a mechanism for physician competence. This is a formative one and we would create a sandbox on compatible rules. This verification process could use the definition of Positive Deviance and allow people to do information exchange.

What is a measure? There are some people that love measures but we need to know about these different measures.

We would oversee the processes about physician competence. This is more in the synergistic mode and communication of these different measures was important. Using a positive deviance force could be good.

The outside world wants a linear rank. Do you group people? Do you have a threshold?

The outside world wants a linear rank. Do you group people? Do you have a threshold?

In the interpretation of the data we felt that we needed to keep the playground in the sandbox. This has to be energetic and fun and we are trying to achieve a higher goal in moving things forward. The reality is that this data will be used for in-appropriate things. No matter what process we come up with it will be used for payment and that is a big risk. Is this a high stakes in or out thing?

The mechanism on assessing physician competence included the idea we don't know much about measuring beyond mentoring. There is a void there. There are states that got rid of their societies. How does one deal with self-growth? If you have a substance abuse issue if you go to the licensing authority you sign some stuff and it's a failure environment. How are we going to deal with that?

We talked about establishing a trusted agent. We felt that we are beyond that and it's not a core purpose we should be involved with. The trusted agent is rules but we don't want a 501c3 and a server sitting somewhere. It was stated that we would create an infrastructure for sharing data but I thought we evolved beyond that.

I thought the trusted agent was envisioned as a revenue source for the Alliance?

The issue about how much money you have to spend on an infrastructure is large? Do we have the consensus to bring people together? We need a common source and a common structure. It's $1million to figure out how to get a $10million infrastructure. The way this was structured and talked about we felt it shouldn't be one of the activities of the Alliance.

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Group Four

There is a lot of nuance in the language about what the Alliance is going to do and to whom. We couldn't agree on what those words meant.

The Alliance would serve as a stable and safe home base to share outrageous ideas.

The Alliance would serve as a stable and safe home base to share outrageous ideas. It would also be a place where we can go to find out what worked.

We think it should be the home of the trusted agent machinery some day and the home of the GMP document.

That said, we took to heart that we shouldn't plan too far out. The trusted agent is many years out and so are the competence assurance parts but let's not define that too closely now.

For those that are healthcare providers how many wash their hands before seeing the patient? Who washes their hands after seeing the patient?

The ecology model is interesting. The environment is the moving food and the Alliance members are the ants. The Alliance's role is to maintain that moving center to be as defined and stable as possible. Another role might be to manage where and how fast that dot is moving.

One role of the Alliance might be to engage in the dialog with the outside world and then come back to the inside world and discuss it. What if a payer is going to do pay for performance? What if another one comes and says we're not paying on these things? The Alliance could be the mechanism to come in and talk about those things and then decide how to respond.

There are a lot of unknowns as well.

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Group Five

We talked about establishing metrics for physician competence. No metric is going to be worth anything unless we establish integrity and credibility. Any metric would have to have physician buy-in with the assumption that the GMP is bought into by physicians. It needs to provide value to the physicians and the community.

We have metrics for things already - certification, maintenance of certification and licensure. We don't know what all the other groups are doing in these areas.

Where can we identify strengths and weaknesses in the data we have?

Where can we identify strengths and weaknesses in the data we have?

We might identify best practices from this but as new metrics are identified we needed grassroots buy-in on what these metrics mean.

From the standpoint of defining metrics we need input into the payer link - that might be a way to go?

As we gain credibility we would expand the metrics programs. We should start with pilots and focus on things we are passionate about first.

What might be incentives? There could be licensing bodies requiring maintenance of certification? There might be CME credit for adopting GMP or reappointment for adopting the GMP or doing 360 degree evaluation?

The timing and the sense of pace is important. Randomness and robustness are needed. We said there are three major activities for the Alliance.

They are:

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Group Six

We wandered around and took in the phrase being filled up and overloaded. We are literally banging these concepts together.

How do we develop and endorse measures? We talked about measures first. We want to mitigate the impact of measures. This is a true culture change. The measures we have now are at an advanced stage. We are talking about measures of patient care and these new competencies we need measures for.

The new developers are not from our organizations that are here. The medical societies are doing a good job but the users of the measures are the group that insure physician competence. The Alliance needs to be a show and tell place. We need to find the positive deviance to find the people that are actually doing it. Where are they being used and how are they working and how are they accomplishing these goals?

We need to get the stakeholders informed about what other stakeholders are doing. We were attracted to Norm's curve but didn't know what it really means.

The Alliance is down here without any structure yet and our current physician competence system is very limited and rule bound and up here (with few options).

The Alliance is down here without any structure yet and our current physician competence system is very limited and rule bound and up here (with few options).

It's the entry level. Having an education program that is accredited and having a set of rules and assessing knowledge through our specialty boards and if you are staying out of trouble you don't get noticed. That is a very optimized way of assessing competence. We have to introduce diversity and move to a mechanism that is continuous across the continuum.

You have to measure in order to know if you have a positive deviant. When you do measure there is a gap - that gap is a profound stimulus for change. Why would physicians seek a gap? We fundamentally don't believe we want a gap. Pay for performance is going to market the idea of a gap.

We need many measures and to open wide to stimulate the growth of as many measures as we can. We need to develop a composite of all the measures. We need the ecology to figure and and shake out the measures.

Comment: I was in that group and I didn't recognize a thing you said [laughter].

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Very good work today. There will not be much more conversation now. A couple of quotes before you go and a note about this evening.

This first quote relates to what you have been through today. Einstein took 11 years to figure out the theory of relativity.

Albert Einstein took eleven years of unremitting concentration to produce the general theory of relativity; long afterward, he wrote, "In the light of knowledge attained, the happy achievement seems almost a matter of course, and any intelligent student can grasp it without too much trouble. But the years of anxious searching in the dark, with their intense longing, their alternations of confidence and exhaustion, and the final emergence into the light - only those who have experienced it can understand it."

It really was a nice mapping of where you are and where you need to go - which defines the mission of the group. It needs a facilitator. You could be one very important group because you understand this.

You are going to shift into a stage of incubation. Here is a quote about that:

"More usually, though, in the classic strategy for achieving enlightenment the weeks of saturation must be followed by a second stage that begins when a problem is deliberately set aside - put out of the active mind, the ceaseless pondering switched off. After several days of silence, the solution wells up."

If you would like to do something interesting there is something at Millennium Park. There are six different dance companies there and they are performing this evening. There are two public sculptures there that are also worth seeing.

That's it. We will see you tomorrow morning. Breakfast is at 7:30 and we start at 8AM.


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