Center for Learning and Professional Development (CLPD ...med.dartmouth-hitchcock.org/documents/RNA_Report... · Frontline Clinicians 173 70 243 73 TOTALS 305 119 424 93 . D. Results

Center for Learning and Professional Development (CLPD) 2014 Regional Survey of Health Care Professionals’

Continuing Education Needs

REVISED FINAL REPORT

Principal Investigator: Curtis A. Olson, PhD

Assistant Professor of Medicine, Geisel School of Medicine at Dartmouth

[email protected] 608-335-3773

Co-Investigator:

Mary G. Turco, EdD Assistant Professor of Medicine,

Geisel School of Medicine at Dartmouth Consultant, Center for Learning and Professional Development (CLPD),

Dartmouth-Hitchcock [email protected]

603-653-6618

Research Assistant: Lisa M. Jackson, MPH

Health care Research Analyst, Center for Learning and Professional Development (CLPD),

Dartmouth-Hitchcock [email protected]

603-653-6631

Originally distributed in October 2014

Revised in April 2015

TABLE OF CONTENTS

EXECUTIVE SUMMARY 3

I. INTRODUCTION 5

II. STUDY OVERVIEW a. Study Objectives and Questions 5 b. Evaluation Approach 6 c. Methods 6 d. Results 7

III. USE OF SOCIAL MEDIA AND INFORMATION TECHNOLOGY 17

IV. CONCLUSIONS AND RECOMMENDATIONS

a. Limitations 18 b. Importance of Perspective for Report Usage 18 c. Clinical Education 18 d. Leadership Training 18 e. Professional Development 19 f. Building Strategic Continuing Education Alliances 19 g. Educational Programming 19 h. Audience Segmentation and Marketing 20 i. Alignment of Education and Quality 20 j. Further Analyses of Study Data 21 k. Survey Burden 21

REFERENCES 22

APPENDICES

a. Methodology 23 b. Analysis of Q1 Responses and Examples 25 c. 80 Opportunities to Improve Patient Care Used in Q2 27 d. Rankings: All Respondents 29 e. Rankings: All Respondents by Geographic Region 32 f. Rankings: Physicians 37 g. Rankings: D-H Clinicians Combined 42 h. Rankings: Nurses 51 i. Rankings: Nurse Practitioners 57 j. Social Media Use 62 k. Information Technology Use 63 l. Study Design 64 m. Sampling Frame 65 n. Usable Records by Occupation and State 66 o. Questionnaire 1 (Q1) 67 p. Questionnaire 2 (Q2) 74 q. Stratified, Random Sample for Q2 82

Regional Survey of Health Care Professionals’ Continuing Education Needs: Revised Final Report |

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EXECUTIVE SUMMARY Introduction

In order to plan programs that enhance the quality of patient care, continuing education (CE) leaders need to know, from the perspective of frontline clinicians themselves, what areas of patient care present the greatest opportunities for improvement. In spring 2014, the then Center for Continuing Education in the Health Sciences, now the Center for Learning and Professional Development, at Dartmouth-Hitchcock Medical Center (DHMC) conducted a needs assessment of health care professionals in northern New England. The goals were to:

a. Produce high quality, actionable information for decision-makers responsible for continuing medical education, continuing nursing education, and interprofessional education offerings in 2014-2015.

b. Identify high priority gaps in patient care as perceived by health care professionals based on profession, geographic area, and clinic location.

c. Identify information technologies and social media being used for CE by the target audience, and describe likely trends in usage.

Methods

Most education needs assessments ask respondents to choose from a list of educational topics that are subject matter driven and predetermined by investigators. Instead, this 2014 Regional Survey utilized an innovative two-phase approach. In the first phase, Questionnaire 1 (Q1) asked health care leaders and clinicians to identify opportunities to improve patient care. The results were used to create a list of opportunities that were then prioritized by a larger sample of clinicians responding to Questionnaire 2 (Q2). Clinicians in northern New England – representing the states of Maine, western Massachusetts, New Hampshire, eastern New York, and Vermont – were queried. Utilizing Qualtrics, an online survey tool, researchers emailed an invitation to complete Q1 to health care organization leaders, managers, supervisors, and frontline providers all directly involved in patient care. Recipients were asked to identify the most pressing patient care issues they faced in their practices and organizations – issues that could be turned into opportunities to improve health care. Ninety-three respondents provided 436 responses to Q1. Responses were analyzed and synthesized into a list of 80 total opportunities to improve patient care. Invitations to complete Q2 were then emailed to a stratified, random sample of 3,711 clinicians, including: physicians, nurses, medical assistants, pharmacists, psychologists/counselors, therapists, dieticians, EMTs/paramedics, health care organization leaders, and others. Respondents were asked to give priority ratings using a Likert-type scale to a randomly-generated subset of 20 (of the 80 total) opportunities identified by Q1 respondents. Q2 also asked respondents to identify what information technologies and social media they currently used and preferred to use for CE. Results A total of 655 health care professionals completed Q2 for a response rate of 18%. Nurses submitted the most Q2 surveys, followed by physicians. Most Q2 submissions came from New Hampshire-based clinicians. Of the Dartmouth-Hitchcock employees who completed Q2, most indicated that they worked at DHMC.


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When all professions across all geographic locations were combined, the top priority opportunities for improvement were:

1. Improving interdisciplinary communication between team members.

2. Improving care transitions from inpatient to outpatient.

3. Reducing medication errors.

4. Taking a more patient-centered approach to care.

5. Improving follow-up on patients discharged from the hospital.

The top-ranked opportunities varied by geographic location, profession, and D-H setting. Respondents reported they commonly use email, video websites such as YouTube, and PowerPoint presentations, as well as computers, tablets, and smartphones for CE. Interestingly, respondents reported a preference for using all technologies and media types at rates lower than their current usage.

Conclusions and Recommendations The findings of this regional education needs assessment highlight specific areas and topics that can be addressed by future, targeted CE offerings. Most of these topics are described in terms that are directly related to patient care. The data suggest a need for more interdisciplinary and interprofessional learning. Specific audiences demonstrated learning needs based upon their unique geographic location and profession, although there were many highly ranked learning needs that cut across geography and profession. Many of the issues identified pertain to quality improvement and systems changes, in addition to CE, and should be of interest to health care organization leaders and change agents as they search for ways to support clinical changes that enhance patient care and health outcomes. The assessment results should be seen as one input into the process of designing educational programs. They should be considered in light of data from other sources such as health care performance measures, expert opinion, and developments in the scientific literature. In addition, further data gathering (e.g., surveys of medical specialties) and further analyses of the rich data collected by this assessment may be required to plan targeted educational interventions most effectively.


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I. INTRODUCTION The literature on effectiveness of continuing education (CE) programs for health professionals shows that programs are most effective at improving clinical practice and patient outcomes when highly targeted to the specific and predetermined needs of learners.1 Dartmouth-Hitchcock Medical Center (DHMC) and the Geisel School of Medicine at Dartmouth College need up-to-date information about the perceived needs of physicians and nurses in northern New England (i.e., western Massachusetts, Maine, New Hampshire, eastern New York, and Vermont) to guide the planning and delivery of CE programs. This information can also inform discussions within the Dartmouth-Hitchcock (D-H) Health Care System, Dartmouth College, and the Geisel School of Medicine to ensure that research and education are, in the words of Executive Vice President for Strategy and Network Relationships and D-H’s Executive Director of the New England Alliance for Health Stephen LeBlanc, “aligned with sustainable health system improvement.” To enhance the effectiveness of continuing medical education (CME), continuing nursing education (CNE), and interprofessional education (IPE), improve quality, and deliver programming that meets the needs of health care practitioners, leaders will benefit from information about how their target audience perceives the quality of care currently being provided. Specifically, leaders need to know, from the perspectives of frontline clinicians (i.e., those directly involved in the day-to-day care of patients), what the most important opportunities for improving patient care are. In addition, technological change is ubiquitous, as are changes in the patterns of use of technological devices and social media. To make decisions about the formats in which CE is delivered, decision-makers need to know how their target audience currently uses technology and social media for CE, and anticipate usage changes. II. STUDY OVERVIEW A. Study Objectives and Questions The specific objectives of the project were to:

a. Produce high quality, actionable information for decision-makers responsible for CME, CNE, and IPE offerings in 2014-2015.

b. Identify high priority gaps in patient care as perceived by health care professionals based on profession, geographic area, and clinic location.

c. Identify information technologies and social media being used for CE by the target audience, and describe likely trends in usage.

The specific study questions were:

a. What patient care opportunities are perceived by frontline clinicians?

b. What do various groups among the respondents consider to be their highest priority educational needs with regard to clinical/patient care issues?

c. What educational technologies and media have respondents used, and which do they prefer to use for CE purposes?


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B. Evaluation Approach

Existing needs assessment survey methods are ill-suited for eliciting clinicians’ views on opportunities for improving care. Most needs assessment surveys of health care professionals present respondents with lists of educational topics that are subject matter driven and created a priori by the investigators (e.g., Which of

the following topics would you like to learn more about? Dermatology, Endocrinology, etc.). For this study, an innovative survey approach was developed and piloted with the expectation that it would serve as a model for similar projects conducted by other academic medical centers. By taking both a problem- and clinically-focused approach , we asked health care providers to assign priorities to a list of clinical/patient care issues and problems that had been identified by other health care leaders and providers. C. Methods The survey was conducted in two phases using two online survey tools designed in Qualtrics. Questionnaire 1 (Q1) in Phase 1 was designed to produce the “raw material” from which Questionnaire 2 in Phase 2 (Q2) would be constructed (see FIGURE 1). A modified Dillman approach2 was used to optimize the response rate. FIGURE 1. Two Questionnaire Survey Design

The following major data collection activities were conducted:

Distribution of Q1 to 424 health care leaders and clinicians: 181 purposefully-selected health care organization leaders, and 243 randomly-selected frontline clinicians (see TABLE 1)

Analysis and synthesis of the 436 opportunities to improve health care received from 93 total Q1 respondents into 80 total opportunities to be used in Q2

Distribution of Q2 to a stratified, random sample of 4,160 health care professionals in northern

New England

Compilation, analysis, and ranking of Q2 responses Further details about the methodology are described in APPENDIX A.

Q1

•Recipients: Health care organization leaders, managers, supervisors , and frontline clinicians

•Goal: Compile a list of potential clinical/patient care focus areas to inform the list presented to survey respondents in Q2

Q2

•Recipients: Physicians, nurses, medical assistants, pharmacists, psychologists/counselors, therapists, dieticians, EMTs/paramedics, and health care organization leaders

•Goal: Ask respondents to rank by importance the clinical/patient care issues/problems derived from Q1’s list


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TABLE 1. Q1Invitations and Responses

NH MA-ME-NY-VT Total

Invited Responses

Health Care Leaders 132 49 181 20

Frontline Clinicians 173 70 243 73

TOTALS 305 119 424 93

D. Results Questionnaire 1. Twenty leaders and 73 frontline clinicians responded to Q1. Respondents provided 436 suggestions of opportunities to improve health care (see TABLE 1 above). These suggestions were analyzed using software for qualitative data by the principal investigator (CO) and research assistant (LJ). Major categories of responses, illustrative examples, and the number of responses per category can be found in APPENDIX B. Some responses were placed in more than one category; the number of responses should not be interpreted as a measure of the importance of the category. Categories with the largest number of responses were: 1) access to care, 2) communication, 3) care coordination, 4) community outreach/linkages, 5) patient education/coaching/counseling, 6) policy/guidelines, and 7) systems. Responses were reduced by combining similar items and eliminating those that were not amenable to change through an educational intervention (e.g., increase housing opportunities for seniors). What resulted was a list of 80 opportunities to improve health care (see APPENDIX C). These 80 opportunities were used in Q2.

Questionnaire 2. A total of 655 health care professionals completed Q2, resulting in a response rate of 17.7% (see TABLE 2). Despite a pre-survey email message from organization leaders encouraging participation, and a systematic, evidence-based approach to the survey design,2 more than half of the invitation emails went unopened (n=2,096). TABLE 2. Q2 Response Rate

N Total Invitations Delivered 3,711 Total Response Submissions 655

Response Rate 17.7% As TABLE 3 on the following page shows, the largest number of responses came from nurses, followed by physicians. Health care providers from New Hampshire comprised roughly three-quarters of the total.


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TABLE 3. Survey Respondents by Occupation and Geographic Area

TOTAL NH MA-ME-NY-VT

N

% of Total:

655 N

% of Total:

655 N

% of Total:

655

Nurse (RN, BSN) 260 39.7% 195 29.8% 65 9.9%

Physician 159 24.3% 114 17.4% 45 6.9%

Other (e.g., pharmacist, social worker) 66 10.1% 51 7.8% 15 2.3%

Nurse Practitioner 52 7.9% 39 6.0% 13 2.0%

Therapist (e.g., physical, occupational) 25 3.8% 21 3.2% 4 0.6%

Psychologist/Counselor 23 3.5% 15 2.3% 8 1.2%

Admin./Manager/Exec./Director 20 3.1% 17 2.6% 3 0.5%

Physician Assistant 15 2.3% 12 1.8% 3 0.5%

Licensed Practical Nurse 13 2.0% 12 1.8% 1 0.2%

Nursing Assistant 7 1.1% 7 1.1% 0 0.0%

Dietician/Nutritionist 7 1.1% 6 0.9% 1 0.2%

Medical Assistant 4 0.6% 4 0.6% 0 0.0%

EMT/Paramedic 4 0.6% 2 0.3% 2 0.3%

TOTALS 655 100% 495 75.6% 160 24.6%

100%

D-H System employee participation is shown in TABLE 4. Again, nurses and physicians comprised the largest number of respondents. TABLE 4 also shows that 64% of NH respondents were also D-H System employees. TABLE 4. D-H System Employee Participation

Bed Con DHMC Kee Man Nash VT Other TOTALS

Dietician/Nutritionist

3

3

EMT/Paramedic

1

1

Medical Assistant

1 1

1

3

Licensed Practical Nurse 1

4 1 1 3

10

Nurse Practitioner

18 1 1

1

21


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Bed Con DHMC Kee Man Nash VT Other TOTALS

Nurse (RN, BSN) 1 4 103 12 3 4 2 1 130

Nursing Assistant

7

7

Physician 1 1 55 4 8 5 5 4 83

Physician Assistant

5 1 2

8

Psychologist/Counselor

4

1 1

6

Therapist (e.g., physical, occupational)

11

11

Admin./Manager/Exec./Director

3

1 2

6

Other (e.g., pharmacist, social worker)

24

3

27

TOTALS 3 5 238 21 16 18 10 5 316 Key: Empty cells = 0

Priority Rankings: All Respondents. APPENDIX D shows how all respondents ranked priorities for the 80 opportunities to improve patient care. Of the items ranked in the top ten, two address relations between disciplines and professions: 1) Improving interdisciplinary communication between team members (the top-ranked item), and 2) Increasing interprofessional cooperation and collaboration. Communication and coordination between and within health care organizations was the focus of one items: Improving coordination of care between hospitals/networks/providers. Two involved what might be called the therapeutic relationship with patients: 1) Taking a more patient-centered approach to care, and 2) Involving patients in the decision-making process. Two items involve the care of patients who transition from the hospital setting: 1) Improving care transitions from inpatient to outpatient, and 2) Improving follow-up on patients discharged from the hospital. Systems issues were prominent in two items: 1) Reducing medication errors, and 2) Making more efficient use of the electronic health record (EHR). The final two items concerned specific clinical issues growing out of two major trends: 1) Improving care for elderly and frail patients, and 2) Applying best practice guidelines for use of opioids in pain management.

Priority Rankings: All Respondents by Geographic Region. As shown in APPENDIX E, there were some significant differences among the top ten issues when data were analyzed by geographic region. Items afforded a much higher priority in New Hampshire were: 1) Making more efficient use of the EHR, 2) Applying best practice guidelines for use of opioids in pain management, 3) Taking a more patient-centered approach to care, and 4) Having discussions with patients with cancer about what quality of life means to them. Conversely, there were several items in the top ten for MA-ME-NY-VT that did not make the New Hampshire top ten and whose rankings were remarkably lower for New Hampshire. These are shown in TABLE 5. TABLE 5. Significantly Different Rankings: MA-ME-NY-VT vs. NH

MA-ME-NY-VT

Rank NH

Rank Taking a team approach to identify and deliver preventive health care services. 4 22 Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and 5 54


10

MA-ME-NY-VT

Rank NH

Rank reasons to choose these meds.

Reducing the number of patients who receive futile care. 6 45 Using evidence-based materials to help providers and patients with shared decision-making. 7 35 Supporting lifestyle modifications to improve diet, exercise, and weight loss. 9 32

Priority Rankings: Physicians. In the total group of respondents, physicians represented 159 of 655 (24%). One hundred and fourteen physician respondents were from New Hampshire (72%), and 45 were from MA-ME-NY-VT (28%). All D-H sites had representation, while DHMC had the largest number of respondents at 55 of 83 (66%). TABLE 6. Number of D-H Physicians Who Submitted Q2 Responses by D-H Location

Bed Con DHMC Kee Man Nash B-VT Other Total

Physician 1 1 55 4 8 5 5 4 83 Bearing in mind that D-H System physicians represented over half of all 159 physician respondents (52%), there were some noteworthy divergences and convergences between all physicians, D-H System physicians, and DHMC physicians beginning with the degree of consensus around the priority assigned to “Improving care transitions from inpatient to outpatient” (see APPENDIX F). This item was the first priority for all three groups. Four other items also appeared in the top ten across all three groups (see TABLE 7); those additional four items were:

Improving coordination of care between hospitals/networks/providers.

Making more efficient use of the EHR.

Applying best practice guidelines for use of opioids in pain management.

Improving communication with families about what is occurring with their loved ones. TABLE 7. Overlapping Rankings Compared to All Physicians’ Top Ten (green cells indicate 1 to 10 rankings)

ALL PHYSICIANS D-H SYSTEM PHYSICIANS DHMC PHYSICIANS

N Mean SD Rank N Mean SD Rank N Mean SD Rank

Improving care transitions from inpatient to outpatient. 37 3.27 0.77 1 19 3.42 0.61 1 12 3.42 0.67 1 Making more efficient use of the EHR. 44 3.14 0.95 2 28 3.11 1.07 5 18 2.94 1.06 10 Reducing medication errors. 39 3.03 1.01 3 20 3.1 0.97 6 14 2.86 1.03 13 Improving coordination of care between hospitals/ networks/providers. 35 3 0.87 4 15 3.2 0.77 2 12 3.42 0.67 1


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Having discussions with patients with cancer about what quality of life means to them. 28 3 0.98 5 15 3 1.07 11 11 3 1.1 9 Supporting lifestyle modifications to improve diet, exercise, and weight loss. 42 2.98 1 6 22 2.73 1.12 28 14 2.57 1.28 41 Improving communication with families about what is occurring with their loved ones. 35 2.97 0.95 7 19 3.05 1.08 9 13 3.15 1.07 4 Applying best practice guidelines for use of opioids in pain management. 35 2.89 0.9 8 13 3.08 0.95 8 12 3 0.95 6 Reducing the number of patients who receive futile care. 46 2.89 1.04 9 22 2.91 1.15 12 15 3 1.07 8 Using evidence-based materials to help providers and patients with shared decision-making. 42 2.86 0.98 10 22 2.68 0.99 35 15 2.67 1.05 30 One of the most valuable comparisons is the priority rankings for D-H System physicians compared to all physicians. TABLE 8 below suggests a strong need for more patient-centered care, interdisciplinary and interprofessional training and communication, as well as QI and system changes. TABLE 8. Top Ten Priority Rankings: D-H System Physicians vs. All Physicians

D-H System Physicians All Physicians

1 Improving care transitions from inpatient to outpatient.

Improving care transitions from inpatient to outpatient.

2 Improving coordination of care between hospitals/ networks/providers. Making more efficient use of the EHR.

3 Improving care for elderly and frail patients. Reducing medication errors.

4 Treating patients who have both chronic medical needs and psychiatric issues.

Improving coordination of care between hospitals/ networks/providers.

5 Making more efficient use of the EHR. Having discussions with patients with cancer about what quality of life means to them.

6 Reducing medication errors. Supporting lifestyle modifications to improve diet, exercise, and weight loss.

7 Improving patient education regarding opiates. Improving communication with families about what is occurring with their loved ones.


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All three groups (all physicians, D-H System physicians, and DHMC physicians) gave highest priority to “Improving care transitions from inpatient to outpatient.” D-H System and DHMC physicians also cited:

Improving coordination of care between hospitals/networks/providers (2, 1).

Treating patients who have both chronic medical needs and psychiatric issues (4, 3).

Making more efficient use of the EHR (5, 10).

Improving patient education regarding opiates (7, 7).

Applying best practice guidelines for use of opioids in pain management (8, 6).

Improving communication with families about what is occurring with their loved ones (9, 4). Items that D-H System physicians placed in the top ten but did not appear in the top ten for all physicians are shown in TABLE 9. Of these, only the ranking for “Improving care for elderly and frail patients” was substantially different. TABLE 9. Top Rankings for D-H System Physicians that were not Top Rankings for All Physicians

D-H System Physicians Ranking

All Physicians Ranking

Improving care for elderly and frail patients 3 19 Treating patients who have both chronic medical needs and psychiatric issues 4 12

Improving patient education regarding opiates 7 11

Taking a more patient-centered approach to care 10 13

Please see the appendices for physician rankings by geography and affiliation, including responses for all 80 opportunities. Priority Rankings: Nurses. The sample of frontline clinicians asked to respond to Q2 included 1,700 nurses (RNs, BSNs), 310 nurse practitioners, 140 licensed practical nurses, and 75 nursing assistants. Of those in the sample, 1,530 were from New Hampshire (see TABLE 10).

D-H System Physicians All Physicians

8 Applying best practice guidelines for use of opioids in pain management.


9 Improving communication with families about what is occurring with their loved ones.

Reducing the number of patients who receive futile care.

10 Taking a more patient-centered approach to care. Using evidence-based materials to help providers and patients with shared decision-making.


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TABLE 10. Number of Nursing Professionals in Q2 Sample

NH MA-ME-NY-VT Combined

Nurse (RN, BSN) 1150 550 1700

Nurse Practitioner 200 110 310

Licensed Practical Nurse 115 25 140

Nursing Assistant 65 10 75

TOTALS 1,530 695 2,225 The total number of nursing professionals who submitted Q2 was 332 (see TABLE 11). Of the 332, 253 (76%) nurses were from New Hampshire (see TABLE 11). TABLE 11. Number of Nursing Professionals Who Submitted Q2 Responses by Geographic Area

NH MA-ME-NY-VT Total

Nurse (RN, BSN) 195 65 260

Nurse Practitioner 39 13 52

Licensed Practical Nurse 12 1 13

Nursing Assistant 7 0 7

TOTALS 253 79 332

In all, 298 D-H System nursing professionals responded to Q2, and of that number, 235 were from DHMC, 26 were from D-H Keene, and 11 from D-H Nashua. The 26 remaining nursing professionals came from other D-H sites; these sites each accounted for eight or fewer respondents. Of the 235 nursing professionals who responded from DHMC, 107 were nurses (RNs, BSNs), 103 were licensed practical nurses, 18 were nurse practitioners, and seven were nursing assistants (see TABLE 12). TABLE 12. Number of D-H Nursing Professionals Who Submitted Q2 Responses by D-H Location

Bed Con DHMC Kee Man Nash B-VT Other Total

Nurse (RN, BSN) 2 4 107 13 4 7 2 1 140

Nurse Practitioner - - 18 1 1 - 1 - 21 Licensed Practical Nurse 1 4 103 12 3 4 2 1 130

Nursing Assistant - - 7 - - - - - 7

TOTALS 3 8 235 26 8 11 5 2 298

A comparison of all nurses, D-H System nurses, and DHMC nurses indicates relational similarities in rankings among categories. All three groups ranked “Improving interdisciplinary communication between team members” first, second, or third. D-H System nurses and DHMC nurses ranked “Doing a better job


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of preventing infections” first. “Improving communication with families about what is occurring with their loved ones” was ranked highly by each of these three groups (see TABLE 13). TABLE 13. Overlapping Rankings Compared to All Nurses’ Top Ten (green cells indicate 1 to 10 rankings)

ALL NURSES D-H SYSTEM NURSES DHMC NURSES

N Mean SD Rank N Mean SD Rank N Mean SD Rank Improving interdisciplinary communication between team members. 70 3.43 0.79 1 38 3.39 0.86 2 27 3.41 0.89 3 Improving follow-up on patients discharged from the hospital. 55 3.35 0.82 2 29 3.38 0.86 5 20 3.25 0.97 10 Involving patients more in the decision-making process. 57 3.25 0.81 3 28 3.25 0.75 10 22 3.27 0.77 8 Doing a better job of preventing infections. 56 3.25 0.84 4 32 3.47 0.67 1 22 3.45 0.67 1 Improving communication with families about what is occurring with their loved ones. 68 3.25 0.87 5 32 3.38 0.79 3 28 3.36 0.83 4 Improving transitions to home and community services. 53 3.21 0.88 6 24 3.25 0.85 11 21 3.24 0.89 12 Taking a more patient-centered approach to care. 64 3.2 0.86 7 33 3.15 0.94 15 24 3.04 1.04 23 Improving care transitions from inpatient to outpatient. 60 3.18 0.79 8 31 3.19 0.91 14 26 3.19 0.9 14 Improving coordination of care and transfer of information across organizations and care settings. 64 3.13 0.9 9 26 3.38 0.8 4 22 3.32 0.84 5 Increasing interprofessional cooperation and collaboration 66 3.11 0.84 10 32 3.28 0.89 7 26 3.23 0.91 13

Priority Rankings: Physicians vs. Nurses. The top rankings for nurses and physicians differed. For example, while all physicians ranked “Improving care transitions from inpatient to outpatient” as their top opportunity, all nurses ranked it eighth (see TABLE 14 on the next page).


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TABLE 14. Top Ten Priority Rankings for All Physicians vs. All Nurses All Physicians All Nurses

1 Improving care transitions from inpatient to outpatient.

Improving interdisciplinary communication between team members.

2 Making more efficient use of the EHR. Improving follow-up on patients discharged from the hospital.

3 Reducing medication errors. Involving patients more in the decision-making process.

4 Improving coordination of care between hospitals/ networks/providers. Doing a better job of preventing infections.

5 Having discussions with patients with cancer about what quality of life means to them.

Improving communication with families about what is occurring with their loved ones.

6 Supporting lifestyle modifications to improve diet, exercise, and weight loss.

Improving transitions to home and community services.

7 Improving communication with families about what is occurring with their loved ones. Taking a more patient-centered approach to care.



9 Reducing the number of patients who receive futile care.

Improving coordination of care and transfer of information across organizations and care settings.

10 Using evidence-based materials to help providers and patients with shared decision-making.

Increasing interprofessional cooperation and collaboration

Priority Rankings: D-H Physicians, Nurse Practitioners, and Nurses. Bearing in mind that nurses made up the largest proportion of survey respondents, the top opportunity for D-H physicians, nurse practitioners, and nurses combined was “Reducing medication errors.” Second was “Improving care transitions from inpatient to outpatient.” Please refer to TABLE 15 below for the top ten rankings for D-H clinicians combined and to APPENDIX G for all 80 rankings. TABLE 15. Top Ten Priority Rankings for D-H Combined (D-H Physicians, D-H Nurse Practitioners,

D-H Nurses)

D-H COMBINED

Total N Averaged

Mean Averaged

SD Combined

Rank Reducing medication errors. 54 3.37 0.75 1 Improving care transitions from inpatient to outpatient. 55 3.34 0.69 2 Having discussions with patients with cancer about what quality of life means to them. 50 3.33 0.95 3 Applying best practice guidelines for use of opioids in pain management. 51 3.28 0.95 4

Making more efficient use of the EHR. 54 3.19 0.84 5


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D-H COMBINED

Total N Averaged

Mean Averaged

SD Combined

Rank Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations). 33 3.18 0.93 6 Improving follow-up on patients discharged from the hospital. 58 3.16 0.79 7 Taking a more patient-centered approach to care. 60 3.15 0.99 8 Improving interdisciplinary communication between team members. 66 3.14 0.84 9 Improving coordination of care between hospitals/networks/ providers. 52 3.09 0.84 10 There were only two items that were among the top ten for D-H physicians, nurse practitioners, and nurses:

Reducing medication errors.

Applying best practice guidelines for use of opioids in pain management. All top ten items for both D-H physicians and D-H nurses appear below (see TABLE 16). TABLE 16. Top Ten Priority Rankings for D-H Physicians vs. D-H Nurses

D-H Physicians D-H Nurses

1 Improving care transitions from inpatient to outpatient. Doing a better job of preventing infections.

2 Improving coordination of care between hospitals/ networks/providers.

Improving interdisciplinary communication between team members.

3 Improving care for elderly and frail patients. Improving communication with families about what is occurring with their loved ones.

4 Treating patients who have both chronic medical needs and psychiatric issues.

Improving coordination of care and transfer of information across organizations and care settings.

5 Making more efficient use of the EHR. Improving follow-up on patients discharged from the hospital.

6 Reducing medication errors. Reducing medication errors.

7 Improving patient education regarding opiates. Increasing interprofessional cooperation and collaboration


Identifying and mitigating patient safety risks in the primary care setting.

9 Improving communication with families about what is occurring with their loved ones.


10 Taking a more patient-centered approach to care. Involving patients more in the decision-making process.


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The items that were among the top ten priorities for D-H nurses compared to D-H nurse practitioners and D-H physicians are shown in TABLE 17. TABLE 17. Top Ten Priority Rankings for D-H Nurses, but not for D-H Nurse Practitioners* or D-H Physicians

Ranking

D-H Nurses D-H Nurse

Practitioners D-H

Physicians

Doing a better job of preventing infections. 1 58 58 Improving interdisciplinary communication between team members. 2 13 15 Improving coordination of care and transfer of information across organizations and care settings. 4 35 20 Improving follow-up on patients discharged from the hospital. 5 8* 35

Increasing interprofessional cooperation and collaboration. 7 23 44 Identifying and mitigating patient safety risks in the primary care setting. 8 5* 60

Involving patients more in the decision-making process. 10 15 48 *There are two exceptions. Items ranked in the top ten by both D-H nurse practitioners and D-H physicians were:

Reducing medication errors. Making more efficient use of the EHR.



Further priority rankings for all nurses, D-H System nurses, and DHMC nurses can be found in APPENDIX H. Priority rankings for all nurse practitioners, D-H System nurse practitioners, and DHMC nurse practitioners can be found in APPENDIX I. III. USE OF SOCIAL MEDIA AND INFORMATION TECHNOLOGY In addition to answering Q2 survey questions about their educational needs, frontline clinicians were asked to respond to questions about information technology and social media. APPENDIX J presents the results of Q2’s social media questions. Most commonly used media were email, video websites (e.g., YouTube), PowerPoint websites (e.g., SlideShare), and podcasts. Technology preferences are shown in APPENDIX K. In terms of current use for CE, computers were highest, followed by tablets (e.g., Nook or iPad), and smartphones. Interestingly, there was a significant gap between current social media and technology use and preferred use. Respondents reported that they preferred to use nearly all social media and technologies at rates that were lower than their current usage (the lone exception was for the mini-tablet technology platform).


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IV. CONCLUSIONS AND RECOMMENDATIONS A. Limitations Understanding and interpreting the survey findings requires an awareness of the limitations and strengths of the methodology used. The reader is encouraged to keep the following in mind:

The sample and the respondents were heavily weighted toward health care providers in New Hampshire.

The sample excluded potential respondents who had not previously taken part in CLPD educational programs.

As anticipated with an online survey, the response rate was relatively low making it difficult to generalize to a broader population.

B. Importance of Perspective for Report Usage

Many stakeholders, each with different perspectives, will benefit from the information generated by this survey. Key beneficiaries will be those individuals responsible for designing CE activities, leadership trainings, and professional development programs, and those responsible for assessing these programs’ effectiveness in improving competence, performance, and patient outcomes.

C. Clinical Education

The opportunities for improving patient care reported here are from the points of view of individual clinicians on the frontlines of patient care. These clinicians are telling clinical and operational leaders that they see opportunities for targeted education to address coordination of care, care transitions, communication, patient education, and applications of guidelines. These personal and team needs validate some clinical and operational improvement projects already underway at D-H and regional sites. Importantly, the survey results also demonstrate a demand for more – not fewer – educational interventions to improve clinical care and practice culture. Leaders should carefully determine what specific, practical opportunities exist to embed focused activities in existing educational venues (e.g., Regularly Scheduled Series). All planning for existing educational series should include attention to the topics identified through this survey. Accreditation applications should require explanations about how a series will address clinicians’ needs as identified through this survey. Additionally, all planning for new live, hybrid, or online activities should address the topics identified by clinicians through this survey. The survey findings should be disseminated widely to assist faculty activity directors and nurse planners in incorporating these opportunity topics. Creative, innovative methods should be encouraged, including, for example, developing online case scenarios that intentionally incorporate learning about two or three opportunity topics. Importantly, any clinical learning activity has the potential for robust outcome measures informed by EHR data before, during, and after the educational interventions. D. Leadership Training With rapid, complicated changes in health care practice, delivery, and reimbursement, leadership training has never been more necessary. Twenty health care leaders – institutional and regional – informed the opportunity topics in Q2 based on their real-life management and clinical challenges. The respondents rated those suggestions based on their lived experiences. The respondents are calling for educational


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interventions about such topics as “Understanding the basics of quality and patient safety in health care,” “Improving team leadership/participation skills,” and “Using community health care resources.” They are particularly interested in “Improving communication between patients and providers, team members, hospitals, networks, and communities.” These findings align with the Accreditation Council for Graduate Medical Education (ACGME) Competencies,3 and Interprofessional Education Collaborative (IPEC) Competencies.4 Planners can use these data to align with the competencies and to customize leadership programs to address complex challenges in the cultures of medicine, nursing, interprofessional practice, and allied health.

E. Professional Development Human resources (HR) leaders responsible for developing the skills of the workforce and providing both training programs and resources will bring a unique perspective to these findings. The data provide information on over 14 categories of employees in the D-H System. All D-H sites are represented. In association with the 2014 Engagement Survey findings, these data will help HR leaders make decisions about where to invest resources, what departments to align or partner with for wider impact, what in-house and external content expertise is needed, and on what employee categories to focus attention. Ultimately, the data may help HR leaders decide where not to focus attention and resources, as well as how best to measure both outcomes and institutional return on investment.

F. Building Strategic Continuing Education Alliances D-H has the benefit of having CME and CNE programs that are closely aligned in an interprofessional CE center with associations to the Chief Clinical, Chief Medical, and Chief Nursing Officers, as well as the Director of Graduate Medical Education and Dean of the Geisel School of Medicine of Dartmouth. Strengthening all of these associations and building strategic CE alliances with D-H Quality and Value, D-H Human Resources, Dartmouth College, The Dartmouth Institute, and the Tuck School of Business are required to address the challenging topics identified in this survey of frontline health care leaders and clinicians. These alliances are being forged by CLPD faculty with other faculty and educators, and should be strengthened. In addition, structural changes in departments, divisions, and practices can take place to facilitate alliances and partnerships. Department center and community group practice directors could appoint a Vice Chair/Director of Education as well as a Vice Chair/Director of Quality to work in collaboration with CLPD faculty and directors, members of the CME Advisory Committee, and the Nursing Continuing Education Council to improve existing educational series and prioritize live, hybrid, or online education interventions. Such strategic alliances and improvements will help with accreditation renewals, Magnet status, and recruitment of new employees and students.

G. Education Programming The results of this needs assessment survey suggest very specific areas in which educational programming might be both needed and welcomed by participants in CE activities. For example, among all physician respondents, the use and management of opioids appears to be of importance, especially as it relates to applying best practices for use of opioids for pain management and improving patient education about opioid use. However, as this example demonstrates, some additional data gathering may be needed to plan a well-targeted educational intervention. In these physicians’ practices, who has responsibility for patient education on opioids? What resources, if any, do physicians already have for this task? To what extent is health literacy a factor?


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While this study suggests areas of educational need tied to health care providers’ perceptions of opportunities to improve care, its results should be seen as but one input into the process by which educational programming decisions are made (see FIGURE 2). Other sources of information, both formal and informal, should receive attention as a way to both supplement and interpret our results. For example, not all educational activities need to be, nor should be, problem- or learner-driven. There was no mention in our results of an update on the latest results from clinical studies on asthma management or the contents of a newly-released tobacco cessation guideline, but both might be highly desirable in certain circumstances. FIGURE 2. Inputs into Educational Programming Decisions

H. Audience Segmentation and Marketing Our data suggest that an educational program aimed at “Improving communication with families about what is happening with their loved ones” would have broad appeal to D-H physicians and nurses. However, understanding what palliative care can offer patients and deciding then to involve palliative care was a top priority only for D-H nurses. Information such as this can inform decisions about the needs of subgroups within the target learner population. Areas of common interest across professions can be seen as fertile ground for IPE as well.

I. Alignment of Education and Quality Few, if any, of the opportunity issues are exclusively educational issues. For example, “Improving care transitions from inpatient to outpatient” is a challenge that likely involves matters of staffing, reimbursement, information technology, as well as education. Further investigation is needed to better understand the nature of the problem and to determine how education can be used as part of a multi-faceted intervention to impact change.

Educational/ Organizational Development

Scientific Evidence

Tailored Needs

Assessment

"Lessons Learned"

Expert Opinion

Successful Models

Mandates, Political Realities

Adult Education Principles


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The example of “Inpatient to outpatient transitions” illustrates another implication: the need for coordination and integration of the CE function with the strategic priorities and operations of health care organizations. Our results can be seen as the basis for discussions among leaders, clinicians, and educationalists about how best to align educational resources with other efforts to improve the quality of patient care.

J. Further Analyses of the Survey Data In compiling this report we were able to include only some of the many possible analyses of the rich data we collected. An opportunity exists to conduct queries of the data tailored to fit the specific needs of decision-makers.

K. Survey Burden The principal investigator on this study (CO) recently wrote an editorial on the topic of survey burden on health care providers and its association with decreasing response rates (available upon request from the author).5 In it he argued that over-surveying health care professionals is rampant and places at risk our long-term ability to collect valuable information. This problem has been exacerbated by surveys that are indiscriminately sent out to an entire population instead of a sample of that population. Combining an evidence-based, systematic approach to the design and implementation of an online survey with a sampling strategy can help increase response rates, but may not be sufficient to produce a desired response rate given the survey burden on the overall target audience. Adding phone or postal mail surveys could produce higher response rates, but only at greatly increased expense. This is a serious issue that deserves the attention of leaders and investigators alike.


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REFERENCES

1. Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282(9):867-74.

2. Dillman DA, Smyth JD, Christian LM. Internet, Mail, and Mixed-Mode Surveys: The Tailored

Design Method. 3rd ed. Hoboken (NJ): Wiley; 2008.

3. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007;29(7):648-54.

4. Interprofessional Education Collaborative. Core competencies for interprofessional collaborative

practice. http://www.aacn.nche.edu/education-resources/ipecreport.pdf. Accessed September 18, 2014.

5. Olson CA. Survey burden, response rates, and the tragedy of the commons. J Contin Educ Health

Prof. 2014;34(2):93-5.


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APPENDICES APPENDIX A. Methodology Survey Population. The survey population comprised of health care professionals (i.e., physicians, nurses, medical assistants, pharmacists, psychologists/counselors, therapists, dieticians, EMTs/paramedics, health care organization leaders, and others) in northern New England. Resident physicians were included because, although they are not traditionally part of the primary target audience for CE programming, they have unique and important knowledge about opportunities to improve patient care, especially in the hospital setting. Sampling Frame. Most potential survey respondents were drawn from a CLPD database containing more than 33,000 unique individuals who had taken part in at least one educational activity certified for CME/CNE credit by CLPD (as noted below, some survey recipients in Q1 were purposefully selected by the investigators). This list was used due to availability and the expectation that a previous interaction between CLPD and potential respondents would help to increase the response rate. We also considered it sufficient for the purposes of a pilot study. However, the CLPD list had significant limitations. The ideal list would have included all health care professionals currently practicing in northern New England and provided complete and current demographic and contact information for each person. The CLPD list lacked this degree of comprehensiveness and completeness (see APPENDICES M and N). Given the limitations of the CLPD list used in this study, the scope of this study should be understood as health professionals currently

practicing in northern New England who have participated in at least one educational activity offered by

CLPD. The results reflect the perspectives of this subset of the larger health care professional population in the region. Q1 Methodology. Q1 comprised several open- and close-ended questions and demographic items (see APPENDIX O) and was administered to potential respondents recruited from two pools: 1) organizational leaders who were nominated by other leaders or whose names were obtained from publicly available lists, and 2) a random, stratified sample of persons drawn from the CLPD list. The goal of Q1 was to compile a list of clinical/patient care issues and needs at the individual, team, practice, and organizational levels. To qualify for the survey, recipients had to affirm that they were either a health care professional, directly involved in patient care, currently practicing, and between the ages of 25 and 75. On March 17, 2014, invitations to take part in Q1 were emailed to 424 health care organization leaders and health care professionals (see TABLE 1). Those who elected to take part were taken to an online consent form.1 The survey closed on April 10, 2014. Q2 Methodology. Q2 (APPENDIX P) asked respondents to rate the 80 opportunities to improve patient care derived from the responses received in Q1, as well as indicate use and preferred use for information technologies and social media for CE. We concluded that asking respondents to rate 80 opportunities would impose an unacceptably high response burden (and thereby reduce the response rate) and elected instead to present each respondent with a randomly selected subset of 20 opportunities. The size of the sample was increased to compensate. Ratings were obtained using a Likert-type scale: not a priority, low priority, medium priority, high priority, essential. 1 This study was reviewed and considered exempt by the Dartmouth College Committee for the Protection of Human Subjects.


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An invitation to complete Q2 was emailed to a stratified, random sample (N=4,160) drawn from the CLPD database (APPENDIX Q). Stratification was at the level of occupation and state, and was designed to ensure that the sample reflected the composition of the survey frame. The survey was opened on May 23, 2014 and closed on June 3, 2014. Survey data were exported into an Excel spreadsheet for inspection and cleaning, and were then brought into Stata 13 to produce descriptive statistics and crosstabulations.


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APPENDIX B. Analysis of Q1 Responses and Examples

Category Example Survey Response

# Responses

Coded

Access to Care Improving access to specialty services and ensuring bed availability. 34

Administration/Management Information on Accountable Care Organizations and opportunities for QI in that payment system. 5

Antibiotic Use/Infection Control Avoidance of antibiotic use during viral bronchitis. 3

Awareness of Resources Better knowledge of resources and how we can better work together. 2

Inter-organizational Communication/Collaboration

Better "regionalization;” better communication/collaboration with our academic affiliates. 7

Communication Better communication of completed studies for patients sent for specialty care. 30

Community Outreach Linkages Offer community education programs regarding common illnesses, especially focusing on what the patient can do prevention-wise. 41

Consultation/Referral Deciding when to bring in palliative care. 4

Coordination of Care Care coordination that addresses gaps in care and ensures clinical information is accurately handed off and shared with patients. 23

Cost of Care Giving financial information regarding testing and treatment to patients; allowing time to discuss and share in the decision. 2

End-of-Life Care and Planning How to integrate advance care planning into a busy clinical practice. 26

Geriatric/Elder Care As the population ages, we need to be able to deal better with dementia and other afflictions of old age. 12

Immunizations Heavily promoting vaccinations in children and adults. 3

Interprofessional Collaboration More effective integration of pharmacy and nursing into patient care plans. 13

Management of Chronic Illness Integrate community health teams to assist with chronic disease management in an effort to prevent reoccurrences. 3

Mental/Behavioral Health Improved screening of mental health issues at the primary care level and appropriate referrals instead of just prescriptions. 25

Pain Management/Opioids Improving early intervention for opiate usage/addiction. 17 Patient Education/Counseling/ Coaching Better education of patients as to when to seek health care services. 37

Policies/Guidelines Increasing funding for preventative care, mental health, and geriatric care. 61

Prevention/Wellness How to combat obesity in the teenager. 15 Creating/Expanding Health Care Services

Providing low cost health care assessments outside of the hospital institution. 18

Safety/QI Understanding patient safety issues in the ambulatory setting and developing more robust ways to prevent and mitigate those risks. 8

Screening

Screening patients more thoroughly for mental conditions, such as depression and anxiety and treating them with the appropriate medication or resources. 12

Shared Decision-making/Family Engagement

How to integrate shared decision-making for controversial preventive screening into busy clinical practice. 14

Systems Implementing two-way sharing of clinical information to enable providers to better coordinate care for patients. 32

Diagnostic Testing Ensuring the correct tests are ordered for the correct patient population. 7


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Transitions of Care Improvement in transition to home and to community services to help reduce readmissions and make discharge to home successful. 8

Treatment Develop more consistent, evidence-based strategies to treat neonates with Neonatal Abstinence Syndrome. 8


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APPENDIX C. 80 Opportunities to Improve Patient Care Used in Q2 ID # Opportunities/Survey Items

1 Improving communication between providers in the community (such as PCPs, therapists, housing managers). 2 Improving interdisciplinary communication between team members. 3 Improving communication of results of completed studies for patients sent to specialty care. 4 Improving communication with families about what is occurring with their loved ones. 5 Delivering bad news to patients and families. 6 Engaging with community groups to promote healthy behaviors. 7 Using community health care resources to improve chronic disease management. 8 Working better with community resources. 9 Improving coordination of care between hospitals/networks/providers. 10 Improving coordination of care and transfer of information across organizations and care settings. 11 Improving coordination with home health and other community resources involved in transitions of care. 12 Giving patients cost information regarding testing and treatment to help in decision-making. 13 Communicating more effectively with "difficult patients." 14 Reading and critiquing the scientific literature. 15 Improving screening, evaluation, and management of older patients with memory problems. 16 Improving care for elderly and frail patients. 17 Understanding what palliative care can offer patients and when to involve. 18 Integrating advanced care planning into a busy practice.

19 Preparing patients and families in the primary care setting for decisions around end-of-life care in advance of terminal illness.

20 Reducing the number of patients who receive futile care. 21 Reducing medication errors. 22 Using technology for more efficient routine follow-up and appointment reminders. 23 Following-up on patients who have not had a primary care provider visit for an extended period. 24 Improving follow-up on patients discharged from the hospital. 25 Increasing immunization rates for children. 26 Increasing interprofessional cooperation and collaboration 27 Achieving better integration of pharmacy and nursing into patient care plans. 28 Taking a team approach to identify and deliver preventive health care services. 29 Integrating mental health care into care plans 30 Addressing the needs of patients/families with low health literacy. 31 Improving screening for and treatment of mental conditions (e.g., depression, anxiety). 32 Treating patients who have both chronic medical needs and psychiatric issues. 33 Making better use of mental health referrals to reduce reliance on prescriptions. 34 Treating neonates with Neonatal Abstinence Syndrome. 35 Preventing and treating obesity.

36 Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations).

37 Managing patients suspected of opioid abuse. 38 Improving patient education regarding opiates. 39 Making better use of pain services.


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40 Coordinating appointments, diagnostic testing, and follow-up visits to reduce burden on patients. 41 Having discussions with patients with cancer about what quality of life means to them. 42 Integrating patient navigators into the work of the team.

43 Helping patients who now have access to a primary care practice due to ACA, but don't know how to take advantage of it.

44 Identifying and mitigating patient safety risks in the primary care setting. 45 Improving staff safety. 46 Managing multiple screening guidelines in a busy practice. 47 Improving cancer screening via mammography, Pap smears, and colonoscopy. 48 Integrating shared decision-making for preventive screening in a busy clinical practice. 49 Educating the community about shared decision-making. 50 Ensuring that patients and families faced with "palliative" or emergency operations have more realistic expectations. 51 Providing more support for shared decision-making for patients facing difficult medical decisions. 52 Involving patients more in the decision-making process. 53 Taking a more patient-centered approach to care. 54 Using evidence-based materials to help providers and patients with shared decision-making. 55 Improving STD counseling, screening, testing, and treatment. 56 Improving men's reproductive health screening. 57 Developing a system of care for traumatic brain injuries (brain injury specialists, PCPs, schools, hospitals, etc.). 58 Making more efficient use of the EHR. 59 Reducing the number of inappropriate or unnecessary lab tests. 60 Improving the interpretation and use of laboratory test results. 61 Improving care transitions from inpatient to outpatient. 62 Improving transitions to home and community services. 63 Improving hand-offs. 64 Reducing the number of "nuisance patient visits." 65 Educating patients about when to seek health care services. 66 Doing comprehensive well woman exams. 67 Doing a better job of preventing infections. 68 Saying no to requests for antimicrobials for viral infections. 69 Choosing antimicrobials more judiciously. 70 Supporting lifestyle modifications to improve diet, exercise, and weight loss. 71 Increasing immunization rates for adults. 72 Increasing interprofessional cooperation during patient rounds 73 Applying best practice guidelines for use of opioids in pain management. 74 Using non-opiate pain relief options 75 Understanding the health care and human services resources available in the community.

76 Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and reasons to choose these meds.

77 Understanding opportunities for quality improvement in the Accountable Care Organization payment system. 78 Understanding the basics of quality and patient safety in health care. 79 Improving your team leadership/participation skills. 80 Understanding who is not seeking health care, why, and what can be done about it.


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APPENDIX D. Rankings: All Respondents ID # Opportunities/Survey Items Ranking N Mean

2 Improving interdisciplinary communication between team members 1 165 3.21 61 Improving care transitions from inpatient to outpatient. 2 149 3.17 21 Reducing medication errors. 3 144 3.15 53 Taking a more patient-centered approach to care. 4 159 3.14 24 Improving follow-up on patients discharged from the hospital. 5 142 3.13 52 Involving patients more in the decision-making process. 6 161 3.07

9 Improving coordination of care between hospitals/networks/providers. 6 158 3.07

16 Improving care for elderly and frail patients. 8 150 3.05 26 Increasing interprofessional cooperation and collaboration 9 167 3.04

73 Applying best practice guidelines for use of opioids in pain management. 10 143 3.03

58 Making more efficient use of the EHR. 10 148 3.03

41 Having discussions with patients with cancer about what quality of life means to them. 12 126 3.02

10 Improving coordination of care and transfer of information across organizations and care settings. 12 160 3.02

4 Improving communication with families about what is occurring with their loved ones. 14 156 2.99

62 Improving transitions to home and community services. 15 143 2.97

28 Taking a team approach to identify and deliver preventive health care services. 16 153 2.96

70 Supporting lifestyle modifications to improve diet, exercise, and weight loss. 17 152 2.95

67 Doing a better job of preventing infections. 18 145 2.94

32 Treating patients who have both chronic medical needs and psychiatric issues. 18 157 2.94

11 Improving coordination with home health and other community resources involved in transitions of care. 20 148 2.93

50 Ensuring that patients and families faced with "palliative" or emergency operations have more realistic expectations. 21 140 2.92

54 Using evidence-based materials to help providers and patients with shared decision-making. 21 161 2.92

29 Integrating mental health care into care plans. 23 163 2.91

78 Understanding the basics of quality and patient safety in health care. 24 156 2.90

40 Coordinating appointments, diagnostic testing, and follow up visits to reduce burden on patients 24 145 2.90

72 Increasing interprofessional cooperation during patient rounds. 24 138 2.90

31 Improving screening for and treatment of mental conditions (eg, depression, anxiety). 24 144 2.90

1 Improving communication between providers in the community (such as PCPs, therapists, housing managers). 28 150 2.89

20 Reducing the number of patients who receive futile care. 28 151 2.89


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75 Understanding the health care and human services resources available in the community. 30 165 2.88

13 Communicating more effectively with "difficult patients." 30 158 2.88

44 Identifying and mitigating patient safety risks in the primary care setting. 30 140 2.88

3 Improving communication of results of completed studies for patients sent to specialty care. 33 142 2.87

30 Addressing the needs of patients/families with low health literacy. 33 155 2.87

19 Preparing patients and families in the primary care setting for decisions around end-of-life care in advance of terminal illness. 33 147 2.87

33 Making better mental health referrals to reduce reliance on prescriptions. 33 135 2.87

7 Using community health care resources to improve chronic disease management. 37 161 2.86

74 Using non-opiate pain relief options 37 133 2.86

36 Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations). 39 119 2.85

65 Educating patients about when to seek health care services. 40 156 2.83 59 Reducing the number of inappropriate or unnecessary lab tests. 41 141 2.82

51 Providing more support for shared decision-making for patients facing difficult medical decisions. 41 151 2.82

8 Working better with community resources. 43 152 2.80

17 Understanding what palliative care can offer patients and when to involve. 44 144 2.79

63 Improving hand-offs. 44 156 2.79

76

Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and reasons to choose these meds. 46 130 2.78

37 Managing patients suspected of opioid abuse. 46 133 2.78 35 Preventing and treating obesity. 48 154 2.77 79 Improving your team leadership/participation skills. 49 161 2.76 45 Improving staff safety. 50 154 2.73 6 Engaging with community groups to promote healthy behaviors. 51 154 2.72 25 Increasing immunization rates for children. 52 96 2.70 38 Improving patient education regarding opiates. 52 145 2.70 39 Make better use of pain services. 52 148 2.70 18 Integrating advanced care planning into a busy practice. 55 128 2.68 5 Delivering bad news to patients and families. 56 150 2.66 69 Choosing antimicrobials more judiciously. 57 130 2.65

12 Giving patients cost information regarding testing and treatment to help in decision-making. 58 146 2.62

15 Improving screening, evaluation, and management of older patients with memory problems. 59 129 2.60

47 Improving cancer screening via mammography, Pap smears, and colonoscopy. 59 123 2.60

23 Following-up on patients who have not had a primary care provider visit for an extended period. 61 127 2.57


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27 Achieving better integration of pharmacy and nursing into patient care plans. 62 144 2.56

68 Saying no to requests for antimicrobials for viral infections. 63 107 2.54 60 Improving the interpretation and use of laboratory test results. 63 136 2.54

43 Helping patients who now have access to a primary care practice due to ACA, but don't know how to take advantage of it. 65 136 2.51

48 Integrating shared decision-making for preventive screening in a busy clinical practice. 66 133 2.47

71 Increasing immunization rates for adults. 66 127 2.47 46 Managing multiple screening guidelines in a busy practice. 68 121 2.46

77 Understanding opportunities for quality improvement in the Accountable Care Organization payment system. 69 138 2.45

80 Understanding who is not seeking health care, why, and what can be done about it. 69 143 2.45

66 Doing comprehensive well woman exams. 71 97 2.44 34 Treating neonates with Neonatal Abstinence Syndrome. 72 69 2.38

57 Developing a system of care for traumatic brain injuries (brain injury specialists, PCPs, schools, hospitals, etc.). 73 129 2.37

14 Reading and critiquing the scientific literature. 74 145 2.36

22 Using technology for more efficient routine follow-up and appointment reminders. 74 145 2.36

49 Educating the community about shared decision-making. 76 154 2.29 42 Integrating patient navigators into the work of the team. 77 138 2.28 55 Improving STD counseling, screening, testing, and treatment. 78 127 2.25 64 Reducing the number of "nuisance patient visits." 79 142 2.06 56 Improving men's reproductive health screening. 80 95 2.02


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APPENDIX E. Rankings: All Survey Respondents by Geographic Region Note: Top ten highlighted in blue. The number of respondents in MA, ME, NY, and VT was not large enough to allow analysis by state.

ID #

Opportunities/Survey Items

NH MA-ME-NY-VT

N Mean SD Rank N Mean SD Rank

1 Improving communication between providers in the community (such as PCPs, therapists, housing managers). 110 2.88 0.99 37 43 2.98 1.01 17

2 Improving interdisciplinary communication between team members. 142 3.23 0.86 1 24 3.04 0.95 10

3 Improving communication of results of completed studies for patients sent to specialty care. 106 2.93 0.89 23 37 2.73 0.93 46

4 Improving communication with families about what is occurring with their loved ones. 120 2.98 0.94 16 36 3 1.07 15

5 Delivering bad news to patients and families. 113 2.65 0.93 57 38 2.71 1.16 49

6 Engaging with community groups to promote healthy behaviors. 117 2.78 0.86 46 38 2.53 0.76 67

7 Using community health care resources to improve chronic disease management. 114 2.9 0.91 29 48 2.75 1.04 43

8 Working better with community resources. 111 2.85 0.93 40 44 2.73 0.92 45

9 Improving coordination of care between hospitals/networks/providers. 122 3.05 0.89 11 38 3.13 0.74 3

10 Improving coordination of care and transfer of information across organizations and care settings. 116 3.03 0.88 12 45 3.02 0.81 11

11 Improving coordination with home health and other community resources involved in transitions of care. 106 2.99 0.88 14 45 2.8 0.87 38

12 Giving patients cost information regarding testing and treatment to help in decision-making. 116 2.57 1 61 31 2.81 0.79 37

13 Communicating more effectively with "difficult patients." 115 2.89 0.89 32 44 2.89 0.84 28

14 Reading and critiquing the scientific literature. 112 2.38 0.9 73 36 2.25 0.77 74

15 Improving screening, evaluation, and management of older patients with memory problems. 94 2.63 0.99 58 37 2.57 0.96 64

16 Improving care for elderly and frail patients. 115 3.01 0.88 13 36 3.19 0.71 1


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ID #


NH MA-ME-NY-VT


17 Understanding what palliative care can offer patients and when to involve. 109 2.82 1.01 43 36 2.69 1.04 52

18 Integrating advanced care planning into a busy practice. 105 2.69 0.98 53 24 2.71 1.12 48

19 Preparing patients and families in the primary care setting for decisions around end-of-life care in advance of terminal illness. 108 2.85 1.04 41 39 2.92 1.01 24

20 Reducing the number of patients who receive futile care. 104 2.81 0.99 45 48 3.08 0.96 6

21 Reducing medication errors. 103 3.21 0.97 3 43 3 0.98 14

22 Using technology for more efficient routine follow-up and appointment reminders. 112 2.31 0.96 75 33 2.52 0.87 69

23 Following-up on patients who have not had a primary care provider visit for an extended period. 97 2.56 0.88 62 31 2.58 0.96 63

24 Improving follow-up on patients discharged from the hospital. 104 3.14 0.9 6 39 3.05 0.97 8

25 Increasing immunization rates for children. 73 2.62 0.97 59 25 2.92 0.86 23

26 Increasing interprofessional cooperation and collaboration 127 3.07 0.86 9 40 2.95 0.81 20

27 Achieving better integration of pharmacy and nursing into patient care plans. 107 2.51 1 64 37 2.7 1.05 51

28 Taking a team approach to identify and deliver preventive health care services. 120 2.93 0.85 22 34 3.12 0.81 4

29 Integrating mental health care into care plans 126 2.89 0.91 34 37 2.97 0.93 19

30 Addressing the needs of patients/families with low health literacy. 114 2.92 0.78 25 42 2.76 0.93 42

31 Improving screening for and treatment of mental conditions (eg, depression, anxiety). 105 2.91 0.95 28 40 2.83 0.9 35

32 Treating patients who have both chronic medical needs and psychiatric issues. 116 2.95 0.91 18 41 2.9 0.89 27

33 Making better use of mental health referrals to reduce reliance on prescriptions. 101 2.91 0.85 27 34 2.74 0.83 44

34 Treating neonates with Neonatal Abstinence Syndrome. 51 2.47 1.06 67 18 2.11 1.08 79

35 Preventing and treating obesity. 110 2.71 0.88 50 45 2.89 1.05 30


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ID #


NH MA-ME-NY-VT


36 Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations). 86 2.87 0.92 38 33 2.79 0.99 40

37 Managing patients suspected of opioid abuse. 97 2.7 0.99 51 36 3 0.86 13

38 Improving patient education regarding opiates. 100 2.73 0.95 48 46 2.59 0.83 61

39 Making better use of pain services 115 2.71 0.85 49 34 2.68 0.88 53

40 Coordinating appointments, diagnostic testing, and follow-up visits to reduce burden on patients. 105 2.89 0.88 31 43 2.98 1.01 17

41 Having discussions with patients with cancer about what quality of life means to them. 91 3.07 0.87 10 35 2.91 0.92 26

42 Integrating patient navigators into the work of the team. 105 2.29 0.91 76 33 2.27 0.94 73

43 Helping patients who now have access to a primary care practice due to ACA, but don't know how to take advantage of it. 103 2.5 0.87 65 33 2.55 1.06 66

44 Identifying and mitigating patient safety risks in the primary care setting. 99 2.95 0.95 20 41 2.71 0.96 47

45 Improving staff safety. 116 2.7 1.04 52 40 2.88 0.97 32

46 Managing multiple screening guidelines in a busy practice. 84 2.31 0.94 74 38 2.84 0.82 33

47 Improving cancer screening via mammography, Pap smears, and colonoscopy. 89 2.61 0.9 60 34 2.59 1.13 62

48 Integrating shared decision-making for preventive screening in a busy clinical practice. 102 2.46 0.96 68 32 2.53 0.84 68

49 Educating the community about shared decision-making. 118 2.26 0.94 78 38 2.32 0.9 72

50 Ensuring that patients and families faced with "palliative" or emergency operations have more realistic expectations. 108 2.92 0.91 26 33 2.91 0.88 25

51 Providing more support for shared decision-making for patients facing difficult medical decisions. 112 2.88 0.85 36 39 2.67 0.84 54

52 Involving patients more in the decision-making process. 118 3.12 0.85 7 44 2.98 0.93 16

53 Taking a more patient-centered approach to care. 118 3.22 0.88 2 42 2.93 0.97 22

54 Using evidence-based materials to help providers and patients with shared decision-making. 126 2.89 0.97 35 37 3.08 0.98 7


35

ID #


NH MA-ME-NY-VT


55 Improving STD counseling, screening, testing, and treatment. 88 2.28 0.97 77 39 2.18 0.85 76

56 Improving men's reproductive health screening. 67 1.99 0.84 80 29 2.07 0.84 80

57 Developing a system of care for traumatic brain injuries (brain injury specialists, PCPs, schools, hospitals, etc). 86 2.43 0.91 70 44 2.25 0.89 75

58 Making more efficient use of the EHR. 114 3.16 0.86 5 36 2.61 0.9 58

59 Reducing the number of inappropriate or unnecessary lab tests. 104 2.84 0.81 42 38 2.76 0.85 41

60 Improving the interpretation and use of laboratory test results. 106 2.52 0.9 63 30 2.6 0.81 60

61 Improving care transitions from inpatient to outpatient. 115 3.19 0.79 4 36 3.17 0.81 2

62 Improving transitions to home and community services. 110 2.95 0.91 18 34 3 0.85 12

63 Improving hand-offs. 122 2.76 0.98 47 35 2.89 0.96 29

64 Reducing the number of "nuisance patient visits." 106 2 0.89 79 38 2.18 0.95 77

65 Educating patients about when to seek health care services. 119 2.86 0.88 39 38 2.79 0.78 39

66 Doing comprehensive well woman exams. 74 2.46 0.98 69 23 2.39 0.89 71

67 Doing a better job of preventing infections. 111 2.97 0.96 17 34 2.82 0.94 36

68 Saying no to requests for antimicrobials for viral infections. 102 2.93 1.01 24 38 2.84 1 34

69 Choosing antimicrobials more judiciously. 90 2.66 1.01 55 42 2.57 1.09 65

70 Supporting lifestyle modifications to improve diet, exercise, and weight loss. 109 2.89 0.89 32 45 3.04 0.9 9

71 Increasing immunization rates for adults. 89 2.47 0.98 66 38 2.47 0.92 70

72 Increasing interprofessional cooperation during patient rounds 80 2.66 1.03 56 28 2.18 1.12 78

73 Applying best practice guidelines for use of opioids in pain management. 109 3.08 0.87 8 35 2.89 1.08 31

74 Using non-opiate pain relief options 96 2.94 0.86 21 39 2.67 0.98 55

75 Understanding the health care and human services resources available in the community. 121 2.98 0.89 15 46 2.7 0.99 50


36

ID #


NH MA-ME-NY-VT


76 Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and reasons to choose these meds.

93 2.67 0.91 54 38 3.08 0.88 5

77 Understanding opportunities for quality improvement in the Accountable Care Organization payment system. 103 2.39 0.93 72 35 2.63 0.81 57

78 Understanding the basics of quality and patient safety in health care. 125 2.9 1.04 30 33 2.94 1.06 21

79 Improving your team leadership/participation skills. 126 2.81 0.92 44 36 2.64 0.96 56

80 Understanding who is not seeking health care, why, and what can be done about it. 112 2.41 0.93 71 33 2.61 0.97 59


37

APPENDIX F. Rankings: All Physicians, D-H System Physicians, and DHMC Physicians Note: Top ten ranked items highlighted in blue.

ID #




1

Improving communication between providers in the community (such as PCPs, therapists, housing managers). 39 2.28 1.05 69 25 2.24 0.97 68 17 2.06 0.9 74

2 Improving interdisciplinary communication between team members. 45 2.67 0.9 38 23 2.83 0.83 15 14 2.79 0.89 17

3 Improving communication of results of completed studies for patients sent to specialty care. 27 2.7 1.07 32 15 2.73 1.1 27 9 2.44 1.13 53

4 Improving communication with families about what is occurring with their loved ones. 35 2.97 0.95 7 19 3.05 1.08 9 13 3.15 1.07 4

5 Delivering bad news to patients and families. 34 2.41 0.92 58 16 2.44 0.73 54 11 2.55 0.69 42

6 Engaging with community groups to promote healthy behaviors. 34 2.56 0.86 45 16 2.63 0.96 39 8 2.5 0.76 44

7 Using community health care resources to improve chronic disease management. 37 2.81 1.05 17 22 2.82 1.05 16 18 2.78 1.06 20

8 Working better with community resources. 34 2.53 1.02 49 22 2.5 1.01 52 14 2.57 1.16 40

9 Improving coordination of care between hospitals/ networks/providers. 35 3 0.87 4 15 3.2 0.77 2 12 3.42 0.67 1

10 Improving coordination of care and transfer of information across organizations and care settings. 45 2.8 0.89 18 22 2.77 0.87 20 14 2.71 0.91 24

11 Improving coordination with home health and other community resources involved in transitions of care. 33 2.76 0.9 22 21 2.86 0.79 13 13 2.69 0.85 26

12 Giving patients cost information regarding testing and treatment to help in decision-making. 45 2.6 0.96 41 21 2.62 1.02 41 13 2.46 1.05 50

13 Communicating more effectively with "difficult patients." 37 2.49 0.77 53 20 2.45 0.83 53 12 2.58 0.9 39

14 Reading and critiquing the scientific literature. 35 2.43 0.98 56 15 2.73 0.96 26 12 2.83 0.83 15

15 Improving screening, evaluation, and management of older patients with memory problems. 35 2.29 0.96 68 17 2.41 0.94 59 9 2.22 1.09 67


38

ID #




16 Improving care for elderly and frail patients. 34 2.79 0.81 19 15 3.13 0.83 3 10 2.8 0.79 16

17 Understanding what palliative care can offer patients and when to involve. 29 2.62 1.05 40 16 2.63 1.15 40 13 2.62 1.19 34

18 Integrating advanced care planning into a busy practice. 31 2.55 1.09 47 17 2.71 1.16 30 13 2.46 1.13 51

19

Preparing patients and families in the primary care setting for decisions around end-of-life care in advance of terminal illness. 39 2.69 1.08 36 16 2.75 1.29 24 11 2.27 1.27 65

20 Reducing the number of patients who receive futile care. 46 2.89 1.04 9 22 2.91 1.15 12 15 3 1.07 8

21 Reducing medication errors. 39 3.03 1.01 3 20 3.1 0.97 6 14 2.86 1.03 13

22 Using technology for more efficient routine follow-up and appointment reminders. 46 2.37 1 63 22 2.32 1.04 66 14 2.14 1.03 72

23 Following-up on patients who have not had a primary care provider visit for an extended period. 35 2.4 0.91 60 18 2.44 0.98 55 10 2.4 1.07 57

24 Improving follow-up on patients discharged from the hospital. 42 2.71 0.99 26 22 2.68 0.99 35 11 2.64 0.81 31

25 Increasing immunization rates for children. 25 2.84 0.85 14 10 2.8 0.79 18 5 3 0.71 5

26 Increasing interprofessional cooperation and collaboration 38 2.82 0.9 15 20 2.6 0.94 44 15 2.6 0.99 38

27 Achieving better integration of pharmacy and nursing into patient care plans. 37 2.54 1.12 48 26 2.65 1.2 38 11 2.64 1.12 32

28 Taking a team approach to identify and deliver preventive health care services. 35 2.71 1.02 28 20 2.8 1.01 19 11 2.73 1.01 23

29 Integrating mental health care into care plans 38 2.71 0.87 25 20 2.5 0.69 50 14 2.5 0.76 44

30 Addressing the needs of patients/families with low health literacy. 32 2.5 0.88 51 12 2.42 0.9 56 10 2.6 0.84 35

31 Improving screening for and treatment of mental conditions (e.g., depression, anxiety). 35 2.77 1 20 18 2.56 1.15 47 13 2.31 1.11 59

32 Treating patients who have both chronic medical needs and psychiatric issues. 33 2.85 1.06 12 18 3.11 1.02 4 13 3.15 0.99 3


39

ID #




33 Making better use of mental health referrals to reduce reliance on prescriptions. 36 2.69 0.82 33 23 2.61 0.94 42 15 2.6 0.91 36

34 Treating neonates with Neonatal Abstinence Syndrome. 24 2.04 1 74 13 1.85 1.14 78 8 1.75 1.04 78

35 Preventing and treating obesity. 31 2.68 1.01 37 15 2.6 0.91 43 8 2.75 0.89 21

36

Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations). 27 2.7 0.67 29 12 2.75 0.75 21 6 2.67 0.52 29

37 Managing patients suspected of opioid abuse. 30 2.7 0.92 30 16 2.69 0.95 33 13 2.69 1.03 27

38 Improving patient education regarding opiates. 27 2.85 0.95 11 11 3.09 0.94 7 7 3 1 7

39 Making better use of pain services. 28 2.14 0.71 73 14 2.36 0.74 63 10 2.2 0.63 68

40 Coordinating appointments, diagnostic testing, and follow up visits to reduce burden on patients 42 2.81 0.89 16 22 2.86 0.89 14 13 2.92 0.76 11

41 Having discussions with patients with cancer about what quality of life means to them. 28 3 0.98 5 15 3 1.07 11 11 3 1.1 9

42 Integrating patient navigators into the work of the team. 38 2 0.87 76 20 2.05 0.89 75 16 2 0.97 76

43

Helping patients who now have access to a primary care practice due to ACA, but don't know how to take advantage of it. 36 2.33 0.93 67 20 2.3 0.92 67 14 2.29 1.07 64

44 Identifying and mitigating patient safety risks in the primary care setting. 40 2.43 1.06 57 19 2.37 1.07 60 12 2.17 0.83 71

45 Improving staff safety. 43 2.23 1.02 70 25 2.08 0.91 73 17 2.06 1.03 75

46 Managing multiple screening guidelines in a busy practice. 38 2.37 0.91 62 17 2.12 0.93 72 11 2.18 0.98 69

47 Improving cancer screening via mammography, Pap smears, and colonoscopy. 40 2.58 1.15 43 22 2.82 1.1 17 13 2.69 1.11 28

48 Integrating shared decision-making for preventive screening in a busy clinical practice. 31 2.16 0.9 72 18 2.17 0.99 70 10 2.1 1.1 73

49 Educating the community about shared decision-making. 46 2.02 0.88 75 27 1.85 0.95 77 18 1.89 1.02 77


40

ID #




50

Ensuring that patients and families faced with "palliative" or emergency operations have more realistic expectations. 42 2.71 0.99 26 19 2.74 1.15 25 11 2.55 1.29 43

51 Providing more support for shared decision-making for patients facing difficult medical decisions. 41 2.56 0.84 44 20 2.5 0.76 51 8 2.63 0.92 33

52 Involving patients more in the decision-making process. 44 2.7 0.95 31 20 2.55 0.94 48 12 2.33 0.98 58

53 Taking a more patient-centered approach to care. 39 2.85 1.09 13 23 3.04 1.07 10 15 2.87 1.19 12

54 Using evidence-based materials to help providers and patients with shared decision-making. 42 2.86 0.98 10 22 2.68 0.99 35 15 2.67 1.05 30

55 Improving STD counseling, screening, testing, and treatment. 32 1.91 0.89 77 15 1.93 0.88 76 7 2.29 0.95 62

56 Improving men's reproductive health screening. 24 1.71 0.75 80 11 1.36 0.5 80 10 1.3 0.48 79

57

Developing a system of care for traumatic brain injuries (brain injury specialists, PCPs, schools, hospitals, etc). 27 2.19 0.88 71 12 2.17 0.72 69 6 2.17 0.75 70

58 Making more efficient use of the EHR. 44 3.14 0.95 2 28 3.11 1.07 5 18 2.94 1.06 10

59 Reducing the number of inappropriate or unnecessary lab tests. 41 2.76 0.8 21 24 2.75 0.79 22 14 2.79 0.89 17

60 Improving the interpretation and use of laboratory test results. 33 2.36 0.96 64 18 2.17 1.04 71 12 2.42 1.08 56

61 Improving care transitions from inpatient to outpatient. 37 3.27 0.77 1 19 3.42 0.61 1 12 3.42 0.67 1

62 Improving transitions to home and community services. 29 2.69 1.04 35 10 2.7 0.82 31 9 2.78 0.83 19

63 Improving hand-offs. 37 2.73 0.99 24 16 2.56 1.03 46 11 2.73 0.9 22

64 Reducing the number of "nuisance patient visits." 31 1.77 0.88 79 15 2.07 1.03 74 9 2.22 0.97 66

65 Educating patients about when to seek health care services. 33 2.73 0.91 23 18 2.72 1.07 29 14 2.43 1.02 54

66 Doing comprehensive well woman exams. 19 1.84 0.9 78 10 1.5 0.85 79 7 1.14 0.38 80

67 Doing a better job of preventing infections. 40 2.6 0.98 42 22 2.41 0.91 58 17 2.47 1.01 48


41

ID #




68 Saying no to requests for antimicrobials for viral infections. 26 2.5 1.03 52 10 2.7 1.06 32 7 2.43 1.13 55

69 Choosing antimicrobials more judiciously. 30 2.5 0.86 50 12 2.42 0.9 56 8 2.5 0.93 47

70 Supporting lifestyle modifications to improve diet, exercise, weight loss. 42 2.98 1 6 22 2.73 1.12 28 14 2.57 1.28 41

71 Increasing immunization rates for adults. 29 2.62 0.94 39 12 2.67 0.89 37 10 2.6 0.97 37

72 Increasing interprofessional cooperation during patient rounds 33 2.36 0.96 64 15 2.53 0.99 49 13 2.46 0.97 49

73 Applying best practice guidelines for use of opioids in pain management. 35 2.89 0.9 8 13 3.08 0.95 8 12 3 0.95 6

74 Using non-opiate pain relief options 32 2.69 0.9 34 19 2.68 0.89 34 14 2.5 0.85 46

75 Understanding the health care and human services resources available in the community. 40 2.4 0.81 59 21 2.57 0.81 45 16 2.69 0.79 25

76

Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and reasons to choose these meds. 32 2.56 0.98 46 17 2.35 0.93 64 10 2.3 1.06 61

77 Understanding opportunities for quality improvement in the Accountable Care Organization payment system. 39 2.33 0.84 66 22 2.36 0.73 62 11 2.45 0.69 52

78 Understanding the basics of quality and patient safety in health care. 31 2.45 1.06 55 16 2.75 0.86 23 13 2.85 0.9 14

79 Improving your team leadership/participation skills. 45 2.38 0.91 61 26 2.35 1.02 65 17 2.29 1.05 63

80 Understanding who is not seeking health care, why, and what can be done about it. 49 2.47 1.02 54 30 2.37 1.07 60 20 2.3 1.03 60


42

APPENDIX G. Rankings: D-H Clinicians Combined Note: Top ten highlighted in blue.

ID # Opportunities/Survey Items

D-H NURSES D-H NURSE PRACTIONERS D-H PHYSICIANS D-H COMBINED

N Mean SD Rank N Mean SD Rank N Mean SD Rank Total

N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

1

Improving communication between providers in the community (such as PCPs, therapists, housing managers). 31 3.03 0.91 23 6 3.00 1.10 26 25 2.24 0.97 68 62 2.76 0.99 40

2

Improving interdisciplinary communication between team members. 38 3.39 0.86 2 5 3.20 0.84 13 23 2.83 0.83 15 66 3.14 0.84 9

3

Improving communication of results of completed studies for patients sent to specialty care. 29 2.90 0.77 33 3 2.67 0.58 42 15 2.73 1.10 27 47 2.77 0.82 37

4

Improving communication with families about what is occurring with their loved ones. 32 3.38 0.79 3 6 2.50 1.38 61 19 3.05 1.08 9 57 2.98 1.08 15

5 Delivering bad news to patients and families. 33 2.88 0.93 37 5 2.60 0.55 47 16 2.44 0.73 54 54 2.64 0.74 54

6

Engaging with community groups to promote healthy behaviors. 28 2.71 0.94 53 4 2.75 0.96 36 16 2.63 0.96 39 48 2.70 0.95 45

7

Using community health care resources to improve chronic disease management. 31 2.74 0.93 47 3 3.33 0.58 10 22 2.82 1.05 16 56 2.96 0.85 17

8 Working better with community resources. 28 2.82 0.90 42 8 2.75 1.16 37 22 2.50 1.01 52 58 2.69 1.02 48

9 Improving 33 3.06 0.93 21 4 3.00 0.82 20 15 3.20 0.77 2 52 3.09 0.84 10


43




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

coordination of care between hospitals/networks/ providers.

10

Improving coordination of care and transfer of information across organizations and care settings. 26 3.38 0.80 4 8 2.75 0.89 35 22 2.77 0.87 20 56 2.97 0.85 16

11

Improving coordination with home health and other community resources involved in transitions of care. 30 3.03 0.85 22 5 2.60 1.14 51 21 2.86 0.79 13 56 2.83 0.93 26

12

Giving patients cost information regarding testing and treatment to help in decision-making. 25 2.52 1.08 68 8 3.00 0.76 19 21 2.62 1.02 41 54 2.71 0.95 43

13

Communicating more effectively with "difficult patients." 33 3.06 0.79 20 6 2.83 1.17 33 20 2.45 0.83 53 59 2.78 0.93 36

14 Reading and critiquing the scientific literature. 35 2.40 0.98 73 5 2.40 0.55 64 15 2.73 0.96 26 55 2.51 0.83 62

15

Improving screening, evaluation, and management of older patients with memory problems. 28 2.54 1.00 66 5 2.60 0.55 47 17 2.41 0.94 59 50 2.52 0.83 60

16

Improving care for elderly and frail patients. 28 3.00 0.98 26 2 3.00 0.00 17 15 3.13 0.83 3 45 3.04 0.60 11

17

Understanding what palliative care can offer patients and when to involve. 23 3.22 0.95 12 7 2.57 0.53 53 16 2.63 1.15 40 46 2.81 0.88 31

18 Integrating advanced 29 2.66 0.94 59 5 3.00 1.00 23 17 2.71 1.16 30 51 2.79 1.03 33


44




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

care planning into a busy practice.

19

Preparing patients and families in the primary care setting for decisions around end-of-life care in advance of terminal illness. 29 3.03 1.09 24 4 2.50 1.73 62 16 2.75 1.29 24 49 2.76 1.37 38

20

Reducing the number of patients who receive futile care. 24 2.96 0.91 29 4 2.50 1.29 58 22 2.91 1.15 12 50 2.79 1.12 34

21 Reducing medication errors. 27 3.30 0.78 6 7 3.71 0.49 3 20 3.10 0.97 6 54 3.37 0.75 1

22

Using technology for more efficient routine follow-up and appointment reminders. 22 2.36 0.90 74 6 2.83 0.75 30 22 2.32 1.04 66 50 2.50 0.90 65

23

Following-up on patients who have not had a primary care provider visit for an extended period. 21 2.57 0.87 64 5 2.20 0.84 71 18 2.44 0.98 55 44 2.40 0.90 69

24

Improving follow-up on patients discharged from the hospital. 29 3.38 0.86 5 7 3.43 0.53 8 22 2.68 0.99 35 58 3.16 0.79 7

25

Increasing immunization rates for children. 19 2.63 1.07 61 1 3.00 . 27 10 2.80 0.79 18 30 2.81 0.93 30

26

Increasing interprofessional cooperation and collaboration 32 3.28 0.89 7 5 3.00 1.00 23 20 2.60 0.94 44 57 2.96 0.94 18

27

Achieving better integration of pharmacy and nursing into patient care plans. 22 2.73 0.98 49 7 2.43 0.79 63 26 2.65 1.20 38 55 2.60 0.99 58

28 Taking a team approach to identify 28 2.89 1.03 36 6 2.67 0.82 44 20 2.80 1.01 19 54 2.79 0.95 35


45




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

and deliver preventive health care services.

29

Integrating mental health care into care plans 30 2.73 0.94 48 7 2.71 1.11 39 20 2.50 0.69 50 57 2.65 0.91 53

30

Addressing the needs of patients/families with low health literacy. 35 3.11 0.76 17 5 2.60 0.55 47 12 2.42 0.90 56 52 2.71 0.74 44

31

Improving screening for and treatment of mental conditions (eg, depression, anxiety). 32 2.94 0.95 31 3 2.33 1.15 66 18 2.56 1.15 47 53 2.61 1.08 57

32

Treating patients who have both chronic medical needs and psychiatric issues. 28 2.82 0.90 42 5 3.20 0.45 12 18 3.11 1.02 4 51 3.04 0.79 12

33

Making better use of mental health referrals to reduce reliance on prescriptions. 24 2.88 0.95 38 2 3.00 0.00 17 23 2.61 0.94 42 49 2.83 0.63 25

34

Treating neonates with Neonatal Abstinence Syndrome. 11 2.73 1.27 50 4 3.00 0.82 20 13 1.85 1.14 78 28 2.53 1.08 59

35 Preventing and treating obesity. 30 2.43 0.97 72 7 2.86 0.90 28 15 2.60 0.91 43 52 2.63 0.93 56

36

Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations). 20 2.80 1.11 44 1 4.00 . 1 12 2.75 0.75 21 33 3.18 0.93 6

37

Managing patients suspected of opioid abuse. 25 2.68 1.11 57 7 2.71 1.11 39 16 2.69 0.95 33 48 2.69 1.06 47

38

Improving patient education regarding opiates. 27 2.67 1.00 58 3 2.67 0.58 42 11 3.09 0.94 7 41 2.81 0.84 29


46




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

39 Making better use of pain services 37 2.89 0.84 35 6 2.83 0.75 30 14 2.36 0.74 63 57 2.69 0.78 46

40

Coordinate clinic appointments, DX testing, and follow-up visits to reduce burden on patients 30 2.83 0.99 41 3 2.33 1.15 66 22 2.86 0.89 14 55 2.67 1.01 51

41

Having discussions with patients with cancer about what quality of life means to them. 34 3.00 0.82 25 1 4.00 . 1 15 3.00 1.07 11 50 3.33 0.95 3

42

Integrating patient navigators into the work of the team. 26 2.58 0.90 63 5 1.80 0.45 77 20 2.05 0.89 75 51 2.14 0.75 77

43

Helping patients who now have access to a primary care practice due to ACA, but don't know how to take advantage of it. 28 2.68 0.86 56 2 2.00 1.41 75 20 2.30 0.92 67 50 2.33 1.06 71

44

Identifying and mitigating patient safety risks in the primary care setting. 27 3.26 0.81 8 4 3.50 0.58 5 19 2.37 1.07 60 50 3.04 0.82 13

45 Improving staff safety. 35 2.94 1.11 32 3 3.67 0.58 4 25 2.08 0.91 73 63 2.90 0.87 21

46

Managing multiple screening guidelines in a busy practice. 18 2.06 0.87 78 3 2.67 1.15 46 17 2.12 0.93 72 38 2.28 0.98 72

47

Improving cancer screening via mammography, Pap smears, and colonoscopy. 29 2.69 0.97 55 6 2.50 0.55 54 22 2.82 1.10 17 57 2.67 0.87 52

48

Integrating shared decision-making for preventive screening in a busy clinical practice. 22 2.50 1.06 69 7 2.86 0.90 28 18 2.17 0.99 70 47 2.51 0.98 63


47




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

49

Educating the community about shared decision-making. 30 2.33 0.84 75 3 2.33 0.58 65 27 1.85 0.95 77 60 2.17 0.79 76

50

Ensuring that patients and families faced with "palliative" or emergency operations have more realistic expectations. 34 3.21 0.73 13 6 2.83 0.75 30 19 2.74 1.15 25 59 2.93 0.88 20

51

Providing more support for shared decision-making for patients facing difficult medical decisions. 32 2.94 0.80 30 6 3.17 0.75 14 20 2.50 0.76 51 58 2.87 0.77 22

52

Involving patients more in the decision-making process. 28 3.25 0.75 10 7 3.14 0.90 15 20 2.55 0.94 48 55 2.98 0.86 14

53

Taking a more patient-centered approach to care. 33 3.15 0.94 15 4 3.25 0.96 11 23 3.04 1.07 10 60 3.15 0.99 8

54

Using evidence-based materials to help providers and patients with shared decision-making. 33 2.85 1.03 39 3 3.00 1.00 23 22 2.68 0.99 35 58 2.84 1.01 24

55

Improving STD counseling, screening, testing, and treatment. 26 2.15 0.97 77 2 1.50 0.71 78 15 1.93 0.88 76 43 1.86 0.85 79

56

Improving men's reproductive health screening. 20 1.95 0.76 79 0 . . . 11 1.36 0.50 80 31 1.66 0.63 80

57

Developing a system of care for traumatic brain injuries (brain injury specialists, PCPs, schools, hospitals, etc.). 26 2.54 0.76 65 4 2.00 1.15 74 12 2.17 0.72 69 42 2.24 0.88 73

58 Making more efficient 24 2.96 0.75 28 2 3.50 0.71 6 28 3.11 1.07 5 54 3.19 0.84 5


48




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

use of the EHR.

59

Reducing the number of inappropriate or unnecessary lab tests. 36 2.72 0.91 51 5 2.80 0.84 34 24 2.75 0.79 22 65 2.76 0.85 39

60

Improving the interpretation and use of laboratory test results. 31 2.48 0.93 70 6 2.50 0.84 57 18 2.17 1.04 71 55 2.38 0.94 70

61

Improving care transitions from inpatient to outpatient. 31 3.19 0.91 14 5 3.40 0.55 9 19 3.42 0.61 1 55 3.34 0.69 2

62

Improving transitions to home and community services. 24 3.25 0.85 11 4 2.50 0.58 55 10 2.70 0.82 31 38 2.82 0.75 28

63 Improving hand-offs. 39 2.90 0.97 34 5 2.60 0.55 47 16 2.56 1.03 46 60 2.69 0.85 49

64

Reducing the number of "nuisance patient visits." 34 1.91 1.03 80 5 2.00 0.71 72 15 2.07 1.03 74 54 1.99 0.92 78

65

Educating patients about when to seek health care services. 26 2.77 0.86 45 8 3.00 0.93 22 18 2.72 1.07 29 52 2.83 0.95 27

66 Doing comprehensive well woman exams. 23 2.70 0.70 54 4 2.50 1.29 58 10 1.50 0.85 79 37 2.23 0.95 74

67 Doing a better job of preventing infections. 32 3.47 0.67 1 4 2.50 1.29 58 22 2.41 0.91 58 58 2.79 0.96 32

68

Saying no to requests for antimicrobials for viral infections. 21 2.62 1.02 62 4 2.75 1.50 38 15 2.53 0.99 49 40 2.63 1.17 55

69

Choosing antimicrobials more judiciously. 22 2.77 1.07 46 6 2.33 1.21 68 12 2.42 0.90 56 40 2.51 1.06 64

70

Supporting lifestyle modifications to improve diet, exercise, weight loss. 28 2.71 0.85 52 0 . . . 22 2.73 1.12 28 50 2.72 0.99 42

71

Increasing immunization rates for adults. 29 2.45 1.09 71 4 2.25 1.26 70 12 2.67 0.89 37 45 2.46 1.08 67


49




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

72

Increasing interprofessional cooperation during patient rounds. 33 2.97 1.02 27 8 3.13 0.99 16 10 2.70 1.06 32 51 2.93 1.02 19

73

Applying best practice guidelines for use of opioids in pain management. 32 3.25 0.67 9 6 3.50 1.22 7 13 3.08 0.95 8 51 3.28 0.95 4

74 Using non-opiate pain relief options 31 2.84 1.04 40 2 2.50 0.71 56 19 2.68 0.89 34 52 2.67 0.88 50

75

Understanding the health care and human services resources available in the community. 36 3.08 0.87 19 5 2.60 1.14 51 21 2.57 0.81 45 62 2.75 0.94 41

76

Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and reasons to choose these meds. 23 2.65 0.88 60 4 2.25 0.96 69 17 2.35 0.93 64 44 2.42 0.92 68

77

Understanding opportunities for quality improvement in the Accountable Care Organization payment system. 33 2.52 1.06 67 6 2.67 0.82 44 22 2.36 0.73 62 61 2.52 0.87 62

78

Understanding the basics of quality and patient safety in health care. 33 3.09 1.01 18 7 2.71 1.25 41 16 2.75 0.86 23 56 2.85 1.04 23

79

Improving your team leadership/participation skills. 34 3.12 0.64 16 2 2.00 1.41 75 26 2.35 1.02 65 62 2.49 1.02 66

80 Understanding who is not seeking health care, 29 2.17 0.93 76 5 2.00 0.71 72 30 2.37 1.07 60 64 2.18 0.90 75


50




N

Aver- aged Mean

Aver- aged SD

Combin- ed Rank

why, and what can be done about it.


51

APPENDIX H. Rankings: All Nurses, D-H System Nurses, and DHMC Nurses Note: Top ten highlighted in blue.




1

Improving communication between providers in the community (such as PCPs, therapists, housing managers). 62 3.00 0.89 26 31 3.03 0.91 23 24 3.04 0.91 22

2

Improving interdisciplinary communication between team members. 70 3.43 0.79 1 38 3.39 0.86 2 27 3.41 0.89 3

3

Improving communication of results of completed studies for patients sent to specialty care. 61 2.90 0.85 41 29 2.90 0.77 33 22 2.91 0.75 33

4

Improving communication with families about what is occurring with their loved ones. 68 3.25 0.87 5 32 3.38 0.79 3 28 3.36 0.83 4



7

Using community health care resources to improve chronic disease management. 66 2.91 0.94 39 31 2.74 0.93 47 23 2.61 1.03 60


9 Improving coordination of care between hospitals/ networks/providers. 60 3.10 0.90 14 33 3.06 0.93 21 29 3.00 0.96 29

10

Improving coordination of care and transfer of information across organizations and care settings. 64 3.13 0.90 9 26 3.38 0.80 4 22 3.32 0.84 5

11

Improving coordination with home health and other community resources involved in transitions of care. 59 3.02 0.78 24 30 3.03 0.85 22 23 2.91 0.90 34

12

Giving patients cost information regarding testing and treatment to help in decision-making. 48 2.52 0.99 69 25 2.52 1.08 68 20 2.55 1.19 66


14 Reading and critiquing the scientific 57 2.30 0.94 76 35 2.40 0.98 73 27 2.56 0.93 64


52



N Mean SD Rank N Mean SD Rank N Mean SD Rank literature.

15

Improving screening, evaluation, and management of older patients with memory problems. 54 2.67 0.93 60 28 2.54 1.00 66 19 2.42 0.96 72

16 Improving care for elderly and frail patients. 64 3.11 0.88 11 28 3.00 0.98 26 24 3.04 1.04 23


18 Integrating advanced care planning into a busy practice. 51 2.75 0.96 51 29 2.66 0.94 59 21 2.67 0.97 56

19

Preparing patients and families in the primary care setting for decisions around end-of-life care in advance of terminal illness. 59 2.97 1.05 30 29 3.03 1.09 24 23 3.04 1.11 25

20 Reducing the number of patients who receive futile care. 49 3.10 0.87 13 24 2.96 0.91 29 16 3.00 0.89 27


22

Using technology for more efficient routine follow-up and appointment reminders. 43 2.21 0.86 78 22 2.36 0.90 74 16 2.44 0.89 71

23

Following-up on patients who have not had a primary care provider visit for an extended period. 46 2.59 0.91 64 21 2.57 0.87 64 15 2.60 0.91 61


25 Increasing immunization rates for children. 41 2.85 0.99 45 19 2.63 1.07 61 13 2.85 1.14 39

26 Increasing interprofessional cooperation and collaboration 66 3.11 0.84 10 32 3.28 0.89 7 26 3.23 0.91 13

27

Achieving better integration of pharmacy and nursing into patient care plans. 55 2.69 0.98 59 22 2.73 0.98 49 18 2.78 0.94 43



30 Addressing the needs of patients/families with low health 71 2.99 0.80 27 35 3.11 0.76 17 29 3.10 0.77 16


53



N Mean SD Rank N Mean SD Rank N Mean SD Rank literacy.

31

Improving screening for and treatment of mental conditions (eg, depression, anxiety). 58 2.84 0.95 46 32 2.94 0.95 31 27 2.93 0.96 32

32

Treating patients who have both chronic medical needs and psychiatric issues. 65 2.94 0.90 34 28 2.82 0.90 42 24 2.83 0.92 40

33

Making better use of mental health referrals to reduce reliance on prescriptions. 53 2.92 0.83 37 24 2.88 0.95 38 19 2.74 0.99 46

34 Treating neonates with Neonatal Abstinence Syndrome. 23 2.65 1.07 62 11 2.73 1.27 50 10 2.70 1.34 54


36

Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations). 46 2.74 1.04 53 20 2.80 1.11 44 12 2.67 1.15 58

37 Managing patients suspected of opioid abuse. 53 2.72 1.01 55 25 2.68 1.11 57 18 2.67 1.08 57

38 Improving patient education regarding opiates. 64 2.73 0.90 54 27 2.67 1.00 58 26 2.62 0.98 59

39 Make better use of pain services. 71 2.86 0.83 43 37 2.89 0.84 35 28 2.79 0.83 42

40

Coordinating appointments, diagnostic testing, and follow up visits to reduce burden on patients 58 3.02 0.98 25 30 2.83 0.99 41 21 2.71 1.10 51

41

Having discussions with patients with cancer about what quality of life means to them. 62 3.05 0.82 20 34 3.00 0.82 25 27 3.04 0.81 21

42 Integrating patient navigators into the work of the team. 58 2.52 0.98 68 26 2.58 0.90 63 21 2.48 0.87 68

43

Helping patients who now have access to a primary care practice due to ACA, but don't know how to take advantage of it. 56 2.66 0.84 61 28 2.68 0.86 56 22 2.73 0.88 48



46 Managing multiple screening 43 2.42 0.93 71 18 2.06 0.87 78 15 1.93 0.88 78


54



N Mean SD Rank N Mean SD Rank N Mean SD Rank guidelines in a busy practice.

47

Improving cancer screening via mammography, Pap smears, and colonoscopy. 51 2.69 0.93 58 29 2.69 0.97 55 20 2.60 0.99 62

48

Integrating shared decision-making for preventive screening in a busy clinical practice. 49 2.53 0.94 67 22 2.50 1.06 69 18 2.50 1.15 67

49 Educating the community about shared decision-making. 61 2.33 0.94 75 30 2.33 0.84 75 21 2.29 0.90 74

50

Ensuring that patients and families faced with "palliative" or emergency operations have more realistic expectations. 58 3.03 0.86 22 34 3.21 0.73 13 27 3.26 0.71 9

51

Providing more support for shared decision-making for patients facing difficult medical decisions. 58 2.93 0.79 36 32 2.94 0.80 30 23 2.87 0.81 35

52 Involving patients more in the decision-making process. 57 3.25 0.81 3 28 3.25 0.75 10 22 3.27 0.77 8


54

Using evidence-based materials to help providers and patients with shared decision-making. 64 2.95 1.03 32 33 2.85 1.03 39 28 2.86 1.04 38

55 Improving STD counseling, screening, testing, and treatment. 50 2.28 0.90 77 26 2.15 0.97 77 19 2.00 0.94 77

56 Improving men's reproductive health screening. 43 2.02 0.83 80 20 1.95 0.76 79 13 1.85 0.80 79

57

Developing a system of care for traumatic brain injuries (brain injury specialists, PCPs, schools, hospitals, etc). 52 2.38 0.84 74 26 2.54 0.76 65 20 2.55 0.76 65







55





64 Reducing the number of "nuisance patient visits." 63 2.03 0.92 79 34 1.91 1.03 80 29 1.72 0.92 80

65 Educating patients about when to seek health care services. 61 2.90 0.81 40 26 2.77 0.86 45 18 2.78 0.94 43





70

Supporting lifestyle modifications to improve diet, exercise, and weight loss. 64 2.89 0.88 42 28 2.71 0.85 52 22 2.77 0.92 45


72 Increasing interprofessional cooperation during patient rounds 61 3.03 0.98 23 33 2.97 1.02 27 26 3.12 0.95 15

73 Applying best practice guidelines for use of opioids in pain management. 63 3.10 0.80 12 32 3.25 0.67 9 30 3.30 0.65 7


75

Understanding the health care and human services resources available in the community. 69 3.04 0.90 21 36 3.08 0.87 19 29 3.10 0.90 17

76

Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and reasons to choose these meds. 53 2.92 0.90 38 23 2.65 0.88 60 17 2.59 0.94 63

77

Understanding opportunities for quality improvement in the Accountable Care Organization payment system. 54 2.50 0.97 70 33 2.52 1.06 67 31 2.48 1.09 69


79 Improving your team leadership/participation skills. 66 2.94 0.80 33 34 3.12 0.64 16 27 3.07 0.68 18


56




80

Understanding who is not seeking health care, why, and what can be done about it. 47 2.40 0.99 73 29 2.17 0.93 76 22 2.14 0.94 76


57

APPENDIX I. Rankings: All Nurse Practitioners, D-H System Nurse Practitioners, and DHMC Nurse Practitioners Note: Top ten highlighted in blue.


ALL NURSE PRACTITIONERS D-H SYSTEM NURSE PRACTITIONERS

DHMC NURSE PRACTITIONERS


1

Improving communication between providers in the community (such as PCPs, therapists, housing managers). 11 2.91 1.04 31 6 3 1.1 26 4 3 1.15 29

2 Improving interdisciplinary communication between team members. 11 3 0.89 19 5 3.2 0.84 13 5 3.2 0.84 13

3

Improving communication of results of completed studies for patients sent to specialty care. 10 2.7 0.67 54 3 2.67 0.58 42 3 2.67 0.58 45

4 Improving communication with families about what is occurring with their loved ones. 13 2.46 1.13 70 6 2.5 1.38 61 5 2.6 1.52 53



7 Using community health care resources to improve chronic disease management. 13 3.08 0.64 14 3 3.33 0.58 10 3 3.33 0.58 9


9 Improving coordination of care between hospitals/ networks/providers. 13 3.08 0.86 15 4 3 0.82 20 4 3 0.82 18

10

Improving coordination of care and transfer of information across organizations and care settings. 13 2.62 0.77 63 8 2.75 0.89 35 8 2.75 0.89 41

11

Improving coordination with home health and other community resources involved in transitions of care. 10 2.8 0.92 43 5 2.6 1.14 51 4 3 0.82 18

12

Giving patients cost information regarding testing and treatment to help in decision-making. 11 2.91 0.7 28 8 3 0.76 19 7 2.86 0.69 34


14 Reading and critiquing the scientific literature. 12 2.33 0.89 76 5 2.4 0.55 64 5 2.4 0.55 63


58





15

Improving screening, evaluation, and management of older patients with memory problems. 9 2.67 0.71 57 5 2.6 0.55 47 4 2.75 0.5 39

16 Improving care for elderly and frail patients. 10 3.1 0.99 13 2 3 0 17 2 3 0 16


18 Integrating advanced care planning into a busy practice. 13 2.85 0.9 40 5 3 1 23 5 3 1 24

19

Preparing patients and families in the primary care setting for decisions around end-of-life care in advance of terminal illness. 13 3 1.22 22 4 2.5 1.73 62 3 3 1.73 30

20 Reducing the number of patients who receive futile care. 10 2.7 1.06 55 4 2.5 1.29 58 3 3 1 24


22 Using technology for more efficient routine follow-up and appointment reminders. 16 2.75 0.86 48 6 2.83 0.75 30 6 2.83 0.75 35

23

Following-up on patients who have not had a primary care provider visit for an extended period. 15 2.87 0.92 34 5 2.2 0.84 71 5 2.2 0.84 68


25 Increasing immunization rates for children. 7 2.86 0.69 35 1 3 . 27 1 3 . 31

26 Increasing interprofessional cooperation and collaboration 12 2.92 1.08 27 5 3 1 23 5 3 1 24

27 Achieving better integration of pharmacy and nursing into patient care plans. 14 2.43 1.02 73 7 2.43 0.79 63 7 2.43 0.79 62



30 Addressing the needs of patients/families with low health literacy. 11 2.82 0.87 42 5 2.6 0.55 47 5 2.6 0.55 51

31 Improving screening for and treatment of mental conditions (eg, depression, anxiety). 12 2.83 0.83 41 3 2.33 1.15 66 3 2.33 1.15 64


59





32 Treating patients who have both chronic medical needs and psychiatric issues. 13 3.15 0.69 9 5 3.2 0.45 12 4 3.25 0.5 11

33 Making better use of mental health referrals to reduce reliance on prescriptions. 7 3 0.82 17 2 3 0 17 1 3 . 31

34 Treating neonates with Neonatal Abstinence Syndrome. 7 2.43 0.98 72 4 3 0.82 20 4 3 0.82 18


36

Making childhood obesity a priority at the primary care level (e.g., track and emphasize BMI -- like is done with vaccinations). 9 3 1.32 23 1 4 . 1 1 4 . 1

37 Managing patients suspected of opioid abuse. 14 3 1.04 20 7 2.71 1.11 39 5 3 1 24

38 Improving patient education regarding opiates. 15 2.6 0.63 64 3 2.67 0.58 42 2 2.5 0.71 58

39 Make better use of pain services. 14 2.86 0.77 36 6 2.83 0.75 30 5 2.8 0.84 38

40

Coordinating appointments, diagnostic testing, and follow up visits to reduce burden on patients 11 2.73 0.9 52 3 2.33 1.15 66 2 2 1.41 72

41 Having discussions with patients with cancer about what quality of life means to them. 6 3.5 0.55 2 1 4 . 1 1 4 . 1

42 Integrating patient navigators into the work of the team. 9 1.78 0.44 79 5 1.8 0.45 77 5 1.8 0.45 74

43

Helping patients who now have access to a primary care practice due to ACA, but don't know how to take advantage of it. 7 2.43 1.27 74 2 2 1.41 75 2 2 1.41 72



46 Managing multiple screening guidelines in a busy practice. 12 2.67 0.89 59 3 2.67 1.15 46 3 2.67 1.15 48

47 Improving cancer screening via mammography, Pap smears, and colonoscopy. 11 2.64 0.81 62 6 2.5 0.55 54 6 2.5 0.55 54

48 Integrating shared decision-making for preventive screening in a busy clinical practice. 16 2.44 0.89 71 7 2.86 0.9 28 6 3 0.89 21


60





49 Educating the community about shared decision-making. 12 2.5 0.8 68 3 2.33 0.58 65 2 2 0 69

50

Ensuring that patients and families faced with "palliative" or emergency operations have more realistic expectations. 11 2.91 0.7 28 6 2.83 0.75 30 5 3 0.71 17

51

Providing more support for shared decision-making for patients facing difficult medical decisions. 14 2.86 0.86 38 6 3.17 0.75 14 6 3.17 0.75 14

52 Involving patients more in the decision-making process. 15 3.07 0.8 16 7 3.14 0.9 15 6 3 0.89 21


54

Using evidence-based materials to help providers and patients with shared decision-making. 15 2.93 0.8 26 3 3 1 23 3 3 1 24

55 Improving STD counseling, screening, testing, and treatment. 12 2.08 1 77 2 1.5 0.71 78 2 1.5 0.71 77

56 Improving men's reproductive health screening. 6 2.5 0.84 69 0 . . . 0 . . .

57

Developing a system of care for traumatic brain injuries (brain injury specialists, PCPs, schools, hospitals, etc). 13 1.77 0.83 80 4 2 1.15 74 4 2 1.15 71







64 Reducing the number of "nuisance patient visits." 10 2.4 0.84 75 5 2 0.71 72 4 1.75 0.5 75

65 Educating patients about when to seek health care services. 15 2.8 1.01 44 8 3 0.93 22 8 3 0.93 23


61









70 Supporting lifestyle modifications to improve diet, exercise, and weight loss. 5 3.4 0.89 4 0 . . . 0 . . .


72 Increasing interprofessional cooperation during patient rounds. 14 3 1.04 20 8 3.13 0.99 16 8 3.13 0.99 15

73 Applying best practice guidelines for use of opioids in pain management. 12 3.5 1 3 6 3.5 1.22 7 5 3.4 1.34 8


75 Understanding the health care and human services resources available in the community. 11 2.91 0.94 30 5 2.6 1.14 51 4 2.25 0.96 65

76

Receiving medications updates for primary care issues (e.g., CHF, DM, COPD, depression), including benefits compared to older meds, and reasons to choose these meds. 13 3 0.82 17 4 2.25 0.96 69 4 2.25 0.96 65

77

Understanding opportunities for quality improvement in the Accountable Care Organization payment system. 14 2.57 0.76 65 6 2.67 0.82 44 5 2.6 0.89 52


79 Improving your team leadership/participation skills. 7 2.57 1.27 66 2 2 1.41 75 1 3 . 31

80 Understanding who is not seeking health care, why, and what can be done about it. 10 2 0.82 78 5 2 0.71 72 5 2 0.71 70

Regional Needs of Health Care Professionals’ Continuing Education Needs Report |

62

APPENDIX J. Current and Preferred Use of Social Media for CE

All Respondents (N=655) Current Use Preferred Use

Blogs 79 (12.1%) 54 (8.2%)

Collaborative writing tools 71 (10.8%) 56 (8.5%)

Email 493 (75.3%) 160 (24.4%)

Microblogs such as Twitter 27 (4.1%) 17 (2.6%)

Podcasts 194 (29.6%) 136 (20.8%)

Vodcasts 32 (4.9%) 48(7.3%)

Really Simple Syndication (RSS) Readers 45 (6.9%) 33 (5.0%)

Photo sites such as Flickr, Picasa 15 (2.3%) 17 (2.6%)

Video sites such as YouTube, Vimeo 258 (39.4%) 97 (14.8%)

PowerPoint slide sites such as SlideShare 218 (33.3%) 116 (17.7%)

Social Bookmarking sites such as del.icio.us, digg 14 (2.1%) 17 (2.6%)

Wikis 70 (10.7%) 25 (3.8%)

Social networking sites such as Facebook 105 (16.0%) 33 (5.0%)

Other Media 24 (3.7%) 14 (2.1%)


63

APPENDIX K. Current and Preferred Use of Information Technology for CE

All Respondents (N=655) Current Use Preferred Use

Computer (desktop or laptop) 618 (94.4%) 254 (38.8%)

Tablet (iPad, Nook) 268 (40.9%) 210 (32.1%)

Mini Tablet 40 (6.1%) 51 (7.8%)

Smartphone 276 (42.1%) 108 (16.5%)

DVD/BluRay Player 113 (17.3%) 46 (7.0%)

CD ROM Audio Player 92 (14.0%) 23 (3.5%)

iPod 70 (10.7%) 26 (4.0%)

Television 129 (19.7%) 42 (6.4%)

Game Console 9 (1.4%) 10 (1.5%)

Other Device 12 (1.8%) 12 (1.8%)


64

APPENDIX L. Study Design

Regional Survey of Health Care Professionals’ Continuing Education Needs Report |

65

APPENDIX M. Sampling Frame – Usable Records from the CLPD Database

Complete Database Records Usable records for NH

Usable records for MA-ME-NY-VT

Total Usable Records in Entire Geographic Target

Region

33,185 8,056 3,214 11,279


66

APPENDIX N. Usable Records by Occupation and State

MA ME NY VT MA-ME-NY-VT NH Total

N N N N N

% of Total: 11,279 N

% of Total: 11,279 N

Nurse Practitioner 45 49 14 148 256 2.3% 561 5.0% 817 Counselor/ Psychologist 0 6 0 67 73 0.6% 116 1.0% 189 Dietician 6 5 2 32 45 0.4% 68 0.6% 113 EMT 0 1 0 42 43 0.4% 70 0.6% 113 Licensed Practical Nurse 3 0 0 74 77 0.7% 326 2.9% 403 Medical Assistant 0 1 0 5 6 0.1% 60 0.5% 66 Nurse (RN, BSN) 113 175 73 1,012 1,373 12.2% 3,236 28.7% 4,609 Nursing Assistant 0 0 0 27 27 0.2% 180 1.6% 207 Other 47 37 15 266 365 3.2% 1,003 8.9% 1,368 Pharmacist 4 0 1 14 19 0.2% 79 0.7% 98 Physician 117 100 30 536 783 6.9% 1,942 17.2% 2,725 Physician Assistant 9 6 6 71 92 0.8% 178 1.6% 270 Therapist (e.g., physical, occupational) 6 6 1 41 54 0.5% 240 2.1% 294 Podiatrist 0 0 0 1 1 0.0% 6 0.1% 7 TOTALS 350 386 142 2,336 3,214 100% 8,065 100% 11,279


67

APPENDIX O. Questionnaire 1 (Q1)


68


69


70


71


72


73


74

APPENDIX P. Questionnaire 2 (Q2)


75


76


77


78


79


80


81


82

APPENDIX Q. Stratified, Random Sample for Q2

Occupation MA-ME-NY-VT NH

Nurse Practitioner 110 200

Counselor/Psychologist 30 40

Dietician 20 25 Emergency Medical Technician/Paramedic 15 25

Licensed Practical Nurse 25 115

Medical Assistant 5 25

Nurse (RN, BSN) 550 1150

Nursing Assistant 10 65

Other 145 355

Pharmacist 10 30

Physician 315 690

Physician Assistant 35 65 Therapist (e.g., physical, occupational) 20 85

SUBTOTALS 1,290 2,870

TOTAL SAMPLE 4,160

Documents

Center for Learning and Professional Development (CLPD ...med.dartmouth-hitchcock.org/documents/RNA_Report... · Frontline Clinicians 173 70 243 73 TOTALS 305 119 424 93 . D. Results