Spreading the gospel of QI one person at a time

Academic detailing an underused tool

Academic detailing — a way of teaching novel concepts one on one — started as a way for pharmaceutical and medical device companies to quickly disseminate information about new drugs and devices by having individual physicians spread the word among their peers. But it is moving beyond its initial purview to other areas, including to hospital quality improvement directors as a way to lead providers to adopt changes willingly.

"Pharma was so effective in engaging physicians," says Barry Patel, Pharm.D., president and co-founder of Total Therapeutic Management, Inc., in Kennesaw, GA, which provides services related to academic detailing to physician practices, health systems and, increasingly, to hospitals. "This is a way to share evidence-based guidelines, identify outliers, and provide them with specific knowledge that will help them improve."

Because academic detailing involves one-on-one learning, it is much easier to get very specific information out and about, Patel says. For instance, if you want to prevent readmissions, you can identify multiple reasons that might apply differently to various providers. What one needs to know may differ from the information that may benefit another. Further, by working individually, you can ensure that physicians don't feel cornered or embarrassed by having their "weaknesses" broadcast. They are even more willing to ask questions that in a public setting would be considered simplistic or even stupid, he says. "They will sometimes admit things they would never admit in another setting."

It may seem inefficient and expensive, but Patel says with proper targeting of data, you can actually make it a more efficient way of changing behavior and implementing change. "With the right data, you can drill down and see who needs the most help on an issue; you can find the outlying physicians." For those doctors, nurses or other providers, peer-to-peer conversation is probably the most effective way of getting them to listen. "And if you end up saving just one or two readmissions, you can cover the higher 'cost' of this individualized learning." This is especially true as more dollars are put at risk for unplanned readmissions, adverse events, and hospital-acquired infections, Patel adds.

The art of doing this well involves how you talk to the physician, whether you are doing it with an internal person or outsourcing the detailing to an organization like Patel's. They have to be able to assure the physician that their concerns about the validity of the data are heard. "They often tell us that patients are sicker, and that's why they are outliers," he says. "We acknowledge the concerns, let them comment, and tell them we are just providing the information for their knowledge." The unthreatening presentation often works in a way that more direct methods don't — the learners end up listening to information about the evidence-based practices that they had either resisted or applied imperfectly in the past.

Patel says for inpatient settings, it's probably better to use internal thought leaders to do the detailing rather than outsourcing it. However, "you have to find that one person whom everyone loves and respects," he advises. "You need someone who understands that disseminating tough data is hard and has to be done thoughtfully."

Timothy Hannon, MD, MBA, the medical director of blood management at St. Vincent Hospital in Indianapolis, has used academic detailing in his own facility and also brought it to others as a consultant. He says that for quality improvement directors, knowing who the opinion leaders are on every unit and in every department could be very helpful not just to assist in reining in outliers for existing quality improvement programs, but also for getting buy-in for new programs.

"These are the people who are most trusted clinically," he says. "And don't assume it's the department head." In most cases, it probably won't be, Hannon says. The department head, the unit nurse — they are often seen as "them" or a "suit" who doesn't understand the clinical staff who work in the trenches. "They become irrelevant."

Along with the highest clinical regard, the thought leader is usually the most abreast of current literature. They are the ones who are asked about new treatments, controversial topics, and novel processes, Hannon says. "Most physicians don't have time to read all the journals, but there's always someone who does."

The thought leader also should be well-regarded by peers. "If you are looking for someone in cardiology, ask who they would want to come help them if things went to hell in a hand basket in the cath lab," Hannon says. "And ask them who they would want to treat them, or their mother, or their son or their husband." If you find the same name coming up in answer to all those questions, "you are on to something."

Hannon says that in patient safety issues, he wants to use every tool he can to change behavior. "It can take 17 years to integrate innovation," he says. "This is something that works. It gets people to adopt and own change." And if the cost and time involved is more than putting out some written educational material or doing an in-service with the whole staff, Hannon says to consider the cost of inaction and the cost of delay. He speaks of creating a change-accepting environment in terms of war — house-to-house battles as you try to expand something from unit to unit. "I don't think it's a fair fight for patient safety and to change practice, so I want everything I can use to accelerate it."

Hannon's work is in changing behavior around the practice of blood products — something that crosses multiple departments and has multitudes of stakeholders. This method, though, is one that Hannon says has been more successful than others. "You have to make use of the opinion leaders. If you know who they are in your facility, you really only have to detail one person — him or her. Then they become the force multiplier and evangelize the process or system." To a degree, just having that key person on board evokes change that comes passively, without teaching or effort, because that is the person everyone wants to mimic. "Identify them and they will push it out to the rank and file."

For more information on this topic contact:

  • Barry Patel, Pharm.D., President and Co-Founder, Total Therapeutic Management, Inc., Kennesaw, GA. Telephone: (770) 795-0935. Email: bpatel@rxttm.com
  • Timothy Hannon, MD, MBA, Medical Director of Blood Management, St. Vincent Hospital, Indianapolis, IN. Telephone: (317) 575-9301 ext. 226.