Topic outline

  • Welcome to the Value Champion Training Curriculum

    • Welcome Page

      We're excited to share this course on how and why becoming a Value Champion is an essential step in improving health care and health equity.

    • Each learning module is organized into sections:

      • Overview: The background and rationale for this module
      • Learning Objectives: “By the end of the session, learners should be able to…”
      • Reading Assignments: Learners are expected to complete these readings, or videos, and come to the session prepared to discuss them
      • Discussion Questions: What learners should be prepared to discuss during the session
      • Additional Resources: some of the small group exercises require the use of additional materials, those are provided here.
      • Project Application: Describes how and where to apply what they learn from this module within their project
      • Facilitator Guide: provides a rationale for the topic, a suggested agenda for the one-hour session, probes for discussion questions, and instructions for a small group exercise for the class.

  • Module #1: High Value Care and Health Equity

    Understanding the intersection between “value” and “equity” can inform conversations between value champions, leadership and stakeholders and inform early project planning activities.

  • Learning Module #2: Engaging Leadership for High Value Care

    Authors: Elizabeth Vossenkemper & Kathy Reims

    “So, an early critical step for our project was leadership engagement. And I remember having multiple meetings. In every meeting that I used to go…in the context of substance use disorder, … I would say, “Okay, so we’re doing this, it’s great, but what are we doing to safely prescribe opioids?”

    -Roberto Diaz del Carpio, MD

    “The success of this project was crucially dependent on institutional support, and, in fact, it really came out of institutional priorities.”

    -George Hoke, MD

    Overview: Engaging leadership in today’s chaotic healthcare environment is a challenge.  And for the Clinical Value Champion, it is critical!  Your project needs a “sponsor,” a respected leader who will publicly endorse your work, help you find the resources you need, and connect you to others in your organization. There are books, articles and ample resources about engaging leadership and this module is not intended to be comprehensive. Rather 6 tips used by clinical champions to engage leadership to provide high value care will be summarized.  The first four tips pertain to Project sponsors or senior leaders, the fifth takes a broader view of leadership, and the sixth turns the spotlight on you as a leader.  Some favorite leadership resources are listed as well. 

    Learning Objectives:

    1. Describe how the health care leaders in your setting think about organizational strategies and priorities.
    2. Plan a strategy for eliciting sustained leadership support in your setting.
    3. Execute your strategy to engage with leadership about your overuse reduction project.

    • Recommended Reading

    • Six tips for Engaging Leaders in your Value Champion Overuse Project URL

      RWJF Value Champions White Paper. September 2020. This reading was written by one of the RWJF Clinical Value Champions, Elizabeth Vossenkemper, and her mentor, Kathy Reims. It summarizes her experience engaging leadership within her community health center by providing “tips” you can use to do so.

      • Vossenkemper E. Reims K. “Six tips for Engaging Leaders in your Value Champion Overuse Project”
    • How to Speak so Health Care Leaders Listen URL

      This white paper describes how to craft your messaging to leaders of health care organizations in a manner that they will understand and connect with.

    • High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs URL

      The purpose of this reading is to help you understand how health care leaders think so that you can engage them more effectively in eliciting support for your project.

      • Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2013. (Available at ihi.org)   Internet Available 8/14/2020

    • Discussion Questions Forum

      Use the link above to answer these discussion questions in one forum post.

      1. How might you assess whether your topic is aligned with the priorities of the organizational leader from whom you are soliciting support?
      2. What would you do if your project aligns with organizational priorities and strategies but not those of the leader who is your “sponsor” for your project?
      3. If you only have time to present one PowerPoint slide with no more than 5 short bullets to your leadership, what are the most important points you would make?
      4. How might you incorporate the 5 High Impact Leadership Behaviors described by Swensen and colleagues into your own work as a Value Champion?
    • Project Application Page

      The learnings from this module are most relevant to activities in three phases of work in your project workbook. The first two are: “Understanding Your Project Landscape” and “Write a Project Charter.” When you explore your environment, you are identifying both formal and informal leaders in your organization who you will need to engage with to increase the likelihood of the success of your project. Your Charter is a document that can be effectively used as a tool to engage leadership, both initially and as a guide for updating them about progress. Finally, it is important that leadership is involved in helping you “Select an Overuse Topic” that is consistent with their strategic priorities, another phase of work in your Project Workbook.

    • For Instructors

  • Learning Module #3: So many to consider: Choosing an Overused Service

    Authors: Reshma Gupta and Leslie Dunlap

    “Choosing the project is key. Make sure it’s aligned with your system and your community…”

    -Roberto Diaz del Carpio, MD

    “I wanted to choose something that was really black and white to start the process of even opening up a conversation about overuse….I have three other pediatric providers that kind of worked with me to say, “Yes, this is a problem, we want to address it,” and so we went forward.”

    -Elizabeth Vossenkemper

    Overview: Overuse of health care services is widespread in most health care settings.  Selecting a target area of overuse as a value champion requires careful consideration of multiple factors that will impact success. Identifying a high value care initiative is more successful when incorporating engagement, technical merit and cultural compatibility.

    Learning Objectives:

    1. Identify at least 3 key ingredients in your setting that should be considered when selecting a target area of overuse for a reduction initiative.
    2. Incorporate input from key stakeholders (leaders, clinicians and patients) to  identify relevant overuse topics in your setting.
    3. Provide two examples of a target area of overuse in your setting that would be considered “low hanging fruit” as defined by the Newman-Toker article.

    • Required Readings

    • Setting a Research Agenda for Medical Overuse URL

      Although ostensibly an article about a research agenda, this reading also provides some guidance on criteria we should use to prioritize areas of overuse to be addressed.

      • Morgan DJ, Brownlee S, Leppin AL, et al. Setting a research agenda for medical overuse. BMJ. 2015;351:h4534. Published 2015 Aug 25. doi:10.1136/bmj.h4534.
    • Addressing Overuse of Health Services in Health Systems: A Critical Interpretive Synthesis URL

      Identifying the factors that contribute to overuse of a health care service can be informative in choosing a topic to address. This synthesis/review identifies most of the major contributing factors.

      • Ellen ME, Wilson MG, Vélez M, et al. Addressing overuse of health services in health systems: a critical interpretive synthesis. Health Res Policy Syst. 2018;16(1):48. Published 2018 Jun 15. doi:10.1186/s12961-018-0325-x.
    • A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction URL

      When considering what overused service to address, it is important to consider it within the context of the clinician-patient interaction, and what drivers of overuse are feasible for you to address in your setting with the resources available to you.

      • Morgan DJ, Leppin AL, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med. 2017;12(5):346-351. doi:10.12788/jhm.2738.
    • Where Is the "Low-Hanging Fruit" in Diagnostic Quality and Safety? URL

      This article is behind a paywall, for subscribers of LWW Journals, Quality Management in Healthcare. Check with your clinic or organization for access.

      • When considering what area of overuse to address, this article suggests that you consider three factors: simplicity of the topic, the order in which problems must be addressed, and problems with a large margin for improvement.
    • Discussion Questions Forum

      Use the link above to answer these discussion questions in one forum post.

      1. What are typical intrinsic and extrinsic factors causing medical overuse and how would they help you identify a low value care service to address? (Refer to reading “Setting a research agenda for medical overuse”).
      2. Why would assessing engagement of key stakeholders help you in selecting an area of overuse to target your project? (Refer to reading “Addressing overuse of health services in health systems: a critical interpretive synthesis.”)
      3. How might you assess the culture of overuse and how would it inform the selection of an overuse topic to address? (Refer to reading “A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction.”)
      4. What clinician/patient factors should you consider when selecting an area of overuse to target in your project? (Refer to reading “Addressing overuse of health services in health systems: a critical interpretive synthesis” and reading “A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction.”)
      5. How might developing contextual influence by identifying key stakeholders and evaluating sampling data help you select and area of overuse to target? (Refer to reading “A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction.”)
      6. How might identifying the drivers influencing medical overuse and the mode of measurement of the overused service help you prioritize selection of a project? (Refer to reading “A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction.”)
      7. Determine various de-implementation problems that can fit the “low hanging fruit” models of simplicity, order, and yield. (refer to reading “Where Is the "Low-Hanging Fruit" in Diagnostic Quality and Safety?”)
    • Project Application Page

      The learnings in this module are most directly applicable to the “Select an Overuse Topic” phase of work in your Project Workbook. 

    • Additional Resources:

    • Ways to Approach the Quality Improvement Process URL
      • Section 4: Ways to Approach the Quality Improvement Process (Page 1 of 2). Content last reviewed January 2020. Agency for Healthcare Research and Quality, Rockville, MD.
    • How to Begin a Quality Improvement Project URL
      • Silver SA, Harel Z, McQuillan R, et al. How to Begin a Quality Improvement Project. Clin J Am Soc Nephrol. 2016;11(5):893-900. doi:10.2215/CJN.11491015

    • For Instructors:

  • Learning Module #4: How to Conduct a Stakeholder Assessment and Why it is Important

    Authors: Robert Fogerty & George Hoke 

    “Another key was a very detailed stakeholder analysis…We learned that we needed to include both nurses and patients in this conversation.”

    -George Hoke, MD, University of Virginia, Charlottesville

    “The number of different departments that I’ve engaged with over this fellowship is actually really incredible and has opened up a lot of opportunity for other relationships for other types of projects.”

    -Elizabeth Vossenkemper, PNP, Tricities Community Health Center, Pasco, WA

    Overview:  The purpose of this module is to introduce the concept of a stakeholder, explain why identifying and engaging them is important, and present approaches for doing so. Any effort to reduce the use of a service impacts multiple stakeholders across an organization. Stakeholders can impede or facilitate your work as a value champion, therefore it is important to understand who those stakeholders are, how efforts to reduce a service will impact them, and approaches to engaging them in your work to increase the likelihood of reducing the use of an overused service.

    Learning Objectives: “At the conclusion of this learning activity, value champion fellows should be able to…”

    1. Describe the reasons why a stakeholder analysis is beneficial when considering a project in high value healthcare
    2. Describe some common stakeholder positions
    3. Develop a strategy to identify stakeholders in the planning stage of a project

    • Required Readings

    • How to Manage and Influence Internal Stakeholders URL

      This article is behind a paywall but you can often read it as one of your limited "free" articles. Check with your clinic or institution for access.

      This article was written from the perspective of someone who is a “buyer” for their organization. Whenever you see the word “buyer” substitute the phrase “clinical champion” (You!). The 5 tips to identify, manage and influence stakeholders within your clinical setting will then make a lot more sense!

      • Jonathan Webb, How to Manage and Influence Internal Stakeholders, Forbes, Dec 27, 2017.
    • Five Questions to Identify Key Stakeholders URL

      This is article is behind a paywall. HBR will allow you one "free"  article a month. Check with your clinic or institution for access.

      The list of potential stakeholders from the large practice of brain and spine surgeons is particularly interesting in this article. It also provides an example of how you need to expand your beyond your usual clinical silo if you are to successfully identify important stakeholders.

      • Graham Kenny, Five Questions to Identify Key Stakeholders, Harvard Business Review, Mar 6, 2014.
    • Identifying and Determining Involvement of Stakeholders URL

      The list of questions for potential stakeholders is especially helpful. They answers to the questions will inform your decisions about which stakeholders you should expend more effort to engage with.

      • Identifying and Determining Involvement of Stakeholders, Centers for Disease Control and Prevention.
    • Discussion Questions Forum

      Use the link above to answer these discussion questions in one forum post.

      1. The CDC reading uses the example of sexually transmitted disease to work through stakeholder identification. What lessons can you take from the CDC example that could be extrapolated to your project?
      2. How might you reframe the “Five questions to identify key stakeholders” to make them more relevant to your overuse reduction project?
      3. Who do you think might be key stakeholders in any health care organization when you are trying to address overuse? Why are they crucial to success?
      4. Once identified, how might you prioritize who you need to engage with, what questions would you ask them and why?
    • Project Application Page

      The learnings from this module are most applicable to the “Understand Your Project Landscape” phase of your project in the project workbook. 

    • Additional Resources

    • For Instructors

  • Lesson #5: The Patient Voice: Engaging Patient Participation in Your Project

    Author: Kelly Rand

    “So, before I started, or as I was going through this, one of the pushbacks [from physicians] was that patients would not be able to do this. So, I did a qualitative interview informally with patients… And in the entire group that I spoke with, they were all in favor of doing this and said they had unlimited text messaging capability and would like to do this.”

    -Lauren Demosthenes, MD

    Overview: Incorporating the patient's perspective and voice in efforts to decrease the use of services has proven to be extremely important for overuse reduction efforts. This Module aims to help participants understand why that is so and provide examples of how value champion fellows might incorporate the patient's perspective in their overuse reduction initiative.

    Learning Objectives:

    1. Understand the spectrum of patient engagement and the benefits to each level.
    2. Experience conversations about overuse from both clinical and patient perspectives through role play and become better attuned to the patient perspective on overuse and what communication levers elicit meaningful stories.
    3. Give examples of three types of ways to engage patients in the project and in sharing their stories.

    • Required Readings

    • Engaging Patients and the Public in Choosing Wisely URL

      This paper provides a compelling framework for different levels of patient participation in your efforts to tackle an overused, low-value care service in your clinical setting.

      • Born KB, Coulter A, Han A, et al. Engaging patients and the public in Choosing Wisely. BMJ Quality & Safety 2017;26:687-691.
    • The Science of What Makes People Care URL

      The 5 principles of engaging others in change efforts is applicable not only to patient participation in your efforts, but also your colleagues and everyone within the clinical setting where you work.

      • Christiano, A & Neimand, A. The Science of What Makes People Care. Stanford Social Innovation Review. Fall, 2018: 26-33.
    • Why Physicians Should Trust in Patients URL

      Provides a compelling rationale for how and why physicians need to trust their patients, especially when discussing low-value care.

      • Grob R, Darien G, Meyers D. Why Physicians Should Trust in Patients. JAMA. 2019;321(14):1347-1348. doi:10.1001/jama.2019.1500.

    • Communicating About Overuse with Vulnerable Populations URL

      What do vulnerable patients think about the topic of overused services? Are our assumptions correct? This results of these interviews may challenge your assumptions.

      • Rand, K. Communicating About Overuse with Vulnerable Populations. 
    • Discussion Questions Forum

      Use the link above to answer these discussion questions in one forum post.

      1. In Christiano and Neimand’s article on “The Science of What Makes People Care,” they name storytelling as one of the top five tools. Can you think of a time when a story changed your mind or helped you develop an opinion about an important issue?
      2. Overuse is often discussed as a result of the U.S.’s fee-for-service system. The Born et al. article is written by a coalition of international campaigns with varying payment structures looking to reduce unnecessary testing. Discuss drivers of unnecessary care for both clinicians and patients? How do you think those drivers affect the stories clinicians and patients tell themselves?
      3. In what ways does trusting your patient make having an overuse discussion easier?
      4. The article by Kelly Rand discusses possible consequences of unnecessary care and poor communication. How do you think listening to patients to hear their story (rather than listening to get the answers to the questions you feel are important as a clinician) will change your interaction dynamic? Do you think your conversation will have different outcomes?
    • Project Application Page

      The learnings in this module are relevant to the “Understand Your Project Landscape,” “Build Your Team,” and the “Design and Implement” phases of work in your project workbook.

    • Additional Resources

    • For Instructors: 

  • Lesson #6: Measurement, Data & Trust: Supporting Change with Data

    Authors: Roberto O. Diaz Del Carpio, MD and John N. Mafi, MD, MPH

    “[A challenge] is the lack of… knowing …How many providers are actually prescribing these medications? What’s the volume? They need the data to help them with that black and white on paper to indicate there might be a problem.”

    -Roberto Diaz del Carpio, MD

    Overview: To build a culture of trust, innovation, and improvement; it is essential to share transparent, meaningful and actionable data about the targeted overused service with stakeholders. Pre-defined measures of overuse are often not readily available and reliable sources of data can take time to identify and even longer to extract into actionable measures within a report or dashboard for providers. Reliable and valid data translated into measures that are clinically meaningful are often critical to getting provider to the table for a discussion about your targeted area of overuse. In addition, it is also extremely important to confirm impressions about the rate of overuse in your setting when selecting your overuse topic/service for your project. Some projects have been derailed because initial anecdotal impressions about a service being frequently overused are not supported by the data.

    Learning Objectives

    1. Describe the differences among outcome, process and balancing measures for an overuse initiative
    2. Understand the steps needed to identify your data source, method of collection, measure specification and how these measures will be reported.
    3. Discuss how to effectively present data that reveals variation in rates of overuse across settings and providers.

    • Required Reading

    • Balancing Measures or a Balanced Accounting of Improvement Impact URL

      Although not focused on de-implementing a low-value care service, the explanation of a ‘balancing measure’ should clearly translate to addressing overused care.

      • Toma M, Dreischulte T, Gray NM, et al Balancing measures or a balanced accounting of improvement impact: a qualitative analysis of individual and focus group interviews with improvement experts in Scotland BMJ Quality & Safety 2018;27:547-556
    • Value of Small Sample Sizes in Rapid-cycle Quality Improvement Projects URL

      A surprising explanation of why large numbers of observations on rates of use of an overused service may not be necessary, and the implications of that for tackling low-value care.

      • Etchells E, Ho M, Shojania KG Value of small sample sizes in rapid-cycle quality improvement projects BMJ Quality & Safety 2016;25:202-206.
    • Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery URL

      A great example of efforts to reduce low-value pre-operative care, how data and measures were obtained used, along with an important example of a balancing measure.

      • Mafi JN, Godoy-Travieso P, Wei E, et al. Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System. JAMA Intern Med. 2019;179(5):648-657. PMC6503569
    • Discussion Questions Forum

      Use the link above to answer these discussion questions in one forum post.

      1. In reading Toma et al, why do you think balancing measures might be particularly relevant in tracking efforts to reduce the use of an overused or unnecessary service?
      2. Finding data and measures on rates of use of a low-value care service from existing sources of data in your organization can cause significant delays in efforts to intervene. How might the article by Etchells et al. change your approach?  
      3. In the reading Mafi et al, how was the QI nurse able to leverage measurement in order to inspire reductions in low-value care across the Los Angeles County safety net health system? 
    • Project Application Page

      The learnings in this module are most relevant to the “Obtain Data and Select Measures” section of the Project Workbook. In addition, the “Understand Your Project Landscape” phase of work includes identifying potential sources of data for your overuse project and points out that dedicating some resources to measurement will probably be necessary, so identifying those resources is important.

    • Additional Resources

    • Working in Concert: A How-To Guide to Reducing Unwanted Variation in Care URL
      • “Working in Concert: A How-To Guide to Reducing Unwanted Variation in Care.” California Health Care Foundation. September 2014

    • For Instructors:

  • Topic 8

    • Topic 9

      • Topic 10