The Road to Commendation

1. The Road to Commendation 2013 Joint KMS and MSMA CME Provider Conference

2. Moderator & Panelists • Rebecca Gaughan, MD • Kansas Medical Society CME Committee Chair • CME Director, Olathe Medical Center • Micah Flint, Chief Programs Officer • Institute for International Medicine (INMED) • Melissa Haddad, CME Coordinator • Via Christi Hospitals Wichita, Inc. • Liz Coon, CME Coordinator • Wesley Medical Center • Traci Lewin, Medical Education Coordinator • Olathe Medical Center

3. Criterion 16 • The provider operates in a manner that integrates CME into the process for improving professional practice.

4. Criterion 16 NOTE: The onus is on the provider to show that they have inserted CME into the processes to improve professional practice. Providers need to show that their CME program has a presence, influence, or contributory role in practice improvement. The provider goes beyond activity planning to show that CME is used as one of the tools to improve professional practice. C16 can also be about the use of CME in facilitating systems based quality improvement activities if the quality improvement activity is about changing professional practice.

5. C16 - Tips and Tricks • Keep it Simple. • This is the entire purpose of CME. Every single provider is doing this task, they just need to document it. • Set up a yearly meeting with all Quality people to discuss what they are working on and what can be scheduled for the next year.

6. Criterion 17 • The provider utilizes non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback).

7. Criterion 17 NOTE: The surveyor is looking for evidence of the use of strategies such as, but not limited to, rewards, process redesign, peer review, audit feedback, monitoring, reminders as tools to enhance, or facilitate change. Some providers are concerned that some of these may be considered ‘educational’ as they potentially change what people ‘know’ or because they inform learners (e.g., “It may be time for you to call back your patients with …”). In C17, the surveyor is looking for tactics that go beyond the educational activity or intervention. Essentially, the surveyor Is looking for providers to be broadening the range of tools they use to facilitate change.

8. C17 – Tips and Tricks • Captivate the Audience. Social media provides one great resource to engage learners and incorporate Criteria 17 into your CME activity. • Keep a folder of Non-Educational Strategies to put items in it throughout the year so you don’t have to struggle to think of any while you are doing your application. • I’m sure every provider is doing this task as well, but just not tracking it. I like to keep a folder of Non-Educational Strategies in an easy-access place to just grab things from meetings and hospitals including Joint Commission updates with physician recommendations and our medical staff orientation book.

9. C17 – Tips and Tricks • I’m sure every provider is doing this task as well, but just not tracking it. I like to keep a folder of Non-Educational Strategies in an easy-access place to just grab things from meetings and hospitals including Joint Commission updates with physician recommendations and our medical staff orientation book.

10. Criterion 18 • The provider identifies factors outside the provider’s control that impact on patient outcomes.

11. Criterion 18 NOTE: The provider has data and information that explains patient outcomes, beyond the performance of their learners. Here the provider demonstrates knowledge of the factors contributing to the health care ‘quality gap’ about which they are concerned.

12. C18 – Tips and Tricks • Get the whole picture. Identifying barriers outside of your learner’s control, that impact patient outcomes, will help in planning your CME activity. • Every single activity has its own issues. If you document the edge of the extent to which you can improve physician practice, you can attain this criterion.

13. Criterion 19 • The provider implements educational strategies to remove, overcome or address barriers to physician change.

14. Criterion 19 NOTE: The provider has data and information on barriers to change applicable to its own learners, and incorporates these insights into its CME program through activities. In C19, the provider shows that activities are included in their educational program that are focused on ‘overcoming barriers to physician change.’

15. C19 – Tips and Tricks • We identified Electronic Medical Records (EMR) as a barrier. • To help overcome this barrier we had a program to teach physicians how to use the computer as a positive instead of a negative during patient appointments. • We also worked with the IT department to develop educational training programs. • We grouped the physicians by specialty in small classes so questions would be relevant to all participants.

16. C19 – Tips and Tricks • This measure involves documenting “putting out fires” in daily CME life. You can assess this by asking the good old: who, what, when, where, why and how. If there’s a gap? You have your barrier.

17. Criterion 20 • The provider builds bridges with other stakeholders through collaboration and cooperation.

18. Criterion 20 NOTE: The provider allies itself with other organizations or components of its own organization in a purposeful manner to achieve common interests. These collaborations may support any aspect of the provider’s CME program in service of achieving its mission. Joint sponsorship, in itself, is not consideration a collaboration that will guarantee compliance with C20. However, joint sponsorship can be a byproduct of a larger collaboration and if this larger collaboration is described, then it could result in compliance with C20. In C20, the surveyor is looking for active engagement in collaborative and cooperative projects.

19. C20 – Tips and Tricks

20. C20 – Tips and Tricks • Brainstorm Stakeholders for your CME Program

21. C20 – Tips and Tricks

22. Wesley CME application Number of 2013 Stakeholder Groups Identified and Connected to Approved CME Activities

23. Criterion 21 • The provider participates within an institutional of system framework for quality improvement.

24. Criterion 21 NOTE: The provider is focused on integrating and contributing to healthcare quality improvement. In C21, the provider has evidence that CME has become a part of institutional, or system, quality improvement efforts. ‘System’ can also include the network of other organizations in the health care ‘system’. (Note: organizational self-assessment and improvement focused on improving the quality of the CME program are recognized and rewarded in C12-15, not in C21.)

25. C21 – Tips and Tricks • The Manager of Medical Staff Services and the Chief Quality Risk Officers both sit on the Medical Education Committee • The CME Coordinator meets weekly with the Manager of Medical Staff Services. Part of the meeting is to review possible topics regarding quality. Those topics are then forwarded to the Medical Education Committee for review. • Programs result from quality improvement issues/updates discussed in regular Medical Staff Meetings.

26. C21 – Tips and Tricks • Call your director of quality, invite yourself to a meeting. Everyone can start working with QI today!

27. Criterion 22 • The provider is positioned to influence the scope and content of activities/educational interventions.

28. Criterion 22 NOTE: In C22, there is an expectation that the provider will play a meaningful role in the formation and direction of activities across its entire CME program.

29. C22 – Tips and Tricks • “Example 4. The provider’s framework and processes position the organization to influence the scope and content of its activities. In addition, the provider cooperates with other similarly-focused specialty societies to develop a core curriculum and ensure that the education obtained is consistent for the specialty. The content of the curriculum is shared with the planning committees for CME activities, so there is continuity regarding major issues and topics.” http://www.accme.org/sites/default/files/504_20130321_Accreditation_Findings_Compendium.pdf • “Yes, Wesley CME is positioned to influence the scope and content of activities/educational interventions. If a physician education activity is requested, it’s through the CME office… Every single CME application documents this effort.” WMC 2011

30. Wesley Medical Center CME Application • Educational Design and Format • Planning Process • Needs Assessment • Outcomes Evaluation Involvement Document

31. Via Christi

33. C22 - What not to do “Example 6. Information collected from the review of activity files and the survey interview showed that the provider delegates many aspects of its CME program to third parties with no mechanism for oversight or reporting. Examples of these delegated functions include activity planning, interaction with planners and speakers, content development and review, and the management of commercial support.” http://www.accme.org/sites/default/files/504_20130321_Accreditation_Findings_Compendium.pdf

34. Accreditation with Commendation If a provider is found in compliance with: • (a) Criteria 1-15; and • (b) all but one of Criteria 16-22 • (c) and the policies measured The provider is eligible to submit a voluntary progress report to be considered for a change in status to Accreditation with Commendation.

35. Thank you!