>>SINGER: So, if we take a step back for a moment and talk about the ACCME and state medical society accredited continuing medical education providers many of them work within a hospital environment, they’re the hospital CME department. Some of them work within, at a healthcare system level as a central coordinating group between the CME function at various institutions, various hospitals and centers. And then certainly there’s whole group of professional organizations, insurance companies, for profit education companies, specialty societies, etcetera. Within the perspective of our criteria, our expectation of those providers, is that we say to them that if you are connecting your CME, the education that you are doing, to a problem in practice, whether that practice is clinical practice, as we’re discussing, or other types of practice like teaching or administration or research; if you’re connected to a problem in practice and you’re looking to measure what happens as a result of that education and to try to change the practice of those physicians and health care teams as a result of the education that that’s sort of our criteria in a nutshell. Within that perspective, because there’s so much variability in the type of provider and the type of practice that we’re looking at, we tell providers that minimally we’re looking for a change in competence, not competency as the medical world defines it, but competence in an adult education standpoint in terms of the strategies that someone has to apply to their practice. So, competence is a minimum, changing strategies, performance, what the practitioner does, or patient outcomes, what’s downstream. So, within that spectrum there are CME providers within healthcare institutions that are addressing different points of that spectrum. Here, with your accountability measures we see that and we can talk about sort of how some strategies that they might take, but there’s an alignment between choosing to address performance and patient outcomes issues sort of specifically within the context of what’s involved in accountability measures and as you sort of stated in your definition of accountability measures. An accountability measure is by definition that within the institution there is a difference between what the team and system and coordination of care is currently doing and what it should be doing or could be doing. So, within that context, what I’d like to spend sort of the last several minutes exploring with you is what are some of the mechanisms, the areas of fulfilling your requirements for hospital accreditation that could be meeting places between CME, professional CME leadership, and the hospital, quality, safety, executive interests and perhaps medical staff, you can sort of dimensionalize this for us.
>>SCHYVE: Yeah. You mentioned, at one point, the team work, and so, what I’d like to do is in answering that question is maybe differentiate between something that one does in terms of improvement for a particular patient or a particular illness. Those are the kind of things that are measured usually by those quality measures. So, Have you given the beta blocker?
>>SCHYVE: You know, Have you given aspirin when somebody comes in with chest pain? Those kinds of very specific questions that are measured. Those are some of the things that can be can be conveyed through CME. So, I think you can see continuing medical education in the context not just however of the physician, but also, of the team. To do these things successfully often means not simply that the physician has been, you know, remembers to order the beta blocker at discharge, you set up hospital systems that essentially facilitate that.
>>SCHYVE: And so, you’re talking about more than just the physician in terms of continuing education. The second thing is that around these particular issues often it is around a specific practice. If we start to look at safety issues, we start to realize that we really need to think much more broadly in terms of the system and how an individual works within the system. So, you really can’t create safety if, in fact, you keep thinking about only the behavior of one individual. So, to train physicians to do X differently isn’t really going to solve many of the safety problems. It comes out of both the culture of the organization and how teams work together. And so, one of the issues that I think is important for, for CME to focus on and for the leaders, the C suite of and an organization and the CME directors and staff to focus in on, is how do they, in fact, help both the physicians, but others within the organization, also, to learn to do things in different ways in terms of the system.
>>SCHYVE: And, and that, I think, will be more productive in terms of improving, certainly safety, but I would argue also, the quality of care in the healthcare organization. Let me give you a specific example to tie that together. I used the example earlier that people understand that you know, we should be washing our hands between patients, we’re generally not doping that. And when I say generally not doing I’ll give you some statistic in a second which is kind of amazing. So, one of the things that we did was create another third unit of the enterprise, again 501(c) 3 not for profit called the Center for Transforming Healthcare. And the idea behind the Center was that people would identify problems like hand washing, but they would try to put in place a solution that they saw from someplace else. And as I said before would find that either it didn’t work that well for them or they couldn’t sustain it very easily. And it turns out that the reason for that is because they haven’t looked in their own organization at exactly what is the cause in our organization for having that problem. The Center has a number of hospitals that have now have agreed actually to work with the Center around these kind of issues. And the first issue they happened to pick was that of hand washing. Well, the first thing is although they realized problem upfront they all thought they were doing it probably 85% of the time. How do we get to 100%? When they actually carefully measured with observers, who were not known to be there observing, they were at 48%. A dramatic difference, not only in terms of what it means for infection control and prevention, but also, in terms of one’s understanding of what we’re actually doing in a particular healthcare organization. So, then they started to use some very rigorous techniques. We call them robust process improvement techniques. Things that come out of things like Lean and Six Sigma to try to identify the actual causes in each of their organizations. There were eight hospitals that actually
>>SINGER: so, let me interrupt for a moment. So, within our parlance or within the CME professionals parlance we’ve discussed a quality gap or professional practice gap of the team
>>SCHYVE: Right. I would call it the safety gap of the system
>>SINGER: OK. The safety gap and what you’re doing now is sort of a root cause analysis to figure out what’s at the basis of
>>SCHYVE: Right. In each hospital separately
>>SCHYVE: and. This is up on our Web site. There’s this fascinating table that has the hospitals, we didn’t identify them by name, but A, B, C, D, E across the top of this table and down the side were the different kinds of causes they found. So, for example, some of them found that the problem was they had these handy alcohol gel dispensers, but people would walking in and out of patients rooms holding something in their hands. What do you do with this when you’re supposed to be putting, you know, using the alcohol gel dispenser? In other kinds of situations the architecture was such that you often didn’t carry things in and out of the room, but the alcohol dispensers had been put up by the engineers, who were listening to the , you know, fire commissioners and they were all not particularly handy. Other cases, the staff truly didn’t know, that just because you’re wearing gloves doesn’t mean that you don’t have to wash your hands. So, there were different reasons, and, in fact, this table is fascinating, because no two hospitals had exactly the same picture of the causes they had. And no single one of these causes appeared in every single one of the hospitals. So, now what they did is say, OK., for our causes let’s develop solutions. And so what we’ve done is put those solutions in a database. We’ve provided a tool that organizations can use to try to figure out, What are our causes in our organization? Without having all the skills of rigorous kinds of work that these organizations did. Diagnose what the causes are here, now I can go to the database and get the right solution. Out of this comes two things that have to do with continuing education, it seems to me. One is that, ah, now we have some actual workable solutions for an individual organization, in which a whole bunch of different people within that organization play a role, including obviously, physicians. So, this the solution, the appropriate solution that seems to be put in place for a particular organization or a couple of different solutions are the ones that, in fact, can be part of continuing medical education in that organization. And again, I would say that
>>SCHYVE: I’d also have to include
>>SINGER: process change, administration, sorry
>>SCHYVE: The second thing is, thinking about what needs to be done, understanding that this is, has to do with how the team works together, of how you understand problems and their causes. That in of itself is something that physicians, nurses, and so on, need to have education in. So, it’s both the issue of here’s a specific change we need to make, just like here’s the change we need to make so we give the beta blockers to all the patients with MI when they’re discharged; here’s the specific thing we need to change so that, in fact, we are all, we wash our hands between patients. But, in addition, it’s clear that taking it just one piece at a time doesn’t help people understand how this all fits together. How should I think about how I make improvements in this organization? What’s my role as a physician in thinking about the systems and processes? I’ve often, as we started to learn more about this I realized that when I was trained and I think this is true for many physicians; when we were trained we thought of our obligation to first do no harm, but we focused it on our individual patients. I think what we’ve begun to learn is that I can’t fulfill my obligation to first do no harm to my patients unless I invest in the systems and processes that are creating the vulnerabilities. It literally has to be part of what I need to do in order to fulfill my responsibility to first do no harm to my patients; I need to be committed to figuring out with others how do we first do no harm to all our patients, because my patients are part of that group. And I can’t control it just with my own behavior. And that’s an educational process. That’s learning both how to think differently about what my work is as a physician. It’s to think differently about how do we make improvements in safety and quality. It’s to think differently about what exactly is the role, my role in a team, and how do we make sure that the team is providing safe care.
>>SINGER: Sure. Ands that can be a tremendous opportunity for leadership and coordination between, in a strategic way, between CME professionals
>>SINGER: other hospital leaders and hospital executives and the place where that occurs can be in grand rounds. It can be in initiatives. You know, we have to sort of break
>>SCHYVE: yes, yes
>>SINGER: break free of our thinking that it can’t be in those sort of venues.
>>SCHYVE: and it includes what goes on in a, say a physician’s practice based learning to use on of the competencies from ACGME’s
>>SINGER: ACGME sure
>>SCHYVE: and ABMS. It also, it also involves a better understanding of this, this other competency ACGME , ABMS, competencies and that is the system’s based practice. It’s understanding that that for me as a physician to really understand system’s based practice doesn’t mean that I learn about the system out there. That, in fact, I have to understand in order to provide good care to my patient. It also means my understanding, what’s my, I’m actually in a system, what’s my role in that system? Who are the other members of the team in that system
>>SCHYVE: and how do we, in fact, work together to create safety and quality?
>>SINGER: Now, there’s a very easy and clear alignment between the things that we’re talking about and the way in which maintenance of licensure is, is developing
>>SINGER: maintenance of certification,
>>SCHYVE: that’s correct.
>>SINGER: both of which are focused on, sort of looking within your practice and within your system to see how you’re doing and how you can improve. And the way in which you’ve described all these approaches and these great opportunities for CME it’s very natural and automatic with trying to improve quality and safety.
>>SINGER: Now, we both know from a pseudo-regulatory perspective, not a government regulatory perspective
>>SINGER: as accreditors that when we talk to our providers they clearly have shared goals, they have a shared value system regarding these things, but they also want to know, OK. But how does this connect to my when you come around for the accreditation survey. So, I want to sort of if we can segue into talking specifically how these things, these approaches, these, the vision and mission of this, connects, does it connect well with requirements? Are their places where the Joint Commission requirements either related to CME or related to physician professional practice, you know, where we can sort of kill two birds here?
>>SCHYVE: I think there is, and in fact, we are in discussions with others about how to relate some of these ideas to what goes on in maintenance of certification. The issue is, what is our ultimate goal? And, our, now meaning, Joint Commission, the Healthcare Organization, the individual physician, and other, other folks, nurses and so on. Our ultimate goal is to provide safe and quality, high quality care to patients. All of us share that same goal. We didn’t share goals we’d all be in trouble.
>>SINGER: Right. A shared vision.
>>SCHYVE: But, we have this shared vision, and , and we at the Joint Commission have, in fact, created a vision statement, that not only says that’s our goal but that we want to do that really consistency, consistently. So, it’s happening all the time.
>>SCHYVE: And that’s another, almost another level of how you do this well. How do you make sure that it happens every time. But, since that’s a shared goal. That is the goal in what we’d like to help and influence organizations to do. We, of course, we accredit organizations, that actually within them physicians and other practitioners work. How do we help the organization, in fact, provide, improve that consistency with which they provide high quality, safe care. And many times if we look at an organization that over time we’ve developed these different silos in the organization, you know, oh well, here’s this thing that needs to be done, maybe because somebody requires it. Here’s this other thing that needs to be done, maybe because somebody else requires it. And I think that what we’re trying to move toward, is say look we’ve got the, here’s the ultimate goal that we all share. How do we, in fact, do that; how do we, in fact, set expectations and guidance for what an organization should do? Just as you set expectations and guidance for how CME should be conducted what we’re really talking about is, is how do we do this in a way that’s all focused on this the shared goal high quality, safe care? And thinking of it from that point of view what does this do in order to focus better on the issue of quality and safety of care. It means that we have to, in fact, be working together how does this all fit together. We can’t, we’re not going to be able to succeed in maximizing the effect, we again thinking about not just the Joint Commission, but, you know, healthcare. We in healthcare can’t succeed on maximizing the quality and safety of care if we, in fact, carry out all these things as if they’re separate silos. So, and to the degree that we start to think that way it also, I believe, as you were asking, will be reducing the redundancy. If, in fact, what goes on in maintenance of certification, if what goes on in continuing medical education, if what goes on because of pay for performance coming from, say, CMS, if what goes on in terms of the Joint Commission’s expectation for what an organization is, is supposed to be doing. If all of those things are focused on the quality and safety of care we’ll start to see the synergies between the activities and as we develop those synergies I think we will see the, oh, this CME process also fulfills some of the requirements that an accredited, a certifying body wants for board certification. Ah, these CME activities actually are a way for an organization to be meeting some of the Joint Commission requirements. I must admit that if I look currently at the Standards on, on the medical staff chapter for hospitals about the participation for physician’s in continuing education it’s kind of over here as this as this silo. It basically says, oh and by the way, I think, literally, it’s the last standard in the chapter, Oh by the way one of the things that needs to be taken into account when you appoint people when you credential them when you appoint them you’ll be given privileges is, are they participating in continuing education? And you know, they need to focus in on something that’s relevant to what they do etcetera. But, the fact is, it’s kind of like this add on. And really it needs to be a central mechanism that an organization uses to make the kind of changes in quality and safety that the organization wants to make. I would hope that if people think this way, the CEO of the organization, and others in the C suite, you know, chief medical officer, chief nursing officer, and so on, would perceive that the work that’s being done by continuing medical education, and I’ll use the broader continuing education that that’s one of the powerful techniques for that organization to use to make the changes that it wants to make in terms of quality and safety.
>>SINGER: So, we’ve talked about some very broad themes and shared values about improving quality and safety and, and how the goals of the Joint Commission in, in supporting it’s providers sort of evolution along that path very much matches up with what CME’s goals are and what our expectations of the providers are. So, let’s sort of zero in on a specific Joint Commission requirement within the Medical Staff Standards there’s a requirement for ongoing professional practice evaluation, focused professional practice evaluation, FPPE, OPPE, can you, can we explore that a little bit?
>>SCHYVE: Sure. Let me first just make clear the Ongoing Professional Practice Evaluation is the ongoing collection of an analysis of data that is related to, to the privileging and the renewal of privileges for an individual. Sometimes in the collection of that data a flag goes up you don’t quite know what it means, but you say, well, I wonder why this is happening? Maybe an increase in the complication rate for a particular physician. And then that means that you now do Focused Professional Practice Evaluation. The idea of the focused is you’re focusing in on that particular issue you’re gathering information from potentially other ways you may have simulation, you may even have somebody observe that person’s performance for a period of time. But, all of this, the FPPE and the OPPE are focused on making decisions about appointment to medical staff and about privileges clinical privileges that a person has.
>>SINGER: Are these focused on the individual physician only?
>>SINGER: Or can it do practices do this as a group or it’s all individual?
>>SCHYVE: Well, that’s a great question. The requirements in the standards for FPPE and OPPE are focused on the individual physician, because the privilege the appointment and privileging decisions are physician by physician. And just as a reminder they actually are recommended by the medical staff, but it’s the board of the organization that actually makes the final decision. So, it’s the board of the hospital that literally grants a particular physician a particular set of clinical privileges. And so, this is the kind of data collection and analysis mechanisms for making sure that those decisions are evidence based and are in the interest of quality and safety of care for patients. With that understanding, then there’s a couple of things that it seems to me that CME clearly can and should be feeding into this process. One is that, if in fact, there is an issue that’s identified for the individual physician that may indicate to CME to CME staff that how can we help the physician with that particular issue? But, the second thing is that, as you were just asking, you obviously now have information about groups that work together, teams that work together. So, the first thing is you’ve collected information which you can now use and bring together to look at across more than one physician, which now could identify opportunities for a quality improvement
>>SINGER: so this sort of bridges our previous discussion
>>SCHYVE: that’s right. Exactly. So, if we think about this now as the team whether it’s in the OR, which of course some members may be constantly changing, but nevertheless what goes on in the OR obviously is team, teamwork. So, the question is, ah is there something here that we’re seeing that when we look at the physicians and the teams that work together to do say a particular procedure that we could make improvement here. And that, that would mean CME could both be providing help around a particular improvement project, but also, as I was suggesting before not just around this specific project, but around these broader concepts of, How do we study and improve the teamwork that we have? One of the critical aspects of teamwork is communication and we’ve certainly discovered as we’ve looked at what we call sentinel events those that when people do a root cause analysis of an event where somebody has been truly, seriously harmed or died, because of, say, an error; that the most common root cause that we discover is that there was a breakdown in communication someplace. The right information wasn’t gotten to the right party at the right time. And so, communication becomes a kind of issue one can say, Ah, if we’ve got this particular problem not just in terms of maybe the one physician where you’re trying to figure out whether they get this privilege, but in addition this seems to be something that maybe we could improve our, you know, our cardiac surgery here. And so, now you’ve got a team of individuals who from the information that can be aggregated, from FPPE and OPPE, from the information that can be aggregated across some physicians may actually identify something that would be an appropriate focus for CME
>>SCHYVE: And as I’ve said before by the way I mean if you think about it from a team point of view it probably means working on this with continuing professional education
>>SINGER: Right. because its across
>>SINGER: It’s interesting when you think about the opportunity here, for educational staff, is, is a perfect answer to the challenge from the administration of for the executive to try to sort of coordinate strategically what is a thread that sort of connects across several different areas around this improvement. So, that just seems to me another benefit. Another opportunity here
>>SINGER: because you’re really looking for a function, as strategic asset to help bridge those different areas.
>>SCHYVE: yeah. One of the things that strikes me about this discussion and these ideas is that, in many ways people working in CME I’ve heard then say, you know, We need to think about the physicians as our customers, How do we, in fact, meet our customers’ needs? Which clearly continues to be an issue, how you, in fact, have physicians willingly participate, because they’re getting something out of it. And it seems to me that one of the linkages is that if, in fact, the, the C suite is setting certain kind of expectations for what they expect the physicians to do or to participate in, physicians may then look to CME to provide them with assistance as to how they do that. So, to go back to a theme I’ve mentioned a couple times, part of, it seems to me, part of the role of CME that’s meeting the need of the organization as well as the physicians is to be able to help physicians learn more about some of these systems’ issues, including, for example, communication. Ah, because that’s going to be something valued both by the C suite, because they see that as something that needs to be improved in their organization if they’re going to improve quality and safety. And by physicians who are saying, I’ll be able to do better for my individual patients if we improve this, plus this is helping me fulfill expectations that are being created through the C suite, you know, the chief medical officer telling us we need to work on this. Who’s going to help me, you know, figure out how to do this better? CME can.
>>SINGER: Paul, thanks for joining us today.
>>SCHYVE: You’re welcome.
This is a transcript of CME Addressing Quality and Safety Challenges: Joint Commission Perspectives (part 2 of 2).
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