>>SINGER: Welcome back.
>>NESTER: Thank you again.
>>SINGER: OK. So, in this part of the video we’re going to talk about GME and CME. Because we’ve discussed that a fair number of CME professionals are professionals that have responsibility for CME in their institution also have responsibility for GME or might have come from GME or may work closely with people that also have responsibility for GME. So, we’re going to try to do in the next several minutes is, is talk about that maybe they don’t have to be independent silos. And that it might be opportunities to blend those things together and what some of the themes are. And then I’m going to try not to forget to talk also about leadership, because that’s an important aspect. So, let’s first back up a moment and, and tell me about you’re your own experience in the way in which you have worked in GME and CME.
>>NESTER: Well I first started out in GME and I’d worked in that area for a year. And continuing medical education was under our larger division. And so when I inherited the CME department I thought there were some ways in which we could sort of combine forces to get better educations for our physicians as well as our residents. And I think you know Criteria number six discusses the ACGME’s core competencies.
>>SINGER: Yeah. Sure.
>>NESTER: And I thought that was common between both GME and CME. So, what I did was actually look for a way in which we could do some activities together. So, the person that came to mind and this was brought about first of through our vice-president for quality and safety. He thought it’d be a great idea to have residents involved with quality and performance improvement and to learn how to work on a team. And on the other side I know from working CME learning CME six years ago that one of the newest areas was PI CME, performance improvement.
>>SINGER: The opportunity to do performance oriented
>>NESTER: Right. And that physicians in the future being held more accountable for showing or demonstrating their competency both to ABMS and for their maintenance of licensure also for their maintenance of certification. So, we thought, well, why don’t we develop a core curriculum whereby we could educate the residents and take a back door approach to working with our faculty. Residents very much are at the forefront or at the sharp end of the spear seeing problems or issues at the bedside and they’re very much in a mode of learning. So, we thought we would start with our chief residents first from our six residency programs. And so, between quality and patient safety as the experts in that arena, and GME and CME, who are really the experts in programming and the glue to kind of keep the whole initiative moving forward that we could work together to provide a program. So that the challenge was, how do we do this in a period of time that would fit an academic year. So, we came up with having a half day training session for our resident chiefs on some basic theories Six Sigma and to talk about the importance of knowing PICME and completing that for future attendings. And also, we wanted them to learn some leadership skills.
>>SINGER: OK. So, let me interrupt for just a moment because you sort of laid out a whole bunch of strategic values in sort of different ways. I want to sort of go back to one thing you said, which was you said a that this resident focused or sort of GME focused education would also be a back door opportunity for educating the faculty. OK so inside of this sort of coming from it’s you mentioned that the quality and safety focus was initiated by your CMO
>>NESTER: Our vice president for Quality
>>SINGER: vice president for Quality
>>NESTER: and Safety
>>SINGER: Quality ands Safety. So, in that is sort of a suggestion that, that skills in quality and safety are not ubiquitous across the environment. And that this may not be something that they get in medical school; it might not be something that is sort of actively taught in the institutions. So that there was a need sort of beyond addressing quality and safety issues, there was a need to sort of introduce well what is quality and safety, how does it work? And that you’re using sort of the construct of that and you mentioned LEAN or Six Sigma]
>>NESTER: Six Sigma.
>>SINGER: Six Sigma, as a curriculum to both sort of refine the skills and introduce those topics both to residents and also to the faculty, who would be sort of helping to run the this programming. OK. So, I’m sorry I interrupted you so continue so they had this sort of a half day program.
>>NESTER: They had a half day training with quality and patient safety team members from the department both the VP as well as the managers the safety officers so forth, and I had the GME and CME staff also attend the sessions. And that’s where they actually learned how to put together a charter, the base, the core of getting started with the project. And the important part
>>SINGER: This is your performance improvement project?
>>NESTER: Yes. Performance improvement projects
>>NESTER: And the requirement of the resident was to get approval on the project from their program director and to find a faculty sponsor. Someone who could help open doors for them, help with barriers and learn with them help lead the project as well.
>>NESTER: So, between. And then they were assigned a mentor. A mentor came from quality and safety as well as myself so we needed six
>>SINGER: I s this also a physician or was this or were these staff members?
>>NESTER: Again they were team members from the Quality and Patient Safety department.
>>NESTER: So, we had one mentor per department to work with the resident chiefs. Along with myself, I volunteered to be part of the larger group of mentors.
>>NESTER: And so, we would have this half day training in September to kind of kick off the academic year and then they would work on their projects over the next about four, five months. And we knew that we had to have sort of a benchmark for them to hit. And to help them get there had the mentors to help them shepherd them along the way in this process of their project and then we had an institution-wide grand rounds where each of the residents presented their projects in ten minutes and we involved the larger institution to educate them as well by having it as a judged competition. And we involved the chief nursing officer, president of the hospital, the chief information officers as well as some other Six Sigma team members that would actually judge the projects.
>>SINGER: And how did they, I can only imagine, how did the residents react?
>>SINGER: I’m sure they were very excited to participate in this.
>>NESTER: They were very excited also very nervous. I’m nervous for them. You know, but this is what I consider their Capstone experience. They put it all together and they present. So, we had an audience award, we wanted to add some esprit de core to the event. The CME event for grand rounds and after the presentations had completed we had team members and we had not only just physicians at the grand rounds there were nurses and allied health care professionals and parts of teams that came along and they got to vote on the initiative or the project that most impacted the institution. And so it was kind of fun to do the audience response system and then eventually we could see who won that prize. But the big prize really was, while all that was going on we would tally the scores from the judges and we would have the judges award and we would have pictures afterwards and following that we would have a celebration with a lunch for the entire team along with the president and the chief medical officer and the safety folks and GME, and CME. And then a plaque is in the resident lounge with a brass tag that names the department that won that year
>>SINGER: Oh fantastic
>>NESTER: with pictures. So, then you know, we have information in the physician newsletter, then to keep abreast of educating the rest of the medical staff about the activity. So, it’s been well received.
>>NESTER: And I’ve had some, it’s been wonderful to see the residents actually learn basic leadership skills, and project managing skills on the job.
>>SINGER: Yeah. And you mentioned a Capstone experience, because is something we talk about in the curriculum in the you know, spectrum the continuum of medical education that from undergraduate to graduate and then CME is that the flow of information is perhaps not from, not from UME upward to CME, but actually the other direction, that information from practice sort of feeds back into what residents need to focus on and then that sort of informs what kind of people we need to be able to do that. When you mentioned a Capstone experience it, as these residents sort of move on from your institution this is something they could put on their resume.
>>SINGER: Sort of a big part of where they learned or became capable and knowledgeable about quality and developing these sorts of performance projects in the future.
>>NESTER: Exactly. One of the selling points I make to the residents why I do this is ultimately for better patient outcomes and to make a difference in our community and in our institution. But, it’s also time for them to be just a little bit selfish and to think about themselves and their last year of residency. What project initiative can they do to help them set themselves apart from other resident physicians, who are going to be competing for some of the same fellowships, some of the same positions that they want in a particular practice or in an institution? So,
>>NESTER: We encourage them to do a really good job with this.
>>SINGER: Great, great. So, let’s pick up the level a little bit say you’ve described a really tremendous activity and sort of approach that you took, let’s sort of pick up the level to say as a result of doing this activity how has that, what has been the impact of that on the faculty? What’s been the impact of that on the, you know, these little performance improvement projects that they did have those been carried on, as well, within, within the institution?
>>SINGER: You know, what’s the overall strategic value that this has provided sort of from a distance?
>>NESTER: Well, there’s several things here. First of all we’ve had some residents that joined the project you know, in they’re PGY two or three year stayed on
>>SINGER: Oh so it’s a recruitment opportunity, that’s one.
>>NESTER: The projects that have probably turned out the best have included members, team members from each of the years
>>NESTER: And so, that’s one area. But several of the projects have been spin offs. For example, surgery they worked on a skipped measure they had to with removal of catheters within two days. They went on to do the next year something to do with VTE. So, you know, one project has lead to another. And I think also many physicians now are looking at their need for PICME credit. We went from I guess it was something like 25 physicians involved with quality and performance improvement projects with the residents in the first years that we did this with about 105 credits, to the next year with 24 physicians earning about 450 credits to a third year of 48 physicians earning about 770 PICME credits.
>>SINGER: OK So, just the opportunity to sort of engage in this sort of work has provided a value of engaging physicians in performance improvement while at the same time satisfying some of their professional requirement s to get credit for
>>SINGER: for licensure.
>>NESTER: And then also our risk management and our quality and safety departments have picked up the projects and taken them on to another level. So, in essence the resident projects were like beta projects
>>SINGER: Oh, really?
>>NESTER: So, now they’re, the key thing is that when you have your, your grand rounds let’s say in March, we have hand off meetings in May whereby the program director, the faculty sponsors, the outgoing chief and incoming chief from that department sit and work with quality, GME, CME to talk about what went well, what didn’t go well and how do we plan for sustainability. And that’s a gap now in the arena of quality and performance improvement, how do we sustain projects? Some projects are meant maybe to only have a fixed over six months, but how do you keep the life of the project going on for two or three more years towards full fruition for the hospital?
>>SINGER: So, we talk a lot about that that there’s great value accredited CME providers can find sort of an easy overlap between the requirements of them our expectations of them around an organizational improvement plan, you know, how effective are we being with our education, what practice gaps are we addressing, how do we, how do we become more effective over time, you know that plan, do, study, act, and when you can overlay that easily with an institutional focus for improvement and it sounds like what you’ve achieved is sort of using the CME value as a learning laboratory for helping to achieve you know, the organization’s focus on saying how do we sustain improvements, the quality and safety of care? How do we be, how do we become more effective in educating our residents and helping residents to want to stay at our institutions, you know, all these sort of outlets?
>>NESTER: Right. And you’re training your future leaders
>>SINGER: Yeah, exactly another benefit.
>>NESTER: to stay in your area. So, this, the quality performance and improvement initiative, those activities were great ways to focus on practice based learning and systems based practice. But, in essence with those types of projects you encompass all the six core competencies.
>>SINGER: The competencies as well.
>>NESTER: For ACGME.
>>SINGER: So, I’m interested to know, now, in the other video, sort of make a little commercial for it that in the other video sort of talk about the arc of your career in the institution that you just left and now you’re at a new institution where you’re responsible for a broad spectrum of education, what are you insights for the, the next accreditation system?
>>NESTER: Right now, for myself, I was hired basically, because of my work in quality and patient safety and research and these are areas in which residencies need to spend more time on and it’s not only the residency it’s the faculty, because there are the Criteria from ACGME you need to complete a certain amount of scholarly activity for both faculty as well as residence. So, you know, I think, ACCME has set the bar well for quality education and ACGME is following along and I think the marriage is really quite good. I think the future of NAS the new accreditation system is that we want to reward programs that are doing well and by not having the, the inundation of a lot of paper work to do the institutional reviews on
>>SINGER: If they’re focused sort of on quality outcomes.
>>NESTER: We can work on other ways of innovation. Innovation really is in developing, you know, educational opportunities, the best educational opportunities for our residents, and obviously our faculty involve with that. And for those in the new accreditation system they’re actually looking at is a way of improvement that if programs are not doing well how do we stay close to them to get to where they need to be in a quicker fashion.
>>SINGER: Maintenance model.
>>NESTER: Yes, so they’re moving more toward a report card system, if you will on an annual basis on improving education and opportunities for resident to learn.
>>SINGER: OK. Thank you, Jane.
>>NESTER: Thank you again.
This is a transcript of Case Study: Integrating CME and GME.
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