>> SINGER: My name is Steve Singer, I’m the Director of Education and Outreach at the Accreditation Council for Continuing Medical Education.
>> NESTER: I’m Jane Nester Executive Director for Medical Education and AHEC, Greensboro, North Carolina at Moses Cone Hospital for the Cone Health System.
>> SINGER: Jane, welcome.
>> NESTER: Thank you.
>> SINGER: Nice to have you.
>> NESTER: Thank you for having me, good to be here.
>> SINGER: Wonderful. What we’re going to do in today’s video is we’re going to talk about is what happens when a professional is sort of thrust into a CME position and we’re going to use you as an example to talk about your experience of how you sort of arrived unknowingly into a CME position and the things that you did in order to really be a transformative part of how CME and Education factored within a health care organization. And hopefully, your colleagues out there who have just bee just sort of found themselves in a CME position and are new to it. Will get some strategies for things that they can do to approaches that they can take to sort of bring CME as a strategic priority to the organization. So, let’s start by, tell us sort of about you background before you were in CME.
>> NESTER: Well, my early career started out as a teacher and I was
>> SINGER: What level?
>> NESTER: Elementary school, actually.
>> SINGER: OK.
>> NESTER: And I loved teaching, I loved education. And I needed a summer job and so I found a work-study position involved in service administration at my local hospital. And from the first day I fell in love with healthcare work. So, I worked in that arena for a while and then, finished a degree in counseling and worked in that area, but came back to healthcare in prevention services for a number of years, probably 10, 15 years.
>> SINGER: OK. And after that you also worked in graduate medical education?
>> NESTER: Well, before that I actually worked in vascular preventive medical research.
>> SINGER: OK.
>> NESTER: And so, I worked with a relatively large number of primary care physicians and specialty physicians all around heart, stroke and peripheral vascular disease, and a good number of physicians out in the community. And when my research project of about six to seven years I finished up transitioned into a new career of graduate medical education.
>> SINGER: And what kind of a role did you have in graduate medical education at that time?
>> NESTER: I was the director for medical education administration. So, I oversaw all of the operations and finances for our six residency programs, as well as , the libraries, EV services and also CME but just at a peripheral level not in terms of direct input, but more or less supervisory making sure operations are moving forward for the division of medical education at our hospital at a medium size hospital in Georgia.
>> SINGER: OK. So, then when, so then the big transition, so what happened?
>> NESTER: Yeah, we had just finished our site visit our first, my first institutional site visit and completing of institutional review documents and we found ourselves without a director for CME, who had retired. And her coordinator, who was working for many years after her first baby decided she wanted to stay home. And so, we had no one. And we found ourselves with no transition plan from the old Criteria to the new Criteria.
>> SINGER: OK so just for our audience the timeline for this probably around 2006, 2005, 2006.
>> NESTER: Yeah. It actually 2007.
>> SINGER: Two thousand seven, OK. So the
>> NESTER: 2008
>> SINGER: OK 2008. So
>> NESTER: Two thousand eight.
>> SINGER: So, this was all new to you, so where did you start what was your approach?
>> NESTER: Well, I had to do some retooling of the team. I had to get some semblance of a CME team together. And I blended a little bit of graduate medical education and continuing medical education. I was able to have a full time CME coordinator and I had about a point two five registrar to help with registration and the transcripts. And then my role was to function as the CME director. And help with the strategic planning side of continuing medical education.
>> SINGER: OK so inside of that already and I think this might be a theme as we talk, you know, you talk about the strategic planning side, so, it seems to me that, was the leadership at your hospital, the hospital that you were at what, has their perspective on CME changed from that first moment when the director left to now?
>> NESTER: Gosh, it’s huge change. It’s been a huge culture change. And I think we’ve transitioned quite well from the old Criteria to the new Criteria. The environments different. We’re more focused on you know more quality education, focused more on quality and patient safety, more tailored programming to physicians, and what the community needs.
>> SINGER: OK. But, I know enough from our conversations that that wasn’t an easy switch. Right?
>> NESTER: Right. Right.
>> SINGER: So, tell us how you started and when we talked before for this interview on the phone you talked about making friends
>> NESTER: Right.
>> SINGER: And sort of finding and going to talk to people where they were working tell us about the processes that you took on.
>> NESTER: Well, I knew we needed to get out there and get the word out about the new Criteria. And I thought I would feel most comfortable if I could make friends and I could connect with people who could be of help and maybe excite some passion among them if they have not been involved in CME they could now. And so, we made a list of maybe 20 some departments that we thought should have some input into the direction for continuing medical education. And we had such departments as Quality Assurance and Safety, a meeting with the Joint Commission team member who lead those activities for us.
>> SINGER: For credentialing?
>> NESTER: For credentialing. We thought that was very important. Obviously, pharmacy and nursing, we also involved our chief medical officer, the president of the medical staff, we involved academic affairs, the executive director for graduate medical education,
>> SINGER: So, you cast a wide net.
>> NESTER: Yes, we did.
>> SINGER: And what were the reactions of those folks, you, you booked those meetings, did you do them under the auspices of some champion or leadership above you who said, you need to talk to Jane or was it just your own gumption?
>> NESTER: Just our own. What we do, we blocked out the coordinator, the senior coordinator, myself we blocked our two to three weeks we just basically set up meetings with all these folks we said, in order for us to maintain our accreditation
>> SINGER: OK.
>> NESTER: We would need to make some changes and we would really like to involve and get your input. And so we set up the meetings, but we had a very structured agenda with that. So we kept it very tight and very focused.
>> SINGER: OK
>> NESTER: And so, what we did was, our agenda was to meet with the key leaders in those areas and talk about with the new Criteria what the changes were
>> SINGER: OK
>> NESTER: What the challenges would be that you would now need to look at needs assessment, into gap analysis, where the need was for programming, there would be less didactic stand up lectures, we needed to measure outcomes both in competency and in performance and hoping to improve patient outcomes. So, we kind of went through those activities. You know here the, we didn’t go over point by point of the Criteria but we gave an overview of it. And then we also talked about PI CME. We had never done PICME before in our institution.
>> SINGER: And for the audience PI CME is the
>> NESTER: Performance improvement
>> SINGER: Performance improvement like using a plan, do, study, act cycle to measure performance at a point in time
>> NESTER: Right.
>> SINGER: Conduct educational interventions and then come back and measure again.
>> NESTER: Exactly.
>> SINGER: To see what kind of improvement. OK
>> NESTER: So, in order to kind of get a pulse of what was happening in the network so that we might be able to focus on programming or PI CME activities we asked them to come prepared to talk about basically three things. One was, what are two things you’re most proud of? What’s going well in your department? The second one, which was a big one, was what are two areas that are of most concern for you? What keeps you up at night? Where might you be able to have some improvements in your department? And then thirdly, what data bases do you use? And what’s the purpose of your data base?
>> SINGER: So, the first two seem very logical to me, what was the purpose of asking the third? What were you hoping to gain in that regard?
>> NESTER: The third one had to do with needs assessment and where do you find data.
>> SINGER: OK
>> NESTER: And so, that’s always a tough thing to do in a hospital, trying to locate databases that’s got good information, good data that you could utilize. And many of our the faculty on the CME committee really wanted to know where could they get data quick and easy. And so, doing this inventory we had 20 some databases that were all very important. For example, like the cardiovascular registry, the trauma registry, the oncology registry, all had great data. And so, many of the team members the registrars were thrilled that we asked them about their data because no one ever does ask them about their data. So, we actually got together a whole list of databases that our faculty and members could use with some of the needs assessment for, to make it more local for our institution.
>> SINGER: OK. So, you talked about that the, the, the transition from the departure of your director, CME director, departure of the coordinator who left to stay home, coincided with the Criteria sort of the implementation of ACCME’s new requirements that happened in 2006 and that part of the context of your conversations was to bring people sort of on board to what was new and changing and with that and with our requirements ion 2006 came a greater focus on looking at professional practice problems or problems, gaps in practice, looking at the way that you measure change in learners, and also, engagements around quality improvement , practice improvement, performance improvement, all those things. OK. So, what I’m interested to know is that, as you, you went sort of to each of these departments it sounds like from the questions that you asked them that you were exploring with them together, What is the place of shared value that we have? What are the things that you’re trying to do, you said the problems that keep you up nights, and to say to them, we have as an accredited CME provider we have both the responsibility we have an expectation of us, but also the opportunity through those rules to embrace the problems that you are having in your department and affect change. OK. So, how did the meetings go? You told me what the format of the meetings were, what were the responses? You said the people were excited to talk about their own data
>> NESTER: Yes. Obviously we were a little bit nervous about our first meetings wondering how we would be responded to but we came back within the very first two very excited ourselves
>> SINGER: OK
>> NESTER: Because people were so responsive to it and so positive.
>> SINGER: So it sort of caught fire?
>> NESTER: Yeah. And there were some instances where if we were meeting with the medical director, physician medical director, and their coordinator, that they were very protective of their data. They didn’t want to tell anybody what Criteria they weren’t meeting, let’s say, for their own accreditation that they needed to work on. So
>> SINGER: OK
>> NESTER: Some were more protective of it and didn’t want to share that, but the coordinators were responsive so
>> SINGER: OK
>> NESTER: So we kind of worked around that. For folks who weren’t as willing to share, but there were only a couple out let’s say 20 some departments that we met with altogether.
>> SINGER: OK. So, so you went around and sort of did your organizational needs assessment with regards to talking to those folks, how did that impact you’re the leadership of your CME program in terms of a CME committee? Did you recruit from those folks to re-staff the CME committee?
>> NESTER: Interesting, yes, yes and no. As Jim Collins, you want to get the right people on the bus right people off the bus and not the right people off the bus.
>> SINGER: Right.
>> NESTER: And so, we thought of that and looked at our committee and knew that we needed to have some changes. We put on our committee for the first time someone from quality assurance and safety. We included some folks from the pharmacy we had had nursing on the group, we included ethics,
>> SINGER: Ethics?
>> NESTER: Ethics and compliance
>> SINGER: OK
>> NESTER: Obviously we kept graduate education on, we include risk management, we had folks from grant writing office, public affairs, community relations and public policy included for the first time.
>> SINGER: Wow.
>> NESTER: Case manager and the care manager as some organizations call it, we had some of the program directors from the residency programs we had the emergency department we’re able to get our chief medical officer, and we also included input from the county and city health departments altogether.
>> SINGER: OK So this doesn’t sound like the the CME committee that’s trying to find a topic for next weeks journal club.
>> NESTER: Right.
>> SINGER: This sounds like a strategic force in the institution. So, from the time in which you sort of started to implement these changes tell me now, because as luck would have it from the timing of our interview you’ve actually finished sort of your tenure at that institution and you’re just about to start at a new place. Right? So, tell me sort of in the few minutes that we have remaining what are some of the biggest successes or what are some of the milestone moments to you as you look back that between having those meetings and assembling this new committee, sort of what are some of the successes that you feel that you had as a result?
>> NESTER: Well, I think besides going out and meeting people and finding data I think our successes were with an incremental approach to helping our committee learn about the Criteria and we did that through what I consider a virtual retreat. Typically our organization had a half day retreat of the committee once a year and they talked about the past activities, the future activities and they were very short. What we did was actually broke it down to about six to nine months where we focused on the mission statement one a month, the next month we would focus on, the next two sessions were on education planning and learning about identifying gaps, how to do that, that process and underlying needs. And then we moved into the next session on evaluation and then we got into commercial support
>> SINGER: OK.
>> NESTER: And then we got into the commendation section and other areas that we wanted to go about. So I think, when we got to that point particularly when we got to the Criteria 16-22 you could see within about nine months the committee was feeling much more educated, more comfortable
>> SINGER: OK.
>> NESTER: OK so now they’re very, they do their due diligence on reviewing applications.
>> SINGER: OK let me flip that around for a second because it sounds like what you have left as a result of your leadership there is a very well informed, well educated and sort a process rich group that understands the accreditation expectations and has sort of a good means to manage programs within that. One of the things I’m interested in sort of flipping around is to say that as a result of your educating them about those Criteria do you feel that they are doing, has it bee of value, like are those Criteria providing a value to the education and to what impact the education is having in the hospital?
>> NESTER: I do. We’re included in just about every aspect or most aspects of the hospital in terms of trying to provide education for physicians. And you know, I often think that the new Criteria for CME has helped to make for better GME.
>> SINGER: Really?
>> NESTER: That if we’re improving the education we’re providing our physicians and many of our residents attend grand rounds and all these other specialty events that they see good education in practice. And so they’re a part of that. And so they learn to become better future attendings. And I think where our real value has start to come now where we’ve had more integrated work and understanding is the involvement of performance improvement, quality and performance improvement projects with the residents physicians with the faculty working along side the residents to learn quality performance and improvement. So, when you would ask me what was one of our, what’s been one of our big successes I think actually moving into that arena and completing about a three years now of quality and performance improvement work with our residents with about 19 projects whereby now those projects have gone on to larger projects, within the institution. We’re now calling and patient safety pick those projects up that the residents began along with the faculty and take it to a larger level.
>> SINGER: OK. So, that’s interesting and we’ll we’re going to do another video in which we’ll talk in more depth about that GME CME sort of collaboration project, but what I hear you saying is that one of the values that the Criteria and that this new construct among your CME committee and the engagement with your institution has brought is sort of using residents and GME and the faculty who are involved with GME and sort of a learning laboratory or a pilot sort of like a test tube for developing quality improvement projects and performance improvement projects that are then taken in a broader context to the rest of the institution.
>> NESTER: I think some of the key success are just being persistent knowing that you’re doing the right thing for the institution and for your physicians, but ultimately your patients that you’re serving to provide better education with, hoping to get better outcomes.
>> SINGER: Yeah.
>> NESTER: but, I also, think that you know, it’s a journey very much an iterative process you learn as you go and you retool and fix and you know, you sort of gather more moss as you go with more inspiration and interest from your colleagues.
>> SINGER: Great. And then this new position that you’ve started, what will you be doing?
>> NESTER: It will be the executive director for medical education in the Greensboro AHEC the area education center of Greensboro, North Carolina. So I’ll be working with the residencies as well as very, very large part of the community regarding health careers and educating nurses, physicians and allied healthcare professionals and doing research.
>> SINGER: Congratulations
>> NESTER: Thank you very much.
>> SINGER: Thanks for coming.
>> SINGER: Thank you
This is a transcript of From the Ground Up: Creating Your Own CME Program.
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