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>>SINGER: Hello, I'm Steve Singer. I’m the Vice President for Education and Outreach at the Accreditation Council for Continuing Medical Education.

>>DURHAM: Hello, I'm Diana Durham, Associate Director for Accreditation for the Veterans Health Administration Employee Education System.

>>SINGER: Diana, thank you for joining me today.

>>DURHAM: Thank you for having me.

>>SINGER: We're going to talk today – you work at the Department of Veterans Affairs.

>>DURHAM: Right.

>>SINGER: Which is a big government Department.

>>DURHAM: Indeed.

>>SINGER: And you're concerned with continuing education to support the needs of the employees and the healthcare professionals that work within the VA system, and also sort of by extension their care for veterans within the United States. We're going to use a case example of a problem that the VA needed to solve and how you were part of a team to help solve the problem or help address the problem using your tool, which is accredited to continued education. And we'll hope, through our brief conversation, that it will be instructive, not just for big government departments, but really for anyone, whether you're at a small physician office or a large institution, about how to look to CME as a resource. So let's start by talking just in the context of where you are in this big system.

>>DURHAM: Okay. Well, I am the lead for continuing education in the health professions for the veterans, US Department of Veterans Affairs. I'm part of the Veterans Health Administration with our 152 hospitals and so forth. I'm in a national program office called the Employee Education System, where I'm responsible for 13 national accreditations and three state accreditations, and I work with a team of highly trained qualified professionals who are experts on different accreditations. It just so happens that ACCME is my favorite so I hold on to that one.

>>SINGER: Oh, why thank you.

>>DURHAM: Yes, it is. I hold on to that one. That's the one I have the longest time running with, 25 years or something like that. So I'm responsible for making sure that when the teams that are planning activities to solve problems with national program offices or regional offices, that they're in compliance with guidelines but that they're, even more than that, keeping in the spirit of what those guidelines were intended to foster in terms of improvement of care.

>>SINGER: Okay. So tell us, give us the problem. And then I'm also interested sort of how your group came to be sort of pulled in.

>>DURHAM: Okay. Well, the one I want to talk about is probably one that's most in the news right now, and that is the issue of access of veterans to their own healthcare. Back in the summer of – late spring, early summer of 2014 – there was a big splash in the news media all centered around the VA medical center in Phoenix. There was evidence to support, there were two physicians who were whistle-blowers. We have very strong protections for whistle-blowers in the federal government, particularly in the VA, Veterans Health Administration. They had documentation that the patient electronic record that dealt with scheduling had patients that were not on the electronic list. They were on paper on sort of under the table, and they were patients who had not been given appointments within the period of time that our secretary, Secretary Shinseki, had asked that they be seen. According to the news media, there were patients who died because they didn't get seen. The VA chose to take a systems approach to this. It was very, I would say it was painstaking and painful and a lot of self-examination of us, ourselves as an organization was going on. The VA looked at, they asked other VA medical centers to come forward on a voluntary basis, and there were other medical centers who came forward and said, "Yeah, well, we're not doing exactly what Phoenix was doing, but... "

>>SINGER: Where it sort of recognized the scope of the problem and internalized it. Is this happening in our institution? Let's fix it.

>>DURHAM: Exactly, that's right. So in addition to that, there was a bill passed last summer by Congress called the VACAA, which has to do with the VA Choice and Access Act. And I'm probably getting the name wrong. It's VACAA, but we call it the Veterans Choice Act. In that Act, there is a section called Section 303, which doesn't have to do with the code you type in the door. It is actually the training section about what will happen. And Congress was a bit prescriptive from my point of view about what will happen, but they did want to put some, a timeframe to it. And once the timeframe is in there and some stipulations about content, it was left up to the staff largely in the improvement teams and also at the high level, national level, also at the Employee Education System to work out how those activities, whether they're online courses or whether they're face-to-face courses, would be deployed, as they would say, in the military.

>>SINGER: Now you explained in another video that we just did, that your section, which deals not only with, as you said, with physician continuing professional development accreditation, but also with other professions as well, is sort of inside of a larger sort of employee training and education. So this report, this sort of edict was then sort of instruction to say that you, broadly, the Department

>>DURHAM: My group, yeah.

>>SINGER: in which you're in, you're entire group, is going to be responsible for implementing this.

>>DURHAM: Correct. So this is headed up by a very high level physician, Dr. James Tuchschmidt and he has years of experience actually as a practicing physician and an administrator at a high level in the VA. He's someone we put a tremendous amount of faith in and trust to help us lead ourselves through – he was involved with the patient aligned care process, and helped lead us through this. I happen to share an office and then be next door to at the Long Beach VA Employee Education System office center, to the woman, Christina Prairie Chicken, who is Lakota Sioux by background. She is the leader for transformation. She headed up the patient aligned care process, and it fell to her to figure out a lot of things about the curriculum of this Veteran's Choice Act training.

>>SINGER: Okay. So as we often talk in the accreditation world about our requirements, we talk about sort of at the simplest level, they are the Plan-Do-Study-Act cycle. So I know that the way to solve this problem for the VA is complex, and probably very much ongoing. Can you help, for us, just for time, just sort of summarize it down to sort of what's the problem, and educationally give us one of the problems that CME sought to address.

>>DURHAM: I will. So the principal problem was that veterans were not getting – r remember when we say veterans, we're talking about patients – so veteran patients were not getting seen within 14 days. Part of the problem was an administrative problem and it had to do with staffing. Phoenix VA MC Medical Center had 400 openings, the VA flipped everything around, and there's a hiring freeze at the national and regional level. All the hiring is going on at the VA Medical Centers because they have to get that down.

>>SINGER: It has to be staffed.

>>DURHAM: Yeah, and I know the Long Beach VA, where my office is, has hired a large number, I think it's close to 200 people. Now, not all those positions are physicians, but it's not just about physicians. It's about the nurses and the physicians and the other people that support the veteran, and about the schedulers. If you don't have people answering the phone, some veterans will make their appointments online, a lot of them want to talk to somebody. It's pretty human nature. A lot of us want to talk to somebody. So the biggest problem had to do with access and working on that as a team, and so I personally sat on the Veteran's Choice Act planning team for the first set of trainings. I have staff who are supporting that as well on my team and there are planners from the Employee Education System, this education unit within the greater Veteran's Health System.

>>SINGER: Now, to contribute my own naiveté to sort of misdirect you, is it the case that addressing this problem, you have this endpoint of being seen in an appropriate amount of time. That was the problem. That was a public health imperative, probably.

>>DURHAM: Yes, it is.

>>SINGER: So did you educate, or are you educating about the physician's role as part of that administrative team?

>>DURHAM: Yeah, that's part of it. It also... Team roles.

>>SINGER: What I'm saying, what's interesting about it to me is that this is not about are you asking the right questions to diagnose a problem at all. Right? This is about a professional practice role of the physician as administrator, as perhaps team member. OK. And that's interesting. It's a very different.

>>DURHAM: It is different. It is different. A lot of our programs, especially some of our performance improvement and quality improvement activities are centered around access. And I'll just give you a bit of context. There are some 8.9 million veterans who are actually enrolled as patients in the Greater Veteran's Healthcare System. There are some 21 million veterans in the United States, we think. They try to keep that, part of that's collected by census data.

>>SINGER: Okay. So sort of the patients that are inside the system and seen are getting good care, and the folks that aren't?

>>DURHAM: Well, they may not have enough access as they would like. So a key component of the Veteran's Access Law, Section 303, had to do with making sure that veterans who live more than 40 miles from a VA facility can go see a local physician. They have kind of a Choice Act card. Literally, it's a card, like you would swipe it. I have a colleague, a friend in Santa Barbara, who is far enough away – Santa Barbara, California – far enough away from a VA Medical Center that for his spinal cord injury, he might still come to the VA because it's so specialized. But for the common cold or the flu, he needs to be able to go see a local physician and have that charged back to the VA through the Choice Act process. So that made a lot of veterans happy that are in rural or remote areas, and there's a whole lot of them. I won't even go into that, but I could. That's part of it. So as a result of that, my Chief Learning Officer and my Division Director and I had the conversation with others in our organization that we needed to figure out some ways to make sure that some of the accredited training on things like, “What should you know about veteran patients?”Military culture courses, things like that, working with veterans and their psychological needs. What is traumatic brain injury? How does that impact the patient visit? We wanted to make sure that some of the training we've already developed makes its way to those physicians who are not VA physicians. So we've worked with the Public Health Foundation which has a learning management platform called TRAIN, literally T-R-A-I-N, and we've put our first four courses out, it happens to be on military culture, up on the TRAIN website for anybody to go to and take those courses for free. So the physicians that I serve and the other clinicians that I serve, have greatly expanded to include anyone who might see a veteran for anything.

>>SINGER: Right. So it's interesting in the frame of, again, being a strategic asset. It's interesting to see as an instructive example for people, again, who may be in institutions or organizations that are very different in scope, in size than the federal government, the ways in which you are not taking a single hammer-to-nail kind of approach but rather saying that one of the ways to address access is to make a bigger net through extension into the community, in rural communities, and also this opportunity to be quite diverse and varied in the approaches that you take.

>>DURHAM: Yeah. Yeah. So one of the other things that's important about that, and I have my personal illustration, we all have our personal stories, you can be, feel remote and be in a city, but my example is my family historically comes from the Appalachian mountains, the Kentucky and North Carolina region. Many young men, and it was all men at that time, found their way to a larger world through the military. It was a way out of areas where the main employer was the coalmine, and so there's a large number of veterans from the south, in particular the Appalachian region, that I'm familiar with and I want their local GP in Harlen, Kentucky, to know about traumatic brain injury. And so being able to put trainings out that they can get to - or PTSD. There's a lot of conditions that you wouldn't necessarily know a person, you don't necessarily immediately think this person is coming to see you in your clinic is a veteran. He or she may tell you that or you may ask the right question, we do want those doctors to ask those questions.

>>SINGER: Right. So that's a huge professional practice gap for physicians of all different stripes to know how to ask the right question and how to understand the healthcare needs of people who've served their country. So thank you very much, Diana, for giving us a window to this very important work. I appreciate it.

>>DURHAM: Indeed. Thank you. Thank you, sir, appreciate it. Thank you for all the things the ACCME does for us, too.

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This is a transcript of A Case Example of Accredited CME Meeting Public Health Imperatives.

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