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

>>HANNIG: Hi, I'm John Hannig, I'm the CME Chairman at Salem Hospital in Salem, Oregon.

>>SINGER: John welcome, thank you for joining us today.

>>HANNIG: Thank you for inviting me.

>>SINGER: Pleasure. So, tell me about the current role of what you do at Salem.

>>HANNIG: I'm the Chairman of the CME committee, well actually the CPD committee because we recently changed our name to...

>>SINGER: CPD being?

>>HANNIG: For Continuous Professional Development.

>>SINGER: Got it.

>>HANNIG: So we changed our name from CME, so now I'm the Chairman of the CPD Committee. And that's my primary role in...

>>SINGER: Is that a committee that addresses the continuing professional development needs of medical staff, physicians only? Or is that broader to

>>HANNIG: Well, originally it was physicians.

>>SINGER: Yes.

>>HANNIG: But we've recently recognized that it's the whole health care team. So we're involved with nursing education, tangentially, in that the nurses take care of their own credits but all of our activities include that other healthcare team members that get recognized. So yeah, our planning for our activities involve the entire health care team.

>>SINGER: Okay, okay. So that's actually a topic that we didn't discuss talking about that we could do a whole other video about. But we'll focus this video on, for people who are watching to say, "How can I engage the leadership of my institution, so that CME or CPD, " as you put it, "Can be a real powerful strategic asset to institutional goals." So I know from talking to you that that's where you are now, but it wasn't always that way.

>>HANNIG: No.

>>SINGER: Let's dial back the clock and tell me where this started and let's talk about...

>>HANNIG: When I got to Salem health, I came on, I'm an obstetrician. So I came on as an OB hospitalist for the hospital. I worked 24-hour shifts on labor and delivery and that's all I do now. And I was told as part of our contract, basically we need to get involved, so I chose the CME Committee. I go to the meetings and we talk about what grand rounds we're going to do, and how many people came, and what breakfast was going to be served. And I've been there for about a year and a half, and Darlene, who was one of the leaders in our department said, "Would you like to be the Chairman?" And I said, "Oh sure." And so I took that position and about a week later she said, "Oh, and by the way, the ACCME recently changed their criteria on what we need to get accredited, and we are four years behind the eight-ball because our outgoing Chairman didn't believe in the concept and said, 'No, we're going to do it the old fashioned way and we don't need you.' And we need to fix that within the next three years so we can get accreditation." I said, "Oh, thank you very much."

>>HANNIG: And so what we did, we brought the following year, you'll remember, we brought our entire committee to this meeting that's coming up, to find out what this was all about. And then we turned it around and last year we got accredited with commendation.

>>SINGER: Okay.

>>HANNIG: And so we did that by changing what we do and how we do it.

>>SINGER: Okay. So that's a great success story and I think it's not uncommon that the... in not just CME accreditation, but in other regulatory areas, that sort of the need or the threat of having to re-up your accreditation is certainly a motivator to sort of get in the know about these things. So that's wonderful, congratulations. I'd like to know more about strategically, how your thinking about the role of CME changed sort of along that time, because certainly from an accreditors stand point, our intention is that these rules that we have, are a road map of how to bring value. But I'm interested from your perspective, there was probably a cultural change that occurred during that.

>>HANNIG: We had a huge cultural shift, our administration recognized that the medical staff, administration, and the board were not necessarily aligned in their strategic goals and they decided we need to change that. So they developed the Quality Operating Committee that involves members from each of those and said, "What are our primary goals?"

>>SINGER: Let me back up for a second. When you said not aligned in the strategic goals with regard to?

>>HANNIG: Quality.

>>SINGER: Okay.

>>HANNIG: Safety. Patient satisfaction. Financial responsibility. So each – the medical staff, the hospital, and the hospital board basically had the same goal. Providing good care the community because we're a community hospital. But how to get there and their priorities were different.

>>SINGER: Unified approach of how to

>>HANNIG: So they all got together and said, "How can we align that?" And then they came to the CME department, the CME Committee and said, "We're going to put together some programs to improve quality, to improve safety, address these issues over the course of the next year, five years, 10 years, these are our goals. What can you do to help us design those programs? And then our engaged physician leaders, how can they get credit for what they do. And with what the ACCME was recommending with the criteria and the performance and competence changes and the patient outcome changes, it fit perfectly with what they wanted because we could say, "Yeah, we've got this. We've got the structure that we can use to help you design your activity." And so that's what's happened over the last four-and-a-half to five years.

>>SINGER: Okay, so the leadership started looking at you and your group here for educational planning as a partner or a tool for producing change?

>>HANNIG: Yes.

>>SINGER: Now, can you give me an example or a couple examples of a particular area where a problem was identified? And I'm interested to know sort of whose problem was it or who identified it as a problem because it is not universal. When I talk to different institutions, it's not universal that leadership will look to CME as sort of the strong tool for change. When they think process improvement, they might think of something else or someone else.

>>HANNIG: One of the projects we're working on right now, the Quality Operating Committee looked at the problem with blood clots in admitted patients, which is the number one killer of patients from hospital-acquired problems in this country. And they said, "We are not doing a good enough job. Most hospitals aren't. And we want to, over a four-month period of time, go from where we are, which is 82% of patients getting appropriate care when they get in, to bringing that up to as close to a 100% as we can over the next four months, and what would that look like?"

>>SINGER: Okay, so you had something, you had sort of an outcome measure, very specific to look at, and what's involved. You're probably – I apologize, I'm interrupting – but sort of what's the trail of who's responsible for that outcome? It's a team approach, right?

>>HANNIG: Yeah, it's definitely a team approach. We have probably four to five physicians on the team. We've got the informational services, we've got nurse specialists. Salem Hospital has engaged the Lean Process, the Kaisan kind of

>>SINGER: These are quality improvement methodologies?

>>HANNIG: Quality improvement that we've been using for a number of years, so we were able to apply that. So we put together a rapid improvement team that said, "Over this course of time, we're going to show it's fully supported by the hospital and the administration with all of the staff that's needed to get this done."

>>SINGER: And then the education has been, – what are you educating about?

>>HANNIG: Well, the education happens in the physicians and nurses who are going to our health informational, we use EPIC

>>SINGER: So like a health record system?

>>HANNIG: Yeah, the electronic health record, to say, "What are we currently doing?" And then they mine that for our current situation, "What are our numbers?" And then we design tests of change, which we're doing, and then we will measure our outcomes. And for that, the physicians involved are going to get performance improvement CME for doing that work. Now, out of this, we'll also come where, the second half of our project is all about educating the physicians on how this process is going to work. In other words, we're going to have to – we can't just put it in place and say, "Here it is." You're going to have to have., we're going to probably do Health Stream, which is an online educational tool that we use, that all of the physicians will be required to take this course that then they know how to place the orders and how to go through the process, and the nursing staff is going to have to get educated on how that's going to look on their end and then they're going to get credit for that. And that's all coordinated through our CME office. That's one example.

>>SINGER: Yeah, so one thing that I, they pull out of that is that it's not the planning process, but the intervention, changing lives. It's complicated.

>>HANNIG: It's very complicated.

>>SINGER: It takes time, there's different interventions at different levels, and it's continuous, right? This is not going to stop.

>>HANNIG: Well, it's certainly applying the... I don't think it's proprietary, the Plan- Do- Study- Act because we're... If our changes don't work, we go back and say, "What were the barriers? What can we change?" And then as we're going through this process, we recognize, "Well, that's a whole another problem we've identified," and we've got to put it on a parking lot over here and say, "We need to get back to that, we can't lose that."

>>SINGER: Right, but you can't do it right now.

>>HANNIG: Right, we can't do it right now but we've got to put together, now, another team of people to address that, and then where does that go on the priority list with the hospitals' goals, with the current goals? Because you can't do everything all at once.

>>SINGER: This role of you at the education department being sort of an educational consultant, not only it's sort of this part of the methodology of how do you promote change and what are the ways to sort of help solve the problem, but also the continuous nature and the idea that there is a list of priorities and you are... You're a leader, sort of who's being consulted with or entrusted with saying, "We've got a bunch of things. The train is moving but we have to sort of try to do what we can." Can you talk just briefly about who you're working with? You talked about the target audience of the different practitioners and the team, but what about looking sort of upwards or in terms of the leadership? How does that work? What's the relationship between you and what you do and

>>HANNIG: I'll give you an example: Our Chief Medical Officer was instrumental in designing what we call the Physician's Leadership Institute, which is an ongoing coursework that we do twice a year.

>>SINGER: Also CME.

>>HANNIG: Yes. We've now graduated over 300 participants, we've given out 7,000 CME hours from this program and 2,500 of which are performance-based CME, and it's fully funded by the hospital. It was developed by the Chief Medical Officer. The entire administration has taken the course, nurses have taken the course, our board members have all taken the course.

>>SINGER: It's not just that Salem is some sort of an education utopia, right? I want to say that like you, they're nice people, but it's not just that. What's the motivation? Why are they paying for this and going to these lengths?

>>HANNIG: And it's a huge expense. They bring in experts from all over the country twice a year over the course of a four-month period of time and do the didactic portion. And then, there’s, the measurable outcomes are performance change in the physicians, each course has performance improvement projects built into it where they identify a gap, a clinical practice gap, and then over a four-month period of time the team of people, usually in five's or six's, two or three physicians, say, "We're going to close that gap in care over this period of time." And those choices of those gaps are driven, again, by the institutions' goals and their priorities. And so, then you can measure those outcomes and you can measure – let's say we have a new policy on start times in orthopedic surgery, and then we're going to measure that in the beginning because they were not doing it as efficiently as they could, and then we'll measure it at the end. Then you can also measure patient outcomes, and you can get all of that out of the electronic health record.

>>SINGER: Okay, so for Salem, this is not a soft science, right? This is an opportunity where they're utilizing sort of institutional priorities, which I think also, you didn't say this, but also connect to measures of other sort of regulatory or pseudo-regulatory bodies, right? The federal government and Medicare wants to know if it performs, joint commission, right? There are connections to other measures.

>>HANNIG: Well, the joint connections' core measures and the CMS requirements and that's –  because we're a community hospital, the board has a responsibility to provide financially balanced healthcare for the whole community, and so that all comes into it. And as a matter of fact, the expert speakers cover that in the didactic portion, and then the team learns how to apply that in a framework. They do that in the performance improvement project. The fun part, because I took this course, for me, is when I got back to my work area and I would see a gap, my personality is to say, "How can I fix that?" So after learning this process, my thought is, "What team of people can I put together over what period of time?" Go to the CME... Come to myself in this case, to the CME department and say, "What can we put together to get credit for this work that we're doing?" And the CME department then has that structure that then they can say, "Okay, let's plug this in. Let's see what time period we can do this." And so it just totally changes the culture. And one of the most important things, I think, is it empowers the whole entire healthcare team that worked on this to say, "This is important. This is what I think as a team member, whether I'm the scrub tech or the pharmacist, the hospital librarian."

>>HANNIG: Everybody, the board members, they can all say, "This is how we do it here at Salem, and this is the purpose, is to change performance of the entire healthcare team including the physicians." It's physician-driven and administration-supported, and then it involves a whole entire healthcare team. So it's a whole cultural change towards teamwork, and that's really important. Like I say, it's not measurable in terms of immediately. In other words, you leave some of the processes, there's a what we call a 360 process that we learn at the course where you do a self-evaluation for your teamwork and your communication, and you wind up saying, "What should I continue doing? What should I stop doing? And what should I change?" And then you send that out to 10 or 12 of you colleagues or the people you work with, and then they give you feedback. You change or adjust over the course of about six months, and then they ask you again, and it goes out again and you ask yourself again. And it says, "During that intermittent six months, did this person change? Did they improve?" And if not, then you look at why not. So it's a continuous process, and again, it goes back to the Plan-Do-Study-Act. Did it work? If not, what are we going to change?

>>SINGER: And it's also in scope, it's over not just practice as clinicians or practitioners or as a nurse, not just clinical practice but in the leadership institute, you're really talking about how to be a better team leader, administrator, educator, these other practice areas that in terms of competencies are more than just clinical care.

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This is a transcript of Engaging Leadership: Aligning CME with Institutional Quality and Safety Improvement Priorities.

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