>>SINGER: Hello. I'm Steve Singer. I am 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 us today.

>>DURHAM: I am so excited to be here. This is something I've always wanted to do, to talk with you about continuing education.

>>SINGER: Oh, great. Great.

>>DURHAM: Yeah.

>>SINGER: We're going to have sort of two conversations today. The first conversation is going to be about the involvement that you have had within continuing education in the Department of Veteran Affairs, around sort of culture shift around interprofessional education. The second conversation, which will be a separate video, but you can link two from the same webpage that we're on, will be about continuing medical education sort of being brought in to solve a problem. So we'll talk more about that later. So, first of all, just to start off, tell me about what you currently do within the – it's a big system.

>>DURHAM: It's a huge system. Yeah. Well, in my role as Associate Director for Accreditation in the Employee Education System, I'm responsible for 13 national accreditations and three state level accreditations. But what do I really do? I make sure along with my team of accreditation specialists and technicians that we are assisting the planners, the project managers that plan activities with national VA program offices and VA regions, that we're making sure that their programs are in compliance with all the guidelines of the different accreditations that we manage, but also that they're in keeping with the spirit of why those accreditations even exist. In other words, if you're talking about CME, what is it? What is the attribute, the physician attribute that you're really trying to address? Have you identified a problem that can be fixed or improved through an educational solution? If you're looking at social work, have you looked at the guidelines for what social work content can be considered for approved education? So, the buck stops with me.I get involved in a lot of high level discussions with my chief learning officer, who's Jim Warner, and sometimes with national program offices: the office of Academic Affiliations headed by Dr. Robert Jesse, the National Office of Social Work, those programs, and how do those interact with one another. Because most of our training is not just CME or not just nursing, it is around interprofessional care because we've really made a commitment as an organization to put the patient in the center, and it's the veteran patient because we have a very specific patient to serve.

>>SINGER: That's a lot of stakeholders.

>>DURHAM: Yeah.

>>SINGER: And it's a lot of, you talked about a number of different professions, different types of practice and both medical practice, social work, and other things. And the unifying thread through all of that, it sounds like, is that you are sort of in a service role,

>>DURHAM: Yes.

>>SINGER: to be an asset – a contributor – to how do we educate, how do we promote change and improvement, sort of in a very complex system. So, specific to that, what change, you talked about that there's a culture shift. What, set it up for us. How did it start? and

>>DURHAM: Okay. In 2009, the VAs, then head of the healthcare system, we have the Veterans Health Administration, the National Cemetery Administration, and we have the Veterans Benefits Administration. And the 152 hospitals that are the VA Medical Centers are part of the Veterans Health System, and there are also 800 and some odd community-based outpatient clinics, 300 Vet Centers, which may not be places where you do a lot of medical care but where you may be seeking a referral and may be a support group. So those are…

>>SINGER: A lot of interactions.

>>DURHAM: That's the vast, that's the vastness of it. And so in 2009, Dr. Petzel, who is then the Secretary for Health within the VA, committed along with a group of advisors to moving us in the direction of being patient-centered. And of course, 2008, 2009 there was a lot of that discussion going on in the greater world, but moving the VA in that direction is like turning a battleship. And not a bad battleship. It's a very fit battleship, but nonetheless, like a lot of healthcare institutions and healthcare systems, I would say we were fairly provider-centered or physician-centered at the time. And what transpired was a lot of research to figure out what the options were, what other organizations were doing, where we had the greatest need to change. And essentially, the needs assessment was a very huge document that I use almost on a daily basis. And I've used it in my re-accreditation document as well.

>>SINGER: Okay. So this is like one of those cooking shows.

>>DURHAM: Yeah, yeah.

>>SINGER: Interview here, where you have the recipe, you make it, you put it in the oven, and then, snap, it comes out baked. So tell me,

[laughter]

>>DURHAM: Well, not exactly.

>>SINGER: I know, I know, what I'm saying, around this needs assessment, which again, through the enormity of the system, very complex, let's boil it down for time, to say what was the problem and why was it a problem? Like, how did you from an educational perspective? I'm assuming that you were enlisted

>>DURHAM: Yes.

>>SINGER: and saying, "We're currently here, but in order to be patient-centered, we need to be over here." And how would you summarize the problems?

>>DURHAM: How I would summarize it is that, it was identified through any number of surveys and interview tools that one of the biggest problems was that care was being delivered in silos. So, that great social work team, great nursing staff, excellent, committed, full-time employed physicians – as with most healthcare systems – but not necessarily as a system, working together around the patient. So, the resolution was to create a number of different levels of training. And, I should go with this actually... And there are five levels of Patient-Aligned Care raining, or PACT training. Three of which we've accredited. And we're continuing to do them, or the greatest push was in 2012, 2013 and 2014. Still doing PACT training, particularly as we bring on new people and as we work with residents with their office of Academic Affiliations as they...

>>SINGER: Okay. So, it's going to take a while to turn this battleship?

>>DURHAM: Oh yeah.

>>SINGER: And can you explain – again, there's so much complexity in getting this done. Can you explain, in the programs and these strategies at different levels, are there a couple of examples that you can share about things that you learned? Or things that were not what you would expect them. It also sounds like that not all of this, or maybe not much of it, was about clinical practice because you said that the social workers and the physicians were working well in their silos?

>>DURHAM: Yes.

>>SINGER: But this is about the professional practice. The professional skill of communicating.

>>DURHAM: Communication.

>>SINGER: working, administering between a team. Can you share some of that?

>>DURHAM: In fact a fair amount of our training focuses on persuading, convincing, coaching people to work together. Professionals to work together in an inter-professional context. The basic level of patient-aligned care training, level one, every employee in the VA had to take that training in some way. Some of them did it in a face-to-face context. There's also, there's some online training that we could do. And we also recruited Dr. Tracy Gaudet from wherever she was before, I think it was Duke, she heads up our patient-centered care.

>>SINGER: So, this is sort of like shared values training?

>>DURHAM: Yes it is.

>>SINGER: Okay.

>>DURHAM: And the level two training, which is my fondest one, actually trained teamlettes at each VA medical center, not just one teamlette – I mean we have hundreds and hundreds of patients and doctors just at the Long Beach VA, for example. So, you don't want to just train one teamlette you want to train a group of trainers who will go out and train other teams in patient-centered care concept, values and practice. And the training, we've tried different things. We tried delivering part of it virtually. But we found that, for most of the team based work, where we can deliver it face-to-face, at the local level, that's been most successful. We also had groups of people coming to other meetings – let's say a meeting that was a face-to-face meeting on Iraq and Iran veterans, Iraq and Afghanistan veterans coming back from the war – we would also had a meeting on to that where the people in a given region, the Southern California region for example, got together and talked about how they could connect that with patient-aligned care. And wrote some work plans that they would follow-up on. Some of them were also interested in doing research.

So, in the learning session too, for patient-aligned care training, there were case studies and they were actually based on real patients but with different, names were changed to protect the innocent and so forth. Privacy Act. And they would always be a player, a person who was a physician, a nurse, a social worker, a psychologist. Sometimes, we'd also have a chaplain there. Non-denominational. We have chaplains of all different creeds and cultures in the VA. And sometimes, often, an administrative person who wasn't necessarily the head of the medical center but someone more who deals with scheduling. Which is the tie from

>>SINGER: Because the logistical part is just as much part of what

>>DURHAM: It is. It is. So, the training had to do with working those cases together. And with the communication elements that caused the patient to feel treated well, believe that his or her caregivers, providers were talking to each other. And that the veteran patient didn't have to go through the experience of saying, "Well, I just told this doctor this, why do I have to tell you again?"

>>SINGER: Right. So, that's interesting, it's not only that you're educating this team and the logistical and the coordination support. You're not just teaching them about how to do in an interprofessional way but you're also teaching them that the doing is just as important as the patient and probably the family's perception of how they are approaching that interaction. So that it's not just well, "We aligned together. We all looked at the charts so we're okay." It's, well, how much of that does the patient understand and appreciate?

>>DURHAM: Yes. Their perception is very important. We also have some veteran support groups that work with us in caregiver training which is not really in my bailiwick, but it's going on within patient education and I think that's important, being patient active.

>>SINGER: Sure. So, the – it's complicated. Not, well, it's complex. It's complicated to change this big goal about moving from provider-centric to patient-centric across all these systems. And you've described it, and we won't have time to do more, but you've described a little taste of that you've used all of the framework of your educator's experience and wisdom to say you're doing different kinds of interventions at different times in different ways with team members in order to try to achieve that change. I know that you're in the middle of moving the battleship.

>>DURHAM: It's moving, yeah. Yeah.

>>SINGER: Yeah, right. Well you just said, it's moving. So, tell us about what you know about what you've achieved - versus when you started in 2008 or 09. And maybe what you don't know yet.

>>DURHAM: What I don't know yet. Yes.

>>SINGER: In your sigh I sense some of that. And the last thing is that, I'm also interested to know when people listen to you talk about this, they are going to understand that you as the education person within the VA, that that role and the complexity of how the system works is well integrated into how the VA approaches changing things. That might not be the case at every institution, so I'm interested know

>>DURHAM: Yeah.

>>SINGER: how do the people above you - how are they responding? Are they satisfied with the way in which education is helping to move this battleship?

>>DURHAM: That's a lot of questions. Let me start with

>>SINGER: Yeah. Start. Take any one.

>>DURHAM: one piece that I do want to add to describing the patient-aligned-care training is something that ACCME would probably call... It's not accredited, but it's an ongoing conversation consult that occurs with the members of the team. Both at their local facility and then nationally and regionally ongoing consults. And so we have it set up as a course, but it's really a conversation where they can share strategies, successes and so forth. And I think that's sort of a virtual equivalent to the hallway conversation that doctors have historically. Always gotten so much from when they're passing each other. "Hey you know that patient... Oh yeah I saw them the other day." Sharing the strategies that work. Sharing the things, that the pitfalls that maybe they've run into that maybe haven't happened. That's a really important component of what we do.

Now, to answer your other question, let me get back to it. Are people, one of the ones I heard you say was, is the leadership satisfied? Well, as the Associate Director for Accreditation, my position was not that when I first came on board. It has increased in visibility, value, and I believe that the Accreditation Service, which is a service within our Employee Education System, it is often said now that accreditation, continuing education, CME, and CE accreditation is one of the most important things that we have to offer, and that's partly because we provide all of our education, CE, CME, free to our VHA employees. They don't have to go outside and go to, they can,

>>SINGER: It's a service within them.

>>DURHAM: It's a service. It also helps with recruitment and retention. I'll give you an example. Recently, 2013, we added the AOTA, the Accreditation Service for Occupational Therapists. I was barraged with emails from the 1100 occupational therapists and multiple techs around the system saying, "Wait a minute. You mean I don't have to take time off, go pay for a hotel and a conference. Get my kids out of school or board the dog. And I can have training that is related to what I actually do with veterans right here at a VA meeting space." And I said... How nice to be able to say, “yes you've got it exactly right.” And that's what we do for our physicians too.

So, what we want the physicians to be thinking about is how does this improve my care of veterans? What is it that I'm bothered by that maybe I haven't connected with the way that the nursing division in my area, in my clinic, does things? Maybe there's something I can do differently. Now, not all clinicians take the time to think, maybe they don't all have the time to think, “how can I do this better?” But I really believe, I choose to believe that they all want to do their best, and that they get up every morning and they say, "I'm going to go out and take care of veterans the best way I can."

And that's what I do even though I'm not in direct patient care. I see veterans everyday as I walk into my office. So, is the leadership happy? I think they're very happy that we are making a difference in terms of satisfying the need for CE credit for our clinicians, but making the training relevant to real problems that are in the VA. We want to make sure that nothing that we do is guided by anybody else's motives or needs than our own to serve the veteran in the caregiver circle where the patient's in the middle.

So we've moved a long way. I have done, I have led a lot of training of the staff that actually meet with national program offices. They're called project managers in the Employee Education System. They are, for example, in my performance improvement, quality improvement courses and trainings that we've done, they would, a project manager is someone who meets with the Office of Quality, Safety, and Value, for example, to say, "What is it you want to change or make better? Who needs to change? Who has that need? And how can we help you move that along, the continuum, from here to there." And I consult personally with a lot of those people, especially in performance and quality improvement, but then the people on my staff also do that, and we are working with the Office of Ethics, and Office of Clinic Administration. A lot of the things that happen in the VA, where there are areas that need to be improved, have to do with making sure that the administrative side of things works with what the patients need the physicians to be able to do. If that makes sense.

>>SINGER: Yeah, okay. So moving this battleship from provider-centered care, to patient-centered care, you've described a lot of rich, varied approaches, in which you've done in the last several years? Do you have the evidence that you've moved, that the battleship is moving, or moved? What do you know?

>>DURHAM: Yes. We do. Well, first of all, we have the numbers of individuals who've been trained. And, I know that that's a utilization number, it doesn't really speak to, how much did they absorb, but at least it's a start. So we know that over 12,000 VA staff in those teamlettes, members of those teams have been trained. I think it's about 4,000 teams, the first year, and as I mentioned the composition of the teams. The nurses, we have, if you count nurses, RNs, we have some 60,000 nurses. If you add in the LVNs and LPNs, and so forth, we have 75,000 nurses. We have almost 24,000 physicians. I'll say that again, almost 24,000 physicians. But then when you add in residents-in-training, through our medical school affiliations, it's a lot more, and we do a Patient-Aligned Care Training with the residents as well.

These staff, nurses, physicians, residents, chaplains, psychologists, social workers, form the basis of most of those Patient-Aligned Care groups. So we've had a progressive number over the three years I mentioned, 2012, '13, and '14, trained, and now we're doing mostly training of people who are coming on board now. So what we're looking at now with, is the data, as it applies to what has changed. And one of the things that we're looking at is, are there more appropriate consults going on? Are there fewer inappropriate consults, that didn't need to happen, or they were about the wrong thing. And that is data that were it's being collected, but we don't have it all yet, now... Yeah.

>>SINGER: Yeah, so... Thank you.

>>DURHAM: It's a process. Yeah.

>>SINGER: That's great. And it's instructive for the audience to understand that, whether you're in a small institution, or you're working in the federal government to serve the needs of those who care for veterans, and veterans themselves,

>>DURHAM: Yes.

>>SINGER: that there are two sides to the data. That comes and goes, from continuing education. There's the data in, you talked about the needs assessment that we discussed at the very beginning. About all the data about the difference between what is currently, and what we would like to be, in terms of patient-centered care. That's data coming in that helps you design education. But now you're discussing, and perhaps you'll come back for another video, when you've interpreted and analyzed

>>DURHAM: Sure.

>>SINGER: and understood the data that comes out of education, about how have things changed. What are the obstacles to change? What do we need to do differently as educators in the future? So, I very much appreciate

>>DURHAM: Thank you.

>>SINGER: the opportunity for you to give us window, a view into this, and thank you very much, Diane.

>>DURHAM: It's been delightful, thank you.

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This is a transcript of Focusing on Patient-Centered Care through Interprofessional Continuing Education.

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