>>SINGER: Hi, I’m Steve Singer, I’m the Director of Education and Outreach at the Accreditation Council for Continuing Medical Education.
>>HORST: Hi, I’m Mike Horst, I’m the Director of Research and continuing medical education at Lancaster General Hospital in Lancaster, Pennsylvania.
>>SINGER: Mike, thanks for joining us today.
>>HORST: You bet, it’s a pleasure to be here.
>>SINGER: Tell me a little bit about the organization that you work in.
>>HORST: I work at Lancaster General Health in Lancaster General Hospital, which is flagship hospital it’s about 600 beds. We have a medical staff between 900 and 1,000. And we’ve got a freestanding health campus which handles all of our ambulatory and ambulatory surgery kinds of things as well as a number of, a free standing women’s and babies hospital which handles OBGYN. And then about a 25-plus primary care network of physician practices, in Lancaster County, which is in southeastern Pennsylvania between Philadelphia and Harrisburg.
>>SINGER: OK. And now, in our former conversation we, you mentioned that your hospital has sort of a couple different departments that are oriented to accountability, right, for the hospital. So, can you explore that a little for our audience
>>SINGER: sort of what that looks like.
>>HORST: I’ll start with probably the core one that we work with the most at the CME or quality department. It’s a large entity that includes physicians, medical directors, nurses, care managers, analysts and a number of support staff. And then we have a department of accreditation and quality standards, which manages a lot of the Joint Commission accreditation, standard interpretation, site visits, planning, applications. They’re also helping us draft Baldrige applications, as well as Department of Health site visits, and those kinds of things. And so, we don’t interface with them nearly as much on the CME side, but they are heavily involved, you know, supporting everybody else and trying to meet those accreditation standards.
>>SINGER: OK. So, from your hospital’s leadership, as well as, expectations of, of I would imagine, state or federal reporting and, and quality improvement expectations, you have some directives and goals that are coming from the accreditation requirements from the hospital. Internally you said the QI department, which
>>SINGER: I’m sure gets a lot of data
>>SINGER: from, from practice. What about the hospital executives, and the medical staff side how does how is that figured within?
>>HORST: We have a Senior Vice President of Medical Affairs, and I should mention that our medical staff between 900 and 1,000 I would say probably a third are employed or kind of under direct contract. The other two thirds are independent practitioners in the community have their own businesses and practices. And so there’s
>>SINGER: they have hospital privileges?
>>HORST: Exactly. They have hospital privileges, but they may practice in several facilities within the community or region. And so, the relationships with them, sometimes they’re competitive, sometimes they’re, you know, a physician on staff and a collaborator so there’s some unique challenges that many hospitals face that are dealing with free medical staff like them.
>>SINGER: managing those expectations
>>HORST: but we have administratively a Senior Vice President of Medical Affairs and then we have an Associate Vice President of Medical Affairs and a number of medical departmental directors, who either are employed or get a stipend from the facility to manage those particular entities. And we’re actually in the process of hiring a Chief Academic Affairs Officer, which hopefully, will be on board sometime in the beginning of the year.
>>SINGER: We talk a lot with accredited providers and with other stakeholders about the value of CME and the opportunity for accredited CME as a change and improvement engine to be of a strategic asset to our organization. Within your organization you, you’ve already described an example of sort of how your CME is sort of fully integrated with quality improvement, but I’m wondering from a, from a mission standpoint or from the organizational executives how do they view CME and where CME sort of in their arsenal of tools for the hospital?
>>HORST: That’s a good question, because I think, my experience in the past has been, I think, on the medical staff side they clearly see it as a, a tool and something that is promoted within the medical staff as an asset. I think, when you get outside the medical staff entity that’s where the real challenge is sometimes. And how do you, I mean we have another department that handles education and the nursing and kind of leadership side, and often you know, when there’s problems that’s who they call. Or, you know, if it’s a physician problem they do call CME. But, I think the challenge sometimes is, you know, pulling it across out of the physician leadership realm. We struggle with that. And I’ll be honest, it is a challenge. And our operation is small, it’s 10% of my time and a fulltime coordinator who handles a lot of the day-to-day planning. And so, I really rely heavily on the physicians, whether it’s OBGYN physician, who sits on our committee and really represents that department or division, cardiology, you know surgery etcetera. I really rely on them to kind of be the eyes and ears and really be the ones involved to you know, connect the linkages between to what’s happening PI-wise in their department or division and say, Hey, here’s something that we really need to address that CME can really play a key role in helping us accomplish that. Some departments are better than others. And I have some, shall I say, course directors or physicians that are better than others, but you know, we take all comers. And we try to you know, facilitate as much as we can with the resources that we have.
>>SINGER: Help me understand a little bit better when you talked about challenges, if the, if the working model, you now, when it works well is from your description, you can help me here, you’re getting from the clinical staff, medical staff, the description
>>SINGER: they’re coming forward with a problem
>>SINGER: a problem in practice or a problem with the patient care that they want to try to address with education, is that how it’s working? Or you know help me,
>>HORST: I’ll give you an example. You know, if I take the core measures related to cardiovascular care and we have a cardiology team that was put together to look at that and that team is a multi-disciplinary team, because most of these issues when they come up are very multi-disciplinary in nature. And throughout that process there were a number of things that came to the surface as far as for managing, for example, heart failure. And so, there were specific targeted CME activities that were put together to look at what’s the family physician’s role in managing heart failure, because they don’t come into the hospital. These days the family physicians are in their private practices. And so management of heart failure is very different for them than an internist who sees the patient manages them in the inpatient side. And so, we actually had separate activities for the inpatient side and for the family practitioners’ side. And then there was a specific directed activity for the entire medical staff. And so, in looking at, you know, talking about scope of practice and the intended audience and so on, and then focusing those to coincide with the initiatives that were going on within that cardiology care management team to try to address the issues around the management of heart failure across the continuum of care on both inpatient, outpatient even before they get in the hospital. You know, reduce the length of stay, reduce readmission rates etcetera. So, I would say the strongest linkages come from those teams of which physicians are a part of and that’s where they would flag and say, Hey let’s do something that meets family medicine, internal medicine or you know, the appropriate departments or areas.
>>SINGER: And is the, does the, does the outcome of those interventions come back through that
>>SINGER: that same group
>>HORST: same group, exactly
>>SINGER: OK. So, and their approach from QI that’s involved with that
>>HORST: yes. All the
>>SINGER: with that
>>HORST: and ultimately manage, that entire group is ultimately managed through the QI function and department.
>>SINGER: OK. So, education is sort of one part of trying to solve that problem.
>>HORST: Right. It’s kind of one tool in the box so to speak that, that and they say, Hey here’s an educational need. And, and then that’s when we become involved at that point.
>>SINGER: OK. So, now sort of for the flip side where you said there were difficulties, where’s, where’s a, you suggested perhaps that, you know, it’s the areas of practice which are most connected to physicians where there’s a most logical connection, I don’t know if it’s correct for me to assume there’s areas where there aren’t as many physicians involved, you know, where does the challenge come from?
>>HORST: My experience has been in our organization there’s still a culture of, I mean I go to meetings I sit on the hospital-wide PI committee and I still get the sense at times that there’s a us them, you know, physicians, we got to get how do we get the physicians in line and then nursing’s kind of in their silo over here. And then you’ve got administration in their silo over here. And I think we still have a lot of challenges in trying to figure out how to cross those. I’ve been at the hospital for a number of years; I think we’re getting better.
>>SINGER: Now are there analogous sort of improvement units within those different silos? Because you mentioned the one for medical staff and QI being sort of working at the department level working better for some than others but it’s
>>SINGER: working. In terms of nursing and administration is there the same
>>HORST: As an example,
>>SINGER: that you know I not making any assumptions
>>HORST: yeah as an example nursing has their own quality council which is just a nursing based committee, but yet there are representatives then that sit on more of the hospital wide which would involve physicians and other you know, entities that would be at the table there. And then like the example I gave of our cardiac care management team that’s a multi-disciplinary group and then they have, you know, various reporting relationships and so on. And so, you know, I’m not sure I’m the best person to tell you all of the linkages between there. I, you know, there are times you still see silos that, you know, the physicians, nurses, even within the physicians, well that’s the internist’s problem, that’s, you know, and so on. So, that’s a challenge in any organization and we’re not immune. We certainly face those challenges as well. As I said I think we’re getting better, we’ve you know, one of the things our CME program has done is we’ve developed the Physician Leadership Institute. And now we’ve taken a more active role in recruiting and actually developing physician leaders it’s about a 12 to 18 month curriculum that they go through in a cohort format. And they training in principles of quality management, negotiation, collaboration, teamwork, leadership, finance, a lot of very specific things about relative to physician based leadership. And I think, one of the goals of that whole program is to try to help develop the competencies and outcomes related to that inner working. You know, how do we need the physicians to collaborate with the hospital, with the community based physicians, with the administration and so on, to better position the organization and achieve outcomes and the mission of the organization itself.
>>SINGER: And you’re administrating that as part of the CME program?
>>HORST: Yes. Yes.
>>SINGER: So, that’s really interesting. So, you’re taking a, you sort of have an expectation and a goal
>>SINGER: and a need
>>SINGER: for physician leaders. You’ve developed a program
>>SINGER: which is a training track
>>SINGER: to grow people into the role that you need to be successful
>>HORST: right. And it’s quite a commitment when they sign up; it’s cohort commitment and they’re committing for the next 12 to 18 months
>>HORST: to participate, in these, in these educational sessions. And they’re not, you know, we do field trips, we do all kinds of activities. And you know, we’re in our second cohort now; it’s modeled on models that Harvard uses, and some other facilities
>>HORST: that we went and visited.
>>SINGER: So, what are the physicians from the first cohort doing?
>>HORST: Some of
>>SINGER: are they now the leadership?
>>HORST: yeah. Some of them were existing leaders, were already medical directors and leaders of various other types of programs, other were specifically recruited as potential leaders. And so, there’s kind of a mixture, I would say the cohorts mixed as far as getting existing leaders and potential leaders. And you know, with the goal of the those that aren’t leaders at some point now they’re in the queue that when opportunities arise we move them up into leadership roles. Or approach them with leadership roles. And, and they will be at least ready to fulfill that responsibility.
>>SINGER: Yeah. There, there, it seems there’s a clear motivation for you to want to do this
>>SINGER: and probably for your leadership and for the hospital’s leadership to want to cultivate this
>>SINGER: For the physicians themselves what do you think motivates their participation in this?
>>HORST: That’s a good question, I mean, you know, I think one thing that we’ve seen particularly with some of the changes in healthcare legislation and so on, I think there is, there’s more and more of, you know, we talk about managing populations and some of those kinds of issues, I think you know, that really starts to cut across the continuum and, and even if I’m a family practitioner in a community clinic, you know, how do I collaborate with the internist who’s discharging my patient and get the data from their inpatient stay so that I make better decisions. And we’re rolling out an electronic medical records we have it in the ambulatory side we’re moving it to the inpatient side. And so, there’s more data available, more outcomes data available. And so, I think, there’s, there’s a pool on both sides if we’re looking at and saying there’s more of a need for collaboration there’s more of an opportunity. And the accountabilities are there now too I think some of the new legislation and so on. That I think that’s helping to facilitate some of that drive for the physicians.
>>SINGER: So, it’s really intrinsic around improvement
>>SINGER: continuing professional development
>>HORST: right. And I’m excited, as a researcher I spend 90% of my time in clinical research supporting the physicians and staff, you know. I’m excited about the access to the data, more comprehensive data, as I’m sure our quality people are as well. And being able to utilize that for short term longitudinal studies to be able to look at: how are we managing patients across the continuum.
>>SINGER: So, what do you see in the future? You know, you’ve described a tremendous program that, that is currently operating and running, what, in the next five years do you see as the things that you would like to try and achieve?
>>HORST: Organizationally, we are, at least the CME functions kind of in transition. We have a Senior Vice President of Academic Affairs which will be coming on in, hopefully, the next nine months or so, which will take over CME research, institutional review board, and the graduate medical education programs. And so I think a lot will depend on the vision of that individual as far as, you know, how that integrates and plays into. There’s also some strategicals around expanding residencies right now we only have family practice residency and a number of fellowships surrounding family practice, geriatrics and palliative medicine. So, I think there’s going to be a lot of growth in expansion of medical clerkships and residencies. So, you know, I think there’s going to be some effort to look at medical education not only on the graduate side but on the CME side and, and kind of strategically kind of look at where we want to go. So, I’m excited about that and I’m looking at, you know, how do we, from a CME perspective, we’ll be going through our accreditation cycle under the new Criteria, 2012. And so, we’ve already sat down in trying to look at, you know, where are we now? Within the next two years what do we need to try to work on to make sure we’re ready for that site visit?
>>SINGER: So, it’s, there are of course resource challenges for hospitals and for healthcare institutions and you mentioned I think you said a tenth of your time is dedicated to CME and you have a coordinator who works with you. So you have all these clinical issues to try to address, all the services you’re trying to provide to medical staff and
>>SINGER: working with QI. All these things that you’re balancing under the duress of, I’m sure, resource restriction. What are you most proud of that you’ve been able to achieve in your current program? And how, sort of a, and how you would like to see that extended? You know if you can talk about something that you’re very proud of that if people understand the value of that, that that would help you to continue to have support for what you’re trying to do?
>>HORST: I think the, the as far as a sense of pride I think the thing that stands out the most is how we’ve been able to, with the limited resources that we do have, really get key physicians involved to apply their knowledge of clinical medicine and the needs and issues within their departments, and as I mentioned before some better than others, but I would say we have kind of a core set of physicians, who are just really good at and have become good over the years at just really figuring out how to address the needs of their particular departments and entities. And I can’t praise them enough for, you know, learning the Standards, working with us. And even where they have struggled we’ve tried to make it as seamless as possible so, they don’t have to know the jargon, the lingo a lot of times. And if they can just articulate sometimes, here’s what we want to do and then, you know, I or my coordinator try to work with them to you know, figure out what we need to do from an accreditation side. But, really just a working relationship with them that whether it’s the department of pediatrics or OBGYN or medicine that makes their job easy. But yet, they’re making our job easy as well. So, I would say that’s probably our, one of our strongest assets, our physician leaders within the CME function. And you know, their support in making it what it is. And obviously we have ties with quality and other entities. But, I think the physicians really are the key.
>>SINGER: Right. So, I wish you continued, continued prosperity with your physician leadership efforts and thanks for joining us today.
>>HORST: No problem, anytime.
This is a transcript of Integrating CME with Quality Improvement and Promoting Physician Leadership.
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