2013 Joint KMS and MSMA
CME Provider Conference
Moderator & Panelists
 Rebecca Gaughan, MD
 Kansas Medical Society CME Committee Chair
 CME Director, Olathe Medical Center
 Micah Flint, Chief Programs Officer
 Institute for International Medicine (INMED)
 Melissa Haddad, CME Coordinator
 Via Christi Hospitals Wichita, Inc.
 Liz Coon, CME Coordinator
 Wesley Medical Center
 Traci Lewin, Medical Education Coordinator
 Olathe Medical Center
Criterion 16
 The provider operates in a manner that integrates
CME into the process for improving professional
practice.
Criterion 16
NOTE: The onus is on the provider to show that they
have inserted CME into the processes to improve
professional practice. Providers need to show that
their CME program has a presence, influence, or
contributory role in practice improvement.
The provider goes beyond activity planning to show
that CME is used as one of the tools to improve
professional practice. C16 can also be about the
use of CME in facilitating systems based quality
improvement activities if the quality
improvement activity is about changing
professional practice.
C16 - Tips and Tricks
 Keep it Simple.
 This is the entire purpose of CME. Every single
provider is doing this task, they just need to
document it.
 Set up a yearly meeting with all Quality people to
discuss what they are working on and what can be
scheduled for the next year.
Criterion 17
 The provider utilizes non-education strategies to
enhance change as an adjunct to its
activities/educational interventions (e.g.,
reminders, patient feedback).
Criterion 17
NOTE: The surveyor is looking for evidence of the use of
strategies such as, but not limited to, rewards, process
redesign, peer review, audit feedback, monitoring,
reminders as tools to enhance, or facilitate change.
Some providers are concerned that some of these may be
considered ‘educational’ as they potentially change what
people ‘know’ or because they inform learners (e.g., “It may
be time for you to call back your patients with …”).
In C17, the surveyor is looking for tactics that go beyond the
educational activity or intervention. Essentially, the
surveyor Is looking for providers to be broadening the
range of tools they use to facilitate change.
C17 – Tips and Tricks
 Captivate the Audience. Social media provides one great
resource to engage learners and incorporate Criteria 17 into
your CME activity.
 Keep a folder of Non-Educational Strategies to put items in
it throughout the year so you don’t have to struggle to think
of any while you are doing your application.
 I’m sure every provider is doing this task as well, but just
not tracking it. I like to keep a folder of Non-Educational
Strategies in an easy-access place to just grab things from
meetings and hospitals including Joint Commission
updates with physician recommendations and our medical
staff orientation book.
C17 – Tips and Tricks
 I’m sure every provider is doing this task as well,
but just not tracking it. I like to keep a folder of
Non-Educational Strategies in an easy-access
place to just grab things from meetings and
hospitals including Joint Commission updates
with physician recommendations and our
medical staff orientation book.
Criterion 18
 The provider identifies factors outside the
provider’s control that impact on patient
outcomes.
Criterion 18
NOTE: The provider has data and information
that explains patient outcomes, beyond the
performance of their learners. Here the
provider demonstrates knowledge of the
factors contributing to the health care ‘quality
gap’ about which they are concerned.
C18 – Tips and Tricks
 Get the whole picture. Identifying barriers
outside of your learner’s control, that impact
patient outcomes, will help in planning your CME
activity.
 Every single activity has its own issues. If you
document the edge of the extent to which you can
improve physician practice, you can attain this
criterion.
Criterion 19
 The provider implements educational strategies
to remove, overcome or address barriers to
physician change.
Criterion 19
NOTE: The provider has data and information
on barriers to change applicable to its own
learners, and incorporates these insights into
its CME program through activities. In C19,
the provider shows that activities are included
in their educational program that are focused
on ‘overcoming barriers to physician change.’
C19 – Tips and Tricks
 We identified Electronic Medical Records (EMR) as a
barrier.
 To help overcome this barrier we had a program to
teach physicians how to use the computer as a positive
instead of a negative during patient appointments.
 We also worked with the IT department to develop
educational training programs.
 We grouped the physicians by specialty in small
classes so questions would be relevant to all
participants.
C19 – Tips and Tricks
 This measure involves documenting “putting out
fires” in daily CME life. You can assess this by
asking the good old: who, what, when, where, why
and how. If there’s a gap? You have your barrier.
Criterion 20
 The provider builds bridges with other
stakeholders through collaboration and
cooperation.
Criterion 20
NOTE: The provider allies itself with other
organizations or components of its own organization
in a purposeful manner to achieve common interests.
These collaborations may support any aspect of the
provider’s CME program in service of achieving its
mission. Joint sponsorship, in itself, is not
consideration a collaboration that will guarantee
compliance with C20. However, joint sponsorship can
be a byproduct of a larger collaboration and if this
larger collaboration is described, then it could result
in compliance with C20. In C20, the surveyor is
looking for active engagement in collaborative and
cooperative projects.
C20 – Tips and Tricks
Local Task Force
• APRN Task Force (KS)
• Immigrant Task Force (KAAP)
• Mental Health (MO)
• KidsFirst (MO)
Associations
• Kansas Health Care Collaborative
• Kansas Hospital Association
• Missouri Hospital Association
• Missouri Primary Care Association
Regional Hospital System
• HCA Midwest Health System (KS)
• Via Christi Health System (KS)
• University of Missouri Health
System (MO)
• Freeman Health System (MO)
Government
• Kansas Health Institute
• Kansas Department of Health and
Environment
• Missouri Department of Social
Services
• Missouri Department of Health
and Senior Services
C20 – Tips and Tricks
 Brainstorm Stakeholders for your CME Program
C20 – Tips and Tricks
EASY STEPS
CME
Partner with
Application
Stakeholders
Document!
Wesley CME application
Number of 2013 Stakeholder Groups Identified and
Connected to Approved CME Activities
13%
12%
Local Task Force
Regional Hospital
Medical Associations
75%
Criterion 21
 The provider participates within an institutional
of system framework for quality improvement.
Criterion 21
NOTE: The provider is focused on integrating
and contributing to healthcare quality
improvement. In C21, the provider has
evidence that CME has become a part of
institutional, or system, quality improvement
efforts. ‘System’ can also include the network
of other organizations in the health care
‘system’. (Note: organizational self-assessment
and improvement focused on improving the
quality of the CME program are recognized
and rewarded in C12-15, not in C21.)
C21 – Tips and Tricks
 The Manager of Medical Staff Services and the Chief
Quality Risk Officers both sit on the Medical
Education Committee
 The CME Coordinator meets weekly with the Manager
of Medical Staff Services. Part of the meeting is to
review possible topics regarding quality. Those topics
are then forwarded to the Medical Education
Committee for review.
 Programs result from quality improvement
issues/updates discussed in regular Medical Staff
Meetings.
C21 – Tips and Tricks
 Call your director of quality, invite yourself to a
meeting. Everyone can start working with QI
today!
Criterion 22
 The provider is positioned to influence the scope
and content of activities/educational
interventions.
Criterion 22
NOTE: In C22, there is an expectation that the
provider will play a meaningful role in the
formation and direction of activities across its
entire CME program.
C22 – Tips and Tricks
 “Example 4. The provider’s framework and processes position the
organization to influence the scope and content of its activities.
In addition, the provider cooperates with other similarly-focused
specialty societies to develop a core curriculum and ensure that
the education obtained is consistent for the specialty. The content
of the curriculum is shared with the planning committees for
CME activities, so there is continuity regarding major issues and
topics.”
http://www.accme.org/sites/default/files/504_20130321_Accreditat
ion_Findings_Compendium.pdf
 “Yes, Wesley CME is positioned to influence the scope and content
of activities/educational interventions. If a physician education
activity is requested, it’s through the CME office… Every single
CME application documents this effort.” WMC 2011
Wesley Medical Center
CME
Application
•Educational Design
and Format
•Planning Process
•Needs Assessment
•Outcomes Evaluation
Involvement
Document
Via Christi
C22 - What not to do
“Example 6. Information collected from the review of
activity files and the survey interview showed that the
provider delegates many aspects of its CME program to
third parties with no mechanism for oversight or
reporting. Examples of these delegated functions
include activity planning, interaction with planners
and speakers, content development and review, and
the management of commercial support.”
http://www.accme.org/sites/default/files/504_20130321_Accr
editation_Findings_Compendium.pdf
Accreditation with Commendation
If a provider is found in compliance with:
 (a) Criteria 1-15; and
 (b) all but one of Criteria 16-22
 (c) and the policies measured
The provider is eligible to submit a voluntary
progress report to be considered for a change in
status to Accreditation with Commendation.
Thank you!