Continuing Medical Education Committee Thursday, May 12, 2016 • 7:00 am

369 Pages·2016·6.81 MB·English

Continuing Medical Education Committee
Thursday, May 12, 2016  7:00 am - 8:00 am
Conference Center Room #6

Agenda

Open Sandra Weber, MD
Welcome and Announcements
*Review of March Meeting Minutes

Family Medicine Molly Benedum, MD

GHS Calvert Warren, MD
Psychiatry Research Showcase May 25, 2016
“Sharing the Journey: Where Spirituality and Mental Health Meet” Approved/Update

Independent

Internal Medicine Nanette Dendy, MD
*Lloyd Hayes Symposium August 20, 2016 Application/Approval

*2016 Stroke Symposium September 24, 2016 Application/Approval

OBGYN William Coleman, MD
C. M. Easley Symposium May 20, 2016 Approved/Update

Oncology David Grisell, DO

Orthopaedics Chris Bray, MD
41st Annual Orthopaedic Day May 20, 2016 Approved/Update

Pediatrics Robert Saul, MD

Surgery Charles Kanos, MD
24th Annual J.D. Ashmore Lectureship June 10, 2016 Approved/Update

*Urology Journal Club (SURUROJC16) Application/Approval

*Urology M&M Conference (SURUROMM16) Application/Approval

*Vascular Lab Conference (SURVASLAB16) Application/Approval
CME Activity Review
*Nurturing Developing Minds February 26, 2016 Robert Saul, MD

60th Annual Greenville Postgraduate Seminar April 20-22, 2016 Molly Benedum, MD

Southeastern Symposium on Mental Health May 6-7, 2016 Calvert Warren, MD

New Business
*Pediatric Quality M&M credit increase from 6 to 12 (1 hour sessions). Robert Saul, MD

Old Business
CME Transition Bob Best, PhD

ACCME Accreditation Bob Best, PhD

Pediatric Grand Rounds Space Robert Saul, MD

CME Software/App Update Debbie Kirkland

*Document attached

The next CMEC Meeting will be held on July 14, 2016
from 7:00 a.m. to 8:00 a.m. in the Conference Center Room #6

SharePoint – All documentation is listed in full on SharePoint, backed-up by
Hospital IT system with a hard copy on file in the CME Office

I:\CME Committee\2016\March 2016

[Type text]
Continuing Medical Education Committee
Thursday, March 10, 2016  7:00 am - 8:00 am
Conference Center Room #6
Meeting Minutes

Members Present
Sandra L. Weber, MD Chairperson
Edward W. Bray, MD GHS GME/CME – Orthopaedics representing C. Bray, MD
Nanette E. Dendy, MD Internal Medicine
Molly Benedum, MD Family Medicine
William A. Coleman, MD OB-Gyn
Charles C. Kanos, MD Surgery
Robert A. Saul, MD Pediatrics
Calvert Warren, MD Psychiatry/Member-at-Large
Hurschell F. Mathews CME Director/ex-Officio

Members Not Present
Christopher C. Bray, MD Orthopaedics – Proxy given to Edward Bray, MD
David L. Grisell, DO Oncology/Member-at-Large

Non-Members Present
Sally Cade CME Coordinator
Rachel Andes CME Coordinator
Debbie Kirkland CME Administrative Assistant
Michael Wiederman, PhD Director of Faculty Affairs

Non-Members Not Present
Robert Best, PhD USC SOMG Office of Faculty Affairs

Open Sandra Weber, MD
Welcome and Announcements -- A quorum was determined and the meeting was opened by Dr.
Sandra Weber at 7:07 a.m. and everyone was welcomed. Dr. Weber extended a warm welcome
to Michael Wiederman, PhD. She invited him to give input as the meeting continued. He
attended the meeting in Robert Best, PhD stead.

Hurschell F. Mathews formally announced to the committee that this would be his last
Continuing Medical Education meeting. He stated that during the past 18 years he has attended
106 meetings. Dr. Weber thanked Hurschell for all of his years of service and dedication.
Michael Wiederman, PhD also thanked Hurschell for all that he has done for the Greenville
Health System’s Continuing Medical Education department. Michael also stated that once the
position is filled then the process would begin for seeking ACCME national accreditation. Dr.
Edward W. Bray was next to thank Hurschell and as the Associate Dean for GME and CME
noted that for those many years with Hurschell in charge of CME and a great chair, he never had
to worry about any CME activity.

Approval of Meeting Minutes
The minutes of the January meeting were distributed and reviewed by all present. A motion to
approve was made by Dr. Robert Saul and a second to the motion was made by Dr. Molly
Benedum. Hearing no additions or deletions, all voted in favor and so the minutes for the January
CMEC meeting were approved.

GHS Calvert Warren, MD
Southeastern Symposium on Mental Health May 6-7, 2016 Approved/Update
Dr. Warren acknowledged that the development and organization of this activity took longer than
any of the committee expected. The fact that most of the committee was new including himself
did not help. The final agenda has been submitted and reviewed by the CME committee. The
CME committee expressed that planning should begin even earlier for this activity next year.
Rachel Andes stated that once the final brochure has been sent to the CME office as a pdf, the
registration will be opened.

Psychiatry Research Showcase May 25, 2016 Calvert Warren, MD
“Sharing the Journey: Where Spirituality and Mental Health Meet” Application/Approval
Dr. Sandra Weber stated the application contains all of the Essentials for CME and would accept
a motion for approval of this application for CME credit.
Motion made to approve by Dr. Robert Saul, second made by Dr. Nanette Dendy, all in favor
and so approved.

Calvert Warren, MD
Quality, Safety and Ethics in Psychiatry Renewal application not received
The application was not submitted for the March meeting but Psychiatry will work hard to have
everything ready for the May CME meeting. Until a new application is receive and approved
there will be no CME credit issued for this activity.

Family Medicine Molly Benedum, MD
60th Annual Greenville Postgraduate Seminar April 20-22, 2016 Approved/Update
Registration has been open for about a week and there are about 57 registered. The Embassy
Suites is in the final stages of renovation and everything should be complete before PGS.

Internal Medicine Nanette Dendy, MD
There are no new activities for Internal Medicine. Everything is going along well.

OBGYN William Coleman, MD
C. M. Easley Symposium May 20, 2016 Approved/Update
Everything is on schedule. The brochure has been sent out with a CME error. Marketing
removed the “The” in the CME accreditation statement. Dr. Weber noted that, we have gotten
sited by our accreditation body, the SCMA, for this very thing. Remind marketing CME
department needs to give final approval prior to sending out.

Orthopaedics Edward Bray, MD
41st Annual Orthopaedic Day May 20, 2016 Application/Approval
CME Committee Meeting Minutes for Thursday, March 10, 2016
Dr. Sandra Weber stated the application contains all of the Essentials for CME and would accept
a motion for approval of this application for CME credit.
Motion made to approve by Dr. Edward Bray, second made by Dr. Robert Saul, all in favor and
so approved.

Pediatrics Robert Saul, MD

Surgery Charles Kanos, MD
24th Annual J.D. Ashmore Lectureship June 10, 2016 Application/Approval
Dr. Sandra Weber stated the application contains all of the Essentials for CME and would accept
a motion for approval of this application for CME credit.
Motion made to approve by Dr. Edward Bray, second made by Dr. Robert Saul, all in favor and
so approved.

Bioskills Lab for Upper Extremity (Journal Club) Application/Approval
Discussion as to whom the activity was designed for, so it was confirmed that the audience is
physicians. CME is very pointed and very little room for interpretation. CME at its core is really
designed for MD/DO’s by physicians. Others can attend and receive attendance and use it in
some cases with their disciplines such as nurses, nurse practitioners, etc. As the continuing
education process continues, how we design activities for the whole of continuity of education
will be reviewed. Dr. Sandra Weber stated the application contains all of the Essentials for CME
and would accept a motion for approval of this application for CME credit.
Motion made to approve by Dr. Edward Bray, second made by Dr. Robert Saul, all in favor and
so approved.

Urology PA Fellowship Didactics Application/Approval
Hurschell stated that an email for clarification was received from Dr. Springhart. The activity
has been designed for PA’s and they have set up a fellowship didactic series through the CPL
and the Clinical University. It is a formal education program but they applied for CME credit and
PA’s can use attendance at a CME activity but this was not designed for physician, it was
designed for PA’s but it must be designed for MD’s/DO’s. Dr. Springhart was informed that the
CME committee would not be reviewing the activity for credit. Dr. Weber stated that we did
want to pass it on that as we look at GRE and this whole continuum of education that this is
something that needs to be addressed. We have many PA’s here at GHS and need to making
sure that the appropriate venue to approve Continuing Education for this group exist.

CME Activity Review
Normal Pressure Hydrocephalus January 16, 2016 Sandra Weber, MD
Dr. Sandra Weber provided a review of the evaluations from Normal Pressure Hydrocephalus.
Twenty-six evaluations were submitted. The feedback was positive. Rachel Andes stated that
they did an excellent job with the brochure and had registration information out early but still the
numbers were low for attendance. Hurschell Mathews stated that this may have been due to the
specialized topic.

Cardiology Symposium January 30, 2016 Nanette Dendy, MD
Dr. Nanette Dendy provided a review of the evaluations from the Cardiology Symposium. There
were 82 evaluations. The comments ranged from very good to excellent. One attendee
committed that it was so good that they didn’t want to take a restroom break. A nurse also
commented that the activity seemed to be geared more toward physicians this year. The CME
CME Committee Meeting Minutes for Thursday, March 10, 2016
committee agreed that this was a well-planned activity and had no recommendations for next
year.

Nurturing Developing Minds February 26, 2016 Tabled until May Meeting
Review of this activity was tabled until next meeting due to the evaluation/attestation 30 day
period has not yet closed.

New Business
*SCMA Accreditation Hurschell Mathews
Greenville Health System has received Accreditation for Four Years from the South Carolina
Medical Association. The Accreditation is good until February of 2020. The two items that
GHS/CME were cited for are listed below. Due to these two citations, we were unable to obtain
accreditation with commendation.

C7 Compliance: The provider develops activities/educational interventions independent of
commercial interests (SCS 1, 2, 6).

Noncompliance: The provider does not develop activities/educational interventions
independent of commercial interests (SCS 1, 2, 6).

Description of performance:
SCS 1.1 - The narrative did not describe a complete process. Documentation review
indicated a lack of evidence of disclosures from all persons involved with planning and faculty
in multiple activity files.

SCS 2.1, 2.3 - Narrative indicated that the "resolution of conflict" process ended with the
completion of the disclosure form - indicated how planner/faculty would resolve their conflict.
Narrative indicated the CME Department staff would review. No follow-up with planner/faculty
indicated in narrative. Provider did submit a revised Disclosure Policy to reflect incorporation of
necessary steps to follow when "conflict" was identified. Evidence of a policy is not evidence of
compliance.

SCS 6 - Narrative indicated an appropriate process; however, evidence from review of
activity files did not provide proof of compliance in multiple files. Comments made during
interview indicated non-compliance due to timing and location of disclosure. Example -
information could be found online when the learner completed evaluation of program.

C8 Compliance: The provider appropriately manages commercial support (SCS 3).

Noncompliance: The provider does not appropriately manage commercial support (SCS 3).

Description of performance:
SCS 3.10 - The narrative does not address C8-SCS 3.10 and no documentation was found
in any of the activity files to reflect a process is in place or followed.

However, the provider did submit a revised policy to include specific guidelines for the
expenses of teachers/authors being paid for their teacher or author role only when they are a
participant of a CME activity. Evidence of a policy is not evidence of compliance.

There was discussion stating that it is the program director’s responsibility to review the
activities, potential conflict of interest, how it would be resolved, collect the documentation
CME Committee Meeting Minutes for Thursday, March 10, 2016
that shows the conflicted was resolved and also provide the outcome. Dr. Bray stated that
we need to make sure that all the situations have been satisfied.

EPIC CME Credit Update Sally Cade
Sally Cade reported to the committee that within the last two months the CME department as had
to develop over 35 new EPIC enduring and live activities based on new information obtained
from new EPIC team members. The curriculum for EPIC has several prerequisites. There were
several methods used to communicate the new expanded listing. Once the list was placed on the
website, the EPIC training team was notified to provide the information after each training,
medical staff was notified via email, other attendees were notified through the WHAG, emails
were sent to persons that had emailed or called CME with questions. The department continues
to work through questions and concerns as they are made known.

CME Transition Michael Wiederman, PhD
Michael Wiederman informed the committee that everything has been put on hold for ACCME
accreditation for Greenville Health System until such time as the Medical Director or such
position is filed through USCSOM.

Hurschell stated that interviews have taken place for a third coordinator. Hurschell let the
committee know that she comes very qualified and highly recommends that she be hired.

Old Business

ACCME Accreditation Hurschell Mathews
Hurschell restated that the ACCME Accreditation has been put on hold until his replacement has
been hired.

Pediatric Grand Rounds Space Robert Saul, MD/Hurschell Mathews
*Letter to Paul Johnson, President - GMH
The enclosed letter was sent to GMH, President Paul Johnson expressing the need for more
conference center space. Pediatric Grand Round and other activities have outgrown our current
space.

A detailed report was generated by the conference center team to identify available locations and
times.

Dr. Saul has reached out to Shriners to see if they have room to host Peds grand rounds and may
have a report for the next meeting. Two issues with this are AV staff and the lack of ability to
Skype. There was discussion around changing meeting times and locations to work to fit the
limitations.

CME Software/App Update Hurschell Mathews

Hurschell reported that the App should be available in May or June of 2016. He would like to
continue to be a part of this project and see it through to the end. The systems and departments
involved (Survey Monkey, CME Tracker and GHS IT) are all working together to make this
happen. We will then be looking for a department to test the app.

CME Committee Meeting Minutes for Thursday, March 10, 2016
Greenwood Genetics Center has reignited interest in establishing a Joint Pediatric Medical
Genetics Residency. This will be significant for the institution and Continuing Medical
Education for those joint learners and it is already having an impact. With the Fellowship in
Maternal Fetal Medicine is establishing a collaborative with Greenwood Genetics Center.
Pediatrics had received approval for this about a year ago to establish a collaboration.

Hearing no other new business Dr. Sandra Weber called for adjournment. The meeting was
adjourned at 7:58 am.

*Document attached

The next CMEC Meeting will be held on May 12, 2016
from 7:00 a.m. to 8:00 a.m. in the Conference Center Room #6

SharePoint – All documentation is listed in full on SharePoint, backed-up by
Hospital IT system with a hard copy on file in the CME Office

I:\CME Committee\2016\March 2016

CME Committee Meeting Minutes for Thursday, March 10, 2016
Form 3

Continuing Medical Education Application

Date: 4/10/16

Pr oposed Title of Activity: Lloyd Hayes Symposium

Proposed Date of Activity: 8/27/16 Time: 8am-5pm

Lo cation of Activity: MSA

Medical Dir. responsible for activity: Michael Fuller

Ph one Number: 455-7882 Fax: [phone] Email: [email protected]

Administrative Contact: Kristie Stone

Ph one Number: 455-7882 Fax: [phone] Email: [email protected]

Affiliation: GHS

Ad dress: 701 Grove Road, Dept of Medicine

City: Greenville State: SC Zip: 29605

Co mmercial/Financial Support [if applicable]: Yes X No:
(A ny source of funds not provided from GHS operational accounts)

If yes, please provide source name: Vendors/displays

Cr edits requested __________________________________________________________________
(add minutes of education activities and divide by 60. Do not include breaks, introduction times, etc.)

Occurrence: Yearly # per year: 1

(i.e. weekly, monthly, etc.)

This application is designed to assist planners in working through the steps that are required by
the Accreditation Council for Continuing Medical Education (ACCME), the South Carolina
Medical Association (SCMA) and Greenville Health System (GHS) prior to approval of CME
activities sponsored by Greenville Health System.

All of the steps must be taken independently of commercial interests. Further, all persons who
are in a position to control CME content must disclose all relevant financial relationships with
regards to commercial interest to the CME Department. The GHS-CME Department must
implement mechanisms to identify and resolve all conflicts of interest before any CME activity
occurs.

1
Revised August 1, 2014
Form 3

E
M
CC7
C

A

Step 1: Identifying the educational gap(s)

The planning process begins by identifying at least one educational gap. This educational gap
can be expressed as the difference between what actually occurs and what should occur to give
the best possible care to our patients.

The person filling out this application must (a) describe the
identified gap(s); (b) determine whether closing the identified
Scientific
gap(s) will improve knowledge, enhance competency, and/or Evidence
change physicians behavior; (c) identify barriers that may need Expert
to be overcome to close the gap(s); and (d) describe how the CME
CME
gap was analyzed so the cause of the problem is being Participant AAcCtTiIVvIiTtYy
addressed through CME.
Environmental

The latter is termed “needs assessment” and must include at Observed
least two different sources. For example, scientific evidence for
the literature; opinion from clinical or scientific experts;
information from the general public, the media and/or other
Sources of Needs
environmental sources; observed data from local or national
databases; and/or survey from past participants or prospective learners. Whenever possible, it is
important to utilize our Quality Initiatives and other forms of organizational data to address your
department needs assessment.

A. What is/are the educational gap(s)? How was this gap (were these gaps)

l
a identified? What is/are the quality gap(s) that this CME activity is
n
o Designed to address? 2
C
i
at The purpose of the Lloyd Hayes Symposium is to provide an update of topics E
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u relevant to primary care providers. The identified gaps are related to recognition of C
ed common and uncommon presentations for conditions encountered in primary care, AC
e diagnosis and treatment of common medical conditions, and self-reflection of
h personal strengths and weaknesses of healthcare delivery.
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g (s
np
yia B. What is the reason that the gap exists? Is it because physicians do not
g
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ti know something (i.e., there is a knowledge deficit)? Is it because
n 3
e physicians are not able to do something (i.e., there is a competency C
d
I deficit)? Is it because the physician did something, or failed to do 2,
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1 something (i.e., there is sub-optimal physician behavior)? E
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p In addition to the above, some of these gap concerns are indeed related to a C
e C
t knowledge deficit, a competency deficit, or behavioral issues. This is discussed in A
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another portion of the application.

2
Revised August 1, 2014