Raising the bar: the importance of hospital library standards in the continuing medical education accreditation process

Abstract

The Connecticut State Medical Society (CSMS) reviews and accredits the continuing medical education (CME) programs offered by Connecticut's hospitals. As part of the survey process, the CSMS assesses the quality of the hospitals' libraries. In 1987, the CSMS adopted the Medical Library Association's (MLA's) “Minimum Standards for Health Sciences Libraries in Hospitals.” In 1990, professional librarians were added to the survey team and, later, to the CSMS CME Committee. Librarians participating in this effort are recruited from the membership of the Connecticut Association of Health Sciences Librarians (CAHSL). The positive results of having a qualified librarian on the survey team and the invaluable impact of adherence to the MLA standards are outlined. As a direct result of this process, hospitals throughout the state have added staffing, increased space, and added funding for resources during an era of cutbacks. Some hospital libraries have been able to maintain a healthy status quo, while others have had proposed cuts reconsidered by administrators for fear of losing valuable CME accreditation status. Creating a relationship with an accrediting agency is one method by which hospital librarians elsewhere may strengthen their efforts to ensure adequate library resources in an era of downsizing. In addition, this collaboration has provided a new and important role for librarians to play on an accreditation team.

BACKGROUND

Continuing medical education (CME) sponsors in the United States are accredited either by the Accreditation Council for Continuing Medical Education (ACCME) or by the state medical societies which are, in turn, recognized by ACCME. For intrastate sponsors of CME in Connecticut, the accrediting body is the Connecticut State Medical Society (CSMS). Accreditation for continuing medical education programs is voluntary. However, only activities sponsored by accredited CME providers can count toward Category 1 CME hours for the American Medical Association's Physician Recognition Award [1]. Hospitals generally require physicians to earn a defined number of accredited CME credits per year to retain their admitting and practicing privileges. If an institution's CME program lacks accreditation, the medical staff must travel elsewhere to gain CME credits. This inconvenience could have an impact on new physicians' choices of affiliation. It may also hinder a hospital's ability to continually improve the performance of its medical staff, as choice of CME presentations is expected to be tied to hospitals' needs assessment and mission. Most important, the loss of an accredited CME program would diminish the hospital medical staff ‘s ability to provide the necessary level of care consistent with current medical knowledge.

At least every four years, the CSMS schedules a survey at participating hospitals. The members of the survey team are chosen on a rotating basis from among the members of the CSMS Committee on CME and directors of medical education of the various hospitals. The CSMS director of scientific affairs attends every site survey. Several weeks prior to visits, hospitals submit answers to the CSMS Presurvey Questionnaire. The form is designed to determine hospitals' compliance with the CSMS Essentials, which are modeled after those of the ACCME [2] (Table 1). Evidence of compliance—such as minutes of board or medical staff meetings, mission statements, announcements of individual CME activities, evaluation forms, or needs assessments—are included. These documents are reviewed by all members of the survey team prior to the site survey. Additional records may be reviewed, leaders interviewed, and CME facilities inspected, including the library. At the survey itself, based on the supplied evidence, the surveyors recommend an accreditation for one to four years, initial provisional accreditation, contingent accreditation, or nonaccreditation. This recommendation is considered by the CSMS CME Committee at its quarterly meetings. Subsequent to the committee meeting, a formal report is sent to the hospital's chief executive officer, outlining the received level of accreditation and the steps, if any, that remain before full accreditation will be granted. If the facility receives a contingency, it must submit a report within a specified period of time, demonstrating at least substantial progress toward meeting specified standards in which it has been found deficient. When appropriate, the CSMS awards an accreditation with commendation. Hospitals in this category are honored at the CSMS annual CME conference.

Table 1 The seven essentials of the Connecticut State Medical Society's continuing medical education (CME) review process

CONNECTICUT STATE MEDICAL SOCIETY (CSMS) AND HOSPITAL LIBRARIANS

The relationship of the CSMS to the state's medical library community has been long standing. Members of the CME Committee have realized that a library is one of the most important components of a well-rounded CME program, because it enables practitioners to educate themselves on a given topic at the time that the need arises—the “teachable moment.” [3] In 1987, the CME Committee voted to adopt the Medical Library Association's (MLA's) “Minimum Standards for Health Science Libraries in Hospitals” [4]. This requirement has been included as part of Essential 6, which looks at administrative support.

In 1990, one director of medical education (DME) asked his hospital's librarian to accompany him on a site survey. He reasoned that she would be better able than he to evaluate the level of the library's compliance with the standards. This librarian's comments were incorporated into the survey team's report. The success of this experiment made the wisdom of the DME's action apparent. Librarians began to accompany physicians to all site surveys. The CSMS director of scientific affairs worked with the Connecticut Association of Health Science Librarians (CAHSL) to recruit its members for survey teams. Any directors or assistant directors of hospital libraries who have some years of experience in their position are considered. Librarians employed at an institution in close geographical proximity to the survey site are ineligible, so as to avoid any appearance of conflict of interest.

In 1997, CAHSL asked the CSMS to appoint a librarian to the CME Committee. CAHSL reasoned that if librarians' input was sought for the site visits, their participation would also be valuable once the survey reports reached the committee. The proposal was accepted, and CAHSL appointed a librarian to fill this role.

CAHSL's current delegate to the CME Committee fills several functions. She attends all CME Committee meetings, voting alongside other members on the accreditation decisions for CME programs. She coordinates the recruitment of librarians for site visits. In 1998, she was asked to draft an additional standard for libraries. It required that the hospital library provide Internet access, that the librarian assist users with Internet searches, and that the librarian perform mediated Internet searches when appropriate. In addition, her familiarity with the CME standards in general and her knowledge of the responses of many hospitals across the state to those requirements increase her ability to interact with the Department of Medical Education in her own institution, although she is not formally a member of that department.

BENEFITS OF THIS PROCESS

The CSMS periodic review of each Connecticut hospital provides an excellent opportunity for an audit of library services and levels of support, performed by outside professionals. If internal planning is conducted well in advance of the site visit and deficiencies are recorded, remedial steps can be taken before the survey. Alternatively, the review can serve as a forum in which the smooth and efficient level of library performance is brought to light, providing invaluable library promotion to the physicians and administrators who are involved in the hospital's CME Review team. This time is when administrators are made aware of any deficiencies that may exist, as well as the consequences of the loss of accreditation.

For example, during 1998, one small community hospital was preparing for a CSMS visit. In preparation for the survey, administrators approved an additional five hours per week for professional library staffing to meet the minimum standards, albeit the bare minimum. Physicians had been vocal in advocating for more hours, but, without the impending CSMS review, none had been added. At another very small institution, the upcoming visit spurred the administration to move the library into a larger space and equip it with a computer, a modem, and Web access and to advertise for a replacement for the library technician who had given three months' notice of her resignation. These preparations were made in the days preceding the site visit, though the remedies had been sought for over a year.

The most opportune time to raise the staffing or budget levels of the library occurs immediately following a CSMS site review. At this time, the formal evaluation has been made and deficiencies, if any, noted. As stated previously, if minimum standards are not met, the hospital may receive a contingent accreditation or nonaccreditation. Either requires remedial action. Institutions unwilling or unable to remedy the deficiencies risk the loss of accreditation for the entire continuing medical education program and the subsequent discontent of the medical staff.

In the wake of a less than full accreditation, numerous hospitals have raised their staffing or budget levels. In the early 1990s, the CSMS recommended that one large city hospital's library increase professional staffing by one full-time equivalent (FTE) and increase the size of its collection. This hospital took CSMS reviews very seriously, and accreditation by outside agencies was promoted through the media as part of their quality campaign. After this recommendation was received, an additional full-time, master's-degreed librarian was added to the staff in fiscal year (FY) 1993, and the budget for library materials was increased.

In October 1998, library staffing proportions at another large hospital in western Connecticut were found to be unbalanced. Of the three existing positions, one was devoted full time to audiovisual equipment duties. The CSMS requested that additional support staff be added to the library and that a letter be received within twelve months detailing how this level of service would be met. The additional staff was included in the FY 2000 budget.

At a Fairfield County hospital library, upon the recommendation of the CSMS, a master's-degreed librarian was hired to replace the non-master's-degreed librarian, who had been promoted from within after the library director had resigned. Another hospital has planned to add one full-time support staff member in the wake of the CSMS site reviews. One mental health library obtained funding for access to the PsycINFO database, as recommended by the CSMS.

One very small, state-run institution, which had no library services at all, chose to forego CSMS accreditation, rather than incur the expense of hiring staff and funding information resources. In this particular case, all physicians were also on staff at other nearby hospitals, where they could easily obtain CME credits. Funding previously earmarked for the medical education program could then be diverted into other areas. Another very small, geographically remote hospital hired a degreed librarian as a consultant [5] in order to avoid loss of accreditation.

One hospital sought initial accreditation by the American College of Surgeons (ACS) for its newly developed cancer center. The realization that the medical education program could feasibly lose its accreditation, due to a substantial lack of staffing in the medical library, was of serious concern to the chair of the center. The ACoS standards require that all associated clinical personnel earn a specified number of continuing medical education credits from an accredited CME provider [6]. This led that physician, who was also a member of the Board of Trustees, to lend his support to the library's request for fifty hours per week of additional staffing, which has been realized.

The CSMS review process can have a very long arm, and its influence can be felt during the years between scheduled visits. At one city hospital library, severe budget cuts were being enacted in 1998. The administration demanded that one staff support position be eliminated. One year previously, the library had undergone a successful CSMS accreditation. The MLA standards and the CSMS accreditation documentation were submitted as arguments against the staffing reduction. During the final review, the administrator referred the executive management team to the CSMS documentation. The physician member of the team, who had headed the review process internally for this hospital, lent his full weight and influence to the importance of this accreditation. The elimination of the support staff position was rejected.

The results of the CSMS review process can be positive and long lasting. Another city hospital had had a disappointing review several years ago. Subsequently, the library had raised its level of staffing and services with the support of the administration. The next CSMS review went very well. The administration and the medical staff were extremely pleased with the library and the librarian, and the good will has continued. Because of the trust established during the review process, administration has been more supportive of the library and receptive to most of its requests. An ongoing positive working relationship has been realized from their investment in library services.

One other benefit from the CSMS CME survey process should be noted. Hospital librarians and the CME program staff have much in common. Both programs, essentially, include the same aims: to educate staff about the current state of knowledge in medicine and to foster the habit of life-long learning [7]. The differences lie primarily in the methods employed. Participating in this survey process together can lead to many interdepartmental collaborations.

DISCUSSION

The authors sought to learn whether other medically related accreditation organizations have adopted library standards, and, if so, whether librarians have been included on the survey teams. The Liaison Committee on Medical Education includes specific library standards in its medical school accreditation standards [8]. To the best of our knowledge, the survey team includes no information professionals. The Pennsylvania, New Jersey, and Massachusetts medical societies have some standards for hospital libraries in the CME accreditation process but have no librarians on the accreditation teams. A report by Ebbinghouse in Searcher documents the accreditation process for law schools, which includes definitive library standards [9]. Librarians are included on the survey teams.

The standards adopted by the CSMS are not the current MLA standards [10]. When the CSMS adopted the MLA standards in 1987, they were current. The CSMS looked forward to MLA's revision of the standards. The nonquantitative form of the 1994 standards was a deliberate decision by MLA, made to align these standards with trends in the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. However, for this specific application—inclusion in a CME review process—objective measures are needed. The CSMS therefore voted, in 1994, to retain MLA's 1984 standards. This decision was most recently upheld in 1998, during a systematic review of all policies, procedures, and standards.

Having affirmed the use of the 1984 MLA standards, the CSMS applies the standards with flexibility. They believe that libraries should not be penalized for creative systems that are controlled and accountable and that work. They do not attempt to blindly enforce strict adherence. Instead, they seek to use the standards—which, as the title makes clear, are intended as minimum standards—to bring hospital library services up to a reasonable level in any given institution. They recognize that services may sometimes be provided by one library for several hospitals, especially in the case of mergers. Libraries, information technology, medicine, and the health care industry are changing at a rapid rate. The CSMS works to ensure sufficient qualified staff and resources to help guide hospitals through these difficult times.

These efforts help fill the gap left by a lack of other enforceable standards. Though the JCAHO no longer requires a qualified medical librarian per se, many standards outside of the knowledge management chapter require access to knowledge-based information, best provided by a qualified medical librarian. There must be access to information by patients and their families (PF.1 to PF.4); performance measures must be evidence-based (PI.2); hospital leadership must consider relevant practice guidelines (LD.1.10); a credible root cause analysis requires consideration of relevant literature; and patient safety programs should incorporate the findings of knowledge-based information [11].

Professions are in the best position to prevent erosion of services and staffing when they require certification or licensing, or when institutions are mandated by law to hire from within their ranks. Librarians in Montana successfully incorporated library services and resources into state law in 1993 [12]. Librarians in New York are currently working toward a return to recognition of library services by the State Board of Regents. Standards for library services were previously mandated by the New York State Board of Health but were dropped in 1989.

The gap left by erosion of other standards for library services is at least partially filled by the results of this collaboration between the CSMS and health sciences librarians. This comes at a pivotal time. The alarming rate of medical error is highlighted in the news media. Hospitals face the toughest fiscal limitations seen to date. In some institutions, libraries and librarians are seen as nonessential, due to the misguided belief that anything worthwhile is available free in full text on the Internet, and everyone has sufficient skill and time to do quality searching. Providing print and electronic resources for the professional and educational needs of hospital staff continues to be most efficiently and cost effectively managed by qualified librarians. The CSMS recognizes this and has incorporated library professionals into their review process and library standards in their review criteria.

CONCLUSIONS

The authors have presented a report of collaboration between health sciences librarians and the state medical society responsible for accreditation and oversight of continuing medical education programs. We believe that this arrangement is unique in the health care field.

We encourage our library colleagues to explore the possibilities of collaboration with organizations or societies that award CME accreditation in their state, to raise awareness among hospital administrators of the value of library service, and to work toward the creation of standards for hospital library services. Librarians should actively explore the incorporation of strong library standards and recognition of the benefits of quality library services into hospital-related policies and strategic plans and into the review processes of accrediting agencies.

Several benefits of the collaboration with the state's CME accrediting body have been realized by hospital librarians in Connecticut during the 1990s. First, a professional librarian from their ranks sits on the Connecticut State Medical Society's CME Committee alongside other medical professionals. This role is new and unique for hospital librarians to hold. Second, this review process presents an opportunity at least every four years for hospital administrators to assess how well their institutions are providing necessary library services as outlined by an outside accrediting agency. Third, and most importantly, because an accredited CME program is essential to the affiliated physicians and because the CME review is conducted by an impartial, state oversight body, the library deficiencies documented in their report carry weight and must be remedied. This tool has proved to be very powerful in Connecticut hospital libraries' defense against downsizing and budgetary cost cutting. Last, if a hospital library receives a glowing CME review, this report can be used as a positive public relations tool for library recognition and awareness with hospital administrators.

If enough librarians in enough locations can make the case for the necessity and benefits of resourceful libraries, the possibility emerges that we may reach a critical mass, at which time efforts toward enforceable national standards may be within reach. The collaboration between the CSMS and CAHSL librarians has been a win-win relationship for both parties. The authors encourage other librarians, perhaps through state consortia, to pursue similar collaborative initiatives with their CME accreditation agencies.