1. Implementation of a 3-year Competency Based Procedures Curriculum Dale A. Patterson, MD Associate Director The Toledo Hospital Family Practice Residency

2. Overview  Requirements –RRC –Hospitals –Duty to Patients  Historical Efforts to Evaluate Competence  Presentation of Longitudinal Curriculum  Evaluation of Curriculum  Discussion

3. Objectives 1.Recognize the varying requirements of documentation of competence in performance of procedures by hospitals and accrediting agencies. 2.Understand the various historical methods employed to demonstrate procedural competence. 3.Become familiar with one system that incorporates several methods of evaluation to demonstrate procedural competence in a family medicine residency.

4. RRC Requirements 2006 “The director and family physician faculty should devise a method by which all procedures are supervised and evaluated. They must also devise a credentialing process to establish whether or not a resident is competent to perform specific procedures. The resident's documentation of procedural learning should include procedure, age and gender of patient, level of performance (e.g., progressing toward independent performance), and number of procedures performed before independent status granted. Procedural teaching should include didactic presentations, indications and contra- indications, risks and benefits, informed consent, appropriate coding and charging, management of aftercare and complications, and acquisition and maintenance of skills.”

5. RRC Requirements 2006: Which Procedures?   “Residents should become competent in the performance of appropriate procedures.”   “… those skills and procedures that are within the scope of family medicine.”   “The residents should develop technical proficiency in those specific surgical procedures that family physicians may be called on to perform.”

6. RRC Requirements 2006: What Procedures?   40 total deliveries   “interpretation of radiographs, aspiration and injection of joints, splinting and casting.”   “surgical excision of skin lesions and performance of other dermatologic procedures”   No other specifics

7. RRC Requirements 2006: What documentation?   “Procedural skill documentation should indicate when the resident is capable of independent performance of the procedure.”   “The residency director and family medicine faculty should develop a list of procedural competencies required for completion by all residents in the program prior to their graduation.”

8. Hospitals/Credentialing   Hospital dependent   No set universal requirements   Often “secret” or unpublished   Sometimes subjective

9. Hospitals/Credentialing   Colonoscopy Credentials – –5 to 169 per AAFP – –50 to 140 in my experience   OB Credentials – –50 deliveries – –Approval of residency director   Specialty Based – –C-sections – –Endoscopy

10. Hospitals/Credentialing   Audience Input?   Cannot guarantee credentials – –Surgery and endoscopy

11. Duty to Patients   Most Important   First do no harm   AAFP Position on Hospital Privileges – –Competence – –Ability

12. Historical Efforts   Supervision – –See one, do one, teach one – –Program director assures competence   Arbitrary Numbers – –Committee Approach – –ASGE   RRC Requirements – –Cardiology (Int Med specialties) – –Surgery

13. Historical Efforts   Endoscopy Guidelines – –ASGE   100 colonoscopies   140 colonoscopies and equivalent experience – –RRC Surgery and ACP   50 Colonoscopies

14. Historical Efforts   Review of Evidence – –Some evidence for endoscopy   ACES study 1996 200 needed   Multiple studies increased completion, decreased complications with higher numbers – –Pulmonary (Chest 2003) arbitrary numbers – –OSATS some reliability (episiotomy) – –ER and Cardiology (3 vs 10 transvenous pacers)

15. Historical Efforts: Review of Evidence and Problems   Consensus on competence   Validation of studies/Conflicting Studies   Variation among learners   Variation among specialties   Ethical concerns with studies

16. Procedures Curriculum: Background   Requirements   Lack of Evidence   Historical perspective   Local Influences   National Influences

17. Procedures Curriculum: Overview   3 year longitudinal   Didactics   Interactive Workshops   Specialty Rotations   Numbers   Faculty assessment

18. Procedures Curriculum: Didactics 1 hour monthly lecture /2 year repeating curriculum Year 1 Informed Consent Skin Procedures 1 Anesthesia for Office Procedures Pediatric procedures Toenail Removal Joint injection/aspiration Intubation/Mechanical Ventilation IUD Placement Endometrial Biopsy Simple OB Procedures Paracentesis/Thoracentesis Nasopharyngoscopy Year 2 Skin Procedures 2 Vaginal Delivery Techniques Circumcision Cervical Cryotherapy and LEEP Flex Sig/Colonoscopy Conscious Sedation Laceration Repair Vasectomy Eye Procedures Pulmonary Function Testing Stress EKG Procedural Potpourri

19. Procedures Curriculum: Workshops  Occur annually  Coding and Billing  Colposcopy and Pap Smear  Casting/Splinting  Flex Sig/ Colonoscopy  Cardio-Sim

20. Procedures Curriculum: Specialty Rotations

21. Procedures Curriculum: Minimum Numbers Based On:  Local Standards (Colonoscopy, LP)  Family Medicine RRC requirements (OB)  Other RRC requirements (Stress Test)  Faculty Consensus (Most others)

22. Procedures Curriculum: Minimum Numbers Required for graduation: Dermatology  Incision and Drainage* 5  Excisional Biopsy*5  Punch Biopsy*5  Cryotherapy*5  Laceration Repair/Suture*5  Skin Tag Removal*3 GI  Anoscopy*5 General Adult  Lumbar Puncture*5  Joint Aspiration/Injection* 5  Toenail Removal*3  Pulmonary Function Testing*5  Assist at Surgery*20  Cast Application*3 General Pediatric  Lumbar Puncture*5  Arterial Blood Gas*3 Gynecology  Pap Smear*1  Breast Exam*1  Colposcopy*10  Endocervical Curretage*10  Cervical Biopsy*3  Endometrial Biopsy*3

23. Procedures Curriculum: Minimum Numbers Required for graduation : Obstetrics^  Threatened Abortion*3  Vaginal Delivery*30  Prenatall Care*10  Postprtum Care*10  Evaluation for Onset of Labor*5  Sterile Speculum Exam*5  Labor Management*10  Episiotomy*3  Laceration/Episiotomy Repair*5  C-Section Assist*10  Non-Stress Test*10  Amniotomy*3  IUPC Insertion*3  Fetal Scalp Electrode Placement*3  Circumcision*10  Induction of Labor*5 While documented experience of the obstetrical * procedures with the above numbers is required for graduation, independent competence is not.

24. Procedures Curriculum: Minimum Numbers Elective:GI  Colonoscopy140  Flex Sig20  EGD130 General Adult  Vasectomy15  Conscious Sedation20  Thoracentesis5  Paracentesis5  Fine Needle Aspiration5  Central Line Placement10  Arterial Line Placement10  Nasopharyngoscopy10  Mechanical Ventilation10  Ocular Tonometry3  Removal Ocular Foreign Body3  Cardiac Stress Testing50  Intubation10 Obstetrics  Manual Removal of Placenta3  VBAC3 General Pediatric  Arterial Line10  Mechanical Ventilation20  Umbilical Catheterization5  Suprapubic Aspiration5 Gynecology  IUD Placement5  Gastric Lavage3  LEEP10

25. Procedures Curriculum: Faculty Evaluation  Scheduling of procedure must be approved by faculty –Opportunity to review indication and knowledge –Insures supervision  Each procedure observed and evaluated –Formal evaluation for each procedure –Specific or generic

26. Procedures Curriculum: Faculty Evaluation

28. Procedures Curriculum: Documentation  Evaluation form entered into a database  Procedural cards completed by resident  Resident responsible for knowing progress toward requirements  Reminded at 6 month evaluations

29. Procedures Curriculum: Documentation

30. Procedures Curriculum: “Sign Off”  Mandatory prior to graduation for required  Optional for elective procedures  Resident must initiate process  Must have minimum number completed  Must perform “test” procedure  If satisfactory, reviewed by advisor and PD

31. Procedures Curriculum: “Sign Off”

32. Procedures Curriculum: Evaluation Current 1 st year Current 3 rd yr equiv. Current 3 rd year now Required Number Lumbar Puncture 2.22.25.45 Assist at Surgery 230.434.420 I & D 1.51.49.25 Vaginal Delivery 33.321.234.430 Circ.27.315.641.810

33. Procedures Curriculum: Resident Perception Question: In your 1 st year 2 nd -3 rd 1 st Aware of requirements for graduation 1.64.8 Opportunity to learn procedures 2.93.6 Competent to perform some 2.63.8 Requirement for independence 2.34.6

34. Procedures Curriculum: Faculty Perception Since the inception of the new procedures curriculum: Procedural Education has improved in the 1 st year3.6 1 st years are better able to perform procedures3.4 I am more aware of the procedural knowledge of the 1 st years3.4 I am more aware of the procedural skills of the 1 st years3.2 Competence can be adequately assessed3.6

35. Procedures Curriculum: RRC Perception Specifically addressed in RRC review Discussed with residents No citations Full 5 year accreditation

36. Procedures Curriculum: Summary Developed 3 year longitudinal curriculum Fits standards of 2006 RRC guidelines Improves documentation for privileging Possibly improves resident performance Needs further refinement and adaptation to other situations

37. Discussion of Survey Program has a: Defined curriculum Defined numbers List of procedures System for competency Number of LP’s Biggest Problem

38. Implementation of a 3-year Competency Based Procedures Curriculum Questions?Discussion?