1. MOVING FORWARD IN THE 21ST CENTURY: IMPLEMENTING THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE TOWN HALL – CLINICS FEB 4, 2013

2. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Patient Centered Care Defined The Structure of the General Practice (GP) Clinic – Comprehensive Integrated Care – Assessment of Competency Instructor Calibration Role of the Group Manager (ex Team Leader)

3. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE REFERENCES: Dental Education at the Crossroads: Challenges and Changes. Marilyn J. Field, Editor; Committee on the Future of Dental Education, Institute of Medicine. The National Academies Press, 1995 Henzi, David et al: North American Dental Students’ Perspectives About Their Clinical Education. Journal of Dental Education; Vol.72, April 2006

4. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE REFERENCES: Formicola, Allan J: Dental School Clinics as Patient Care Delivery Centers: A Paradigm Shift in Dental Education. Journal of Dental Education, Vol. 72 No. 2, 2006 Taleghani, M et al: Non-Graded Evaluation of Dental Students in a Competency-Based Education Program. Journal of Dental Education, Vol. 68, No. 6, 2004

5. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE REFERENCES: DePaola, Dominick P et al: Reforming Dental Health Professions Education: A White Paper. Journal of Dental Education, Vol. 68 No. 11; Nov. 2004. Licari, Frank W. et al: Some Paradoxes in Competency-Based Dental Education. Journal of Dental education, Vol. 72, No. 1, 2008.

6. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE REFERENCES: Manual: Integrated Clinical Care. Richardson, James and MacNeil, M. A. J.; UBC 2010 About Patient Clinics: University of Louisville. Louisville.edu\dental (2012) Listserve communication: Robert A Cederberg, Associate Dean for Patient Care; University of Texas at Houston (2012)

7. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE REFERENCES: Listserve communication: Boyd E Robinson, Associate Dean for Clinical Affairs; University of Florida College of Dentistry (2012). Listserve communication: Jeanne Panza, Associate Dean for Clinical Affairs, University of Oklahoma College of Dentistry. (2012). American Dental Association. Future of Dentistry. Chicago: American Dental Association, Health Policy Resources Center:2001.

8. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE REFERENCES: ACFD 2011 Biennial Conference: Clinical Evaluation. McGill University. ADEA Regional Accreditation Workshop: Strategies for Assessing Students’ Progression Toward Competency. 2012 ADEA Signature Series: Breaking Down Silos – Engaging Across Disciplines and Professions. 2012

9. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE REFERENCES: Commission on Dental Accreditation, American Dental Association. 2012.

10. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE COMPREHENSIVE PATIENT CARE: The system of patient care in which individual students examine and evaluate patients; develop and prescribe a treatment plan; perform the majority of the care required, including care in several disciplines of dentistry; refer patients to specialists as appropriate; and assume responsibility that the patient has received total oral care.

11. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Patient Centered Care Defined Puts the interests of patients before the interest of the dental healthcare provider and ensures the provision of safe, professional, quality patient dental care. Follows the axiom of “Do No Harm”. Respects the patient’s right to confidentiality in all personal and healthcare matters. Respects the patient’s right and ability to make informed choices regarding dental care.

12. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Traditional CareComprehensive Care Specialist role model Generalist role model Student-centred instructionPatient-centred instruction Segmented patient carePatient-centred education Procedure focusEvaluation/management Numerical requirementsCompetency criteria

13. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The best practice of clinical education is that students provide patient care in a manner and setting similar to a general dental practice. This is no wonder, as our goal as teaching institution is to graduate competent general dentists that provide comprehensive care to their patients.

14. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Significant shift from the traditional way our dental school clinics have been organized. Currently, students’ initial clinical dental experience begins as a pseudo comp-care intro course, progresses to discipline-specific third year clinical care, and finally a senior year discipline-based general practice clinic.

15. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE STRATEGIC PLANNING GOAL: Moving from this hybrid method of comprehensive patient care to a true system of comprehensive care which involves true vertical integration of third and final year students with a corresponding horizontal integration of dental hygiene students.

16. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE CHALLENGES Recruiting patients, and matching patient needs with individual student needs to gain competency in doing specific procedures. Increasing faculty workloads and accountability and/or adding “Group Managers” to existing staff.

17. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE CHALLENGES Locating and integrating quality and qualified part-time staff Managing interdisciplinary tensions To date, most dental schools have adopted a system involving patient centred comprehensive care and evaluating students based on competency rather than numerical requirements.

18. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE In a system that on any level is based on students meeting departmental procedural requirements, patient care becomes a by- product of education. This results in a lack of treatment continuity, as patients are passed from one student provider to another.

19. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The fact has long been recognized by many progressive dental schools that student requirement systems based on individual dental procedures rather than overall patient treatment does not provide the best approach to either student learning or patient care.

20. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Dental students have also voiced ethical concerns over the effect of procedural requirements on patient care. Students under the requirement system tend to ‘cherry pick’ and hoard patients that will meet specific clinical procedures and thus fulfill requirements, often to the detriment of comprehensive patient care.

21. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE We must have that, as an underlying principle, our graduates have had the kind of clinical experience beginning in the earliest stages of practice which replicates the comprehensive care environment of the general practitioner.

22. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Integrating third and fourth year clinical students into highly organized and properly mentored groups or teams, along with a meaningful evaluation method will create an efficient pathway in the learning process.

23. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE It has been shown that clinical education and patient care have been improved by the comprehensive care approach. Students will gain more experience in this system, and this approach must not be compromised by silo-type clinics based on the requirement system which could lead to under-care, over-care or both.

24. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Students, guided and monitored by group leaders or managers follow patients through all procedures in a single general clinic, referring to specialty clinics where necessary and are evaluated and assessed based on competency, rather than frequency levels.

25. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Thus, for ethical and practical reasons, we must embrace the comprehensive care model in our clinics, where the setting is similar to an efficient private practice or community care clinic. Here, responsibility and accountability for comprehensive patient care rests with the student through the group or team leader.

26. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE THE STRUCTURE of GP CLINIC From the time students enter GP Clinic, they are expected to provide a mix of urgent, limited, palliative and comprehensive patient care in a patient centred care facility at the competency level expected of them at any particular time during their clinical education.

27. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE What is “COMPETENCY”? Competency is a combination of knowledge, skills and values that are repeated in a clinical context in a predictable fashion. This continuum of performance is demonstrated at or above the defined standard of care that one would expect of a student practitioner at any given time in their education.

28. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Upon graduation, the competent student would demonstrate the levels of knowledge, skills and values required to begin independent, unsupervised dental practice. Conscious Competency

29. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Unfortunately, it has become slang at many schools that students ‘take competencies’ – using the term to refer to a testing method rather than referring to the underlying set of skills, understanding and values that are being taught and evaluated. Competency is acquired in a clinical setting or in the context of patient care.

30. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Assessment of competency and faculty calibration There are essentially two types of clinical assessments: 1.Summative assessments 2.Formative assessments

31. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Summative assessments: – A high stakes assessment. – Summative competency testing is a one- time snapshot of a student’s performance, and is not generally predictive of future performance. – It is criterion defined and highly structured.

32. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Summative assessments cont’d: – Ethical issues: secondary informed consent is generally needed from the patient, as it is an extraordinary appointment wherein the student practitioner is being specifically examined. – Patient safety issues, as raised student apprehension and ‘arms-length’ supervision can increase the risk of clinical error – ACFD Clinical Associate Deans on record have recommended against having patient based competency exams.

33. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Formative assessments: – are norm-defined, that is, compared to the average as to what can be expected of the student practitioner at that stage of learning and leads to establishing and confirming competency. – requires instructor sensitivity to the expected stage of progression of learning. With this model, students learn and build upon formative sessional experiences, offering as well a self-assessment reflection in the formative feedback process.

34. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Competency-based dental education is not prescriptive or a fixed procedure, but it is a point of view or set of values about education, which Approaches fixed outcomes through flexible means Recognizes that learners progress through various stages of mastery of a discipline Accepts outcomes as the ultimate test of this educational process Insists that that evaluation is authentic and is representative of the situation in which an individual is expected to perform

35. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The traditional method of student assessment by a faculty member simply looking at a student’s work and making snap decisions about the product are highly subjective and variable, and tend not to impact positively on learning. Teaching opportunities and discussion, as well as providing the forum for student feedback are missed.

36. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Formative assessments, through well- constructed rubrics and effective faculty calibration can: Eliminate summative clinical grading (patient- based clinical tests) Establish clinical performance norms based on the competency model Transition to a normative assessment model that compares student performance to those clinical performance standards

37. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Formative assessments: Enhance faculty/student relationships and environment to better foster collegiality Diminish student feelings of threat in the clinic Diminish faculty feelings of stress in a graded situation Enhance the mentored education model Ensure student transition from passive to enduring active learners with enhanced critical thinking and clinical decision-making skills

38. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Formative assessments: As we have a competency based curriculum, instructors must be calibrated to provide a reliable method of assessing our students in order to determine students’ strengths and weaknesses and to predict as accurately as possible their future performances. Our goal is to comfortably graduate safe practitioners fundamentally grounded in our competency based curriculum.

39. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Gaining enough ‘experience’ Rather than provide a fixed numerical requirement, students get experience in a broad range of treatments in order to demonstrate competency through formative evaluations. Some students need more experience to demonstrate competency at a reliable level, others need less time and experience to do so.

40. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Gaining enough ‘experience’ The earlier summative approach to student evaluation has given way in progressive educational thinking to ongoing and cumulative formative assessments of clinical competence. This is also frequently supported with “objective, structured clinical examinations” (OSCE’s).

41. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Gaining enough ‘experience’ Group Managers, through careful monitoring of the student’s formative grade and instructor feedback comments can help determine whether the student clinical performance is at a competent level. Patient transfers can be arranged through the Group Managers so all students can be provided with an opportunity to have the broadest range of clinical experiences.

42. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE Gaining enough ‘experience’ Group Managers may refer to the Quality and Quantity (Q2) system as a management tool for patient assignment, global measurement of student progress, and to provide an overall perspective of the scope and depth of each student’s clinical experience for internal and external audit purposes.

43. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The approach to learning through instruction has changed over the years. In the ‘old school’ instructional paradigm, the instructor was the expert source of information. This information was to be transferred to students, who were ‘knowledge receptacles’. The students were then examined on their level of knowledge at any one particular moment in time.

44. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE This instructional method did not account for different styles or pace of learning. Faculty would typically classify and sort students according to a ranking from best to worst, which could lead to a continuum of bias against one or more students as being ‘pegged’ as a particular type of performer. Students were individualized and were highly competitive and concerned with “marks”

45. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The more current method of learning is more self-directed - student becomes an active participant in learning. In all disciplines, competencies are developed at varying rates, and are measured continually and consistently over time. This is a more collaborative and collegial ‘teamwork’ approach to learning and assessment. Importantly, it does require ongoing instructor training and calibration.

46. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The role of the clinical instructor In order to successfully achieve sound clinical training and evaluation of our students under the total patient care model, we must begin with a team of strong, calibrated instructors.

47. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Importance of Instructor Calibration: The predictability, confidence in, and ultimately the value of an instructor’s assessment of a student are fundamentally seated in the assumption that instructors are calibrated. Instructor calibration can be achieved ideally through a process that takes an experienced practitioner through the students’ pre-clinical course of instruction and then on to the clinic floor.

48. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Importance of Instructor Calibration: Participating as a pre-clinical instructor facilitates the clinical instructor’s ability to understand exactly what the student has been taught pre-clinically, which can then be brought forward into the clinic. An alternative would be to have an experienced practitioner mentored for a period of time by a seasoned clinic instructor.

49. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Importance of Instructor Calibration: It is important to also have monthly instructor calibration sessions, which would follow an initial orientation (one full session) to clinic protocol, standard operating procedures used in each discipline, training in axiUm and MiPacs.

50. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Importance of Instructor Calibration: Calibration in treatment planning is also essential, which could be accomplished in grand rounds type sessions using case presentations in an interactive forum. I-clickers could be used by instructors to make choices in treatment planning options and then discussed as the likely “Manitoba approach’ to a particular case.

51. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager The philosophical base for comprehensive care stems back to the ‘60’s Reorganizes clinics and places emphasis on not only clinical education but patient care issues Group (or team) practice model has been implemented as a modern management system to improve efficiency in the provision of ‘general dentistry’ comprehensive care.

52. QUESTIONS/DISCUSSION BREAK MICROSOFT CLIP-ART

53. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager The Group Manager’s role is critical in this evolution to comprehensive patient-centred care. Students are trained to the level of a competent novice practitioner, and experienced general practitioners as group managers are typically best suited to mentor students through this process.

54. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager It is important to clearly separate the functioning and provision of dental care in our clinics from academic departments and have a group that is specifically devoted to the oversight of such care.

55. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager Our faculty is slowly moving to the Group Manager model to coordinate and enhance students’ clinical experience and to increase faculty accountability under the umbrella of comprehensive patient centred care. Rather than concentrating on performing a prescribed number of procedures, students are now mentored on efficiency, quality and responsibility for ethical care from the patient’s perspective.

56. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager The Clinical Group Manager’s role is student centered. The primary role is to support and mentor a combined vertically and horizontally integrated team of 3 rd and 4 th year dental students and/or second year dental hygiene students as they experience the bulk of their clinical education in the GP and Dental Hygiene clinic.

57. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager Through regular group and individual meetings they help guide students to maximize their learning from ongoing patient care experiences. The Group Managers are responsible for monitoring and tracking the progress of the students in their clinical group.

58. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager They should be aware of the formative feedback each student receives from their clinical instructors, know of their strengths and weaknesses, their need for more clinical experience in one or more disciplines to ensure competency, and assign students new patients to that end.

59. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager Group Managers also act as a liaison between students, patients, clinical instructors or other faculty. An overall benefit to this model is that the faculty members become very familiar with the students in their team, and Group Managers can devote undivided personal attention toward a student’s clinical activity.

60. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager Group Managers will track student progress based on procedural experience and instructor feedback. It is anticipated that students will have multiple opportunities to demonstrate competence.

61. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager – Patient Management In concert with the Patient Management Administrator, Clinical Group Managers may routinely assign, allocate, transfer and dismiss patients. This most often is prompted by a student request or upon a review of a student’s clinical progress.

62. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager – Patient Management Managers should also be involved in handling patient complaints and perform chart and patient audits as part of the clinic quality assurance protocols. Group Managers should conduct weekly patient and chart audits - with the patient present - the chart should be reviewed for completeness. The patient should also be examined intra orally to ensure a continuum of quality care.

63. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager – Interdisciplinary Case Studies Group Managers would be responsible for holding scheduled weekly interdisciplinary case studies seminars. The seminars are focused on the fundamentals of treatment planning. Both third and fourth year members of their respective groups will be rotated through these sessions. In that way, third year students will be introduced to comprehensive treatment planning, and fourth year students will work toward being competent in that area.

64. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager - Clinical Group Meetings Once a week, regularly scheduled Clinical Group Manager meetings are encouraged. Issues discussed can be: – Patient assignment, transfer of patients within the group to allow everyone a broad clinical experience, patient dismissal, review of patient referrals

65. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager - Clinical Group Meetings – Review which experiences apply to which competency to ensure compliance with accreditation requirements – Discuss overall student performance to assess program – strengths and weaknesses.

66. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager - Clinical Group Meetings Consider which cases need follow-up. Follow-up on cases-may involve:  Chart or patient audits (patient audit is rare)  Instructor interview  Patient interview  Student interview, provide, feedback and suggestions.

67. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE The Group Practice Model and the role of the Group Manager - Individual student meetings - Scheduled ad hoc with any concerns arising from clinical activities or regarding clinic concerns, progress issues or Complex Treatment Plans. Group forums - monthly meetings to discuss ‘housekeeping ‘issues, information sharing, facilitation of patient transfers within the group.

68. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE ANTICIPATED OUTCOMES OF GROUP MANAGER MODEL: ACROSS DISCIPLINE COORDINATION OF PATIENT CARE GROUP MANAGER FACILITATES COMPREHENSIVE PATIENT CARE, RATHER THAN PROCEDURES BEING STUDENT DRIVEN CONSTANT and CONSISTENT MONITORING OF STUDENT EXPERIENCES and PROGRESS AND PATIENT CARE CHART REVIEWS AND PATIENT Q.A. REVIEWS LESSENS NEED FOR CSS BEHIND-THE SCENES MONITORING OF CHARTS

69. THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE ANTICIPATED OUTCOMES OF COMPREHENSIVE PATIENT CARE AND GROUP MANAGER MODEL: PATIENT SAFETY AND ETHICS ARE NOT COMPROMISED PROMOTES COMMON ESSENTIAL LEARNING OF THEMES THAT ARE CROSS-DISCIPLINE REDUCED DOWN TIME IN CLINIC – GENERAL PRACTICE CLINIC WHERE OPERATORIES ARE NOT ‘SILOED’ LESSENS THE LABOUR-INTENSIVE END-OF-YEAR EXERCISE OF CHART DISPOSITION AND STUDENT CLEARANCE

70. QUESTIONS/DISCUSSION MICROSOFT CLIP-ART