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Preparing the Future Primary Care Workforce Together Primary Care Faculty Development Initiative (PCFDI) CBME in the Ambulatory Setting Nov.

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Presentation on theme: "Preparing the Future Primary Care Workforce Together Primary Care Faculty Development Initiative (PCFDI) CBME in the Ambulatory Setting Nov."— Presentation transcript:

1 Preparing the Future Primary Care Workforce Together Primary Care Faculty Development Initiative (PCFDI) CBME in the Ambulatory Setting Nov

2 PCFDI (Primary Care Faculty Development Initiative) Outline  CBME background  Key concepts and definitions  Frameworks and outcomes  Where we are/where we need to be  The role of milestones and entrustment in the assessment and evaluation of competence

3 PCFDI (Primary Care Faculty Development Initiative) Competency versus Competent  Competency: an observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes.  Competent: demonstrating the required abilities in all domains in a certain context at a defined stage of medical education or practice. Adapted from: The International CBME Collaborators, 2009

4 PCFDI (Primary Care Faculty Development Initiative) What does competency- based medical education means to you?

5 PCFDI (Primary Care Faculty Development Initiative) Competency-Based Medical Education  is an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies  Bottom line:  CBME = Outcomes-based Medical Education (OBME) The International CMBE Collaborators 2009

6 PCFDI (Primary Care Faculty Development Initiative) The Framework: ACGME Competencies  Medical knowledge  Patient care and procedural skills  Interpersonal and communication skills  Practice-based learning and improvement  Systems-based practice  Professionalism

7 PCFDI (Primary Care Faculty Development Initiative) Outcome?

8 PCFDI (Primary Care Faculty Development Initiative) Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet The Outcome

9 PCFDI (Primary Care Faculty Development Initiative) What is the outcome?  A competent (at a minimum) practitioner aligned with: IOM Six Aims for Quality CMS Triple Aim National Priorities Partnership

10 PCFDI (Primary Care Faculty Development Initiative) Individual Physician Readiness: The Gaps  Office-based Practice Competencies  Inter-Professional team skills  Clinical IT Meaningful Use skills  Population management skills  Reflective practice and CQI skills  Care Coordination  Continuity of Care  Leadership and management skills  Systems thinking  Procedural Skills Crosson Health Affairs 2011

11 PCFDI (Primary Care Faculty Development Initiative) Is CBME/OBME Just a “Fad”?  Pet rocks  Leisure suits  Streaking  Disco music  Yugos  Pokemon  Tickle me Elmo …probably not…

12 PCFDI (Primary Care Faculty Development Initiative) Is CBME/OBME a Paradigm Shift? Thomas Kuhn (1962): “Normal science, the activity in which most scientists inevitably spend almost all of their time, is predicated on the assumption that the scientific community knows what the world is like. Much of the success of the enterprise derives from the community’s willingness to defend that assumption, if necessary at considerable cost” Thomas S. Kuhn. The Structure of Scientific Revolutions. University of Chicago Press. Chicago Pg. 5.

13 PCFDI (Primary Care Faculty Development Initiative) Could the Same be True of UME and GME?  “Normal medical education, the activity in which most faculty inevitably spend almost all of their time, is predicated on the assumption that the medical educational community knows what the world is like. Much of the success of the enterprise derives from the community’s willingness to defend that assumption, if necessary at considerable cost” Thomas S. Kuhn. The Structure of Scientific Revolutions. University of Chicago Press. Chicago Pg. 5.

14 PCFDI (Primary Care Faculty Development Initiative) Is CBME/OBME a Paradigm Shift?  Maybe…but perhaps that is not the main point:  CBME is yet another stage on what should be the ongoing evolution and improvement of medical education  The focus on outcomes is worthy of our attention

15 PCFDI (Primary Care Faculty Development Initiative) Competency Based Education Fixed length, variable outcome Variable length, defined outcome Structure/Process Knowledge acquisition Single subjective measure Norm referenced evaluation Evaluation setting removed Emphasis on summative Competency Based Knowledge application Multiple objective measures Criterion referenced Evaluation setting: DO Emphasis on formative Caraccio et al 2002 The Transition to Competency

16 Milestones The definition of expected outcomes or competencies

17 PCFDI (Primary Care Faculty Development Initiative) Milestones  A significant point in development that identifies the discrete knowledge, skills, and attitudes expected of learners as they progress through training.  Milestones should enable the trainee, program and the certification board to know an individuals trajectory of competency acquisition.

18 PCFDI (Primary Care Faculty Development Initiative) Dreyfus & Dreyfus Development Model Dreyfus SE and Dreyfus HL. A 1980 Carraccio CL et al. Acad Med 2008;83:761-7 Time, Practice, Experience Novice Advanced Beginner Competent Proficient Expert/ Master MS3 MS4 PGY1 PGY3

19 Reporting Milestones-IM

20 PCFDI (Primary Care Faculty Development Initiative) ACGME Competency Developmental Milestones Informing ACGME Competencies Approximate Time Frame Trainee to Achieve Stage Assessment Methods/Tools Clinical skills and reasoning  Manages patients using clinical skills of interviewing and physical examination Historical Data Gathering 1.Acquire accurate and relevant history from the patient in an efficiently customized, prioritized, and hypothesis driven fashion 2. Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g. family, records, pharmacy) 3. Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient 6 months 9 months 18 months Standardized patient Direct Observation Simulation Sub-bullet “Curricular” Milestone

21 PCFDI (Primary Care Faculty Development Initiative) Milestones Benefits  Provide the learner with a clear path of progression  There are no surprises  Allow for rich formative feedback. Learners know where they are and where they need to go  Define specific behaviors that can focus assessment

22 PCFDI (Primary Care Faculty Development Initiative) Milestones Criticisms  Milestones are too reductionist  Checklist = competence  Checking off a milestones list does not equal competent practice in a highly complex health care environment  Operationalize the milestones to develop and apply meaningful assessment and evaluation.

23 Entrustment/Entrustable Professional Activities (EPAs) A framework for work-based assessment?

24 PCFDI (Primary Care Faculty Development Initiative) Entrustable Professional Activities  EPAs represent the routine professional-life activities of physicians based on their specialty and subspecialty  The concept of “entrustable” means:  ‘‘a practitioner has demonstrated the necessary knowledge, skills and attitudes to be trusted to independently perform this activity.’’ 1 1 Ten Cate O. Acad Med. 2007;82(6):542–547.

25 PCFDI (Primary Care Faculty Development Initiative) An Entrustable Professional Activity  Part of essential work for a qualified professional  Requires specific knowledge, skill, attitude  Acquired through training  Leads to recognized output  Observable and measureable, leading to a conclusion  Reflects the competencies expected…  EPA’s together constitute the core of the profession 25 ten Cate et al. Acad Med 2007

26 PCFDI (Primary Care Faculty Development Initiative) “Entrustment in Medical Education”  Focused assessments around what faculty and training programs already “entrust” trainees to do?  Reflects the most important outcome of training: a trainee’s readiness to bear professional responsibility”  Enables work-based assessment focusing on demonstrating competence in desired outcomes of training.

27 PCFDI (Primary Care Faculty Development Initiative) Baystate Ambulatory LMT Model  Learners: have Direct supervision  Faculty member sees every patient  Managers: have Indirect supervision  Faculty member discretion to see patient  Teachers: Oversight from faculty  Resident discretion to allow patients to leave before precepting Adapted from Sudeep K. Aulakh & Michael J. Rosenblum. Presented at ICRE 2012, Ottawa.

28 PCFDI (Primary Care Faculty Development Initiative) Ambulatory Milestone: Demonstrates patient-centered interviewing using the Invite, Listen, Summarize format  Failure -Frequently does not use these skills  Needs work -Inconsistently uses these skills  Competent -Consistently uses Invite & Listen; Summarizes in a reporter fashion  Proficient -Consistently uses all three skills, Summarizes interpreted information  Expert -Consistently uses all three skills, Summarizes interpreted information in complex cases Adapted from Sudeep K. Aulakh & Michael J. Rosenblum. Presented at ICRE 2012, Ottawa.

29 Competencies, Milestones and EPAs COMPETENCIES EPAs MILESTONES CharacteristicCompetenciesMilestonesEPAs GranularityLowModerate to HighLow to Moderate Synthetic/IntegratedModerateLow to ModerateHigh Practicality (application) LowModerateHigh ConceptualHighLowLow to Moderate

30 PCFDI (Primary Care Faculty Development Initiative) The Synthesis – Analytic Tension  Physicians do not apply each competency independently in caring for patients  As a result, judging overall performance is a synthetic/integrative assessment activity However,  You will often have to pull things apart (analysis) to create shared mental models and to provide meaningful and actionable feedback to the resident

31 Lets watch a video. What has this resident been entrusted to do? If this were your institution, could you attest that the resident had the required competence to provide this care?

32 PCFDI (Primary Care Faculty Development Initiative) With Your Neighbor -  Pick a goal of training that would meet a national priority for ambulatory-based care.  Identify two to three entrustments in training that could serve as a focus for assessment in that competency?  What assessment methods would you use?  What process will you use to make an entrustment decision?  What facilitators and barriers would you face?

33 The “System” Assessments within Program: Direct observations Audit and performance data Multi-source FB Patient experience Simulation ITExam Judgment and Synthesis: Committee Residents Faculty, PDs and others Milestone and EPAs as Guiding Framework and Blueprint Accreditation: ACGME/RRC NAS Milestones Board Reporting Program Aggregation Certification: Board No Aggregation Institution and Program

34 PCFDI (Primary Care Faculty Development Initiative) Break


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