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Building and Assessing Competence David C. Leach, M.D. Executive Director ACGME September 12, 2002.

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Presentation on theme: "Building and Assessing Competence David C. Leach, M.D. Executive Director ACGME September 12, 2002."— Presentation transcript:

1 Building and Assessing Competence David C. Leach, M.D. Executive Director ACGME September 12, 2002

2 Objectives To clarify what you have known all of your professional life about competence To explore how residents learn to make good clinical judgments To define specific steps that can be taken to respond to the ACGME Outcome Initiative

3 Reasons this is hard Yet can also be immensely satisfying.

4 Reason Number One Competence is a Habit

5 Competence …the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Epstein and Hundert JAMA, Jan. 9, 2001

6 Why worry about it? Public concerns with safety Variability in patterns of care that are not based on science Poor customer service

7 ACGME Outcome Project The ProjectA long term initiative The Visionto enhance residency education The Processthrough educational outcome assessment

8 Reason Number Two ACGME/RRCs judge competence of Programs Boards judge individuals

9 A slight problem … We accredit programs Programs dont exist The only things that are real are the humans and the relationships between humans in so- called programs These relationships can either inhibit or facilitate learning

10 So what do we accredit? Humans? Sets of relationships? Educational outcomes?

11 Reason Number Three Humans: the important things are hard to measure

12 Dee Hocks Criteria for Hiring People Integrity Motivation Capacity Understanding Knowledge Experience

13 Reason Number Four Knowing the rules is not enough Residents need to prepare for the unknown

14 Agreement Certainty Chaos Zone Of Complexity Control Stacey, 1996

15 Needed are a few organizing principles to have conversations about our work. Marvin Dunn, M. D. Paul Batalden, M.D.

16 Organizing Principles General competencies Continuum Measurements Improvement models

17 The General Competencies Patient care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice

18 Accreditation Aside You must call your mother every Sunday. Prescription or invitation?

19 The Continuum Life after competent

20 Dreyfus Model of Skill Acquisition Novice Advanced Beginner Competent Proficient Expert Master

21 Dreyfus Model NoviceRules Advanced BeginnerRules + Situation CompetentRules + Selected Contexts + Accountable ProficientAccountable + Intuitive Immediately sees what ExpertImmediately sees how MasterDevelops style Loves surprise

22 To become competent you must feel bad Hubert Dreyfus

23 Between Advanced Beginner and Competent The number of potentially relevant details becomes overwhelming Exhausting to manage with rules Choose a perspective Result depends on the perspective adopted by the learner/risk taking Fright replaces exhaustion

24 Two Paths Go back to rules –Cycle between advanced beginner and competent –Burn out Become fully involved –Feel bad when wrong and good when right

25 Next Proficient - intuition replaces reasoned responses. - immediately sees the problem - recognizes patterns Expert - immediately sees how to solve problem Master – styles, continuous learning

26 Conceptual Model Patient Care Med Know Practice Based Learning Inter & Comm Skills Profess- ionalism System- based Practice Novice Advance Beginner Comp Proficient Expert Master

27 Reason Number Five Residents seek practical wisdom

28 Aristotle Episteme –Cognitive knowledge, science Techne –Craft/Art of medicine Phronesis –Practical wisdom

29 Accreditation Aside Minimal threshold Do your graduates know the rules? Can they apply them in complex contexts without supervision?

30 Accreditation Aside Improvement Model Do your graduates have the habit of accountability? Have they acquired practical wisdom?

31 Reason Number Six The quality of the program is dependent on the quality of the relationships.

32 Medicine, education and management are cooperative arts rather than productive arts. Therefore the quality of the activity is dependent on the quality of the relationships.

33 Cooperative Arts Medicine cooperates with the bodys natural tendency to heal Teaching cooperates with the minds natural tendency to ascend to the truth Management cooperates with peoples natural tendency to form communities

34 Microsystems: another unit of learning

35 Real learning (intelligent adaptation) occurs in microsystems And sometimes in macrosystems.

36 Health care systems consist of macrosystems and microsystems Paul Batalden, M.D.

37 Substance is enduring; form is ephemeral. Preserve substance; modify form; know the difference. Dee Hock

38 Substance attracts resources; form attracts expenses. Dee Hock

39 Microsystems have a high substance to form ratio; macrosystems have the reverse.

40 Characteristics of High Performing Microsystems Integration of information Measurement Interdependence Supportiveness of the larger organization Constancy of purpose Investment in improvement Alignment of roles and training Connection with community Julie Mohr, Ph.D.

41 Reason Number Seven Introducing learners can enhance or inhibit the function of a microsystem. This is a big opportunity for improvement.

42 Rehearsals are good for relationships and outcomes. A restaurant in Chicago Simulation offers a huge opportunity for improvement.

43 Whatever we measure we tend to improve.

44 Useful Concepts about Measurement Life is not condensable We use models to understand life All models are limited, some are useful Measurements are applied to models Both measurements and models must be constantly reassessed We need structured dialogue about measurement

45 Useful Concepts Rules and context Science is universal; art is always unique Objective and subjective

46 Characteristics of good assessment Measures actual performance Identifies areas for improvement Satisfies reasonable request for accountability Is practical Is done over time to discern growth


48 Assessment toolbox References Table of best methods Key considerations in selecting and implementing assessment approaches Assessment approaches

49 RRC Think Tank Chair Gail McGuiness, M.D. Clarify expectations for programs Clarify operational issues for RRCs Identify PIF questions relevant to assessment for relational database

50 What to Do Right Away

51 Forming the Initial Response Show evidence of initial plans Institutions build in competencies and their assessment into internal reviews Change the verbs Start with Global Assessments Organize Focused Assessments Patient and/or Professional Associate Assessment

52 What if you were crazy enough to go beyond the minimal? What would an improvement model look like?

53 Accreditation Aside Minimal threshold – hide flaws Improvement – expose problems and show how they were addressed Requires much greater trust

54 Excellent programs will use rehearsals. Simulations are not the same as simulators

55 Excellent programs will develop virtuous cycles between the microsystems and education.

56 Excellent programs and institutions get to pick their own indicators. Remember the Northern New England Cardiovascular Surgery experience.

57 To teach is to create a space in which obedience to truth is practiced. Abba Felix Desert Father

58 What we attend to and how we attend to it defines who we are.

59 A Community of Practice General Competencies Open data systems Celebrate benchmarks across disciplines Build knowledge about medical education Build knowledge about improving patient care Enhance public accountability

60 To Teach/Learn is to create a Space/Community in which obedience to truth is practiced.

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