Comparison: Traditional vs. Outcome Project Evaluative Processes Craig McClure, MD Educational Outcomes Service Group University of Arizona December 2004

Current Problem Increasing public concerns with quality and safety. Variable patterns of care that are not based on medical science. Poor quality of interpersonal “service.” Public encounters difficulty in assessing physician competence (initial and continuing ) and judging quality.

The ACGME Mission To improve the quality of health care in the United States by ensuring and improving the quality of graduate medical educational experiences for physicians in training.

Problem Plus Mission ACGME responded to the challenge by changing focus to: –How well do we learn what is being taught –How well do we practice what we learn?

A new way of thinking Competency Structure & process How to change the educational and accreditation system from…

Program Goal OLD: goal was for the Program to comply with the written RRC Requirements NEW: the Program Director must determine if residents achieve the learning objectives set by the Program.

Six Domains Medical Knowledge Patient Care Professionalism Communication and Interpersonal Practice Based Learning and Improvement Systems Based Practice

Purpose of Assessment 1.Assess residents' attainment of competency-based objectives 2.Facilitate continuous improvement of the educational experience 3.Facilitate continuous improvement of resident performance 4.Facilitate continuous improvement of residency program performance

Whatever we measure we tend to improve. David C. Leach, M.D. Executive Director ACGME September 12, 2002

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

Types of Evaluation Formative Improve performance Summative Note achievement Both types of evaluation can be used to evaluate either an individual or a program.

Characteristics of good assessment Systematic Dependable Comprehensive Congruent Practical

Characteristics of good assessment (continued) Makes professional practice more transparent Deconstructs the role of physician Clarifies levels of expertise by distinguishing functional levels

Characteristics of good assessment (continued) Measures actual performance Identifies areas for improvement, i.e., self, others Satisfies reasonable requests for accountability

Traditional Evaluation 1.Global 2.End of rotation 3.Subjective 1.Anchored to norms seen by attending (therefore variable) 2.“I like/didn’t like the resident” 4.Focused on rotation goals (not movement toward competency)

Outcome Based Evaluation 1.Formative, focused on specific competencies required for a physician 2.Measure the full scope of professional characteristics from very specific procedures to skills involving a synthesis of component abilities 3.Specific evaluative techniques chosen to match the skill being assessed

Assessment Tools (The Toolbox) 360° Evaluation Instrument Chart Stimulated Recall Oral Exam (CSR) Checklist Evaluation of Live or Recorded Performance Objective Structured Clinical Exam (OSCE) Procedure, Operative or Case Logs

The Toolbox (continued) Patient Surveys Portfolios Record Review Simulations and Models Standardized Oral Exams Standardized Patients (SP) Written Exams (MCQ)

Evaluation Method OLD: global checklist format NEW: Type of evaluation chosen specifically to measure the chosen skill drawn from the 6 domains

Frequency of Evaluation OLD: once per rotation NEW: multiple intervals assessing component behaviors as well as the integrated practice of medicine.

Timing of Assessment OLD: End of rotation NEW: Timing chosen to facilitate evaluation of a specific competency

Anchors for Evaluation OLD: Most frequently the preceptor evaluated the resident against the norm of previous residents in that experience NEW: Criteria defining competence are utilized as the standard against which resident performance is measured

Target of Evaluation OLD: at best tended to address the resident’s success at the goals for the rotation NEW:Criteria for evaluation describe the qualities of the competent physician, so are more wide ranging or more specific

Number of Evaluators OLD: typically one per rotation NEW: multiple, both physician and non-physician evaluators

Other Outcome Characteristics Authentic More Individualized Reflection and Self-knowledge Critical

“Authentic” Justification for elements included in the curriculum is that competence as a practicing physician requires that skill, knowledge or attitude Evaluation is of the actual skill, knowledge or attitude used by practicing physicians

More Individualized A principle of a criteria-driven physician curriculum is that everyone can become competent with sufficient exposure Residents obtain skills at different rates with requirements for disparate learning experiences An optimal outcome-driven system would have an intake assessment followed by an individualized program of study

Reflection and Self-knowledge Critical Criteria for competence are provided to the learner Impetus for improvement arises from desire to narrow the gap between criteria and performance Accurate self-assessment is essential to the resident gauging personal performance

In Summary Traditional method: Not systematic Subjective & Normative based Global rotation end Outcomes-based: Systemic and comprehensive Based on criteria defining competence Multiple measures and intervals