GME Faculty Development: Competency-Based Education May 28, 2010

Why Are You Here? What Do You Want to Get Out of These Sessions?

Objectives To Review the 6 Core Competencies To Understand Competency-Based Goals and Objectives To Explore Evaluation Techniques to Assess the Competencies To Review the Elements of the Annual Program Review

Some of the Pressures on GME Increasing Acuity Decreasing Length of Stay Increasing Volume (patients, information) Increasing Emphasis on Productivity can Limit Teaching Time and Limit Opportunities for Faculty Development Static Number of Residents Relative Decrease in Financing

Some of the Pressures on GME Implementing Core Competencies Addressing Work Hours Increasing Regulatory Burden (CMS, ACGME)

IOM Competency Model IOM, 2003

The ACGME Core Competencies Patient Care Medical Knowledge Professionalism Interpersonal Skills and Communication Practice Based Learning and Improvement Systems Based Practice

IOM Competency Model IOM, 2003

Medical Knowledge Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this knowledge to patient care.

Patient Care Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Professionalism Residents are expected to demonstrate: 1.compassion, integrity, and respect for others; 2.responsiveness to patient needs that supersedes self interest; 3.respect for patient privacy and autonomy; 4.accountability to patients, society and the profession; and, 5.sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

Interpersonal Skills and Communication Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

Interpersonal Skills and Communication Residents are expected to: 1.communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds; 2.communicate effectively with physicians, other health professionals, and health related agencies; 3.work effectively as a member or leader of a health care team or other professional group; 4.act in a consultative role to other physicians and health professionals; and, 5.maintain comprehensive, timely, and legible records.

PBL&I and SBP What do these mean?

Practice-based Learning and Improvement Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

PBL & I Two major themes: –Effective application of EBM to patient care Diagnostics, therapeutics, etc Includes clinical skills! –Quality improvement Individual improvement: reflective practice Systems improvement: active participant

PBL&I Residents are expected to develop skills and habits to be able to meet the following goals: 1.identify strengths, deficiencies, and limits in one’s knowledge and expertise; 2.set learning and improvement goals; 3.identify and perform appropriate learning activities; 4.systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;

PBL&I 5.identify strengths, deficiencies, and limits in one’s knowledge and expertise; 6.set learning and improvement goals; 7.identify and perform appropriate learning activities; 8.systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;

Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

SBP Residents are expected to: 1.work effectively in various health care delivery settings and systems relevant to their clinical specialty; 2.coordinate patient care within the health care system relevant to their clinical specialty; 3.incorporate considerations of cost awareness and risk benefit analysis in patient and/or population-based care as appropriate; 4.advocate for quality patient care and optimal patient care systems;

SBP 5. work in interprofessional teams to enhance patient safety and improve patient care quality; 6. participate in identifying system errors and implementing potential systems solutions.

Questions?

Systems-based Practice Residents are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care Internal Medicine Working Group

Systems-based Practice Apply evidenced-based, cost conscious strategies to prevention, diagnosis, and disease Collaborate with other members of the health care team to assist patients to deal effectively with complex systems and improve systematic processes of care

Systems-based Practice Understand, access and utilize the resources, providers, and systems necessary to provide optimal care Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient

Teaching and Learning PBL&I and SBP What is quality of care?

Quality of Care: What Is It? Institute of Medicine, 1990: –Quality consists of the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (evidence)” Blumenthal, NEJM

IOM Definition “Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and with cultural sensitivity.” IOM, 2001

IOM Recommendations Six major aims for health care: –Safe –Effective –Patient-centered –Timely –Efficient –Equitable

IOM’s 10 Rules 1.Care should be based on continuous healing relationships 2.Customization based on patient needs and values 3.The patient as the source of control 4.Shared knowledge and free flow of information 5.Evidenced-based decision making

IOM’s 10 Rules 6.Safety as a system property 7.The need for transparency 8.Anticipation of needs 9.Continuous decrease in waste 10.Cooperation among clinicians

Reflective Practice Definition Reflective practice simply refers to a systematic approach to review one’s clinical practice, including errors, seek answers to problems, and make changes in practice habits, styles, and approaches based on self- reflection and review. Value –Accountability –Self-assessment

Quality of Care: Residency Clinic Does patient care provided by our residency clinic meet these IOM criteria? Does current inpatient care meet these criteria? Why or why not?

Residents and QI skills Understand key definitions and IOM rules Defining aim and mission statement How to measure quality Understand micro-systems Process tools: –PDSA –Flowcharts

Residents and QI skills Role of physician leadership –What is a physician opinion leader/champion? Working in inter-disciplinary teams –Move beyond the ward team concept

Mission Statements Key ingredients for the explicit expression of goals: –Measurables –Deliverables –Timeline Dembitzer, Stanford Contemporary Practice, 2004

Effective Mission Statements Clear and concise and unambiguous – Define the “problem” to be fixed Measurable and specific – Context, target population, duration – Outcome-based (explicit positive rate or failure rate target) Dembitzer, Stanford Contemporary Practice, 2004

Effective Mission Statements Reasonable, worthwhile, relevant, important topic – Issue around which to rally – Reality-based goal for broad buy-in Related to baseline status for comparison

Example: Mission Statement Improve blood pressure control in hypertensive patients VERSUS “Within the next 12 months, 80% of our hypertensive patients will have documented blood pressures less than 140/90”

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo IHI: Nolan

PDSA Cycle Plan: –Identify the problems/process first –Describe current process around improvement opportunity –Describe all possible causes of the problem - agree on root causes –Develop effective and workable solution and action plan - select targets!

TIPS -Flowchart a process, not a system -Avoid too much detail -Process should reflect mission statement -Get all necessary information -Show process as it actually occurs, not in ideal state -Critical stage: take as much time as needed -Show the flowchart to other front line people for input -Look for areas of delay, rework loops, hassles, complaints Pt makes appt Pt checks in Pt brought to room Pt examined by MD MD completes papers Pt processed by checkout staff Flowcharting Rudd, Stanford Contemporary Practice, 2004

PDSA Cycle Do –Implement the solution of process change Study –Review and evaluate the result of the change –Will almost always require some form of data collection (medical record audit, patient satisfaction, etc)

PDSA Cycle Act –Reflect and act on the what was learned “Reflective practice for the group” –Assess the results, recommend changes –Continue improvement process where needed, standardize when possible –Celebrate success!