Starting with the End in Mind: UW Internal Medicine & the Next Accreditation System

Transcription

1 Starting with the End in Mind: UW Internal Medicine & the Next Accreditation System John H. Choe, MD, MPH Assoc. Program Director, UW Medicine Residency Dermatology Division Meeting September 13, 2013

2 Milestones, Entrustable Professional Activities, Learning Objectives BACKGROUND

3 A key element of the NAS is the measurement and reporting of outcomes through the educational milestones, which is a natural progression of the work on the six competencies.

4 NAS Highlights Every 6 month assessments (no longer q5 year biopsy) Starting 7/2013 for core internal medicine, 6 other specialties; 7/14 for everything else Many areas of review will be the same; faculty survey added Visits will be focused upon the educational environment of the institution across multiple programs = CLER visit Programs must track trainees PROGRESS along MILESTONES

5 Mastery Time/ Experience

6 ACGME IM-RRC has called out 22 of these SUBCOMPETENCIES Works effectively in interprofessional team Develops comprehensive management plan Monitors practice with goal for improvement Mastery Time/ Experience

7 Mastery Develops comprehensive management plan These markers of progress are MILESTONES Time/ Experience

8

9 IM Competency: Patient Care Subcompetency: Define Pt Problems

10 DERM Competency: Patient Care Subcompetency: Hx, PE, Presentation

11 Evaluating Progress You are the attending physician supervising Dr. K, a 29 yearold intern on a cardiology rotation. Dr. K is neither the best nor the worst intern you have ever encountered in your times as attending. He seems to get the work done, usually answers your questions correctly, usually has taken care of his work on time. How would you judge his progress in: Medical knowledge? - Professionalism? Interpersonal communication? - Patient care? Systems-based practice? - Practice-based learning?

12 Alternate Progress Assessment Instead of being asked to judge Dr. K on the 6 general competencies, you are instead asked the following questions: Would you trust this intern to be able to recognize and manage uncomplicated acute coronary syndrome? Why or why not?

13 Trustworthiness

14 COMPETENCE Caverzagie

15 Manage acute coronary syndrome COMPETENCE Distance supervision in ambulatory clinic Safely discharge patient Ward supervisor Manage team caring for critically ill ICU pts Caverzagie

16 Entrustable Activities Attendings assess a multi-dimensional construct of trustworthiness when deciding a level of supervision Entrustment implies a level of competence Requires specific knowledge, skills, attitude applied to specific clinical context Leads to observable and measureable outcomes Kennedy, et. al. Acad Med 2008; 83(10 Suppl): S89-92 ten Cate et al. Acad Med 2007; 82:

17 Entrustment All-or-nothing EPA: OUTPATIENT With Complete Supervision (Needs a supervising physician present with the resident) With Partial Supervision (Needs a supervising physician available prior to a patient leaving the building) With Minimal Supervision (Needs a supervising physician available for feedback after a patient has left the building.) Independently (Able to perform without a supervising physician. Ready for independent practice.) Aspirational (Consistently performs as a role model. Truly exceptional.) INPATIENT (Needs a supervising physician present with the resident) (Needs a supervising physician available to join the resident) (Needs a supervising physician available by telephone) (Able to perform without a supervising physician. Ready for independent practice) (Consistently performs as a role model. Truly exceptional.)

18 Process with faculty: Learning objectives mapped to subcompetencies REBUILDING EVALUATIONS

19 Learning Goals & Objectives Entrustable Activities

20 STEP 1: Write EPA/Learning Objectives March 2012 rotation directors/ key faculty meeting: Divide into small groups to develop learning goals for Medicine Wards Subspecialty Experience Continuity Clinic Identify 6-12 things a resident should be able to DO after completing this educational experience Can be both PROCESS-focused and CONTENT-focused Prioritize goals that are OBSERVABLE: think ACTION verbs Representative, not comprehensive

21 UWMC Gen Med Rotation Learning Goals By the end of this rotation, we expect that the resident will Manage a hospitalized pt with decompensated liver disease. Provide initial workup & treatment for a solid organ transplant patient with signs of infection Coordinate discharge for a patient that will reduce their chances of readmission Discuss code status and appropriate treatment options with a patient (or family) effectively and compassionately Recognize when consultation is indicated and effectively coordinate care for the patient once consultants are involved. Safely transition a patient to/from the MICU, the operating room, or a procedure area Recognize clinical deterioration and manage it promptly and effectively (for example acute or worsened respiratory distress, altered mental status, bleeding, or sepsis)

22 HMC Wards- Learning Objectives Evaluate, begin appropriate tx for a pt with IVDU presenting with a fever Coordinate complex discharge for a pt to a skilled nursing facility Effectively communicate/ coordinate care with surgical colleagues re the perioperative management of patients on Medicine service Effectively and appropriately use interpreter services to admit a pt with limited English proficiency Manage a patient in active alcohol withdrawal with altered sensorium Coordinate care with a pt s primary care provider at admission Effectively/compassionately discuss care goals/code status w/ pt or family Recognize when consultation is indicated and effectively coordinate care once consultants are involved Effectively and safely provide or receive sign-out. Recognize clinical deterioration and manage it promptly and effectively (e.g. respiratory distress, altered mental status, bleeding, or sepsis)

23 Evaluation Instructions

24 UWMC Gen Medicine Wards Evals

25 Coaching Feedback

26 Grand Unified Theory Learning Goals & Objectives Entrustable Activities Under full supervision Learner Under partial supervision Under minimal supervision Ready for Independence Aspirational Milestones (and Milestone Elements) Individual Progress Report (in Subcompetencies) Evaluator CCC ACGME

27

28 Implications Evaluations no longer One-size-fits-all Evaluations will all be rotation-specific Trustworthiness is not trust by level but overall trust Same form for R1 and senior resident on the same rotation More direct observation from faculty will be required Faculty to gauge only those directly observed activities; N/A otherwise

29 Implications Interns are expected to require much supervision, and OVER THREE YEARS progress toward independence Feedback grounded to the actual work of the rotation Perfection is not the expectation ( but progression is ) James Arrighi, MD, Chair ACGME IM-RRC HUGE culture shift; faculty (and resident) development: Not more grading, more coaching

30 Early results; and implications for training programs MOVING FROM GRADING TO COACHING

31 Attending Feedback What do you think about this evaluation form? Easy to complete Better than the old form. An improvement- like the emphasis on progression to independence Much more meaningful than using a Likert scale. I suspect there will be less inconsistency between evaluators It speaks to the selection of entrustable activities that I observed all but one during this rotation. In other words, it is well matched to UW wards May be a better assessment of competency than the previous means of evaluation. It may be a better assessment of tangible skills, and that may be the best we can do, and may be all that we should do in our evaluation of the residents

32 Attending Feedback In completing this evaluation, it seems to me the resident will want a sense of how she is doing compared to her peers. The old form would likely give you a better sense of that. This evaluation may seem harsh because it is for such a new intern. Time will tell whether this is better than the old evaluation. Somehow, I don't feel I can convey my impression of the house officer as easily with this form as the old one.

33 More Grounded Resident Feedback Much better I really finally had something to talk about during the feedback I liked being able to see where I m supposed to be going We got to talk about feedback specific to the ward experience My attending didn t know much about the form, and was filling this out by how well he thought I should be doing as an intern (Received mostly 5 )

34 Diagnosis of Learner Lesions Works effectively in interprofessional team Develops comprehensive management plan Monitors practice with goal for improvement Mastery Time/ Experience

35 Academic Handoffs

36 Identification of Curricular Gaps

37 Curricular Disparities Atlas: Degree of difference by EPA

38 Evaluation Observation Sign-out

39