To Record Your Attendance (Faculty, Fellows, Residents & Students)

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1 To Record Your Attendance (Faculty, Fellows, Residents & Students) Text 5392 to (405) (Please make certain your mobile phone number is listed on your profile at cme.com) Online Evaluation To receive your AMA PRA Category 1 Credits you must complete the online evaluation. The online evaluation will be active at the end of the conference. Log in at cme.com Click on My CME Click on Evaluations and Certificates Once you have completed your evaluation, you will be able to print your CME certificate Relevant Disclosure Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. Mo Gessouroun, MD Alix Darden, PhD, MEd I have no relevant financial relationships or affiliations with commercial interests to disclose. 1

2 Relevant Disclosure Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. Eric Holmboe, MD, FACP, FRCP Mosby Elsevier Publishing Royalties Textbook The conflict was resolved by Dr. Holmboe agreeing that the presentation will not include discussion of any products or services from the commercial interest and he will refrain from making clinical recommendations on topics in which the conflict exists. TRANSFORMING MEDICAL EDUCATION TO MEET 21 ST HEALTH CARE NEEDS: WHY AND WHY NOW? ERIC HOLMBOE 2

3 CHARLES Charles is a 83 y.o. PhD trained mechanical engineer still working when he suffers an acute, extensive large bowel infarction due to incarceration. Despite 2 operations, delirium and a week long ICU stay, Charles is successfully transferred to the medical ward, under the care of rotating hospitalists, for continued recovery, PT and therapy for swallowing dysfunction. CHARLES Unfortunately, multiple medical misadventures ensue: 1. Delayed diagnosis of HAPneumonia 2. Delayed diagnosis and treatment of pseudogout 3. Stage 3 sacral decubital ulcer 4. Poor care coordination between cardiologist, infectious disease and multiple hospitalists 5. Repeated hand-off errors 3

4 CHARLES Despite all this and more, Charles is ultimately discharged to a (for profit) rehab facility where: 1. He continues to receive, for unclear reasons, multiple salt tablets daily, leading to anasarca 2. Unnecessary trip to ED due to diagnostic error 3. Second case of pneumonia due to feeding error 4. Multiple missed PT sessions IATROGENICALLY-INDUCED ALLOSTASIS Charles loses ground and is subsequently discharged from the rehab center to home under hospice care. On discharge he describes his rehab center experience as being treated like a thing. He dies 8 days after discharge. McEwen BS and Wingfield JC. What s in a name? Integrating homeostasis, allostasis and stress. Hormones and Behavior. 2010; 57:

5 CHARLES CARE: DISCUSS Have you ever experienced this with a family member or as a health care professional? What outcomes, or lack thereof, are demonstrated in Charles story? How could outcomes-based education, using competencies, help improve care for patients like Charles? WHAT ARE THE MOST IMPORTANT OUTCOMES AND HOW ARE WE DOING? 5

6 THE ULTIMATE OUTCOMES FOR CLINICAL CARE & EDUCATION A competent (at a minimum) practitioner aligned with: CMS Triple Aim 6

7 THE QUALITY OF AMBULATORY CARE (2007) DELIVERED TO CHILDREN IN THE UNITED STATES DIAGNOSTIC ERRORS (2015) IOM Report Released September 2015 At least 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error. Postmortem examination research shows diagnostic errors consistently contribute to ~ 10 percent of patient deaths. Diagnostic errors account for 6 to 17 percent of hospital adverse events Accreditation Council for Graduate Medical Education 7

8 FREE FROM HARM: NPSF 2015 Some successes, but many gaps remain. Institutions must embrace safety as a core value Advancing patient safety requires an overarching shift from reactive, piecemeal interventions to a total systems approach 2015 Accreditation Council for Graduate Medical Education MAKARY AND DANIEL (2016) 2015 Accreditation Council for Graduate Medical Education 8

9 ISABEL AND JASON MAUDE Isabel experienced a medical error. Doctors failed to recognize necrotizing fasciitis complicating chicken pox, leading to multiple surgeries and a prolonged ICU stay MEDICATION ERRORS 9

10 THE RISE OF OUTCOMES-BASED EDUCATION EARLY SIGNALS Increasing pockets of evidence and concern arise around the quality and safety of healthcare in the 1960s and 1970s A.L. Cochrane: Effectiveness and efficiency J. Wennberg: Unjustifiable regional variations in care delivery R. Brook: medical errors 10

11 EARLY PRINCIPLES World Health Organization (1978): The intended output of a competencybased programme is a health professional who can practise medicine at a defined level of proficiency, in accord with local conditions, to meet local needs. McGaghie WC, Miller GE, Sajid AW, Telder TV. Competency-based Curriculum Development in Medical Education. World Health Organization, Switzerland, CBME DRIVERS Growing evidence and concern around quality and safety problems Lack of attention to 21 st century competencies Uneven product Too many trainees graduating with deficiencies Recognition of gaps in training Desire to improve educational and clinical outcomes Inflexible training models Pluri-potential stem cell philosophy Costs of training, including debt 2015 Accreditation Council for Graduate Medical Education 11

12 OBME: A GLOBAL INITIATIVE Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet FUNDAMENTAL CHARACTERISTICS OF CBME Competencies are derived from the needs of patients, organized into a coherent guiding framework. Graduate outcomes in the form of achievement of predefined desired competencies are the goal. Time is a resource for learning, not the basis of progression of competence. Teaching and learning experiences are sequenced to facilitate an explicitly defined progression of ability in stages. 12

13 FUNDAMENTAL CHARACTERISTICS OF CBME Learning is tailored to the learner's individual progression in some manner. Numerous direct observations and focused feedback contribute to effective learner development of expertise. Assessment is planned, systematic, systemic, and integrative. DISCUSS How can these characteristics of CBME improve the care of children here in Oklahoma? Better prepare pediatricians? 13

14 U.S. CBME JOURNEY U.S. COMPETENCY JOURNEY: PHASE 1 Dates Event/Change 1997 ACGME begins work on developing competencies 1999 Six general competency framework approved by ABMS/ACGME 2001 Launch of Outcomes Project 14

15 MOVING FROM ASSURANCE TO IMPROVEMENT BATALDEN, ET. AL. From the past, accreditors get the essential knowledge and skill content. From the present, accreditors discover and recognize exemplars and a few charlatans. It is in the present that accreditors help maintain the boundaries of the commons. For the future, accreditors work to make sense of the core in ways that encourage faithful innovation 15

16 BATALDEN, ET. AL. When accreditors encourage innovation, not everyone loves it. After all, accreditors have a responsibility to make standards clear and methods of review and enforcement, predictable. When accreditors explicitly encourage change, they must show that those changes can be linked to what contributes to good learning for good patient care. U.S. COMPETENCIES Implementation, General Competencies however, of an Outcomes-based Patient approach Care was hard and confusing Medical Knowledge Educators struggled to understand how Professionalism competencies translated into curriculum and Interpersonal assessments. Skills & Communication Educators and faculty PBL & lacked I a shared mental model Systems-based Practice 16

17 A key element of the NAS is the measurement and reporting of outcomes through the educational milestones N Engl J Med 2012; 366: THE MILESTONES INITIATIVE 17

18 U.S. COMPETENCY JOURNEY: MILESTONES Dates Event/Change 2007 First Milestone summit Internal Medicine 2009 First Milestones published Milestone sets created for all specialties 2013 First 7 specialties start using and reporting Milestones 2014 All specialties fully in system MILESTONES - WHAT ARE THEY? By definition a milestone is simply a significant point in development. Milestones should enable the residents, fellows and the training program to better know an individual s trajectory of competency development. 18

19 MILESTONES: GENERAL TO SPECIALTY-SPECIFIC General Competencies Patient Care Medical Knowledge Professionalism Interpersonal Skills & Communication PBL & I Systems-based Practice SPECIALTY TRANSLATION Specialty Specific Milestones PROFESSIONAL DEVELOPMENT: DREYFUS MODEL Curriculum Assessment Curriculum Assessment MILESTONES Curriculum Curriculum Curriculum Curriculum Assessment Assessment Assessment Assessment Expert/ Master Proficient Competent Development is a non-linear phenomenon Advanced Beginner Novice Time, Practice, Experience Dreyfus SE and Dreyfus HL Carraccio CL et al. Acad Med 2008;83: Accreditation Council for Graduate Medical Education 19

20 Competency Sub-competency Developmental Progression or Set of Milestones PC1. History (Appropriate for age and impairment) Level 1 Level 2 Level 3 Level 4 Level 5 Acquires a basic Acquires a Efficiently acquires Gathers and physiatric history comprehensive and presents a synthesizes including physiatric history relevant history in a information in a integrating medical, prioritized and highly efficient medical, functional, and hypothesis driven manner functional, and psychosocial fashion across a psychosocial elements wide spectrum of elements ages and impairments Acquires a general medical history Seeks and obtains data from secondary sources when needed Specific Milestone Elicits subtleties and information that may not be readily volunteered by the patient Rapidly focuses on presenting problem, and elicits key information in a prioritized fashion Models the gathering of subtle and difficult information from the patient 2015 Accreditation Council for Graduate Medical Education THE GME ASSESSMENT SYSTEM Residents Assessments within Program: Direct observations Audit and performance data Multi-source FB Simulation ITExam Faculty, PDs and others Qual/Quant Data Synthesis: Committee Milestones and EPAs as Guiding Framework and Blueprint 2015 Accreditation Council for Graduate Medical Education D FB FB J U D G E M E N T Unit of Analysis: Program D Accreditation FB Certification and Credentialing Unit of Analysis: Individual P U B L I C 20

21 EARLY LESSONS: U.S. MILESTONE EXPERIENCE INDIVIDUAL RESIDENT PROGRESSION (SINGLE PROGRAM) PC1 (EMERGENCY MEDICINE) 21

22 MILESTONE: LEVEL DESCRIPTIONS RESIDENTS ATTAINING LEVEL 4 OR HIGHER FOR PC SUB-COMPETENCIES (JUNE 2015) Neurological Surgery Proportion 0.8 PC08 PC PC01 PC06 PC PC07 PC PC Traumatic Brain Injury Critical Care Brain Tumor Spinal Neurosurgery Pediatric Neurological Surgery Vascular Neurosurgery Pain and Peripheral Nerves Surgical Treatment of Epilepsy and Movement Disorders PC08 PC02 PC01 PC06 PC05 PC07 PC04 PC Yr1 Yr2 Yr3 Yr4 Yr5 Yr6 Yr7 22

23 RADAR PLOT: FIRST YEAR OF MILESTONES Li ST, Tancredi DJ, Schwartz A, et. Al. Competent for Unsupervised Practice: Use of Pediatric Residency Training Milestones to Assess Readiness. Acad Med. 2017;92:

24 PEDIATRICS MILESTONE DISTRIBUTIONS 2016 QUALITATIVE EVALUATION: GENERAL THEMES Areas of Milestone Positive Impacts: Quantity and quality of feedback to residents CCC process Improving assessment Dealing with residents in difficulty Curriculum Facilitates examination of curriculum Helps with curricular improvements Faculty development Improving assessment of faculty CQI nature of system 2015 Accreditation Council for Graduate Medical Education 24

25 QUALITATIVE EVALUATION: GENERAL THEMES Areas of Milestone Challenges: Logistics and data entry/transfer Assessment processes Negative wording of some Milestone sets Faculty struggling need for faculty development Construct misalignment (old evaluation forms do not fit with developmental model) Language in subset of Milestones (selected specialties) Harmonize some subcompetencies across specialties Synthesize multiple assessments into a Milestone judgment Time and resources ( RVUs always win ) 2015 Accreditation Council for Graduate Medical Education BACK TO CHARLES Charles is Dr. Kenneth Charles Holmboe, PhD. His experience with the healthcare system severely shook my faith, a sort of mirror to self. Current systems of curriculum and assessment are simply insufficient our goal is to make things continuously better. 25

26 THANK YOU AND QUESTIONS 26