APDIM Fall Meeting How Do They Do That? Practical Approaches to Individualized Training October 25, 2009 Kevin T. Hinchey, MD, FACP Baystate Medical Center Springfield MA Community of Practice Learner Manager Teacher Improve each other Improve Program 1 File Location/File Name 1
Individualized Training Progression Remediation Special Interest 2 Frame Work for Competency Base Progression Learner, Manager, Teacher Model 3 File Location/File Name 2
Patient Education Autonomy Resident Supervision Attending 4 Learner UME CME Supervision Autonomy 5 File Location/File Name 3
Manager UME CME Supervision Autonomy 6 Milestones 37 Milestones Markers of Progression Specific Behaviors 7 File Location/File Name 4
Milestones # Competency Fundamental Categories For the Internist Location Fundamental skills/behaviors Failure Needs Work Competent Proficient Expert 1 All Core Competencies Initiative/ Self Reflection PD/APD Applies self reflection to identify strengths and Deficits Recognize areas of knowledge deficits and demonstrates initiative by implementing strategies for improvement of medical knowledge Unable to identify knowledge deficits without assistance Inconsistently identifies the deficits and/or has no initiative or strategies for improvement Consistently identifies deficits and allocates the appropriate effort for improvement Identifies deficits easily and is able to implement effective strategies accordingly Systematically identifies deficits and has excellent strategies for remediation Invite, Listen, Summarize 2 Interpersonal & Communication Skills Patient-Centered Interview L1-Amb L2-Amb Demonstrates patient-centered interviewing using the Invite, Listen,Summarize (ILS) format with attention to Summarizing skill in the later rotations. Frequently does not use these skills Inconsistently uses these skills Consistently uses Invite & Listen; Summarizes in a reporter fashion Consistently uses all three skills, Summarizes interpreted information Consistently uses all three skills, Summarizes interpreted information, complex cases Effectively Establishes rapport 3 Interpersonal & Communication Skills Establishing Rapport L1-Amb L2-Amb M-Amb To what extent does the resident demonstrate the essential skills of rapport building in interactions with patients and their families? Essential Skills: Elicits and responds to patient's concerns Shows positive regard Uses empathic statements Uses facilitative non-verbal communication Fails in any of the essential skills Inconsistent in any of the essential skills Consistent with most of the essential skills in uncomplicated interactions Consistent with all of the essential skills in most interactions Consistent with all of the essential skills in challenging interactions 8 Milestone 2 Evaluation Statement: Demonstrates patient-centered interviewing using the Invite, Listen, Summarize (ISL) format with attention to Summarizing skill in the later rotations Frequently does not use these skills Inconsistently uses these skills Consistently uses Invite and Listen and Summarizes in a reporter fashion Consistently uses all three skills, Summarizes interpreted information Consistently uses all three skills, Summarizes interpreted information, complex cases Reference: D. Boyle, B. Dwinnell and F. Platt, Invite, Listen, and Summarize: A patient-centered Communication Technique. 2005, Academic Medicine 80(1), 29-32. 9 File Location/File Name 5
Ambulatory Competency Based Progression 10 Own Your Education Ambulatory CheName: Each Learner must complete the check list before they will be considered for progression to the Ambulatory Manager role. The entire check list should be completed within the first six months of training. Systems based practice: Knows how to look up HSHC schedule. (Direct Observation)(Accountability)Faculty/Staff SignatureIs consistently on time for the first appointment(accountability)medical Assistants SignatureHas handed off a clinical issue appropriately to the Nurse/NP. Follow-up with NP (with appropriate documentation).(accountability) NP and Faculty SignatureChecks in with the nurse and MA for any patient related updates(accountability)nurse/medical Assistants SignatureAble to get an expedited consultant appointment when needed.(accountability)attending/team NurseUnderstands the Microsystems in ambulatory care (e.g. importance of other professionals in the multidisciplinary management/coordination of care, and local resources)(knowledge)faculty, Nurse, Case Mgr, Social Worker SignatureUnderstands the Macrosystems of ambulatory care: (i.e. cost utilization, insurance coverage)(knowledge)faculty SignatureRecognizes the importance of work flow(prioritization)faculty SignatureAble to prioritize what can be done the following workday(prioritization)faculty Signature Practice based learning improvement: Is able to identify when a medical error has occurred(integrity)faculty SignatureIs able to identify skills that are lacking in patient interactions i.e. knows when she does not have the skills for a manipulative patient interaction (Direct Observation)(Initiative)Faculty SignatureApplies guidelines for ambulatory conditions appropriately as demonstrated in the documentation of chronic disease management(analytic Thinking)Faculty Signature : Applies knowledge of basic Pathophysiology to formulate a differential diagnosis for common ambulatory conditions.(analytic Thinking)Faculty Signature/ CEXTimely and accurate documentation(accountability) Faculty Signatureck List 11 File Location/File Name 6
Ambulatory Check List Name: Each Learner must complete the check list before they will be considered for progression to the Ambulatory Manager role. The entire check list should be completed within the first six months of training. Systems based practice: Knows how to look up HSHC schedule. (Direct Observation)(Accountability)Faculty/Staff SignatureIs consistently on time for the first appointment(accountability)medical Assistants SignatureHas handed off a clinical issue appropriately to the Nurse/NP. Follow-up with NP (with appropriate documentation).(accountability) NP and Faculty SignatureChecks in with the nurse and MA for any patient related updates(accountability)nurse/medical Assistants SignatureAble to get an expedited consultant appointment when needed.(accountability)attending/team NurseUnderstands the Microsystems in ambulatory care (e.g. importance of other professionals in the multidisciplinary management/coordination of care, and local resources)(knowledge)faculty, Nurse, Case Mgr, Social Worker SignatureUnderstands the Macrosystems of ambulatory care: (i.e. cost utilization, insurance coverage)(knowledge)faculty SignatureRecognizes the importance of work flow(prioritization)faculty SignatureAble to prioritize what can be done the following workday(prioritization)faculty Signature Practice based learning improvement: Is able to identify when a medical error has occurred(integrity)faculty SignatureIs able to identify skills that are lacking in patient interactions i.e. knows when she does not have the skills for a manipulative patient interaction (Direct Observation)(Initiative)Faculty ) y SignatureApplies guidelines for ambulatory conditions appropriately p as demonstrated in the documentation of chronic disease management(analytic Thinking)Faculty Signature : Applies knowledge of basic Pathophysiology to formulate a differential diagnosis for common ambulatory conditions.(analytic Thinking)Faculty Signature/ CEXTimely and accurate documentation(accountability) Faculty Signature 12 Self Reflection 6 months In New Innovations Reflect on core competency Reflect on learning plan from last meeting Project Remediation Bring to meeting with PD or APD for review and compare to faculty evaluations. 13 File Location/File Name 7
Individualized Promotion Early Managers (Ambulatory) Increase autonomy-increase self confidence Early Managers (Inpatient) Strong intern who is hurt by supervision from an R3 14 Early Promotion R1 as Manager Inpatient Our System 15 File Location/File Name 8
Individualized Remediation Milestones have led to early remediation More specific, detailed remediation plans 16 Tracks Really special interest groups Business in Medicine Community Medicine Geriatric Medicine Hospital Medicine International (REACH) Osteopathic Primary Care Research Women s Health 17 File Location/File Name 9
Community of Practice Learner Manager Teacher 18 19 File Location/File Name 10
Inpatient Structural Change Old System New System 20 Early Promotion Inpatient Our System R1 as Manager 21 File Location/File Name 11