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
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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
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Patient Care
Medical Knowledge
Professionalism
Interpersonal Skills and Communication
Practice Based Learning and Improvement
Systems Based Practice
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.
7.
8.
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10.
Safety as a system property
The need for transparency
Anticipation of needs
Continuous decrease in waste
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 selfreflection 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
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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”
Model for Improvement
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?
Act
Plan
Study
Do
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!
Flowcharting
Pt makes appt
Pt processed
by checkout staff
Pt checks in
Pt brought
to room
MD completes
papers
Pt examined
by MD
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
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!