department of graduate medical education (gme) conflict of interest kim walker – no conflicts of...

Department of Graduate Medical Education (GME)

Conflict of Interest

Kim Walker – No conflicts of interest to disclose Ann Dohn – No conflicts of interest to disclose Nancy Piro – No conflicts of interest to disclose

Kim Walker, PhD

Program Manager/Education Specialist

Ann Dohn, MA

DIO & GME Director

Nancy Piro, PhD

Program Manager/Education Specialist

PC002c Coordinators and Clinical Competency

Committees: How to Streamline and Support the Work of your Program’s CCC


Session Outcomes

Participants will be able to:

Identify new aspects of the coordinators’ evolving role in program administration.

Understand and use program requirements as a guide for planning, organizing and implementing educational and assessment tools.

Develop and utilize a newly developed comprehensive resident performance profile tool to streamline the work of the CCCs.


New Role


Evolving Role for Coordinators in Evaluations

• Deliver evaluations• Develop evaluation forms for PDs

to approve• Schedule semi annual evaluations• Ensure summative evaluations

completed and filed

• Constructing new milestone evaluations to pilot/deliver

• Reviewing evaluation completion data for accuracy

• Aggregating data for the CCC from multiple sources and forms

• Milestone data to ACGME

Administrator Scheduler Supreme

Education & Evaluation

Coordinator/ManagerExtraordinaire


Now I’m really confused!

CCCsEPAs

Milestones

Outcomes

Goals and Objectives

Evaluations


Where do I begin?


Know the NAS Building Blocks: Concepts defined

NAS Core Competencies

– Milestones– EPAs– Curriculum and Evaluations

Clinical Competency Committee (CCC)


NAS – Next Accreditation System

What is NAS – in a nutshell:“an outcomes-based accreditation process through which the doctors of tomorrow will be measured for their competency in performing the essential tasks necessary for clinical practice in the 21st century.”

http://www.acgme.org/acgmeweb/tabid/435/ProgramandInstitutionalAccreditation/NextAccreditationSystem.aspx





Major Changes:Accreditation based on…

Pre-NAS– Competencies– Site Visits – Up to 5+

year cycles– Internal Reviews– ADS Updates– PIFs– Resident Surveys

Current (New) NAS– Competencies with

Milestones– Self-Studies at ~ 8-10 year

intervals– Detailed ADS Updates– CLER Visits ~ 18 – 24

months (Institution)– Resident & Faculty

Surveys


The New Accreditation System (NAS)… Outcomes

Increased Annual reporting by Programs (online) Reduced volume of accreditation demands … but

increased attention to accuracy and completeness of information submitted online

PIF-less Surveyor visits (unless new application)– Two Field Surveyors per visit

No Faculty CVs (only PD)….but Faculty & Resident Scholarly Activity required.


The Six AGME Core Competencies

MedicalKnowledge

Six CoreCompetencies

For QualityPatient Care

Practice-based

Learning & Improvement

Professionalism

Systems-based Practice

PatientCare Interpersonal &

Communication Skills


What Are Milestones?

High Level - Milestones are simply defined as areas of competency/expectations for our trainees

Linked to six core competencies Defined as a continuum of progressive

growth/learning


Dreyfus Model (1980): Stages of developing expertise

1 Novice

* Rigid adherence to taught rules or plans* Little situational perception* No discretionary judgment

2 Advanced Beginner

* Guidelines for action based on attributes or aspects* Situational perception still limited* All attributes and aspects are treated appropriately and given equal importance

3 Competent

* Coping with 'crowdedness'* Now sees actions at least partly in terms of longer-term goals* Conscious deliberate planning* Standardized and routinized procedures

4 Proficient

* Sees situations holistically rather than in terms of aspects* See what is most important in a situation* Perceives deviations from the normal patterns* Decision-making less labored* Uses maxims for guidance, whose meaning varies according to the situation

5 Expert

* No longer relies on rules, guidelines or maxims* Intuitive grasp of situations based on deep tacit understanding* Analytic approaches used only in novel situations or when problems occur* Vision of what is possible

Source: Eraut, M. Developing Professional Knowledge and Competencies. (1994)


Milestone Level Definitions

Level 1: The resident is a graduating medical student/experiencing first day of residency.

Level 2: The resident is advancing and demonstrating additional milestones.

Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates the majority of milestones targeted for residency.


Milestone Level Definitions (continued)

Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target – not requirement.

Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.


Reporting the Milestones

V.A.1.b).(1).(b) prepare and assure the reporting of Milestones evaluations of each resident semi-annually to ACGME (Core)

Milestones are reported directly through ADS Reporting windows are:

– November 1- December 31– May 1- June 15


Entrustable Professional Activities (EPA)

Professional life activities that define a medical specialty: – Ground the competencies in a physician’s everyday

work – Activities lead to some outcome that can be observed – Complexity of the activities requires an integration of

knowledge, skills and attitudes across competency domains


Examples of EPAs

Facilitate handovers to another healthcare provider either within or across settings

Contribute to the scholarly work of the subspecialty

Co-manage patients with generalists and other subspecialists

Source: https://www.abp.org/abpwebsite/taskforce/reslib/24.ppt


Curriculum: Rotation-specific goals and objectives & links to milestones


Milestones Impact on Evaluations:Linking questions to milestones

Step Two: Ensure specific evaluation questions are linked to milestones

Advises the referring health care provider(s) about the appropriateness of a procedure in routine clinical situations


Milestones Impact on Evaluation System

Allows for more objective methods of assessment and provide better feedback

Provides a process for early identification of residents that are having difficulties

All old and new evaluations and questions should be aligned with and tracked to milestones



V.A.1. The program director must appoint the Clinical Competency Committee.(Core)

V.A.1.a) At a minimum the Clinical Competency Committee must be composed of three members of the program faculty.(Core)

V.A.1.a).(1) Others eligible for appointment to the committee include faculty from other programs and

non- physician members of the health care team.(Detail)

ACGME Common Program RequirementsApproved: February 7, 2012; Effective: July 1, 2013 Approved focused revision: June 9, 2013; Effective: July 1, 2013


V.A.1.b).(1) The Clinical Competency Committee should:

V.A.1.b).(1).(a) review all resident evaluations semi-annually; (Core)

V.A.1.b).(1).(b) prepare and assure the reporting of Milestones evaluations of each resident semi-annually to ACGME; and, (Core)

V.A.1.b).(1).(c) advise the program director regarding resident progress, including promotion, remediation, and dismissal.(Detail)



V.A.1.b) There must be a written description of the responsibilities of the Clinical Competency Committee.(Core)

ACGME Common Program RequirementsApproved: February 7, 2012; Effective: July 1, 2013 Approved focused revision: June 9, 2013; Effective: July 1, 2013



Clinical Competency Committee (CCC):Written description


How the CCC does its work can be decided by the Program Director – Subcommittees– Assigning residents to faculty members for pre-review– Pre-review work will vary– Scheduling and frequency of meetings



What Should a CCC Do First?

Understand their specialty Milestones (Posted on acgme.org)

Decide how to assess the Milestones – Program Evaluation Strategy

If necessary, identify new evaluation tools from program director associations, societies, colleges


NAS and Milestones and YOU

The program coordinator will play a crucial role in developing, implementing, collecting data on and reporting of milestone evaluation tools.


Managing it all…


U - R - IT!

1. Understanding RRC program requirements

2. Requirements applied to evaluation methods/process

3. Implementing new evaluation system

4. Tracking completion and accuracy (outliers) for data aggregation


1. Understand Your Program’s New Requirements

Core

Outcomes

Details


Each standard/requirement is categorized: Outcome - All programs must adhere Core - All programs must adhere Detail – Considered mandatory for new

programs and those that fail to meet core requirements. Allows high-performing programs to innovate.

Source: Implementing The Next Accreditation System ACGME Webinar John R. Potts, III, M.D.: 4 November 2013



Example Program Requirement: VI.B. Transitions of Care


(Core)

(Core)

(Outcome)


Example Program Requirement: VI.B. Transitions of Care

When core and outcome not in compliance, then:


Details


U - R - IT!


2. Requirements applied to evaluation methods/process– Linking milestones/EPAs and objectives to evaluation

questions– Utilizing milestone scales




2. Requirements Specific to CCC Review of Trainee

Aggregating/compiling multiple evaluations of individual trainees (V.A.1. Formative Evaluation)

Tracking trainee participation in conferences, journal clubs, didactics (IV.A.3. Didactic Sessions)

Monitoring duty hour compliance (VI.G. Duty Hours) Reviewing involvement in quality improvement and

patient safety activities (IV.A.5.c. PBLI) Reviewing scholarly work (IV.B. Scholarly Work) Monitoring and reporting procedure logs (IV.A.5.a)


U - R - IT!







3. Implementing

Evaluation systems– Milestone-based/EPAs– Rotation-specific– Patient handovers– Define evaluator groups (faculty, staff, patients)– Set up and timing of delivery systems


3. Implementing

Documentation and reporting systems for:– Conference attendance– Scholarly work (Learning Portfolios)– Quality Improvement and Patient Safety

(Learning Portfolios / Safety reporting systems)– Duty Hours (recording, monitoring, reporting)– Case Logging (if applicable)


U - R - IT!







4. Tracking and Reporting…

Start with the end in mind:– CCC biannual reporting windows to ACGME

November 1- December 31 / May 1 - June 15

Back track and set calendar events for:– Periodic monitoring of evaluation completion– Running aggregate reports and reviewing milestone

evaluation data– Reviewing case logs, learning portfolios, duty hours


Pulling the Data Together

Clinical Competency Committee

End-of-Rotation

Evaluations

Safety Incident Reports

Case Logs

Patient/ Family

Evaluations

Clinical Skills

Assessment

Nursing and Staff / Techs Evaluations

Progress on Milestones

SimLab

In-service training exams

Quality Improvement

Activities


Managing it all:How will I pull this off?


The Toolbox


Creating a Resident Performance Profile Goals to support your CCC

Resident performance data that is: Comprehensive Consolidated / Aggregated Easy for CCC to identify strengths, areas for

improvement, opportunities for advancement


Creating a Resident Performance Profile:Compiling and centralizing data


Creating a Resident Performance Profile:Apply visual formatting for trends


EvaluationsMilestone End of Rotation (Total)Medical KnowledgePatient CareInterpersonal & Communication SkillsProfessionalismSystems-Based PracticePractice-Based Learning & Improvement

Creating a Resident Performance ProfileStep 1 – Defining what to track


In-service Assessments (MK; PC)Routine procedure technical skills assessment: Level 2-3Complex procedure technical skills assessment: Level 3-4Medical Knowledge Assessments



Case Logs / Clinical Experience (PC)VAGINAL DELIVERYCAESAREAN SECTIONPEDIATRICSPEDIATRICS UNDER 3CARDIACENDOVASCULAR



Quality Improvement/ Patient SafetyQI ProjectQI Committee ParticipationQI Course Work (e.g., IHI )SAFE Report / Adverse Event ReviewPatient Handover Evaluations



Practice-Based LearningPatient outcomes / Case Study PresentationScholarly Activity: Research studyScholarly Activity: PublicationsPresentation(s) at Internal/National Meetings



Interpersonal and Communication SkillsPatient Feedback

Staff EvaluationMedical Student FeedbackPatient Handover Evaluations



Creating a Resident Performance ProfileStep 2 - Link data sources to milestones

Evaluations MilestonesMilestone End of Rotation (Total) 24Medical Knowledge MK A1Patient Care PC A1-10Communication ICS A1-2Professionalism PROF 1-5Systems-based Practice SBP A1-2Practice-based Learning PBLI A1-4

Quality Improvement/ Patient SafetyQI Project PBLI1-2QI Committee Participation PBLI1-2QI Course Work (e.g., IHI ) PBLI1-2SAFE Report / Adverse Event Review PROF1/ 2; SBP1Patient Handover Evaluations SBP1; ICS1


Creating a Resident Performance ProfileStep 3: CCC defines performance ranges

At or Above Expectation: 2.8 and higher

Below Expectation:1.7 – 2.7

Remediation:Below 1.7

Example:

For all aggregate milestone evaluation scores for a PGY 3, the CCC has defined these ranges by PGY level in advance of the meeting:

STRENGTH WATCH AT RISK


Creating a Resident Performance ProfileStep 4 – Set conditional formatting


Example: Aggregate milestone evaluation data cells

Highlight cells to apply the conditional formatting




Set Ranges: > , < , between


Select, “Greater Than” “Less Than” or “Between” to Set Value RangesChoose the corresponding fill color (e.g., red, yellow, green)



Resident Performance Profile:Step 5: Enter in data


Creating a Resident Performance ProfileVisual trends and detailed data


More tools…


Leveraging Resident Management System (RMS)Tools, if Available

RMSs – becoming more feature rich Curriculum

– Goals and Objectives and learning outcomes by rotation

– Teaching and Assessment methodologies Evaluation tool development

– Sharing between programs and institutions


Conference attendance statistics– Core competencies linked to specified

conferences– Attaching conference materials for later reference

Procedures and levels; linked procedure evaluations



• Resident portfolio toolsQI participation and outcomesScholarly Activity logs



Aggregate reporting and graphic summaries Peer or departmental average, individual average, minimum

and maximum scores, standard deviation or listing of all scores



Set “data gathering and reporting” appointments with yourself

Remember to start with the end in mind (e.g., CCC meeting dates)

Break down large tasks into smaller tasks to keep it manageable

Leveraging Calendaring and Task Management Software


Leveraging Calendaring and Task Management Software


Learning through Experience


When a CCC Meeting…Doesn’t go well

Data – not complete– not organized– not accurate

PD or faculty member dominates meeting

Prolonged inefficient decision making with inability to gain consensus

Unsubstantiated/unreliable conclusions

Does go well

Data– complete – organized– accurate

Cooperative, collaborative decision making

Efficient use of time Sound valid conclusions

aligned with data


Successful Resident RankingPGY1- 4: Ready to graduate

Thetical, Hypo Date Completed 6/30/08 6/30/09 6/30/10 6/30/11Evaluations MilestonesMilestone End of Rotation (Total)

251.5 2.3 3.1 3.9

Medical Knowledge MK A1-6 1.3 1.9 3.1 3.6Patient Care PC A1-10 1.4 2.0 2.9 4.0Interpersonal Communication Skills ICS A1-2 1.1 2.3 2.9 3.9

Professionalism PROF 1-3 2.1 2.8 3.5 4.2

Systems-based Practice SBP A1-2 1.3 2.0 3.0 4.1Practice-based Learning & Improvement PBLI A1-2 1.5 2.8 3.2 3.8


PGY 1 Ranked at Graduation Level

1

?

Milestone range for a PGY1 should not be a 4.0, 4.5 or 5.0 …


Improvement evident

Thetical, Hypo Date Completed 6/30/08 6/30/09 6/30/10 6/30/11Evaluations MilestonesMilestone End of Rotation (Total)

250.9 1.5 2.7 4.0

Medical Knowledge MK A1-6 0.8 1.9 2.6 4.0Patient Care PC A1-10 0.9 0.9 2.9 4.2Interpersonal Communication Skills ICS A1-2 0.7 0.8 2.7 4.2

Professionalism PROF 1-3 0.9 0.5 2.0 3.9

Systems-based Practice SBP A1-2 1.0 2.0 3.0 4.1Practice-based Learning & Improvement PBLI A1-2 1.1 2.8 3.2 3.8


We Should not be at this Point


Beyond data…Creating a climate of CCC Success

Gentle Words of Wisdom

Tight efficient meetings Ground Rules Beware of Negative Group Think Schedule firm standing meeting dates in advance Reserve room of appropriate size with required

audio-visual tools if needed …..and have snacks


Use Technology to Your Advantage…You can be a ‘Rock Star’


Session Recap in a Nutshell…

Know your program requirements and follow them unconditionally

Use simple spreadsheet, calendaring and task organizational tools to manage, track and present resident performance data to your CCC

Resident education is a cyclical process – revisit and revise tools and processes each year


Questions


Contacts

Kim Walker - [email protected] Ann Dohn - [email protected] Nancy Piro - [email protected]

mailto:[email protected]

department of graduate medical education (gme) conflict of interest kim walker – no conflicts of...

Documents

objectives evaluations

programs ccc slide

new milestone evaluations

annual evaluations

summative evaluations

new application

new aspects

ma dio gme director