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Tracy S. Hunter, RPh, MS, PhD

Assistant Dean, Experiential Education

UNM College of PharmacyOctober 2016

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I do NOT have, nor does my family have, financial interests to disclose.

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Organization of Discussion

Vision

External Forces

Strategies

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Vision 4

Prepare UNM Student Pharmacists to be Leaders in Pharmacy Practice Today & Tomorrow

Vision 5

Design experiences that benefit both the preceptor and student pharmacist.

Organization of Discussion

Vision

External Forces

Strategies

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Converging Forces

Health Care EnvironmentHealth Care Environment

ACPE 2016 StandardsACPE 2016 Standards

ASHP Residency StandardsASHP Residency Standards

NAPLEX BlueprintNAPLEX Blueprint

EPAsEPAs

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Changes in Health Care Environment

Expanding role of Pharmacists on Health Care Team Expanding role of Pharmacists on Health Care Team

Reimbursement ChangesReimbursement Changes

Patient expectations & access to informationPatient expectations & access to information

Aging of the populationAging of the population

Bottom lineBottom line

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Changes in Health Care Environment

Expanding role of Pharmacists on Health Care Team Expanding role of Pharmacists on Health Care Team

Reimbursement ChangesReimbursement Changes

Patient expectations & access to informationPatient expectations & access to information

Aging of the populationAging of the population

All doing more with lessAll doing more with less

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Forces on Education: ACPE Outcomes: 2016

The curriculum prepares all students to provide entry-level, patient-centered care in a variety of practice settings as a contributing

member of an interprofessional team.

Team exposure includes prescribers as well as other healthcare professionals.

The curriculum prepares all students to provide entry-level, patient-centered care in a variety of practice settings as a contributing

member of an interprofessional team.

Team exposure includes prescribers as well as other healthcare professionals.

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The ACPE Outcomes: 2016

• Provide direct patient care in a variety of healthcare settings

Practice-ready

Practice-ready

• Contribute as a member of an interprofessional collaborative patient care team

Team-readyTeam-ready

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Focus on Experiential learning 12

Doing is primary focus

Knowing

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IPPEs: Pre-Advanced Pharmacy Experience Curriculum

Prepares for APPEPrepares for APPE

IPPE exposure to contemporary practice models:IPPE exposure to contemporary practice models:• Interprofessional shared patient care decision making• Professional ethics• Expected behaviors• Intentionally structured sequenced “…purposely integrated into

didactic curriculum”

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IPPEs: Pre-Advanced Pharmacy Experience Curriculum

P1: Community in SummerP1: Community in Summer

P2: Institutional in SummerP2: Institutional in Summer

P3: Concurrent Transitions of Care 2016P3: Concurrent Transitions of Care 2016

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New Postgraduate Year One (PGY1) Residency Accreditation Standards 15

• Purpose of revision:• Align standards to current pharmacy practice trends

• Global changes:

Design and Conduct of the Residency Program

• NEW statement: 3.3.a.(6)

• “Residents must spend two thirds or more of the program in direct patient care activities”

• NEW preceptor qualifications (“6 of 6” vs. “4 of 7”)• NEW designation of “Preceptors-in-Training”

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NAPLEX Blueprint: 2 Areas

Ensure Safe & Effective Pharmacotherapy & OutcomesEnsure Safe & Effective Pharmacotherapy & Outcomes

Safe & Accurate Preparation, Compounding, Dispensing, & Admin of Meds & Provision of Health Care Products

Safe & Accurate Preparation, Compounding, Dispensing, & Admin of Meds & Provision of Health Care Products

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http://www.nabp.net/programs/examination/naplex/naplex-blueprint

NAPLEX Blueprint 18

:Ensure Safe & Effective Pharmacotherapy &Outcomes

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NAPLEX Exam November 2016 19

• Increase in length for clinical cases • 185 to 250 items• 4.25 to 6 hours time

Which of the following most closely matches your knowledge of EPAs?

• I am Well-versed about what EPAs are & how to use them?

• I have some understanding of what EPAs are and & how to use

• I have very minimal understanding of what EPAs are or how to use them

• This is my first time learning about EPAs

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What are EPAs?

• Entrustable Professional Activities• EPAs -- units of practice or descriptors of work. • Defined as specific task or responsibilities that trainees are “trusted” to perform with direct supervision

• Independently executable, observable & measurable in their process & outcome

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What are EPAs?

• EPAs for New Pharmacy Graduates • discreet, • essential activities & tasks • that ALL new graduates Must be able to perform without direct supervision upon entering practice or graduation.

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Entrustable Professional Activities

•Patient Care Provider Domain1

•Population Health Promoter Domain2

• Information Master Domain3

•Practice Manager Domain4

•Self-Developer Domain5

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EPA Example: Patient Care Provider Domain

Collect information to identify a patient’s medication related problem

Collect information to identify a patient’s medication related problem

Analyze info. to determine effects of med therapy, identify med-related problems, & prioritize health-related needs.

Analyze info. to determine effects of med therapy, identify med-related problems, & prioritize health-related needs.

Establish patient-centered goals, create a plan for a patient with patient, caregiver(s), & other hps that is evidence-based & cost-effective.

Establish patient-centered goals, create a plan for a patient with patient, caregiver(s), & other hps that is evidence-based & cost-effective.

Implement care plan in collaboration with the patient, caregivers, & other health professionals

Implement care plan in collaboration with the patient, caregivers, & other health professionals

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Converging Forces

Health Care EnvironmentHealth Care Environment

ACPE 2016 StandardsACPE 2016 Standards

ASHP Residency StandardsASHP Residency Standards

NABPLEX BlueprintNABPLEX Blueprint

EPAsEPAs

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Vision

External Forces

Strategies

Organization of Discussion 26

Qualified Preceptors

Demonstrate expertise Demonstrate expertise

Enthusiastic for TeachingEnthusiastic for Teaching

Strong communication skillsStrong communication skills

Willingness to provide feedbackWillingness to provide feedback

Willingness to receive feedbackWillingness to receive feedback

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How many Preceptor roles & Responsibilitiescan you name? 28

Preceptor Roles & Responsibilities

Teacher/educatorTeacher/educator

Skilled CommunicatorSkilled Communicator

Facilitator -- MotivatorFacilitator -- Motivator

SocializerSocializer

Role ModelRole Model

Expert patient care providerExpert patient care provider

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Teacher educator roles

AssessorAssessor

PlannerPlanner

ImplementerImplementer

EvaluatorEvaluator

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Assessor Role

Determine current levelDetermine current level

Determine Learning needs

Determine Learning needsAssess early:

EDOCAssess early:

EDOC

ListenListen

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Assessment Activities

Diagnose Student deficits and strengthsDiagnose Student deficits and strengths

Determine what works well or not for youDetermine what works well or not for you

Develop & implement a assessment system for competency development over the experiencesDevelop & implement a assessment system for competency development over the experiences

Chart student progress Chart student progress

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Planner: Preventative Care

Design OrientationDesign Orientation

Select learning activitiesSelect learning activities

Create learning contractCreate learning contract

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Vision

External Forces

Strategies

Organization of Discussion 34

Concrete Steps: The preceptor’s role & tasks

Setting suitable experiences Setting suitable experiences

Posing problems to solvePosing problems to solve

Setting boundaries Setting boundaries

Supporting learners Supporting learners

Insuring physical & emotional safetyInsuring physical & emotional safety

Facilitating the learning processFacilitating the learning processGass MA, Gillis HL, Russell KC (2012)

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The preceptor’s role & tasks

Striving to be aware of our: Striving to be aware of our:

Biases Biases

Judgments Judgments

Pre-conceptions & Pre-conceptions &

How these influence the learner.How these influence the learner.Gass MA, Gillis HL, Russell KC (2012)

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The preceptor’s role & tasks

Recognize & encourage spontaneous opportunities for learningRecognize & encourage spontaneous opportunities for learning

Design of experience to include the possibility to learn from natural consequences, mistakes & successesDesign of experience to include the possibility to learn from natural consequences, mistakes & successes

Gass MA, Gillis HL, Russell K.C (2012)

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Concrete Tasks: Preceptor development

Increase sense of worth & confidenceIncrease sense of worth & confidence

Competent in at least one modelCompetent in at least one model

Common models includeCommon models include• The one-minute preceptor• Pimping

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Steps to Making Precepting a joy

The Teachablemoment

The Teachablemoment

1-minute Preceptor1-minute Preceptor SNAPPSSNAPPS Aunt MinnieAunt Minnie 2-minute

Observation2-minute

Observation

ActivatedDemonstration

ActivatedDemonstration

See One, Do One, Teach One

See One, Do One, Teach One

TeachingScripts

TeachingScripts

Ask-tell askAsk-tell ask “Pimping”“Pimping”

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One Minute Preceptor

The One Minute Preceptor

• https://www.youtube.com/watch?v=hmKvei3thwQ

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How would you apply this in your practice?

• JS, a 48 yo woman with a history of T2D, obesity, HPT, & migraine headaches is admitted for Syncope work up. Her recent A1c is 7.4%.

• She was diagnosed with microalbuminuria (1945mg/dl) [Jan. 2015].

• Last 3 reading: BP 154/86 mmHG pulse 78bpm• Med list: Metformin 1000 BID

• Glyburide 10 mg BID• Lisinopril 20 QD• Ibuprofen 200mg prn

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SNAPPS

• S Summarize the client history & current status

• N Narrow the hypotheses to 2-3 relevant possibilities

• A Analyze the issues by comparing & contrasting possible hypotheses

• P Probe preceptor -- ask questions about uncertainties, difficulties or alternative approaches

• P Plan intervention approach

• S Select a case-related issue for self-directed learning

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SNAPPS: Learner-Centered Model

• Facilitates active learning conversation• Research proven • Shared responsibility• Described as “cognitive dance”• Learner initiates – not passive• Focus on “Learnable Moments”• Student probes preceptor for relevant information

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Pimping: Rounding with the Team

“Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

Abraham Flexner

“Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

Abraham Flexner

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Rounding with the Team

“I must say that pimping accomplished only four things for me: “I must say that pimping accomplished only four things for me:

establishment of a pecking order among the medical staff;

establishment of a pecking order among the medical staff;

suppression of any honest and spontaneous intellectual question or pursuit;

suppression of any honest and spontaneous intellectual question or pursuit;

creation of an atmosphere of hostility and anger; &creation of an atmosphere of hostility and anger; &

perpetuation of the dehumanization for which medical education has been criticized.”

perpetuation of the dehumanization for which medical education has been criticized.”

Stanton C. LetterJAMA 262(1989):2541-2 [pubmed]

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Practice Reflection

What key ideas did you encounter that

build on, or conflict with your practice?

What key ideas did you encounter that

build on, or conflict with your practice?

What ideas do you commit to implementing?What ideas do you commit to implementing?

What connections with others can you develop to help you accountable to change?What connections with others can you develop to help you accountable to change?

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Key Takeaways

What are your key Takeaways?What are your key Takeaways?

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Key Takeaways

Prepare earlyPrepare early

Set expectations earlySet expectations early

Assess early Assess early

Give feedback early & oftenGive feedback early & often

Evaluate and documentEvaluate and document

Find techniques that works for you Find techniques that works for you

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Making Precepting a joy51

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TSHunter@salud.unm.edu

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Green GM, Chen EH. Top 10 ideas to improve your bedside teaching in a busy emergency department. EMJ 2015;32(1):76-77.

Gass MA, Gillis HL, Russell KC (2012). Adventure therapy: Theory, Research, and Practice. New York, NY: Routledge. http://www.aee.org/what-is-ee

Cunningham AS. Blatt SD, Fuller PG. Weinberger HL. The Art of Precepting. Socrates or Aunt Minnie. Arch Pediatr Adolesc Med. 153. Feb 1999

O’Neil TO, Aust MP. HealthStream Onboarding Series: Essential Best Practices in Preceptor Training. A White Paper accessed 08.20.2016 at: www.healthstream.com

Lindsey ED, etal . Constructive ways to prevent, identify,, & remediate deficiencies of “challenging trainees” in experiential education. AM J Health-Syst Pharm. 2016;73(13):9961009.

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Objectives

Identify best practices and approaches to your clinical teaching environment -- One Minute Preceptor modelIdentify best practices and approaches to your clinical teaching environment -- One Minute Preceptor model

Articulate learning expectations – EPAs and ACPE Standards -- in clinical teachingArticulate learning expectations – EPAs and ACPE Standards -- in clinical teaching

Define significance of Entrustable Professional Activities (EPA)Define significance of Entrustable Professional Activities (EPA)

Discuss ways to implement 1 Minute Preceptor modelDiscuss ways to implement 1 Minute Preceptor model

Constructively address ways to prevent, identify, & address KSAissues in experiential educationConstructively address ways to prevent, identify, & address KSAissues in experiential education

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At the end of this presentation, pharmacists will be able to:

Objectives for Technicians

Explain the benefits of a Pr66872ecepting program to your career and your place of practiceExplain the benefits of a Pr66872ecepting program to your career and your place of practice

Define Entrustable Professional Activities (EPA)Define Entrustable Professional Activities (EPA)

List the process of One Minute Preceptor modelList the process of One Minute Preceptor model

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At the end of this presentation, technicians will be able to: