Daniel Robitshek, MD, FACP, SFHM

Program Director, Internal Medicine Residency

Redmond Internal Medicine Residency

Components of

Faculty Engagement

Today:

1. Be able to describe important ACGME requirements

General Program/Faculty requirements

Faculty & Resident Scholarly Activity requirements

2. Be able to describe the basics of Milestones,

Competencies, EPAs and Assessments

Understand the evaluation and feedback process

Next Week:

1. Med Hub Program Management Software

2. Recognizing Impaired Resident/Fatigue

3. High Value Care/Choosing Wisely

RESIDENT READY FOR UNSUPERVISED PRACTICE

Faculty Accountability

Program

Accountability

Resident

Accountability

Curriculum Design

Clinical Rotations

Instructional Goals

Motivation & Work Ethic

Organizational Skills

Portfolio Development

Clinical Supervision & Instruction

Role-Modeling

Evaluation & Feedback

PROGRAM EVALUATION OF RESIDENT

PRE-DEFINED COMPETENCIES

MILESTONE BASED

ACGME OVERSIGHT

ENSURING PROGRAM COMPLIANCE

FACULTY/RESIDENT EVALS

THE NEW ACCREDITATION SYSTEM

Rules

Corresponding

Questions

“Correct or Incorrect”

Answers

Citations and

Accreditation Decision

EVERY 3-5

YEAR

ON-SITE

EVAL

BIG

BROTHER

APPROACH

The New Accreditation System

Continuous

Observations

Identify

Opportunities for

Improvement

Program

Makes

Improvement(s)

Assess

Program

Improvement(s)

Promote

Innovation CONTINUOUS ASSESSMENT AND FEEDBACK

REPORT DATA YEARLY TO ACGME

MAJOR SELF-ASSESSMENT EVERY 10 YRS

CQI

APPROACH

© 2013 Accreditation Council for Graduate Medical Education Information Current as of December 2, 2013

Annual Data Review Elements

Continuous Data Collection

Resident Survey

Faculty Survey (primarily CORE faculty)

Faculty and resident scholarly activity

Milestone data

Certification examination performance (ABIM)

Hospital accreditation data

New Programs

2 Year Assessment – All Elements of Compliance

Requirements:

Core – All programs must adhere

Outcome – All programs must adhere

Detail – All “Newly Accredited” programs

must adhere

Programs with status of “Continued Accreditation”

may innovate

The faculty must:

devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities; and to demonstrate a strong interest in the education of residents (Core)

administer and maintain an educational environment conducive to educating residents in each of the ACGME competency areas (Core)

provide advising for residents in the areas of educational goalsetting, career planning, patient care, and scholarship (Detail)

meet professional standards of behavior (Core)

The faculty must:

devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities; and to demonstrate a strong interest in the education of residents (Core)

administer and maintain an educational environment conducive to educating residents in each of the ACGME competency areas (Core)

provide advising for residents in the areas of educational goalsetting, career planning, patient care, and scholarship (Detail)

meet professional standards of behavior (Core)

RESIDENTS ASSESS

FACULTY &

PROGRAM

The faculty must:

Establish and maintain an environment of

inquiry and scholarship with an active

research component (Core)

The faculty must regularly participate in

organized clinical discussions, rounds,

journal clubs, and conferences (Detail)

Some members of the faculty should demonstrate

scholarship by one or more of the following:

(1) peer-reviewed funding; (Detail)

(2) publication of original research or review articles in

peer reviewed journals, or chapters in textbooks;

(Detail)

(3) publication or presentation of case reports or clinical

series at local, regional, or national professional and

scientific society meetings; or, (Detail)

(4) participation in national committees or educational

organizations. (Detail)

Faculty Scholarly Activity

Faculty Scholarly Activity

Faculty Scholarly Activity

Faculty Scholarly Activity

Faculty Scholarly Activity

Faculty Scholarly Activity

Faculty Scholarly Activity

Held positions of

Resident Scholarly Activity

Similar to

Faculty

Template

The curriculum must contain the following educational

components:

Overall educational goals for the program, which the program must

make available to residents and faculty; (Core)

Competency-based goals and objectives for each assignment at

each educational level, which the program must distribute to

residents and faculty at least annually, in either written or

electronic form; (Core)

Patient based teaching must include direct interaction between

resident and attending, bedside teaching, discussion of

pathophysiology, and the use of current evidence in diagnostic

and therapeutic decisions (Core)

The curriculum must contain the following educational

components:

Overall educational goals for the program, which the program must

make available to residents and faculty; (Core)

Competency-based goals and objectives for each assignment at

each educational level, which the program must distribute to

residents and faculty at least annually, in either written or

electronic form; (Core)

Patient based teaching must include direct interaction between

resident and attending, bedside teaching, discussion of

pathophysiology, and the use of current evidence in diagnostic

and therapeutic decisions (Core)

FACULTY AND

RESIDENT

EVALUATION OF

PROGRAM

© 2013 Accreditation Council for Graduate Medical Education (ACGME)

Patient Care Medical Knowledge

Practice-based Learning

and Improvement

Interpersonal and

Communication Skills

Professionalism Systems-based Practice

By definition a milestone is a

significant point in development

Milestones should enable the

learner and training program to

know an individual’s trajectory

of competency development

Competency Sub-competency

Specific

Milestone

Developmental

Progression or Set of

Milestones

EPAs represent the routine professional-life

activities of physicians based on their

specialty and subspecialty

The concept of “entrustable” means:

‘‘a practitioner has demonstrated the

necessary knowledge, skills and attitudes to

be trusted to perform this activity

[unsupervised].’’1

1Ten Cate O, Scheele F. Competency-

based postgraduate training: can we

bridge the gap between theory and

clinical practice? Acad Med. 2007;

82(6):542–547.

AAIM Education Redesign Committee

End of Training EPAs

1. Manage care of patients with acute common diseases across multiple care

settings

2. Manage care of patients with acute complex diseases across multiple care

settings

3. Manage care of patients with chronic diseases across multiple care settings

4. Provide age-appropriate screening and preventive care

5. Resuscitate, stabilize, and care for unstable or critically ill patients

6. Provide perioperative assessment and care

7. Provide general internal medicine consultation to nonmedical specialties

8. Manage transitions of care

9. Facilitate family meetings

10. Lead and work within inter-professional health care teams

11. Facilitate the learning of patients, families, and members of the interdisciplinary

team

12. Enhance patient safety

13. Improve the quality of health care at both the individual and systems level

14. Advocate for individual patients

15. Demonstrate personal habits of lifelong learning

16. Demonstrate professional behavior

Clinical

Competency

Committee

Faculty

Evaluations

Peer

Evaluations

Self

Evaluations Procedure

Logs

Student

Evaluations

Patient/

Family

Evaluations

Operative

Performance

Rating Scales

Nursing and

Ancillary

Personnel

Evaluations

Assessment of

Milestones

Clinic

Workplace

Evaluations

Mock

Orals

OSCE

ITE Sim

Lab

Members of CCC synthesize assessment data and

make a consensus decision (i.e. judgment) about

the progress of each resident against the

Milestones

Offer a group perspective to program director

Serve as an early warning system for residents

failing to progress

Structured Portfolio

Medical record audit &

QI project

Multi-source Feedback

(Pts, RNs, Staff)

3. PRACTICE-BASED LEARNING & IMPROVEMENT

6. SYSTEMS-BASED PRACTICE

CEXs, SIM & OSCEs

4. INTERPERSONAL SKILLS AND COMMUNICATION

Board Review/Ambulatory

Quizzes & ITE

2. PATIENT CARE Faculty

Evaluations

EBM/JC Presentation

1. MEDICAL KNOWLEDGE

5. Professionalism

■ Learner-directed ■ Direct observation

Dreyfus & Dreyfus Development Model

Dreyfus SE and Dreyfus HL. 1980

Carraccio CL et al. Acad Med

2008;83:761-7

Time, Practice, Experience

Novice

Advanced Beginner

Competent

Proficient

Expert/

Master

MILESTONES Competency

Assessment

Competency

Assessment

Competency

Assessment

Competency

Assessment

Competency

Assessment

Development is a

non-linear phenomenon

1. NOT time consuming

2. Based on observable behaviors, activities

3. Easily accessible (on-line)

4. Focused on what resident demonstrated on that specific

rotation or activity

5. Provides multiple data points over time

6. NOT cognitively onerous

7. Maps easily to Competencies and Milestones

8. Provides a concrete framework for faculty feedback to

the resident

9. NOT time consuming

Content Goals and Objectives

1. Demonstrate basic EKG reading skills

2. Refer patients for appropriate cardiac imaging

3. Counsel patient on lifestyle modifications for aggressive risk

factor modifications

4. Differentiate cardiac versus non‐cardiac chest discomfort

5. Diagnose acute coronary syndrome (unstable Angina, NSTEMI,

STEMI)

6. Manage heart failure (acute, chronic, systolic and diastolic)

7. Begin initial management plan for basic arrhythmias

Process‐Based Goals and Objectives 1. Perform an accurate physical exam

2. Develop prioritized differential diagnoses

3. Develop an evidence‐based diagnostic and therapeutic plan

4. Recognize the scope of his/her abilities and ask for supervision and assistance appropriately

5. Minimize unnecessary care including tests

6. Gather subtle, sensitive, and complicated information that may not be volunteered by the patient

7. Integrate clinical evidence into decision making

8. Evaluate complex medical patient in a timely manner

9. Provide appropriate preventive care

10. Demonstrate empathy, compassion, and a commitment to relieve pain and suffering

Resident Performed These Content

Specific Activities Well

Rarely Sometimes Often Always

Demonstrated Basic EKG Reading Skills

Counseled Patients on Lifestyle

Modifications

Differentiated Cardiac vs. Non-Cardiac

Chest Pain

Managed Heart Failure

Resident Performed These Process

Based Activities Well

Rarely Sometimes Often Always

Perform an accurate physical exam

Minimize unnecessary care including

tests

Evaluate complex medical patient in a

timely manner

Demonstrate empathy, compassion, and

a commitment to relieve pain and

suffering

Content Goals and Objectives

1. Initiate basal bolus insulin therapy and manage blood glucose over time

2. Manage elevated blood pressure

3. Diagnose the cause of loss of consciousness and differentiate syncope from other

etiologies

4. Initiate antibiotic(s) for pneumonia

5. Initiate antibiotic(s) for skin and soft tissue infections

6. Initiate venous thromboembolism prophylaxis

7. Initiate cost effective workup of venous thromboembolism

8. Manage exacerbations of obstructive lung disease

9. Initiate CIWA protocol in patients at risk for alcohol withdrawal

10. Manage derangements of potassium

11. Identify causes of delirium

12. Initiate cost‐effective workup for anemia

13. Initiate work‐up of diabetic foot ulcer

14. Assess and treat pain

15. Initiate fall precaution orders in patients at risk for falls

16. Initiate workup and management of fever

Process‐Based Goals and Objectives

1. Acquire accurate and relevant history

2. Perform an accurate physical exam

3. Develop prioritized differential diagnoses

4. Develop an evidence‐based diagnostic and therapeutic plan

5. Demonstrate accurate medication reconciliation

6. Provide accurate, complete, and timely documentation

7. Identify the appropriate clinical question for consultative services

8. Identify clinical questions as they emerge in patient care activities and access medical information resources

9. Perform bedside presentations that engage the patient and focus the discussion around the patient’s central concerns

10. Minimize unfamiliar terms during patient encounters

11. Demonstrate shared decision‐making with the patient

12. Use teach‐back method with patients regarding medications and plan

13. Communicate with primary care physicians

14. Recognize the scope of his/her abilities and ask for supervision and assistance appropriately

15. Minimize unnecessary care including tests

16. Use feedback to improve performance

17. Demonstrate empathy, compassion, and a commitment to relieve pain and suffering

Resident Performed These Content

Specific Activities Well

Rarely Sometimes Often Always

Initiate basal bolus insulin therapy and

manage blood glucose over time

Initiate venous thromboembolism

prophylaxis

Assess and treat pain

Initiate CIWA protocol in patients at risk

for alcohol withdrawal

Resident Performed These Process

Based Activities Well

Rarely Sometimes Often Always

Demonstrate accurate medication

reconciliation

Provide accurate, complete, and timely

documentation

Perform bedside presentations that

engage the patient and focus the

discussion around the patient’s central

concerns

Communicate with primary care

physicians

1. Resident not trusted to perform skill even with

supervision

2. Resident trusted to perform skill with direct

supervision

3. Resident trusted to perform skill with indirect

supervision

4. Resident trusted to perform skill independently

5. Resident trusted to perform skill at aspirational level

6. Skill was not observed on this rotation

“Specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance.”

“Feedback is an assessment for learning rather than an assessment of learning.”

Micro vs. Macro Feedback

Micro

In the moment

Daily

Brief (1-3 min)

“Feedback

nugget”

Macro

Mid-rotation

Less frequent

More detailed (5-15

min)

More

formal/structured

Learning Cycle

Goals

Observe

Performance

Feedback

Learning Plan

Education without Feedback

Signpost

Use the “F word”

“I want to give you

some feedback.”

1. Start With a Question

“How do you think your history on Mr. Smith went?”

2. Based on Observable Data

“When you presented the history on Mr. Smith, I observed that you missed the family portion”

3. Frame Importance

“Why is the Family history important, especially in Mr. Smith’s case?”

4. Link to Expected Goals

“It is our expectation that every history include the family portion”

5. Guide Future Behavior

“One way to remember all the components of a history is to develop a mnemonic like…” “to use a template like this…”

6. Tell Me What You Heard and What Your Plan Is

Resident Ready for Unsupervised Practice

Faculty Accountability

Program

Accountability

Resident

Accountability

Program Model

Clinical Rotations

Instructional Design

Motivation

Work Ethic

Organization

Clinical Supervision

Instruction

Role-Modeling

EVALUATION AND FEEDBACK