moving forward in the 21st century: implementing the comprehensive patient care model and patient...

MOVING FORWARD IN THE 21ST CENTURY:IMPLEMENTING THE COMPREHENSIVE PATIENT CARE MODEL and

PATIENT CENTRED CARE

TOWN HALL – CLINICSFEB 4, 2013

THE COMPREHENSIVE PATIENT CARE MODEL and PATIENT CENTRED CARE

• Patient Centered Care Defined• The Structure of the General Practice (GP)

Clinic –Comprehensive Integrated Care–Assessment of Competency

• Instructor Calibration• Role of the Group Manager (ex Team Leader)


REFERENCES:• Dental Education at the Crossroads: Challenges

and Changes. Marilyn J. Field, Editor; Committee on the Future of Dental Education, Institute of Medicine. The National Academies Press, 1995

• Henzi, David et al: North American Dental Students’ Perspectives About Their Clinical Education. Journal of Dental Education; Vol.72, April 2006


REFERENCES:• Formicola, Allan J: Dental School Clinics as

Patient Care Delivery Centers: A Paradigm Shift in Dental Education. Journal of Dental Education, Vol. 72 No. 2, 2006

• Taleghani, M et al: Non-Graded Evaluation of Dental Students in a Competency-Based Education Program. Journal of Dental Education, Vol. 68, No. 6, 2004


REFERENCES:• DePaola, Dominick P et al: Reforming Dental

Health Professions Education: A White Paper. Journal of Dental Education, Vol. 68 No. 11; Nov. 2004.

• Licari, Frank W. et al: Some Paradoxes in Competency-Based Dental Education. Journal of Dental education, Vol. 72, No. 1, 2008.


REFERENCES:• Manual: Integrated Clinical Care. Richardson,

James and MacNeil, M. A. J.; UBC 2010• About Patient Clinics: University of Louisville.

Louisville.edu\dental (2012)• Listserve communication: Robert A Cederberg,

Associate Dean for Patient Care; University of Texas at Houston (2012)


REFERENCES:• Listserve communication: Boyd E Robinson,

Associate Dean for Clinical Affairs; University of Florida College of Dentistry (2012).

• Listserve communication: Jeanne Panza, Associate Dean for Clinical Affairs, University of Oklahoma College of Dentistry. (2012).

• American Dental Association. Future of Dentistry. Chicago: American Dental Association, Health Policy Resources Center:2001.


REFERENCES:• ACFD 2011 Biennial Conference: Clinical

Evaluation. McGill University.• ADEA Regional Accreditation Workshop:

Strategies for Assessing Students’ Progression Toward Competency. 2012

• ADEA Signature Series: Breaking Down Silos – Engaging Across Disciplines and Professions. 2012


REFERENCES:• Commission on Dental Accreditation,

American Dental Association. 2012.


COMPREHENSIVE PATIENT CARE:

The system of patient care in which individual students examine and evaluate patients; develop and prescribe a treatment plan; perform the majority of the care required, including care in several disciplines of dentistry; refer patients to specialists as appropriate; and assume responsibility that the patient has received total oral care.


Patient Centered Care Defined• Puts the interests of patients before the

interest of the dental healthcare provider and ensures the provision of safe, professional, quality patient dental care.

• Follows the axiom of “Do No Harm”.• Respects the patient’s right to confidentiality

in all personal and healthcare matters.• Respects the patient’s right and ability to

make informed choices regarding dental care.


Traditional Care Comprehensive CareSpecialist role model Generalist role modelStudent-centred instruction Patient-centred instructionSegmented patient care Patient-centred educationProcedure focus Evaluation/management Numerical requirements Competency criteria


The best practice of clinical education is that students provide patient care in a manner and setting similar to a general dental practice.

This is no wonder, as our goal as teaching institution is to graduate competent general dentists that provide comprehensive care to their patients.


• Significant shift from the traditional way our dental school clinics have been organized.

• Currently, students’ initial clinical dental experience begins as a pseudo comp-care intro course, progresses to discipline-specific third year clinical care, and finally a senior year discipline-based general practice clinic.


STRATEGIC PLANNING GOAL:

• Moving from this hybrid method of comprehensive patient care to a true system of comprehensive care which involves true vertical integration of third and final year students with a corresponding horizontal integration of dental hygiene students.


CHALLENGES• Recruiting patients, and matching patient

needs with individual student needs to gain competency in doing specific procedures.

• Increasing faculty workloads and accountability and/or adding “Group Managers” to existing staff.


CHALLENGES• Locating and integrating quality and qualified

part-time staff• Managing interdisciplinary tensions

To date, most dental schools have adopted a system involving patient centred comprehensive care and evaluating students based on competency rather than numerical requirements.


• In a system that on any level is based on students meeting departmental procedural requirements, patient care becomes a by-product of education. This results in a lack of treatment continuity, as patients are passed from one student provider to another.


• The fact has long been recognized by many progressive dental schools that student requirement systems based on individual dental procedures rather than overall patient treatment does not provide the best approach to either student learning or patient care.


• Dental students have also voiced ethical concerns over the effect of procedural requirements on patient care. Students under the requirement system tend to ‘cherry pick’ and hoard patients that will meet specific clinical procedures and thus fulfill requirements, often to the detriment of comprehensive patient care.


•We must have that, as an underlying principle, our graduates have had the kind of clinical experience beginning in the earliest stages of practice which replicates the comprehensive care environment of the general practitioner.


Integrating third and fourth year clinical students into highly organized and properly mentored groups or teams, along with a meaningful evaluation method will create an efficient pathway in the learning process.


• It has been shown that clinical education and patient care have been improved by the comprehensive care approach.

• Students will gain more experience in this system, and this approach must not be compromised by silo-type clinics based on the requirement system which could lead to under-care, over-care or both.


• Students, guided and monitored by group leaders or managers follow patients through all procedures in a single general clinic, referring to specialty clinics where necessary and are evaluated and assessed based on competency, rather than frequency levels.


• Thus, for ethical and practical reasons, we must embrace the comprehensive care model in our clinics, where the setting is similar to an efficient private practice or community care clinic.

• Here, responsibility and accountability for comprehensive patient care rests with the student through the group or team leader.


THE STRUCTURE of GP CLINICFrom the time students enter GP Clinic, they are expected to provide a mix of urgent, limited, palliative and comprehensive patient care in a patient centred care facility at the competency level expected of them at any particular time during their clinical education.


What is “COMPETENCY”?Competency is a combination of knowledge, skills and values that are repeated in a clinical context in a predictable fashion. This continuum of performance is demonstrated at or above the defined standard of care that one would expect of a student practitioner at any given time in their education.


• Upon graduation, the competent student would demonstrate the levels of knowledge, skills and values required to begin independent, unsupervised dental practice.

Conscious Competency


Unfortunately, it has become slang at many schools that students ‘take competencies’ – using the term to refer to a testing method rather than referring to the underlying set of skills, understanding and values that are being taught and evaluated.

Competency is acquired in a clinical setting or in the context of patient care.


Assessment of competency and faculty calibration

There are essentially two types of clinical assessments:1. Summative assessments2. Formative assessments


• Summative assessments:–A high stakes assessment. – Summative competency testing is a one-

time snapshot of a student’s performance, and is not generally predictive of future performance. – It is criterion defined and highly structured.


• Summative assessments cont’d:– Ethical issues: secondary informed consent is

generally needed from the patient, as it is an extraordinary appointment wherein the student practitioner is being specifically examined.

– Patient safety issues, as raised student apprehension and ‘arms-length’ supervision can increase the risk of clinical error

– ACFD Clinical Associate Deans on record have recommended against having patient based competency exams.


• Formative assessments:– are norm-defined, that is, compared to the

average as to what can be expected of the student practitioner at that stage of learning and leads to establishing and confirming competency.

– requires instructor sensitivity to the expected stage of progression of learning. With this model, students learn and build upon formative sessional experiences, offering as well a self-assessment reflection in the formative feedback process.


Competency-based dental education is not prescriptive or a fixed procedure, but it is a point of view or set of values about education, which• Approaches fixed outcomes through flexible

means• Recognizes that learners progress through various

stages of mastery of a discipline• Accepts outcomes as the ultimate test of this

educational process• Insists that that evaluation is authentic and is

representative of the situation in which an individual is expected to perform


• The traditional method of student assessment by a faculty member simply looking at a student’s work and making snap decisions about the product are highly subjective and variable, and tend not to impact positively on learning.

• Teaching opportunities and discussion, as well as providing the forum for student feedback are missed.


Formative assessments, through well-constructed rubrics and effective faculty calibration can:• Eliminate summative clinical grading (patient-

based clinical tests)• Establish clinical performance norms based on

the competency model• Transition to a normative assessment model

that compares student performance to those clinical performance standards


Formative assessments:• Enhance faculty/student relationships and

environment to better foster collegiality• Diminish student feelings of threat in the clinic• Diminish faculty feelings of stress in a graded

situation• Enhance the mentored education model• Ensure student transition from passive to

enduring active learners with enhanced critical thinking and clinical decision-making skills


Formative assessments:As we have a competency based curriculum, instructors must be calibrated to provide a reliable method of assessing our students in order to determine students’ strengths and weaknesses and to predict as accurately as possible their future performances. Our goal is to comfortably graduate safe practitioners fundamentally grounded in our competency based curriculum.


Gaining enough ‘experience’• Rather than provide a fixed numerical

requirement, students get experience in a broad range of treatments in order to demonstrate competency through formative evaluations.

• Some students need more experience to demonstrate competency at a reliable level, others need less time and experience to do so.


Gaining enough ‘experience’• The earlier summative approach to student

evaluation has given way in progressive educational thinking to ongoing and cumulative formative assessments of clinical competence.

• This is also frequently supported with “objective, structured clinical examinations” (OSCE’s).


Gaining enough ‘experience’• Group Managers, through careful monitoring

of the student’s formative grade and instructor feedback comments can help determine whether the student clinical performance is at a competent level.

• Patient transfers can be arranged through the Group Managers so all students can be provided with an opportunity to have the broadest range of clinical experiences.


Gaining enough ‘experience’Group Managers may refer to the Quality and Quantity (Q2) system as a management tool for patient assignment, global measurement of student progress, and to provide an overall perspective of the scope and depth of each student’s clinical experience for internal and external audit purposes.


• The approach to learning through instruction has changed over the years.

• In the ‘old school’ instructional paradigm, the instructor was the expert source of information.

• This information was to be transferred to students, who were ‘knowledge receptacles’.

• The students were then examined on their level of knowledge at any one particular moment in time.


• This instructional method did not account for different styles or pace of learning.

• Faculty would typically classify and sort students according to a ranking from best to worst, which could lead to a continuum of bias against one or more students as being ‘pegged’ as a particular type of performer.

• Students were individualized and were highly competitive and concerned with “marks”


• The more current method of learning is more self-directed - student becomes an active participant in learning.

• In all disciplines, competencies are developed at varying rates, and are measured continually and consistently over time. This is a more collaborative and collegial ‘teamwork’ approach to learning and assessment.

• Importantly, it does require ongoing instructor training and calibration.


The role of the clinical instructor• In order to successfully achieve sound clinical

training and evaluation of our students under the total patient care model, we must begin with a team of strong, calibrated instructors.


The Importance of Instructor Calibration:The predictability, confidence in, and ultimately the value of an instructor’s assessment of a student are fundamentally seated in the assumption that instructors are calibrated. Instructor calibration can be achieved ideally through a process that takes an experienced practitioner through the students’ pre-clinical course of instruction and then on to the clinic floor.


The Importance of Instructor Calibration:Participating as a pre-clinical instructor facilitates the clinical instructor’s ability to understand exactly what the student has been taught pre-clinically, which can then be brought forward into the clinic. An alternative would be to have an experienced practitioner mentored for a period of time by a seasoned clinic instructor.


The Importance of Instructor Calibration:• It is important to also have monthly instructor

calibration sessions, which would follow an initial orientation (one full session) to clinic protocol, standard operating procedures used in each discipline, training in axiUm and MiPacs.


The Importance of Instructor Calibration:• Calibration in treatment planning is also

essential, which could be accomplished in grand rounds type sessions using case presentations in an interactive forum.

• I-clickers could be used by instructors to make choices in treatment planning options and then discussed as the likely “Manitoba approach’ to a particular case.


The Group Practice Model and the role of the Group Manager• The philosophical base for comprehensive care

stems back to the ‘60’s• Reorganizes clinics and places emphasis on not only

clinical education but patient care issues• Group (or team) practice model has been

implemented as a modern management system to improve efficiency in the provision of ‘general dentistry’ comprehensive care.

QUESTIONS/DISCUSSION BREAK

MICROSOFT CLIP-ART


The Group Practice Model and the role of the Group Manager• The Group Manager’s role is critical in this

evolution to comprehensive patient-centred care. • Students are trained to the level of a competent

novice practitioner, and experienced general practitioners as group managers are typically best suited to mentor students through this process.


The Group Practice Model and the role of the Group Manager• It is important to clearly separate the

functioning and provision of dental care in our clinics from academic departments and have a group that is specifically devoted to the oversight of such care.


The Group Practice Model and the role of the Group Manager• Our faculty is slowly moving to the Group Manager

model to coordinate and enhance students’ clinical experience and to increase faculty accountability under the umbrella of comprehensive patient centred care.

• Rather than concentrating on performing a prescribed number of procedures, students are now mentored on efficiency, quality and responsibility for ethical care from the patient’s perspective.


The Group Practice Model and the role of the Group Manager• The Clinical Group Manager’s role is student

centered. • The primary role is to support and mentor a

combined vertically and horizontally integrated team of 3rd and 4th year dental students and/or second year dental hygiene students as they experience the bulk of their clinical education in the GP and Dental Hygiene clinic.


The Group Practice Model and the role of the Group Manager• Through regular group and individual meetings

they help guide students to maximize their learning from ongoing patient care experiences.

• The Group Managers are responsible for monitoring and tracking the progress of the students in their clinical group.


The Group Practice Model and the role of the Group Manager• They should be aware of the formative feedback

each student receives from their clinical instructors, know of their strengths and weaknesses, their need for more clinical experience in one or more disciplines to ensure competency, and assign students new patients to that end.


The Group Practice Model and the role of the Group Manager• Group Managers also act as a liaison between

students, patients, clinical instructors or other faculty.

• An overall benefit to this model is that the faculty members become very familiar with the students in their team, and Group Managers can devote undivided personal attention toward a student’s clinical activity.


The Group Practice Model and the role of the Group Manager• Group Managers will track student progress

based on procedural experience and instructor feedback.

• It is anticipated that students will have multiple opportunities to demonstrate competence.


The Group Practice Model and the role of the Group Manager – Patient Management• In concert with the Patient Management

Administrator, Clinical Group Managers may routinely assign, allocate, transfer and dismiss patients.

• This most often is prompted by a student request or upon a review of a student’s clinical progress.


The Group Practice Model and the role of the Group Manager – Patient Management• Managers should also be involved in handling

patient complaints and perform chart and patient audits as part of the clinic quality assurance protocols.

• Group Managers should conduct weekly patient and chart audits - with the patient present - the chart should be reviewed for completeness.

• The patient should also be examined intra orally to ensure a continuum of quality care.


The Group Practice Model and the role of the Group Manager – Interdisciplinary Case Studies• Group Managers would be responsible for holding

scheduled weekly interdisciplinary case studies seminars. The seminars are focused on the fundamentals of treatment planning. Both third and fourth year members of their respective groups will be rotated through these sessions. In that way, third year students will be introduced to comprehensive treatment planning, and fourth year students will work toward being competent in that area.


The Group Practice Model and the role of the Group Manager - Clinical Group Meetings• Once a week, regularly scheduled Clinical Group

Manager meetings are encouraged. Issues discussed can be:–Patient assignment, transfer of patients

within the group to allow everyone a broad clinical experience, patient dismissal, review of patient referrals


The Group Practice Model and the role of the Group Manager - Clinical Group Meetings

–Review which experiences apply to which competency to ensure compliance with accreditation requirements

–Discuss overall student performance to assess program – strengths and weaknesses.


The Group Practice Model and the role of the Group Manager - Clinical Group MeetingsConsider which cases need follow-up. Follow-up on cases-may involve:

Chart or patient audits (patient audit is rare)

Instructor interview Patient interview Student interview, provide, feedback

and suggestions .


The Group Practice Model and the role of the Group Manager -• Individual student meetings - Scheduled ad hoc

with any concerns arising from clinical activities or regarding clinic concerns, progress issues or Complex Treatment Plans.

• Group forums - monthly meetings to discuss ‘housekeeping ‘issues, information sharing, facilitation of patient transfers within the group.


ANTICIPATED OUTCOMES OF GROUP MANAGER MODEL:• ACROSS DISCIPLINE COORDINATION OF PATIENT CARE• GROUP MANAGER FACILITATES COMPREHENSIVE

PATIENT CARE, RATHER THAN PROCEDURES BEING STUDENT DRIVEN

• CONSTANT and CONSISTENT MONITORING OF STUDENT EXPERIENCES and PROGRESS AND PATIENT CARE

• CHART REVIEWS AND PATIENT Q.A. REVIEWS LESSENS NEED FOR CSS BEHIND-THE SCENES MONITORING OF CHARTS


ANTICIPATED OUTCOMES OF COMPREHENSIVE PATIENT CARE AND GROUP MANAGER MODEL:• PATIENT SAFETY AND ETHICS ARE NOT COMPROMISED• PROMOTES COMMON ESSENTIAL LEARNING OF

THEMES THAT ARE CROSS-DISCIPLINE• REDUCED DOWN TIME IN CLINIC – GENERAL

PRACTICE CLINIC WHERE OPERATORIES ARE NOT ‘SILOED’

• LESSENS THE LABOUR-INTENSIVE END-OF-YEAR EXERCISE OF CHART DISPOSITION AND STUDENT CLEARANCE

QUESTIONS/DISCUSSION MICROSOFT CLIP-ART

moving forward in the 21st century: implementing the comprehensive patient care model and patient...

Documents

system of patient care

patient clinics

patient care delivery

integrated clinical

journal of dental education

future of dental education

dental accreditation

clinical education