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Planning for CBD: Initiatives & Innovations
for a New Culture Change Author: Sara Cover
Date: October 2017
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I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.
Je n’ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d’appareils médicaux ou un cabinet de communication.
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Introduction
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• Things you should know about the NOSM Anesthesia Program
• 2 resident in-take per year; no fellowship programs at NOSM
• One site program (within a distributed school) • We are NOT service based; we do not have
seamless call • Our academic schedule and clinical scheduled
are not based on each other – they run separate from each other
• One learner per OR
Where did we start?
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Step one: Form an IMPLEMENTATION GROUP This group will make key decisions regarding:
Needs Assessment
Program Organization
Organizational Structure
Suggest Funding
plans
Plan for Resident
Orientation
Our Members: PA, PD, CID
5 Faculty Members 1 Resident (PGY2)
Implementation Group
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Meeting Topics • Draft a 24 month schedule (TTD & Foundations) • Plan integration of academic program • Competency Committee • Organizational Structure (Funding) • Funding (Organizational Structure) • Faculty Development • ePortfolio/assessment strategy for each EPA; Tour ePortfolio • Academic Coaches/Advisors • Program Evaluation • FPA CCC and CBD Integration • Non-CBD aspects of CanMEDs 2015
Step 2: Paint a picture….
Personalized Learning Block (PLB)
• Traditional Stream: PGY2-5, 1 block/year between January & June Residents are required to:
» Identify learning objectives for a 1 month block of anesthesia • Must include at least one intrinsic CanMeds role
» Determine an appropriate assessment strategy » Formulate 1 new learning objective at the end of the block,
based on reflection of their PLB
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Personalized Learning Block
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• CBD Stream:
Same requirements as our traditional stream.
Strategically placed throughout their years to accommodate flexibility of obtaining experiences that will allow them to complete their EPA’s.
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start of Yr1 start of Yr2
Month July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June June July Aug Sept Oct Nov Dec Jan Feb MarBlocks 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9
Stage of Training
Core Academics
Module
Discipline ANE ANE ANE ANE OB ANE PLB GEN SX IM ER PEDS COMM ANE ANE ANE ANE PLB ANE PLB ICU ANE ANE ANE ANE PLB ANE PLB ANE PLB
SchedulingOff-Service
Based on Learner Needs
EPAsF19, F20, F22
F2, F4, F5, F7, F15, F29
F4, F5, F7, F15
F4, F7, F8, F14
F27, F28F24, F25, F27
Required Training Experiences
Longitudinal RTE's
Summer Series First Cycle of Academics Second Cycle of Academics
OB AnePEDS Ane
Based on Learner NeedsBased on Learner Needs
-Pre/Intra/Post Op Care- Clinical/OR/APS/ PACU
OB ANE Rooms
Periop Care-Consults-APS-OR
Module 4
NOSM's Competency By Design Schedule
Transition to Discipline
(TTD)
TTD Module
Foundations (16-20, max 24)
Module 1 Module 2 Module 3Mod 2 & 3
ANE PLB
2.2 ACLS2.3 ATLS
1.3. Assessment of patients in the Emergency Room (F4, F8, F14)
1.4. General Surgery (or any surgical specialty) inpatient unit including consultations (F3, F4, F5, F7, F15, F29)
1.5. Internal Medicine (or any medical subspecialty) inpatient unit including consultations (F4, F5, F7)
1.6. Pediatrics: medical or surgical inpatient unit including consultations and/or ambulatory clinics and/or emergency department (F27, F28)
3.4 Trauma Team
F1, F2, F3, F16, F20, F29
3.3. Rapid response or emergency response team (F4)
Foundations Wrap Up
Increased Complex Room Assignments: Vascular,
Thoracics, Cardiac, Neuro?
OB ANEPain
Consults
3.4 Trauma Team
Oct: LMCC Part 2
1.1.1. Pre-operative assessment (F1, F2, F24)1.1.2. Anesthesiology consult service (F1, F2, F8, F24)
1.1.3. Acute pain service (F29)1.1.4. Perianesthetic areas including post-anesthetic care unit (F2, F3, F9, F10, F11, F12, F13, F14, F15, F16, F17, F18, F29)
1.2. Labour and delivery unit (anesthesiology and obstetrical perspective ) (F19, F20, F21, F22, F23)3.4. Trauma Team (F8)
F9, F10, F11, F12, F16, F17
F3, F7, F8, F13, F14, F15, F17, F18, F22, F23, F29
Orientation to:-CBD/ePortfolio/ Assessment-NOSM Program-Simulation - more of this in first two months-Machine Check Assessment
Resident WellnessBuddy Call - Must have PGY3 and above for buddy call
TTD1, TTD2, TTD3, TTD4
Questions this lead to:
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"PGY 1"Month July December JuneBlocks 1 2 3 4 5 6 7 8 9 10 11 12 13
Stage of Training
Core AcademicsModule
Description
Other Program Review Program Review
"PGY 2" Month July December JuneBlocks 1 2 3 4 5 6 7 8 9 10 11 12 13
Stage of Training
Core AcademicsModule Periop Med 1
Description see next line
Other Program Review Program Review
"PGY 3"Month July December JuneBlocks 1 2 3 4 5 6 7 8 9 10 11 12 13
Stage of Training
Core AcademicsModule
Description ANE PLB
Other Program Review
"PGY 4"Month July December JuneBlocks 1 2 3 4 5 6 7 8 9 10 11 12 13
Stage of Training
Core AcademicsModule
Description ANE PLBSR EM & POCUS
Other Program ReviewProgram Review
"PGY 5"Month July December JuneBlocks 1 2 3 4 5 6 7 8 9 10 11 12 13
Stage of Training
Core AcademicsModule
Description ANE PLB ANE PLB ANE PLB
Other
Royal College Written Exam
Program Review
Management of High Risk Patients 2
Foundations (16-20, max 24)
Anesthesia - Perioperative care, Obstetrics and Obstetrical Anesthesia, PLB
Off Service - EM, IM, Pediatrics, Surgery Anesthesia - Comprehensive perioperative care and community anesthesia
Foundations Wrap Up Mgmt of the High Risk Patient
Core Foundations (16-20, max 24)
Second Cycle of Academic Program
Thoracic/ Vascular Periop Medicine 2 Neuro/ ICU PainPeriop Medicine 1
1 Block of Cardiology, 2 blocks of anesthesia including PAC
and PACU
1 Block of Thoracic and 1 Block of Vascular
Anesthesia
IM rotations: Geriatrics, Nephrology and Respirology
2 Blocks of MS ICU with a focus on neuro/trauma topics, 1 block of Neuro
anesthesia
Regional Anesthesia and Chronic Pain
Pediatric anesthesia (HSC Toronto)1 block of community anesthesia, senior
OB and 2 weeks protected time for scholarly activity
2 blocks of Cardiac Anesthesia, 1 block of CVICU, Longitudinal experience in TEE
Module 2&3 ANE PLB Module 4
Core (30-36 months, max 42)
Introduction to advanced anesthesia topics and the complex patient
Program Review
Pediatrics Consolidative Module Periop Cardiac
Core (30-36 months, max 42)
2 Blocks of MS ICU, 1 Anesthesia for the complex patient
NOSM Anesthesiology Competency By Design Overview
Royal College Oral Exams
Program Review
Core Wrap Up
Transition to Practice
Transition to Discipline (TTD)
Summer Series First Cycle of Academic Program
Third Cycle of Academics
Core
TTD Module Module 1 Module 2 Module 3
ANE HIGH RISK ANE
Introduction to anesthesia concepts, CBD, HSN and Buddy
Call
• How will CBD schedules integrate with current residents’ schedules?
• What will this look for multiple residents in the same cohort?
• What will this look like with all CBD cohorts? (i.e.: in 4 yrs., in 5yrs.)
• How do we know that our numbers will balance out (i.e. not having all resident off service at the same time)
CBD Overview Clinical Schedule
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FPA Residents
First Name
Home Base
Year
Sam Sudbury 1
Julie Sudbury 1
Melanie Sudbury PGY5
Kenneth Sudbury PGY5
Fady SudburyPGY4
Alexandre SudburyPGY4
Liam Sudbury PGY3
Cassandra Sudbury PGY3
Krista Sudbury PGY1/2
Scott Sudbury PGY2
ShellonHamilton
Guyana PGY 3
Clinical Schedule for Dept. of Anesthesia Sudbury2017-2018
First Year of CBDBlock 1
OrientationBlock 2
ABCBlock 3 Block 4 Block 5 Block 6
FPA CaRMSBlock 7xmas
Block 8CBD CaRMS
Legend for CC Meeting rows: Pre CBD/ Current Residents CBD Residents in Foundations CBD Residents in Core CBD Residents in TTP
Block 9 Block 10March Break
Block 11 Block 12 Block 13
May 7- June 3 June 4- June 30
Transition to Discipline Foundations Module 1 Foundations Module 2 Foundations Module 3
Competency Committee Meetings
Nov. 20-Dec.17 Dec. 18-Jan 14 Jan. 15-Feb. 11 Feb. 12-Mar.11 Mar.12-Apr.8 Apr.9-May 6
CC meeting:
2 FPA
Transition to
Practice meeting: 2 FPA
Transition to
Foundations
meeting:
Voting members: TTD lead, Chief,
and Fac. Member2 CBD2 FPA
CC meeting2 CBD
4 pre CBD
Anes SUD Anes SUD Anes SUD OB Anes SUD Anes SUD PLB PEDS
General Surgery IM: SelectiveAnes SUD Anes SUD Anes SUD Anes SUD OB Anes SUD PLB
ER
Jul 1-30 July 31 - Aug 27 Aug. 28-Sept. 24 Sept. 25 - Oct. 22 Oct. 23-Nov. 19
IM: Selective General Surgery Anes SUD Anes SUDCommunity
Anes
Anes SUDER PEDSCommunity
AnesAnes SUD
4 5 4 4 5
Emerg
Number of residents on service
7 4 6 6 5 6 55
CC meeting4 pre CBD
CC meeting4 pre CBD
CC meeting4 pre CBD
2 FPA
Anes SUD
ICU ICU Anes SUD ElectiveAnes SUDTHORACIC
Julien Marti
IM: GeriatricsMcElhaney/
ClarkeElective
Anes SUDPLB
Rya BoscariolIM: Cardiology
Anes SUDRegional/PACU
Anes SUDVASCULAR
Sumit Sharan
Anes SUDOBS
Rob AndersonAnes SUD
Anes SUDPLB
Rya BoscariolAnes SUD
Anes SUD ICU ICUIM: Respirology
(Tbay)IM: Infectious
Disease
Anes SUDTHORACIC
Julien MartiAnes SUD Senior ICU Senior ICU
Anes. TbayJen
Whittingham
IM: Respirology (Tbay)
Anes SUDOBS
Rob Anderson
Emergency Medicine SR Anes. HSN
Anes SUDRegional/PACU
ElectiveAnes SUD
PLBRya Boscariol
Elective Anes SUD
Senior ICU Senior ICU ElectiveIM: Hematology
ShivakumarIM: Respirology
(Tbay)
Anes. TbayJen
Whittingham
Emergency Medicine SR Anes. HSN
Anes SUDNEURO
Ashleigh Farrell
Anes SUDPLB
Rya BoscariolAnes PEDS Toronto
Emergency Medicine SR Anes. HSN
IM: Cardiology Elective
Anes PEDS Toronto Anes SUD IM: Cardiology**Emergency
Medicine SR Anes. HSN
IM: ICU HSNAnes SUD
NEUROAshleigh Farrell
IM: Respirology (Tbay)
Anes SUDPLB
Rya BoscariolICU ICU Elective
Anes SUDVASCULAR
Sumit Sharan
Anes. TbayJen
Whittingham
Anes SUDCARDIAC
Kirk DuguayIM: Nephro
Anes SUDCARDIAC
Kirk Duguay
IM: GeriatricsMcElhaney/
ClarkeICU ICU Anes SUD
Anes. TbayJen
Whittingham
Anes SUDVASCULAR
Sumit SharanElective
Anes SUDPLB
Rya BoscariolIM: Nephro Elective
Anes SUDTHORACIC
Julien MartiIM: Cardiology
Anes SUDAnes SUD
NEUROAshleigh Farrell
Anes SUDCARDIAC
Kirk Duguay
Anes SUDTHORACIC
Julien Marti
Anes SUD Anes SUD Anes SUD
Anes SUDAnes SUD
PLBRya Boscariol
Community Anes
Parry SoundElective IM: Nephro Anes SUD
Anes SUDPre Admin
Sylvain Cote
Anes. TbayJen
WhittinghamIM: Nephro Anes SUD
Community Anes
Huntsville
Anes SUD OB
Rob AndersonAnes SUD
Community Anes
TimminsAnes SUD Anes SUD
Anes SUDPLB
Rya BoscariolElective Anes SUD
Anes SUDAnes SUDPre Admin
Sylvain CoteAnes SUD
Anes SUD OB
Rob Anderson
Community Anes
Parry SoundAnes SUD
My Lessons Learned….
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• Very time consuming; homework • Pre-set meeting dates worked for us • Started with a birds eye view and then
zoomed in • Thought of all this from the perspective of a
resident
Scheduling
Your Turn!
• What are the major challenges that you have undergone/ foresee for your program when you think about scheduling?
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First year with all 5 years of CBD residents at NOSM
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Sam Sudbury 5
Julie Sudbury 5
Pat Sudbury 4
Joy Sudbury 4
Ron Sudbury 3
Peter Sudbury 3
Mike Sudbury 2
Stella Sudbury 2
Sally Sudbury 1
John Sudbury 1
Competency Committee Meetings
Transition to
Foundations
meeting:
2021-20225th Year of CBD
Block 1Orientation
Block 2ABC
Block 3 Block 4 Block 5Block 6
FPA CaRMSBlock 7xmas
Block 8CBD CaRMS
Block 9Block 10
March BreakBlock 11 Block 12 Block 13
Transition to Core Meeting:
CC Meeting2 CBD
Transition to Practice 6-9 months, max 12
Anes SUD PLB Anes SUD Anes SUD Anes SUD Anes SUD Anes SUD Anes SUD
Pediatrics & Remote Locations/Periop Cardiac
Consolidative ModulePediatrics & Remote Locations/
Periop Cardiac
Anes SUD PLB
Anes SUD Anes SUD Anes SUD Sr. ICU Anes SUD PLB Anes SUD PLB Anes SUD Anes SUD Anes SUD Anes SUD
Periop Medicine 1 Thoracic/ Vascular Periop Medicine 2(Geriatrics, Nephro, Resp)
Pain
Neuro/ Senior ICU
Anes SUD CARDIAC/ Echo
Anes SUD CARDIAC/ Echo
CV/ ICU Anes SUD PLBScholarly/
High Risk OB/ NICUCommunity
AnesPediatrics (Sick Kids)
Pediatrics (Sick Kids)
Anes SUD PLBCommunity
AnesScholarly/
High Risk OB/ NICUAnes SUD
CARDIAC/ EchoAnes SUD
CARDIAC/ EchoCV/ ICU
Core: 30-36 months, max 42Cardiology Anes Tbay Anes SUD PLB
Anes SUDVASCULAR
Anes SUDTHORACIC
Elective Geriatrics Nephro Respirology Anes SUD PLB ElectiveAnes SUD
Regional/ PACUAnes SUD
Chronic Pain
Anes Tbay Cardiology Anes SUD PLBAnes SUDTHORACIC
Anes SUDVASCULAR
ElectiveAnes SUD
Regional/ PACU
Anes SUD PLB ICU Anes Tbay Anes SUD Anes SUD Anes SUD PLB Anes SUD PLB Anes SUD PLB
Anes SUD PLB Anes SUD PLB Anes SUD ICU Anes Tbay Anes SUD
Module 2 & 3 ANE PLBModule 4
(OB ANE, Pain, Consults & increased complex rooms)
Foundations: 16-20
months w/ max of 24 months
Anes SUDCommunity
Anes
Anes SUD ICU SUD CHEO Anes SUD Anes SUD
Anes SUD OB Anes SUD Anes SUD PLB PEDS
General Surgery IM: Selective ER PEDS
ER IM: Selective General Surgery
Anes SUD Anes SUD OB Anes SUD PLB
75 5 5 5 5 7
Anes SUDPLB
Rya Boscariol
CC meeting6 CBD2 CBD2 FPA
Transition to Practice meeting:
2 FPA2 CBD
Transition to Practice meeting: Voting
members: Core Lead, PD CCC, External
2 CBD
CC meeting:
2 FPA
Anes SUD Anes SUDCommunity
Anes
Anes SUD TTD: 1-2 months w/ max of 3
months
Elective Anes SUD
Foundations Module 1 Foundations Module 2 Foundations Module 3
MED/SX/ ICU
Anes SUD PLB ElectiveAnes SUD
Chronic Pain
Sr. ICU
Mgmt of High Risk Patients 2
SR EM & POCUSAnes SUD High
RiskAnes SUD High
Risk
Anes SUD High Risk
Anes SUD High Risk
Anes SUD
Voting members: Foundations Lead, PD, CCC, Core Lead
2 CBD
Emerg add to below numbers
Number of residents on service
7 7 8
Voting members: TTD lead, Chief,
and Fac. Member2 CBD2 FPA
CC meeting4 CBD 2 CBD
Anes SUDNEURO
SR EM & POCUS
Neuro/ Senior ICU
Core Wrap Up
7 6
Consolidated FPA - Kemora
Anes SUD Anes SUD
6
FPA Anes SUD Anes SUD Anes SUD FPA: SLO Anes SUD
Anes SUD Anes SUD
Transition to Discipline
Anes SUD PLB
MED/SX/ ICU
Core: Mgmt of High Risk Patient(ANE, MED/SX/ ICU & elective)
Elective
Elective
Anes SUDNEURO
Sr. ICU
ElectiveAnes SUD PLB Anes SUD PLB Anes SUD PLB Anes SUD
Foundations Wrap up
Nephro Respirology Geriatrics
For Argument sake right now, plugged in Anes SUD for numbers at the both
My Lessons Learned….
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• Very time consuming; collating data from many source to make it easier on the file reviewer
• Communication & Training Faculty • CQI
Competency Committee’s
Your Turn!
• What has worked best in implementing your CC and why?
• What hasn’t worked at all and why not?
OR
• How can you start planning today for your CC?
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Lessons Learned/ Recommendations
26
Scheduling: • Very time consuming; homework • Pre-set meeting dates worked for us • Started with a birds eye view and then
zoomed in • Thought of all this from the perspective of
a resident • Room for flexibility/ Individualized
programming
Competency Committee: • Very time consuming; collating data
from many source to make it easier on the file reviewer
• Communication & Training Faculty • CQI
Addressing Barriers to Change
• Lack of engaged faculty/ opportunity for new blood
• Size of program • Re-mapping EPA’s • How other’s around your
program will be affected by YOUR CBD planning
• Changing other’s mindsets • Use of multiple systems
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• Download the ICRE App,
• Visit the evaluation area in Videotron Hall, near Registration, or
• Go to: http://www.royalcollege.ca /icre-evaluations to complete the session evaluation.
Help us improve. Your input matters.
• Téléchargez l’application de la CIFR
• Visitez la zone d’évaluation qui se trouve dans l’aire Vidéotron, près du comptoir d’inscription, ou
• Visitez le http://www.collegeroyal.ca /evaluationscifr afin de remplir une évaluation de la séance.
Aidez-nous à nous améliorer. Votre opinion compte!
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