winning strategies for developing

Winning Strategies for Developing Dynamic Residency Programs

Michelle W. McCarthy, PharmD, FASHP

[email protected]

DisclosureIn accordance with the ACPE’s and ACCME’s Standards for Commercial Support, anyone in a position to control the content of an educational activity is required to disclose their relevant financial relationships. In accordance with these Standards, ASHP is required to resolve potential conflicts of interest and disclose relevant financial relationships of presenters.

• In this session:

All planners, presenters, reviewers, and ASHP staff report nofinancial relationships relevant to this activity.

Objectives Describe innovative techniques used in resident practice

management, clinical development, and professional development

Identify resident projects that will contribute to the achievement of organizational goals

Summarize quality improvement processes for continuousdevelopment of overall program operations.

List strategies for maintaining an engaging precepting environment for learners, preceptors, and RPDs.

2018 National Pharmacy Preceptors ConferenceWinning Strategies for Developing Dynamic Residency Program

©2018 American Society of Health-System Pharmacists of 27

Outline ASHP Foundation Pharmacy Residency Excellence Award Program Innovative techniques

• Mini‐rotations• Inclusion of emergency management elective competency• Multi‐media continuing education presentations

Resident projects and organizational goals Quality improvement processes

• Preceptor and resident evaluation• Self‐evaluation

Learning environment• Residency committee structure• Professional involvement• Core curriculum

I am familiar with the ASHP Foundation Pharmacy Residency Excellence

Awards Program.

YesNo

ASHP Foundation Pharmacy Residency Excellence Awards (PREA)

Recognizes excellence and leadership of residency programs and practitioners that/who have excelled in the training and mentoring of pharmacy residents.

Honors leading practice facilities and mentors. Widely disseminates the accomplishments in order

to foster innovations in pharmacy residency training.

2018 National Pharmacy Preceptors Conference Winning Strategies for Developing Dynamic Residency Program


ASHP Foundation PREA

Annual awards for:• Preceptor• New Preceptor• Program

ASHP Foundation PREA Extensive application assesses:

• Innovation• Quality improvement• Resident training environment• Preceptor engagement and development• Service Excellence• Achievement record• Letters of support

ASHP Foundation PREA Timelines:

• Application released in spring• Due in early summer

Panel review by select past recipients and ASHP staff Award presented at ASHP Midyear meeting Stay tuned to ASHP Foundation for details/ deadlines








UVA Program Background

PGY1 pharmacy residency begin in 1991 with 1 resident; 9 in 2018 PGY1 community‐based pharmacy (n=1) Nine PGY2 programs

• Ambulatory care, cardiology, critical care, infectious diseases, oncology, pediatrics, transplant, pharmacy informatics, health system pharmacy administration

• Consistent history of early committing many positions from PGY1 class



UVA Program Background Alignment with graduate medical education (GME)

• Mandatory GME orientation mid‐June (2 days)• Salary and benefits, policies, credentialing, logging of duty

hours Five week rotation blocks (n=8)

• One four week elective only block (last rotation)• Days off (for any reason) should not exceed 20% of the duration of the

experience

UVA Program Background Rotation requirements

• Ambulatory care (internal medicine, cardiology, ID, or family medicine clinics)

• Adult general medicine (internal medicine, acute care cardiology, or acute care neurology)

• Acute care specialty (benign hematology, ED, heme/onc, ID, pediatrics, SOT)

• Critical care (any of 7 ICUs)• Medication use policy • Practice management

Question: How does your program manage the November‐January time

period?

Schedule rotation(s)Schedule research blockSchedule elective only experiencesOther



Late November ‐ Early January If used as a rotation

• Resulted in fewer than 17 rotation days• Three or four rotation starts

If used as a research block• Resulted in more research days than we

purposefully schedule into the program• Questions arose about efficient use of research

days

Mini‐rotations Mini‐rotations were “born”

• Abbreviated experiences (2‐10 days in duration)• Total time commitment varies each residency year

(10‐17 days)• Initially provided lots of opportunities within

pharmacy and the medical center• Currently, primarily scheduled with pharmacy team

members

Mini‐rotationsProvide residents with exposure: No current scheduled rotation Repeat exposure beyond current scheduled rotations Varied experience beyond scheduled rotations

• Peds ED vs. adult ED• Ambulatory heme/onc vs. inpatient heme/onc

Services/ departments outside of the pharmacy• Nutrition services• Toxicology• Pharmacogenomics research lab



Mini‐rotationsScheduling Mini‐rotation dates are selected to allow for as many full 5

day weeks as will fit All approved preceptors/ established rotations are made

available for selection Pharmacy preceptors are queried to ensure availability Residents are asked to rank top 6 choices and indicate a

requested number of days in select areas PGY1 program director/ PGY2 program coordinator

schedules all experiences

Mini‐rotations

Mini‐rotations



Mini‐rotationsFeedback from applicants to our program:

• Recognize as unique• Identify it as an area to obtain additional experience beyond

scheduled rotations Resident feedback:

• “Ability to get exposure to a variety of pharmacy specialties within just a few days, particularly emerging/ new/ growing areas”

• “Unique, focused insights into highly specific sub‐specialty areas of healthcare”

• “Augmented my learning experiences in several of my traditional rotations”

• “Exposure to non‐pharmacy areas”






Code response is a required residency experience at my

institution.

YesNo



Emergency Response

Pharmacists provide 24/7 response to:• Codes• STAT pharmacist pages• Sepsis/SIRS alerts

Elective CAGO E5.1 “Management of medical emergencies” added into program

Emergency Response Resident expectations

• Codes + STAT pharmacist: Dayshift primary response pharmacist: rotate week to week (depending upon rotation)• Always accompanied by secondary code

pharmacist (PGY2 resident, clinical pharmacist or clinical coordinator)

• Sepsis/ SIRS alerts: respond to alerts for assigned patients or patients in geographic location

Emergency Response Resident training:

• ACLS• Departmental training specific to role of

pharmacist• Post‐training test (score of 100% required)

• Annual requirements to participate in departmental or institutional code simulation



Emergency Response Feedback/ evaluation on performance:

• Secondary responder debriefs with resident after events and submits feedback in Pharmacademic™

• Resident keeps log of responses and documents in quarterly report

• RPD evaluates #s to ensure each resident has adequate opportunities

• Schedule changes are made for residents with fewer response opportunities






Multimedia Continuing Education (CE)

Required CE presentations• 1 hour ACPE‐accredited pharmacist seminar• 0.5 hour ACPE‐accredited “Tech Talk”• ACPE‐accredited for both live and “home

study”



Multimedia CE

Pharmacist‐accredited Seminar• 2 live sessions (7 AM for night shift, 2 PM

for day and evening shift)• Encore session is recorded

Tech Talk• Recorded only

Multimedia CE

Recorded presentations are posted to a private YouTube channel Additional CE requirements• Active learning • Post‐activity questions + response rationale

Multimedia CE Feedback

• Requires adjustment to presenting without a live audience

• Provides exposure to technology‐intense presentation/ prepares for distance learning

• Offers additional data to future employers (electronic CE hyperlinked in CVs and letters of recommendation)



Multimedia Preceptor Development

Same technology used for resident CE Used to address: • “Just in time” development needs• Evaluation definitions

• Regularly scheduled preceptor development sessions






Residency Project Overview

Quality improvement project• Singular research question; complete in first half of year• Presentation of a complete poster (results and

conclusion) in December• Write‐up in SBAR format due in early January• Presentation to appropriate institutional committee by

end of Q3; all summative evaluations completed by Q3



Residency Project OverviewResearch project

• More complex research question than quality improvement project

• Goal: complete data collection/ assessment by middle of Q4

• Platform presentation that includes results and conclusions at regional residency conference (May)

• Final write‐up in manuscript format due to project preceptor/ RPD in early June

Alignment of Projects and PrioritiesOrganizational/departmental priorities

• Safety• Alignment with best practices• Stewardship

Areas of focus• Sepsis • Mortality • High risk drugs: anticoagulation, insulin, opioids, antimicrobials,

antineoplastics• Transitions of care• Appropriate utilization

Project ExamplesUtilization initiatives:

• Intravenous Immune Globulin and Albumin• Medication use evaluations (MUEs) guidelines

for use/ standardized dosing order sets• Physician and senior leadership support• Results: significant cost savings, increased

adherence to formulary restrictions and guidelines for use



Project ExamplesBest practices:

• Antimicrobial selection for surgical prophylaxis for in‐unit open chest procedures in our thoracic cardiovascular surgical intensive care unit • Initial project identified broach spectrum antimicrobial

agents were used more than narrow spectrum agents• Narrow spectrum agent designated as standard of care• Follow‐up evalua. on iden� f ed ↑ adherence to

standard of care (narrow spectrum agent), ↓ Clostridium difficile infection rate, positive impact on antibiogram

Project ExamplesOrganizational priority

• Sepsis‐related mortality• Initial project evaluated timing of antibiotic initiation in

emergency department (ED) in septic patients before and after implementation of evening ED clinical pharmacy services

• Results: signif cant ↓ me to f rst dose and order to administra� on me, signif cant ↑ in receipt of f rst dose within one hour

• Improvements resulted in expanded pharmacy coverage in ED• Subsequent resident projects focused on improving sepsis

alerts within the electronic health record for patients

Project Feedback Quality Project

• Project completion and presentation early in the year• Opportunity to implement solution to a problem/issue• Able to see impact of the work within our patient

population Research Project

• Impact on patient care • Opportunity to share findings external to organization

Overall• Gained greater understanding of healthcare costs• Grew in project management skills• Had opportunity to lead groups to consensus



My organization has involved residents in supporting organization technology

initiatives.

YesNo

Resident Involvement in InitiativesElectronic health record (EHR) conversion Go‐live(s)

• Trained as end‐users• Residents worked alongside clinical pharmacists and coordinators

to support order “cutover” between systems

Smart pump conversions• Phase 1: Implementation of smart pumps• Phase 2: Integration of smart pumps and EHR• Trained as super‐users• Residents worked alongside pharmacists/nurses/biomedical

engineering staff to support smart pump conversions (order and medication changes, library support)

Resident Involvement in Initiatives Feedback

• Residents: gained full understanding of magnitude of changes, acquired new skills, able to serve as expert resource to the teams

• Patient care team: appreciated having support and expertise of medication expert and someone with whom they were already familiar/ comfortable

• Senior leadership: highly complimentary, observed firsthand the impact of resident involvement in our priorities








Quality Improvement ProcessesProgram design in Pharmacademic™ RPD co‐signs all evaluations & feedback RPD designates “achieved for residency (ACHR)” Many rotations are team taught

• Primary preceptor used for summative evaluations Timelines (in accordance with accreditation standard)

Quality Improvement Processes

Evaluation expectations: Formative evaluation• Formative feedback/ Feedback Fridays




Evaluation expectations: Summative evaluations

• Emphasis on what to:• Keep doing• Start doing• Stop doing

Quality Improvement Processes Preceptor evaluations

• Emphasis on:• Preceptor roles most frequently utilized • Preceptor’s strengths• What did I learn from this preceptor? • What could the preceptor do to make future

experiences more valuable?

Quality Improvement Processes Learning experience evaluations

• Emphasis on:• What was the most valuable aspect of this

experience? • What did I learn from this experience? • What could be done in the future to make

the learning experience better?




Resident self‐evaluation required elements:• What did I do? (little emphasis)• How well did I do it? • What did I learn? • What will I do differently next time?


Administrative support personnel downloads overdue evaluations report from Pharmacademic™ weekly to every other week Reports submitted via e‐mail to those with

overdue evaluations with CC to RPD and supervisor (if necessary)


Collation and distribution of resident feedback• RPD/ administrative support personnel queries

all evaluations • Emphasis on: strengths, weaknesses,

suggestions for improving the learning experience

• Distributed via email to preceptor team and others, as necessary







Learning environment• Residency committee structure• Professional involvement • Core curriculum

My residency program has committee or group with oversight of resident projects/ research.

YesNo

Residency Committee Structure

ROC

RACs

Preceptor Development

Competencies/Training

Research



Residency Committee Structure

Residency Oversight Committee (ROC)• All program directors/ assistant directors• Responsible for overall planning,

coordination, and evaluation of all residency programs offered by the Pharmacy Department

Residency Committee StructureResidency Advisory Committee (RAC) RAC per program; combined meetings Current and next rotation preceptors, annual advisors,

longitudinal preceptors (staffing, projects) Purpose: share current resident progress/plans/

strengths and areas for improvement Conduct periodic evaluations of program, accreditation

standards, goals, and objectives

Residency Research Committee Charge: oversight of residency research initiatives Evaluates projects for all residents from design to final

presentation Led by 3 departmental coordinators Membership includes pharmacists and data analyst Significant commitment of time Continuously seeking strategies to gain efficiencies

• Project design workshops in spring • Research orientation at beginning of residency year• Required resident attendance at presentations



Project Identification/ VettingResearch Committee focuses on:

• Feasibility for allotted time • Measurability of data points • Availability of data• Value of project to resident/ organization/

department• Impact on total body of knowledge

Research Committee Feedback

Projects are meaningful, sound, and feasible Project preceptors are appreciative for the

expert “peer review” that solidifies design Residents feel well prepared for regional

residency conference





Learning environment• Residency committee structure• Professional involvement • Core curriculum



Professional Involvement

Charlottesville Free Clinic Virginia Commonwealth University School of

Pharmacy• Teaching and Learning Certificate• Teaching assistants for lab


Annual resident site visit VSHP Resident Forum• One day seminar for all residents in VA• Hosted 2018 event


ASHP Fall Resident Visit• Annual trip to Bethesda

ASHP Visiting Leaders Program• Hosted Harold Godwin in 2016• Invited numerous VA programs



ASHP Visiting Leaders Program Guidance from ASHP Foundation and speaker on

structure of visit; involves coordinating travel, lodging, meals, space, and people

HSPA‐tracked PGY1 served as primary contact/ coordinator

Day 1: focused on residents Day 2: interfaced with managers and all program

directors

Visiting Leader Visit Feedback

“…opportunity to interact with significant pharmacy leader and other residents in VA” “..learned more about ASHP and how to

maintain involvement throughout my career” Ideas shared resulted in program changes for

the following year.

Core Curriculum

Group topic discussions for all residents One hour weekly Residents gain exposure to topics regardless of

rotation schedule Efficiently uses preceptor time



Core Curriculum

Core Curriculum Feedback

Preceptors: efficient way to provide interactive topic discussions with all residents Residents: gain knowledge for topics in areas

where rotations are not scheduled Students: opportunity to interface with

residents and preceptors

Learning Environment

“Phamily”• Jobs • Birthdays• Traditions• Holidays



Residency Retention

0%

50%

100%

FY14 FY15 FY16 FY17 FY18

Residents staying on for PGY2 training or employment in the department

PGY1 retention PGY2 retention Total

Self‐Assessment Question 1

What training may be necessary before having residents respond to medical emergencies?

Answer: ACLS, departmental competency and assessment, and participation in simulation sessions



Self‐Assessment Question 2

What opportunities exist for exposing residents to professional organizations and leaders?

Answer: ASHP Fall Resident Visit, ASHP Foundation Visiting Leaders Program, local organizations, programs, and groups

Key Takeaways Key Takeaway #1

• Mini‐rotations and core curriculum provides residents with additional exposure to preceptors/patients/areas that vary from scheduled rotations.

Key Takeaway #2• Aligning resident quality improvement and research projects

with priorities and involving learners in organizational initiatives has resulted in positive departmental and organizational outcomes.

Key Takeaway #3• Incorporating traditions into our program leads to a sense of

“phamily” thereby contributing to positive resident retention rates.



Quality Improvement Proposal Form

Research Proposal Form



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