Transcript NAS-CLER - LLU Physician Lounge

10th Annual Program Directors Retreat
Program Director and Coordinator Faculty Development
Welcome
What was LLU named between
1915 and 1963?
A.American Medical
Missionary College
B.Burden Memorial
College
C.College of Medical
Evangelists
D.Mound City
College
86%
14%
Co
l
Ci
ty
va
ng
e.
..
Co
lle
ge
0%
M
ou
nd
lE
ed
ic a
le
ge
of
M
M
rd
en
Bu
Am
er
ic a
n
M
ed
em
ica
or
ia
lM
iss
lC
ol
io
.. .
le
ge
0%
College of Medical Evangelists
»Medical
~ Medical Knowledge
~ Patient Care
~ Problem-based Learning and Improvement
»College
~ Interpersonal and Communication Skills
~ Systems-based Practice
»Evangelists
~ Professionalism
~ Global and Local
GME 2013
Graduate Medical Education
Business Model
»Hertz hires and trains
workers
»At the end of training,
80% of them will go to
work for competitors
Graduate Medical Education is
Inherently a Community Benefit
»Among MD’s practicing in San
Bernardino County
~One third did their residency at
LLUMC
~Half trained or teach (or both) at
LLU.
Business of Medical Education
»UME is profitable to very profitable
~ Hence, there has been a steep increase in
the numbers of medical school seats being
offered in LCME, AOA and off-shore medical
schools.
»GME costs teaching hospitals to break even
~ Hence, no significant increase in the numbers
of PGY-1 positions since 1996.
Shortage of PGY-1 Positions
What Happens When Noticeable
Numbers of LCME Graduates
Cannot Get a PGY-1 Position?
Next Accreditation System
Safe Care for Current and Future Patients
Next Accreditation System: 2 Parts
»CLER visits
» Annual Reports
»Patient Safety
»Supervision
»Quality & Disparities in
Healthcare
»Transitions
»Supervision
»Duty Hours
»Professionalism
»Attrition
»Changes
»Scholarly Activity
»Board Pass Rate
»Clinical Experience
»Resident Survey
»Faculty Survey
»Milestones
NAS: “Continuous accreditation
model”
»Annual review of the following performance indicators:
~
~
~
~
~
~
~
~
~
1) Program Attrition
2) Program Changes
3) Scholarly Activity
4) Board Pass Rate
5) Clinical Experience
6) Resident Survey
7) Faculty Survey
8) Milestones
9) CLER site visit data
»Collected now as part of the program’s annual ADS update.
»ADS streamlined this year: 33 fewer questions & more multiple
choice or Y/N
»Collected now as part of annual administration of survey
»Boards pass rates provide annually
1. Program Attrition
» General Definition: Composite variable that measures the
degree of personnel and trainee change within the program.
» How measured: Has the program experienced any of the
following:
~ Change in PD?
~ Decrease in core faculty?
~ Residents withdraw/transfer/dismissed?
~ Change in Chair?
~ DIO Change?
~ CEO Change?
2. Program Changes
»General Definition: Composite variable that
measures the degree of structural changes to the
program.
»How measured: Has the program experienced any
of the following:
~ Participating sites added or removed?
~ Resident complement changes?
~ Block diagram changes?
~ Major structural change?
~ Sponsorship change?
~ GMEC reporting structural change?
3. Faculty & Resident Scholarly
Activity
» General Definition: Indicator that measures scholarly
productivity within a program for faculty and for learners.
» ACGME will eliminate faculty CVs and replace them with a
new “table” to collect scholarly activity information.
~ Primarily text that is not quantifiable
~ Currently used by RC only at time of site visit
~ Takes up significant amounts of space ACGME
database
~ 35% of support calls related to faculty CVs
» Expectations for faculty and learners w/ regard to
scholarly activity will be different for core and subspecialty
programs.
4. Board Pass Rate
5. Clinical Experience Data
»Graduate Survey to final-year
residents
OR
»Case Logs
» How well prepared are you to perform procedures without
supervision?
~ List from PRs
» How well prepared are you to perform patient care activities without
supervision?
~ HCM, Newborns, Acute illness, Resus/Stabilize/Triage,
Behavior/Mental Health
» How satisfied are you with the patient volume, range of patient ages,
variety of medical conditions, and extent of progressive responsibility
in the care of patients?
» How satisfied are you with the educational experiences to help you
achieve competency in patient care skills?
~ PC tracked sub-competencies
» How satisfied are you with aspects of your longitudinal outpatient
experience?
» Are you well prepared to competently practice general pediatrics?
6. Resident Survey
» Administered annually Jan-May
» Questions on RS relate to 7 areas:
~ Duty Hours
~ Faculty
~ Evaluation
~ Educational Content
~ Resources
~ Patient Safety
~ Teamwork
7. Faculty Survey
» “Core” faculty only because they are most knowledgeable
about the program
~ dedicate an average of 15 hours/week
~ trained in the evaluation and assessment of the
competencies;
~ spend significant time in the evaluation of the residents
~ advise residents w/ respect to career and educational
goals
» Similar domains as the Resident Survey
» Will be administered at same time as Resident Survey
» Start in winter-spring 2013 for 2012-2013 for Phase 1
8. Milestones
»Competency Committees determine
when residents reach specialtydetermined milestones and the program
reports this on WebADS
Two New Committees (2014)
»Clinical Competency
Committee (CCC)
»PD Appoints 3 +
Faculty +/- Residents
»Focused on Individual
Residents attainment
of milestones
»Advises PD
(Milestone data sent
to ACGME)
»Program Evaluation
Committee (PEC)
»PD appoints 3 +
Faculty and Residents
»Focused on
Residency Program
improvement
»Produces Annual
Program Evaluation
(APE) for GMEC
9. CLER
»Every 18 month visit by a team of
surveyors assessing the quality and
educational environment of the
sponsoring institution.
~
~
~
~
~
~
Patient Safety
Quality Improvement
Transitions in Care
Supervision
Duty Hours/Fatigue
Professionalism
Agenda
»Morning:
~CCC
»Afternoon
~Milestone Management
~PEC
~CLER
On a CLER day, you can see . . .
Clinical Learning Environment
Review (CLER)
»10-14 days advanced notice
»CEO and DIO Must attend both initial
and exit meetings
»Option to pass on first scheduling
attempt
5 Key Questions
»Who and what form the hospital’s infrastructure
designed to address the focus areas?
»How integrated is the GME leadership and
faculty in hospital efforts across the focus
areas?
»How engaged are the residents?
»How does the hospital determine the success of
its efforts to integrate GME into the focus areas?
»What the are areas the hospital has identified for
improvement?
Guess Who Is Coming?
»ACGME CLER Regional VP(s)
~Tend to be former DIO’s
~Western region has not been hired yet
»CLER Field Staff
~Tend to be former PDs
»Volunteer Staff (4+)
~Current PDs, Patient Safety Officers,
DIO’s, etc.
Schedule
»Monday – visit team travels to site and meet in
the evening
»Tuesday – Initial visit with:
~ CEO (required)
~ DIO (required)
~ CMO
~ CNO
~ CFO, COO and Dean of SOM (optional, but
helpful)
“Walking Rounds”
»Resident guides from different programs
~ Preferably senior residents from core
programs
~ Not in other meetings
»Guides should be comfortable navigating the
site visitors to all areas
»No preparation necessary
»During visit may need to adjust timing of end
and start of daytime walking rounds by 30-60
minutes
Schedule
»Patient Safety Interview
~ Patient Safety Officer
~ Outcomes Specialist
~ Performance Improvement
»Program Directors, Faculty and Residents
~ Assorted individuals from various programs
~ Visit team will provide guidance
»Exit Conference with CEO and DIO
(Wednesday)
Stated Goals
»Aha’s! Experiences that inform learning
»Guides for voluntary improvement efforts
»A progressive set of activities for higher performance in
organizational engagement in GME
»A basis for empiric understanding of what is possible
»Indications of areas ripe for future work
»Not intended to provide:
~ Gotcha’s
~ New stealth accreditation requirements
In you program, how well will senior residents
consider the six elements have been met?
PREPAREDNESS
ASSESSMENT
Supervision
»Direct supervision – attending or senior resident
at elbow
»Indirect supervision with direct supervision
immediately available – attending or senior
resident in the same institution
»Indirect supervision with direct supervision NOT
immediately available (i.e. telephone back up)
»Retrospective Review – “I’ll see you in the
morning.”
Faculty & Residents recognize
supervision is:
ph
on
et
e,
im
bu
es
...
re
tro
sp
ec
t iv
e.
..
So
m
im
So
m
et
at
ay
s
es
by
le
as
ti
m
m
ed
ia
di
ay
s
w
Al
w
0%
te
..
re
ct
4%
Al
A.Always direct
B.Always at least
immediately available
C.Sometimes by phone, but
readily available
D.Sometimes retrospective
review
48% 48%
Faculty & Residents recognize
transitions in care process
38%
33%
bu
sy
e’
re
W
ss
es
se
ac
h
to
o
ot
...
...
ri
en
ts
a
by
su
pe
rv
iso
Re
sid
da
r
St
an
As
se
ss
ed
ed
fo
rm
at
an
...
14% 14%
di
z
A.Standardized format and
time, monitored
frequently
B.Assessed by supervisor
intermittently
C.Residents assess each
other in 360 evaluations
D.We’re too busy
Fatigue Education
ec
t
al
av
e
eh
W
bu
sy
0%
to
o
e’
re
ur
e/
vid
fa
tig
ss
en
d
so
r
Su
pe
rv
i
0%
eo
...
ue
d.
..
0%
W
A.Supervisors send
fatigued residents
home enough to be
noticed
B.We have a
lecture/video
annually
C.We’re too busy
A typical senior resident would
say about Patient Safety
60%
20% 20%
&
...
du
rin
g
M
&
M
/.
.
in
ta
at
ye
lle
d
Ig
et
W
e
e
re
vi
ew
da
Pa
tie
nt
a
do
ne
M
Sa
in
n
of
a
rt
pa
Ih
av
e
Ih
av
fe
..
s..
.
0%
be
en
A.I have been part of an
institutional project
B.I have done a Patient
Safety project in the
department
C.We review data in M&M/QI
Committee
D.I get yelled at during M&M
if anything goes wrong.
What percentage of your residents
inaccurately report duty hours
A.None (<5%)
B.5 to 25%
C.25-50%
D.50-75%
E.Over 75%
37%
33%
17%
8%
Ov
er
75
%
50
-7
5%
25
-5
0%
to
5
No
ne
(<
5%
)
25
%
4%
How would a typical senior
resident view health disparities?
A.I changed care patterns
B.I have done a health
disparities study
C.I see lots of medically
underserved patients
D.What’s health
disparities?
95%
es
?
iti
’s
he
al
th
di
sp
ar
un
...
lly
ha
t
lo
ts
o
a
Is
ee
do
ne
e
Ih
av
W
he
al
fm
ed
ic a
th
pa
re
ca
ge
d
ha
n
Ic
5%
0%
di
sp
.. .
tte
rn
s
0%
Quality Improvement
1. “I conducted a QI project looking at immunizations for
my clinic patients last week/month.”
2. “I am working on a ‘class’ project, my role is limited to
designing a short data collection form”
3. “I am working with a hospital quality improvement team
to help standardize discharge planning to reduce
readmissions”
4. “If I see a problem in care I report it to my department
chair and he fixes it”
5. “I do not have time for that quality stuff”
A typical senior resident involvement
in Quality Improvement:
A.“Conducted a QI project
in department.”
B.“Role in a class project”
C.“Working on institution QI
team.”
D.“Report problems to
Chair.”
E.“No time for QI”
32%
27%
23%
14%
5%
t.
ec
j
ro
Ip
o
“C
d
te
c
u
nd
a
Q
“R
e
ol
in
.
a
c
s
las
o
“W
pr
t”
ec
j
o
in
rk
go
n
ti
it u
t
s
in
r
po
e
“R
on
ro
tp
..
o
st
em
bl
ai
Ch
I”
r.”
e
“
No
tim
rQ
fo