POwER, SNAPPS AND THE FUTURE OF PRECEPTING George Maxted, MD Associate Program Director Tufts University Family Medicine Residency at Cambridge Health Alliance 33 rd Annual FMEC Northeast RegionMeeting 10/24/14

Objectives of This Seminar Review the development of “precepting” at a family medicine residency: TUFMR/CHA Explain the rationale behind the materials and methods now used at the residency Know POwER Precepting and SNAPPS Explain Miller’s Pyramid, the goal of the pinnacle and the challenges of getting there in an intense learning environment Look at future goals and challenges

Precepting at TUFMR – brief history POwER Precepting – guide developed, 9/2010 The One Minute Preceptor – Microskills Precepting Surveys – March 2013 Preceptors (core faculty and community) and residents Precepting Improvement, Development and Evaluation – PRIDE Team convenes – April 2013 Regular meetings end April to present Draft revisions of POwER Precepting guide Co-location of preceptors into clinical areas Adoption of SNAPPS model of precepting – May 2014

Summary of Surveys: “opportunities for improvement” More time for reflection Improve overall clinic systems, especially for complex care E*Value hard, or never got access or instruction Residents “batching” at end of session Preceptors arriving late Respecting residents’ time Preceptors distracted or engaged in other activities Preceptors not attending to resident needs Talking about things not perceived as relevant

PRIDE Work Members: Judy Fleishman, Nathan Cardoos, Warren Bodine, Lara Hall, George Maxted, Sam Mekrut, Randi Sokol Products in process: Revision of POwER Precepting Guide Co-Location plan Precepting Strategies – updates for residents and preceptors

Precepting and Co-Location Part of a broader PCMH initiative at MFMC Co-locating Teams. Devlopment of the Teamlet core functions Locating the Preceptor at the center of clinic activities – Pods A, B and C Pilot project on Pod C Preceptor and Teamlet Preceptor role expanded to include more collaboration with all teamlet members

More goals – next PDSA cycle More “real-time”/ less “batching” precepting More level 4s More seeing patients/confirming physical findings More residents seeing their own patients (schedules changed) More procedures Richer education for residents and preceptors (more focus on medical-decision making, when appropriate) More assisting with nursing and MA needs Clinical sessions and precepting ending on time Evaluation of preceptors

POwER Precepting P – Preparing Pre-precepting. Planning. O – Orchestrating Coordinating, managing schedules, collaborative care Patient safety w E – Educating The top of Miller’s pyramid R – Reviewing Summarize. Identify learning opportunities. Challenges Based on the work of Melly Goodell, MD Department of Family Medicine at MedStar Franklin Square Medical Center

Preparing Arrive at designated time: Review schedule - identify year of residents, other preceptors Scan through patient charts; determine if any resident providers can switch patients so they can see their own patients Walk around - touch base with staff “Huddle” with residents/staff: Pre-precept with individual residents to prepare them for specific patients and all OB patients Orchestrating Monitor patient flow, coordinate resident schedules Be available to residents and staff Know information resources. Know hospital and community resources Encourage resident use of staff for problem solving Encourage residents to precept at every patient visit

Educating SNAPPS Respect residents’ time (e.g., no personal charting) Do CogDoc on all precepting encounters. Do as much direct observation as is appropriate. Reviewing: “Wrap-up” Stay until scheduled time What did they learn today?

Changes due to POwER implementation All preceptors are in pods (clinical area) Specific work space for preceptor – designated computer Patient confidentiality Encourage residents to control computer Use white board to manage flow Update: PA consults Update: Huddle

SNAPPS vs One Minute Preceptor SNAPPS SUMMARIZE: condense facts. More abstraction. < 50% of precepting time NARROW: the differential – Ddx of 2 to 3 most likely ANALYZE: the differential – thinking, analyzing PROBE: the preceptor – specific questions, uncertainties PLAN: develop management plan SELECT specific case for review – self directed learning One Minute Preceptor Get a commitment – what is going on? What do you want to do? Probe for supporting evidence – How did you decide and what else did you consider? Teach ONE general rule Tell the learn what s/he did right and the effect it had Correct mistakes

SNAPPS vs One Minute Preceptor SNAPPS Resident led (preceptor facilitated) Resident identifies learning needs Resident as active learner More focus on clinical reasoning and thought process Less focus on facts Resident asks questions and expresses uncertainties Resident select cases for self- directed learning One Minute Preceptor Preceptor led Preceptor identifies learning needs Resident as receptive learner More focus on facts Less focus on clinical reasoning and thought process Does not encourage resident- led questions, expression of uncertainties Lack of resident self-directed learning

SNAPPS Practical Doc: prof/teaching-nuts-bolts/snapps/ prof/teaching-nuts-bolts/snapps/

Precepting examples One Minute Preceptor: E E More traditional: SNAPPS: MFMC: RPFP Alberta:

Preceptor Training Modules 1. Introduction to precepting at MFMC Goals (knowledge) – learning, patient care and safety Culture at TUFMR – collaborative, learner-centered Logistics: what, how, when, where Rules, billing, procedures Behaviors: focus on teaching, let residents drive 2. The Structure Macro: POwER – especially pre-precepting and orchestrating Micro: SNAPPS – resident directed, focus on analysis Nano: Direct observation, including shadow and video

Preceptor Training Modules 3. Documenting Resident Performance EPAs. CogDoc. 4. Information at Your Fingertips Point of care resources. Epic tools and tricks. Dynamed. 5. Special Situations Disgruntled, frustrated residents Challenged learners

Portfolio – the “Holy Grail” Rotation Evaluations – Assessment on Rotation Procedures – evaluations and logs BSQs – basic skills qualifications EPAs – CogDoc Reflective Writing (“Blogging”) – personal files 360 ⁰ Evaluations – professionalism Shadow precepting Video evaluation and analysis ITE results Salon H at 3:30 – Building and on-line portfolio

Identify Competencies: EPAs “Entrustable Professional Activities” (EPAs) Specific, measurable areas of practice Clinical situations in which residents shall be entrusted to perform competently upon graduation The “mass of critical elements that operationally define” Family Medicine. Cate and Scheele. Acad Med.2007;82(6):

TUFMR Direct Observation Shadow Precepting and Video Establish resident-directed learning goals Observe behaviors specific to the learning goals Provide meaningful feedback to assist in attaining goals Observe and document resident perfomrance and behavior during patient care.