Competency-Based Practice Management Curriculum with Assessment and Validation Tools David E. Kolva, MD Christopher P. Morley, MA, CAS SUNY Upstate Medical University Department of Family Medicine St. Joseph’s Hospital Health Center Family Medicine Residency Program Syracuse, NY Society of Teachers of Family Medicine *41 st Annual Spring Conference* Saturday, May 3, 2008 Baltimore, Maryland

Abstract Existing SJHHC FMR Program’s PM curriculum - checklist (content) based. Guiding Philosophy - Enable Opening New Practice Current Reality - Vast Majority are Corporate Employees with Little Decision-making Power Needs Assessment: Modernize the Practice Management Component of Residency Program’s Curriculum to Address Changing Demographic Realities -AND- Account for New Nationwide Requirements from ACGME

First Research Initiative: The “100 Hours” RRC Family Medicine Training Requirements IV.A.5.b (12) Effective 7/2007: Management and Leadership Training…. must receive at least 100 hours of management and leadership instruction to include both the didactic and the practical settings.

Second Research Initiative: The “Six Competencies” 1.Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health 2.Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care 3.Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care 4.Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals 5.Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population 6.Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Task Synthesis Faculty Charged with Re-Examining our Existing Practice Management (or “Business of Medicine”) Curriculum to Meet these TWO Requirements. MEMO: “Make Them Fit!!” Signed, Program Director Which of the Six Competencies Address PM related instruction and goals? Some of #3, plus #5 and #6? = Rapid realization of un-workability!

Research, Review and Eureka! Old AAFP P.M. Content List (Orig.9/85, Rev.1/03) Plus Elaboration of ACGME Competency Definitions Plus ACGME “Outcomes Project” Suggestions and a Pinch of Common Sense Equals Ten (10) Workable Outcomes Goals Statements

The Outcomes Goals Statements What Do Want Them to Do in the Real World? 1.Demonstrate successful use of the tools needed to secure satisfying employment after graduation. 2.Demonstrate adequate knowledge of common legal problems & foster M.D.- attorney relationship. 3.Efficient Work Habits & Maximum Productivity in Team Environment. 4.Adequate Financial Compensation and Protect Financial Future 5.Demonstrate Good Problem- Solving Skills 6.Physicians are “Adult Learners” with Evidenced-Based Medicine principles 7.Personal Physical and Mental Health are Keys to Success 8.Demonstrates Ethical Behavior at All Times 9.Physicians are Leaders in the Group and Community. 10.Use of Continuous Quality Improvement Principles in Patient Care

PM Curriculum Content Design: Strengthened June/July PGY- 1 Orientation to Model Unit New “Core Lectures” for PGY-1 Dell Axim© Handhelds + InfoRetreiver & Epocrates NextGen© EMR Weekly CAT/PICO Conferences Monthly Team Meetings (PGY 1 thru 3), & PGY-3 FMC Management Committee Practice Management Faculty Champion (DK) Learner’s Portfolio with 360° Assessment Month-Long Block Rotation in P.M. During PGY-3 with Written Final Exam Longitudinal 6 month Service Project (FOCUS-PDCA Workbook) in PGY-3 Weekly PGY-3 Senior Seminar with P.M. Dominance and Guest Speakers in Law & Finance/Management

First Graduating Group Survey Likert Scale Self-Assessment of Knowledge Gains Survey Performed June 2007 to New and Graduating Residency Classes and Remote Grads (Attendings) Results Encouraging ►New Assessment Tools Designed (2007) and Enhanced Content Based on the 10 Outcomes Goals 66 total respondents; 52 residents following completion of the PM curriculum, and 16 Residency graduates (Mean yrs in practice = 4.59 yrs, SD=1.99 yrs)

Mean Knowledge Assessment Levels for Each Class

First Graduating Group (June 2007) Survey VariabletSig.Mean Resident = 0 Mean Practicing = 1 Principles of Office Visit Coding How to Select a Successful Practice Opportunity Electronic Medical Records Principles of Malpractice Risk Management State Licensure Requirements Office Insurance Needs Components of a Malpractice Lawsuit Function of Office Policy and Procedure Manuals Principles of Patient Abandonment Rules H.I.P.A.A Managing Medical Office Personnel “Physician Burnout Syndrome” Patient Education Materials Principles of Employment Contract Law Types of Family Medicine Careers “Pay-for-Performance” Understanding of Professional Misconduct C.L.I.A “Open Access” Scheduling Use of Internet for Evidence Search

First Graduating Group Survey: Analysis of Results One quarter to one third of 20 self-rated variables were rated higher by attendings who had not received formal PM training in residency than by current residents who have been through the PM Curriculum HOWEVER, three quarters to two thirds of the variables were NOT statistically different between practicing physicians with no formal PM training in residency, and residents who underwent current training

Conclusions and Ultimate Goals Published All Curriculum Materials in STFM Digital Resource Library (4/08) Keyword: Practice Management Curriculum National Standardized Practice Management Curriculum for Residency Programs Develop Objective Assessment Tools to Complement Current 360° Observations, Written Examination, and Learner’s Portfolio Yearly Knowledge Retention and Validation- of-Outcomes Surveys

Revised (2008) Practice Management Knowledge Retention Survey We need to know your ESTIMATED knowledge level of the following subjects that are included in the Practice Management Curriculum CONTENT. 1 = Very Poor Knowledge, 2 = Fairly Poor Knowledge, 3 = Average Knowledge, 4 = Fairly Good Knowledge, 5 = Very Good Knowledge 1.Components of a Professional Curriculum Vitae 2.Locum Tenens 3.Limited Liability Corporation 4.Medical Group Management Association (M.G.M.A.) Benchmarking Surveys 5.“Restrictive Covenant” 6.Occurrence versus Claims-Made Policies 7.Business Disability Overhead Expense Insurance 8.Office of Professional Medical Conduct (O.P.M.C.) 9.Components of Physician Burnout Syndrome 10.Summons and Complaint 11.Principles of Malpractice Risk Management 12.“Informed Refusal” 13. Patient Abandonment Rules 14. H.I.P.A.A. Privacy Officer 15.C.L.I.A. Waived Test 16.P.Q.R.I. Program 17.N.P.I. number 18.Worker’s Compensation Proximate Cause of Injury 19.State Licensure Requirements 20.“Open Access” Scheduling 21.Coding Requirements for Level Office visit 22.Overhead Expense Ratio 23.FOCUS-PDCA 24.Credentials Committee 25.Interviewer’s Prohibited Sexual Discrimination Questions

1.In the past year, have you changed jobs? a.If YES, was job satisfaction the primary cause of your change? b.If YES, was a spouse’s needs the primary cause of your change? c.If NO, please rate the current level of your job satisfaction on the 5 point satisfaction scale 1=completely dissatisfied, 5=completely satisfied. 2.In the past year, have you encountered any problem in your employment that was not covered in your employment agreement? a.If YES, did you retain an attorney to resolve this issue? b.If YES, did you handle the resolution yourself? c.If NO, do you feel that your original employment contract was complete? 3.Do you regularly review the financial information from your practice? a.If YES, is this review part of a formal group activity? b.If YES, do you feel that your Residency Program training prepared you to comfortably participate in this review? c.If NO, are there any plans for you to begin this review activity in the next year? d.If NO, are you prohibited from reviewing this financial information? 4.Do you, or your group, compare this financial information against any national benchmarks? 5.Do you own personal long-term disability insurance? a.If YES, do you have an “own-occupation” clause? b.If NO, do you plan on purchasing this type of policy in the next year? 6.Do you own an IRA (Individual retirement Account)? a.If YES, did you contribute funds to it this year? b.If NO, do you plan on opening an IRA this year? 7.Do you participate in any formalized Continuous Quality Improvements efforts in your practice? 8.In the past year, have you formally conducted an anonymous, standardized patient satisfaction survey in your practice? a.If YES, did you incorporate the results to make changes in the daily operations of the practice? b.If NO, do you plan on performing such a survey this year? 9.In the past year, have you, or any member of your group, been involved in any type of professional malpractice action? a.If YES, do you feel that your training in the Residency Program helped you in any way? b.If NO, do you feel that your training has helped avoid any type of professional malpractice actions? 10.In the past year, have you, or any member of your group, been involved in any type of professional misconduct action? a.If YES, do you feel that your training in the Residency Program helped you in any way? b.If NO, do you feel that your training has helped avoid any type of professional misconduct action? 11.Do you feel that you are experiencing any signs or symptoms of “Physician Burnout Syndrome”? a.If YES, does your CURRENT practice have a policy to address these issues? b.If NO, does your CURRENT practice encourage any preventative measures to combat this problem? 12.Do you feel knowledgeable in recognizing signs or symptoms of “Physician Burnout Syndrome” in your colleagues? 13.Does your State have an Impaired Physician reporting body where a confidential referral can be made if needed? 14.Does your practice have a formal Policy and Procedures Manual? a.If YES, is it in Print or Electronic form? b.If NO, does your group plan to create a Policy and Procedures Manual in the upcoming year? 15.Please rate the level of your CURRENT knowledge level concerning “business of medicine” or “practice management” related issues in your practice: 1=Poor 2=Fair 3=Average 4=Good 5=Excellent Revised (2008) Practice Management Outcomes Survey

Future Research Goals Case-Based Vignettes: Similar to Clinical OSCE’s: For Each Outcomes Goal. “SimPractice” Internet-Based Simulated Family Medicine Practice with Benchmarked Patient Panels, Payer Mix, Income Statements and Employee Problems. Long Term Tracking Survey for Curriculum Improvement and Validation

Future Research Goals Systematic Review of Residency Programs Curriculum in Practice Management: Competency-Based Design and Suggested Outcomes Measures. David Kolva, MD, Kathleen Barzee, MPH and Christopher Morley, MA, CAS May 2008 (In Press)