Translating Leadership Potential Into Reality: A Longitudinal Curriculum Natasha Bhuyan, MD Sarah Coles, MD Banner – University Medical Center Family Medicine Center Phoenix, AZ

Disclosure of Conflicts We do not have any actual or potential conflicts of interest in relation to this program or presentation.

Objectives Describe how universal leadership training in family medicine residency programs is critical for achieving the Triple Aim and health care transformation. Describe the process of successful implementation and evaluation of a longitudinal leadership curriculum in family medicine residency. List four to six activities to engage residents in advocacy and community leadership.

Importance of Leadership Rapidly evolving US healthcare system Shifting to values- and outcomes-based care through innovative delivery Family Medicine for America’s Health Physicians are unfamiliar with proficiency in management and leadership skills In the presence of a rapidly evolving and changing US healthcare system, training of leadership and advocacy has never been more crucial. Payment and clinical models have changed, shifting to a value and outcome based system through new and innovating delivery models. Family Medicine for America’s Health demands that family physicians lead healthcare delivery change with an understanding of these new models to better serve our patients. Research has demonstrated that physicians are unfamiliar with proficiency in management and leadership skills. Leadership and advocacy are not commonly taught in a systematic way in medical school or residency.

Importance of Leadership Training Little community advocacy training at the undergraduate or medical school level Few family medicine residencies systematically teach all residents how to lead through leadership development curriculum Despite evidence that indicates it yields superior clinical outcomes Leadership training is vital to helping residents understand their roles in achieving the triple aim

Milestones SBP-1 Provides cost-conscious medical care The new competency-based milestones have leadership and advocacy tied through them. Primary, under SBP-3. However, a few other areas include: SBP-1 Provides cost-conscious medical care Level 1: Understands that health care resources and costs impact patients and the health care system SBP-4 Coordinates team-based care Level 5: Role models leadership, integration, and optimization of care teams to provide quality, individualized patient care PROF-1 Completes a process of professionalization Level 2: Knows institutional and governmental regulations for the practice of medicine Level 5: Demonstrates leadership and mentorship in applying shared standards and ethical principles, including the priority of responsiveness to patient needs above self-interest across the health care team Develops institutional and organizational strategies to protect and maintain these principles PROF-3 Demonstrates humanism and cultural proficiency Level 3: Identifies health inequities and social determinants of health and their impact on individual and family health Level 5: Demonstrates leadership in cultural proficiency, understanding of health disparities, and social determinants of health Develops organizational policies and education to support the application of these principles in the practice of medicine

Evaluation of Leadership Discussed at Academic Affairs Optional pre- and post-surveys 21 out of 25 initial responses Given those above Milestones, in our residency, there is a smattering of leadership/advocacy among residents that is not systematic. We initially heard feedback from residents that many were uncomfortable in areas of leadership. We wanted to determine a baseline sense of residents attitudes, skills and knowledge regarding leadership and advocacy so we created an 18-question survey. 21 out of 25 residents responded, indicating to us there is strong interest in this curriculum Responders: 7/8 interns, 8/10 R2s, and 6/7 R3s

Baseline Strengths Weighted Avg. 4.62 Weighted Avg. 4.10 Leadership strengths mostly seemed to be related to interpersonal skills, which we would expect from our residents at all levels Weighted Avg. 4.62 Weighted Avg. 4.10

Baseline Weaknesses Weighted Avg. 2.71 Weighted Avg. 2.9 Major weaknesses were related to governmental policy and an understanding of the healthcare system. Interestingly, the breakdown hold true across all classes, which suggests that even our R3s are uncomfortable with these topics despite their advanced level of training. Weighted Avg. 2.71 Weighted Avg. 2.9

Mixed Data Weighted Avg. 3.62 Weighted Avg. 3.33 NATASHA: We expect all family medicine physicians to serve as leaders within the healthcare team, so it was surprising to see lackluster feedback in this area. Regarding leadership positions, the data was spread across the board. We suspect exposure to leadership opportunities is not consistent across residents in our program. This was another theme that emerged: residents want equal opportunities for leadership. Weighted Avg. 3.62 Weighted Avg. 3.33

Structured Residency Curriculum Longitudinal and integrated Specific Educational level appropriate training Goals: Successful navigation of healthcare system Fluency with payment and clinical models of care delivery Leadership skills for clinic, community, and national systems and organizations Culture of leadership As a results of feedback from our residents, we created a STRUCTURED and OPTIONAL longitudinal leadership curriculum. Our curriculum was adopted from the American Academy of Family Physicians with additional specific activities and objectives, with a goal of fostering leadership behaviors among residents.

Educational Objectives Leadership Skills Organizing Consensus-building Strategic thinking Conflict resolution Communication Setting patient-centered goals U.S. Healthcare System Local and National Resources Quality Improvement Interprofessional Care Information Technology Payment Models If you refer to your handout, you can see the major objectives of our curriculum. They focus on a few different areas, including 1.) an understanding of the healthcare system and health policy; 2.) the ability to advocate for patients through resources, QI projects, and information technology; 3.) leadership skills and roles…In addition, given the recent Family Medicine for America’s Health Report, we decided to make understanding payment model and reimbursement reform a part of this curriculum. OBJECTIVES At the end of residency, the resident should: Assume a leadership role in their practice and community (both regionally and nationally). Demonstrate awareness of the changes in the U.S. healthcare system. Utilize an array of resources to advocate for patients and physicians socially, politically and economically. Manage a project to improve the quality of care and services to the broader patient population. Compare the different payment models utilized in primary care, health systems management and operations. Work in and lead an interprofessional care team. Utilize the tools of information technology to enhance clinical care and streamline healthcare delivery. Practice key leadership skills, including but not limited to: organizing, consensus-building, strategic thinking, mentorship, conflict resolution, effective communication, and setting patient-centered goals.

PGY 1 Focus on clinical leadership and direct patient care Healthcare blogs: (In-Training, Costs of Care, HealthBeat, KevinMD, HealthENews, etc.) Complete courses through the Institute for Healthcare Improvement Open School Complete the free online STFM Advocacy Module: https://www.stfm.org/Advocacy/AdvocacyToolkit Meet with a senior resident mentor throughout residency who role models leadership skills in clinical and community settings Meet with faculty advisor to evaluate strengths and weaknesses in leadership and develop specific goals Write a letter to your local representative about a current issue in healthcare Attend a variety of Noon Conference lectures or Ambulatory Seminars on leadership skills Pick a current issue in healthcare and write a submission for a healthcare blog Work with interprofessional team in the clinical setting, including but not limited to panel managers, social work, behavioral health, and advanced clinical practitioners

PGY 2 Focus on advocacy, involvement in organized medicine, serving as a role model in the hospital community and locally Hospital Committees: (IRB, Patient Quality & Safety, JCAHO preparedness, Department of Family Medicine) FMIG Activities: including procedure workshops, noon talks, and student mentoring Participate in clinical committees at Family Medicine Center as well as hospital-wide Participate in local med school Family Medicine Interest Group activities Work with a faculty advisor on a quality improvement project, consider submission to the annual High Value Care Contest and STFM Annual Meeting Complete practice management rotation in order to analyze models of care Serve as the Doctor for the Day at the State Legislature through constituent chapter of AMA Attend the Residents as Educators seminar Attend national leadership conference such as Family Medicine Congressional Conference, Telluride Patient Safety Summer Camp, Society of Teachers of Family Medicine Conference on Practice Improvement, AAFP Chief Resident Leadership Development Program Participate in the Arizona Academy of Family Physicians (Board of Directors, Legislative Affairs, Education Committee, AzAFP Foundation, taskforce, etc.)

PGY 3 Focus on administrative leadership, national advocacy, shaping clinical environment, health care transformation We really encourage residents to actively pursue leadership positions that require elections or applications their R3 year. Serve as a chief resident or chair position in community service, recruitment, social, Coumadin Clinic Participate in Arizona Academy of Family Physicians Emerging Leaders Day Complete the Faculty Development Fellowship through the University of Arizona College of Medicine – Phoenix Lead community health events, such as serving as high school team physician, health fairs, and free clinics. Participate in faculty development curriculum through University of Arizona College of Medicine – Phoenix, such as faculty learning communities Serve as medical educator and mentor to rotating medical students in clinic, hospital, and community settings Volunteer for a resident national leadership position through organizations such as the American Academy of Family Physicians or Society of Teachers of Family Medicine Participate in Banner Health’s Advanced Leadership Program for Residents

Any Questions? Any questions?

References American Academy of Family Physicians Recommended Curriculum Guidelines for Family Medicine Residents Leadership. http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint292_Leadership.pdf Bohmer, R. Managing the new primary care: the new skills that will be needed. Health Affairs. Vol 29, issue 5; 1010–14. 2010. Blumenthal, D. et. al. Addressing the Leadership Gap in Medicine: Residents' Need for Systematic Leadership Development Training. Academic Medicine. Vol 87, issue 4; 513 – 522. 2012. Earnest MA, Wong SL, Federico SG. Physician advocacy: What is it and how do we do it? Acad Med. 2010;85:63–67. “Family Medicine Milestone Project.” The Accreditation Council for Graduate Medical Education and The American Board of Family Medicine. Sept, 2013. http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf Porter, ME. A strategy for health care reform — toward a value-based system. New England Journal of Medicine. Vol 361; 109–12. 2009. THANK YOU!