Shift Cards in the Resident Outpatient Clinic How to observe and provide real time feedback to residents- and inform your Clinical Competency Committee

Learning Objectives Describe the difficulty of obtaining resident observations in the outpatient clinic and ways in which residents receive feedback Describe how the Shift card can be used by the outpatient faculty to provide real time feedback Demonstrate how the Shift card can provide helpful information for CCC members Analyze how a Shift card can be an EPA with associated milestones Examine advantages of the Shift card from faculty, resident, and CCC perspective. Your learning objectives may differ but the card is still a useful modality for capturing data real time and providing immediate feedback. Seeing the card as an EPA with attached milestones is an important point. You can consider mentioning the card may have utility in reporting to the ACGME. It is important to make the point that the card can be helpful to all parties. It is to be emphasized that the card can help monitor a resident’s progression over time. The more cards completed will serve to give the resident, outpatient faculty, and ultimately the Clinical Competency Committee a good understanding of a resident’s development and growth.

Intended Shift Card Audience CCC members Program director Associate Program directors Core faculty members Outpatient clinic supervisory faculty

What is a Shift card? A simple and easy to use tool derived, in part, from Emergency Medicine. (Bandiera 2008) The card can: provide feedback to learners help faculty determine where a resident falls on the learning curve in their progression through residency based on selected milestones be acceptable to learners and faculty provide useful information for the CCC It is important to emphasize that the Shift card provides the CCC with useful outpatient data that can help guide its assessment of a resident and make suggestions for improvement over time.

Why was the Shift Card Created? Need for outpatient observations regarding residents Need for outpatient data for supervising clinic faculty to help gauge learning and development over time Need for outpatient information to feed to the CCC Your needs may be different and you can use this slide to discuss data you need to obtain. As per the previous slide, it is important to make the point that CCC members can use card data to help them determine growth/competence in the outpatient setting.

Shift Card as an EPA Utilizes milestones Applicable for all program sizes Helpful in following performance over time Potential use in reporting to ACGME This point needs emphasis as the CCC requires this information in its assessment and reporting mandates.

What does the Shift Card Look Like? It is a two-sided piece of paper that includes the resident’s name, date the card was completed and the preceptor’s name It includes selected milestones to be evaluated for a new problem/acute illness on one side. On the reverse it includes milestones for chronic disease management and preventative care On the bottom of both sides of the card is space to provide comments/specific case illustrations This slide could be eliminated as you can pass the card out at this point (or earlier) and describe it while the audience is looking at it. It is important to emphasize that comments/examples are extremely important. It is also important to make the point that the card does not have any numbers attached to any of the categories thus added comments are quite valuable.

Comments/specific cases/illustrations: Name of Resident: __________________________________ Date of Shift Card: _________________ Preceptor: ____________________ Milestones for new problem/acute illness Sub Competency Critical Deficiency Requires Direct Supervision Requires Indirect Supervision Ready for Unsupervised Practice Aspirational PC1- Gathers and Synthesizes essential and accurate information Inaccurate history and physical Incomplete history and physical skills or limited differential diagnosis Can use history, physical and other data to identify central clinical problems Hypothesis driven history and physical or appropriately prioritized differential diagnosis Obtains subtleties and recognizes unusual clinical presentations PC2/PC3-Develops and achieves comprehensive management plans/ Manages patients with progressive responsibility Inappropriate care plans or does not assume responsibility for patient management decisions Has difficulty developing care plan without assistance Develops appropriate care plans and/or recognizes urgent/emergent issues without preceptor assistance Can independently manage unusual acute problems or can modify plans based on changing clinical scenario Able to develop complete care plan even when faced with diagnostic uncertainty and uses cost conscious principles MK1/MK2 – Clinical knowledge/knowledge of diagnostic tests Does not have knowledge to care for patients Incomplete knowledge of common medical conditions or treatments Demonstrates knowledge of common medical conditions Demonstrates and applies knowledge of complex medical problems Demonstrates and applies knowledge of treatment or diagnosis of unusual medical problems PROF3 – responds to each patient’s unique characteristics (culture, gender, race, ethnicity, etc…) Unwilling to modify care plan for patient unique needs Requires assistance to modify care for patients unique needs Aware of patients unique needs and can modify care plan with minimal assistance Independently and appropriately modifies care plans to accommodate patients unique needs Role model s and teaches others (colleagues, care team) on unique needs for patients ICS1 – communicates effectively with patients and caregivers Makes no attempt to share decision making Needs help to develop a shared decision making with a patient even for straight forward concerns Can engage shared decision making for uncomplicated discussions, but might needs help for complicated problems Independently engages patients in shared decision making for complicated problems, including caregivers when appropriate. Role model of engaging patients in shared decision making, including caregivers, even in complicated and changing clinical situations. Shift card side 1 (new problem/acute illness); encouraging faculty to provides comments/examples is very helpful in evaluating performance over time Comments/specific cases/illustrations:

Shift card side 2 (chronic disease management and preventative care) Name of Resident: __________________________________ Date of Shift Card: ________ _ Preceptor: ____________________ Milestones for chronic disease management and preventative care Sub Competency Critical Deficiency Requires Direct Supervision Requires Indirect Supervision Ready for Unsupervised Practice Aspirational PC1- Gathers and Synthesizes essential and accurate information Inaccurate history, physical or data review Incomplete history and physical skills or does not review prior notes to understand purpose of visit Uses history, physical and chart review to make complete and prioritized problem list Efficiently uses history, physical and data review to appropriately prioritized problem list and minimize need for further testing Obtains subtleties and recognizes unusual clinical presentations PC2/PC3-Develops and achieves comprehensive management plans/ Manages patients with progressive responsibility Inappropriate or inaccurate care plans or does not assume responsibility for patient management decisions Has difficulty developing care plan without assistance Develops appropriate care plans for controlled problems without preceptor assistance Can independently manage complex patients with multiple uncontrolled chronic problems Able to independently develop complete care plan and coordinate care even when faced with complex social barriers to good care MK1/MK2 – Clinical knowledge/knowledge of diagnostic tests Does not have knowledge to care for patients Lacks knowledge of common clinical guidelines Demonstrates knowledge of common clinical guidelines Demonstrates and applies clinical guidelines and understands appropriate times to deviate from guidelines Demonstrates knowledge of latest literature that may not be yet included in guidelines but could influence care of the patient SBP1 – Works effectively with an interprofessional team(Nursing, social work, pharmacy, diabetes educators) Frustrates team members Does not know what team members are available or how they can help patients May need prompting from preceptor to utilize skills of other team members Independently engages team to maximize and efficiently deliver best care to patients Viewed as a leader of team care. Effectively and efficiently coordinates care even when away from the office. ICS1 – communicates effectively with patients and caregivers Makes no attempt to share decision making Needs help to develop a shared decision making with a patient even for straight forward concerns Can engage shared decision making for uncomplicated discussions, but might needs help for complicated problems Independently engages patients in shared decision making for complicated problems, including caregivers when appropriate. Role model of engaging patients in shared decision making, including caregivers, even in complicated and changing clinical situations. Shift card side 2 (chronic disease management and preventative care) Comments/specific cases/illustrations:

Shift Card Completion Have the small groups observe selected videos SBIRT: HTN case (published 2013 on YouTube) The Value of Non Physician Observations in Resident Assessment: Outpatient Case (1:11-2:34, published 2014 on YouTube) The Shift card is then completed using both sides - one side for each video Resident to patient - acute problem Resident to attending - chronic problem The entire card does not have to be completed - only the observed milestones You can consider using standardized patients or create your own videos. The first case involves a hypertensive patient with the added somewhat more acute problem of excess alcohol intake. The second involves Diabetes management in a more chronic context. The entire card does not have to be completed - only what you observe. In time, with other cards being completed by the same or other observers, a more complete picture can emerge.

Debrief with the Group What worked? What didn’t work? Here you can learn more about the card in an effort to change things if needed. Getting the perspective of outpatient faculty, core program leaders, and CCC members can help you tweak things, look at other milestones, for ex.

Positive Aspects of a Shift Card It allows for a snapshot of clinical performance over time and in real time It eliminates the need for faculty to recall a resident’s performance over time-in some cases perhaps six months prior Unlike the mini-CEX, the Shift card was developed during the NAS era and incorporates reporting milestones Again, the use of the card is helpful as it incorporated milestones. You can use time here if needed to compare/contrast the mini-CEX and the Shift card.

Shift Card Beneficiaries Residents - feedback is given in real time which can impact future performance on the path to competence Outpatient faculty - cards completed over time can be used to follow resident progress CCC members - the card provides information about outpatient milestones and growth Obtaining this information is needed on an ongoing basis. Multiple parties can benefit with the use of such a simple tool.

Shift Card as a Tool PROS ✔ “Real-time” direct observation Lots of performance sampling Uses EPAs/Milestones Easy to use Immediate feedback for residents and data for CCCs CONS  Feasibility issues depending on program resources/size Reporting milestones may not be “granular enough” No validity data yet You might choose to eliminate this slide or discuss it briefly. The PROS are the key points to be made. While validity data may be somewhat lacking, the card may provide all parties with useful information that previously was not being obtained. It is anticipated the card will soon be validated.

With newer technologies, you can explore paperless modalities Action Plan Other milestones to be addressed may lead to more Shift card(s) being developed With newer technologies, you can explore paperless modalities You can use this slide to think toward the future—there may be innovations that the group will come up with that can lead to a more robust tool

References Bandiera G, Lendrum D. Daily encounter cards facilitate competency-based feedback while leniency bias persists. CJEM 2008 Jan Vol 10 (1):44-50   SBIRT: HTN Case-average medical resident example (May 21, 2013) retrieved from https//www.youtube.com/watch?v=NAHJRdKY4dI The Value of Non Physician Observations in Resident Assessment: Outpatient Case (Sept. 28, 2014) retrieved from https//www.youtube.com/watch?v=1N3muSELSeE