Conflict of Interest Kim Walker – No conflicts of interest to disclose Ann Dohn – No conflicts of interest to disclose Nancy Piro – No conflicts of interest to disclose

PC002c Coordinators and Clinical Competency Committees: How to Streamline and Support the Work of your Program’s CCC Kim Walker, PhD Program Manager/Education Specialist Ann Dohn, MA DIO & GME Director Nancy Piro, PhD

Session Outcomes Participants will be able to: Identify new aspects of the coordinators’ evolving role in program administration. Understand and use program requirements as a guide for planning, organizing and implementing educational and assessment tools. Develop and utilize a newly developed comprehensive resident performance profile tool to streamline the work of the CCCs.  

New Role

Evolving Role for Coordinators in Evaluations Education & Evaluation Coordinator/Manager Extraordinaire Administrator Scheduler Supreme Constructing new milestone evaluations to pilot/deliver Reviewing evaluation completion data for accuracy Aggregating data for the CCC from multiple sources and forms Milestone data to ACGME Deliver evaluations Develop evaluation forms for PDs to approve Schedule semi annual evaluations Ensure summative evaluations completed and filed

Now I’m really confused! Outcomes Evaluations CCCs EPAs Clarify and briefly define, especially the different between EPAs and milestones. Milestones Goals and Objectives

Where do I begin?

Know the NAS Building Blocks: Concepts defined Core Competencies Milestones EPAs Curriculum and Evaluations Clinical Competency Committee (CCC)

NAS – Next Accreditation System What is NAS – in a nutshell: “an outcomes-based accreditation process through which the doctors of tomorrow will be measured for their competency in performing the essential tasks necessary for clinical practice in the 21st century.” http://www.acgme.org/acgmeweb/tabid/435/ProgramandInstitutionalAccreditation/NextAccreditationSystem.aspx

Major Changes: Accreditation based on… Pre-NAS Competencies Site Visits – Up to 5+ year cycles Internal Reviews ADS Updates PIFs Resident Surveys Current (New) NAS Competencies with Milestones Self-Studies at ~ 8-10 year intervals Detailed ADS Updates CLER Visits ~ 18 – 24 months (Institution) Resident & Faculty Surveys

The New Accreditation System (NAS)… Outcomes Increased Annual reporting by Programs (online) Reduced volume of accreditation demands … but increased attention to accuracy and completeness of information submitted online PIF-less Surveyor visits (unless new application) Two Field Surveyors per visit No Faculty CVs (only PD)….but Faculty & Resident Scholarly Activity required.

The Six AGME Core Competencies Patient Care Interpersonal & Communication Skills Medical Knowledge Six Core Competencies For Quality Patient Care Practice-based Learning & Improvement Need to redo- Should be PBL&I Professionalism Systems-based Practice

What Are Milestones? High Level - Milestones are simply defined as areas of competency/expectations for our trainees Linked to six core competencies Defined as a continuum of progressive growth/learning Advanced Beginner PGY-1 Competent PGY-2 and 3 Proficient Practitioner PGY-4/5 Expert Practitioner - Ongoing Each trainee assessed with respect to level for each competency

Dreyfus Model (1980): Stages of developing expertise Source: Eraut, M. Developing Professional Knowledge and Competencies. (1994)

Milestone Level Definitions Level 1: The resident is a graduating medical student/experiencing first day of residency. Level 2: The resident is advancing and demonstrating additional milestones. Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates the majority of milestones targeted for residency.

Milestone Level Definitions (continued) Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target – not requirement. Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.

Reporting the Milestones V.A.1.b).(1).(b) prepare and assure the reporting of Milestones evaluations of each resident semi-annually to ACGME (Core) Milestones are reported directly through ADS Reporting windows are: November 1- December 31 May 1- June 15

Entrustable Professional Activities (EPA) Professional life activities that define a medical specialty: Ground the competencies in a physician’s everyday work Activities lead to some outcome that can be observed Complexity of the activities requires an integration of knowledge, skills and attitudes across competency domains How EPAs Relate to Milestones Situates competencies in the clinical, authentic context in which they are demonstrated Aligns what is assessed with what physicians really do in the realm of patient care Adds meaning to assessment by focusing on integration of competencies in care delivery

Examples of EPAs Facilitate handovers to another healthcare provider either within or across settings Contribute to the scholarly work of the subspecialty Co-manage patients with generalists and other subspecialists Source: https://www.abp.org/abpwebsite/taskforce/reslib/24.ppt

Curriculum: Rotation-specific goals and objectives & links to milestones

Milestones Impact on Evaluations: Linking questions to milestones Step Two: Ensure specific evaluation questions are linked to milestones Advises the referring health care provider(s) about the appropriateness of a procedure in routine clinical situations

Milestones Impact on Evaluation System Allows for more objective methods of assessment and provide better feedback Provides a process for early identification of residents that are having difficulties All old and new evaluations and questions should be aligned with and tracked to milestones

Clinical Competency Committee (CCC) V.A.1. The program director must appoint the Clinical Competency Committee.(Core) V.A.1.a) At a minimum the Clinical Competency Committee must be composed of three members of the program faculty.(Core) V.A.1.a).(1) Others eligible for appointment to the committee include faculty from other programs and non- physician members of the health care team.(Detail) ACGME Common Program Requirements Approved: February 7, 2012; Effective: July 1, 2013 Approved focused revision: June 9, 2013; Effective: July 1, 2013

Clinical Competency Committee (CCC) V.A.1.b).(1) The Clinical Competency Committee should: V.A.1.b).(1).(a) review all resident evaluations semi- annually; (Core) V.A.1.b).(1).(b) prepare and assure the reporting of Milestones evaluations of each resident semi-annually to ACGME; and, (Core) V.A.1.b).(1).(c) advise the program director regarding resident progress, including promotion, remediation, and dismissal.(Detail)

Clinical Competency Committee (CCC) V.A.1.b) There must be a written description of the responsibilities of the Clinical Competency Committee.(Core) The reason for a required written description is so that every participant knows what his or her responsibility is to the CCC, and to ensure a fair process that all the members and the program director agree to follow. The responsibilities may go beyond what is listed in the ACGME Program Requirements. For some programs, the CCC will also be the Curriculum Committee or the Program Evaluation Committee, or may exist with a different name with additional responsibilities. ACGME Common Program Requirements Approved: February 7, 2012; Effective: July 1, 2013 Approved focused revision: June 9, 2013; Effective: July 1, 2013

Clinical Competency Committee (CCC): Written description

Clinical Competency Committee (CCC) How the CCC does its work can be decided by the Program Director Subcommittees Assigning residents to faculty members for pre-review Pre-review work will vary Scheduling and frequency of meetings Advisory to Program Director Does not vote Confidential Assessment of all residents Data provided includes summary evaluations plus resident self-assessment Provide narrative to PD

What Should a CCC Do First? Understand their specialty Milestones (Posted on acgme.org) Decide how to assess the Milestones – Program Evaluation Strategy If necessary, identify new evaluation tools from program director associations, societies, colleges

NAS and Milestones and YOU The program coordinator will play a crucial role in developing, implementing, collecting data on and reporting of milestone evaluation tools. You are a big part of the equation in how you are able to support your program’s mission at all levels… many balls to juggles requires many hands, many minds. You are the “coordinator” of it all!!!

Managing it all…

U - R - IT! Understanding RRC program requirements Requirements applied to evaluation methods/process Implementing new evaluation system Tracking completion and accuracy (outliers) for data aggregation

1. Understand Your Program’s New Requirements Core Outcomes Details

1. Understand Your Program’s New Requirements Each standard/requirement is categorized: Outcome - All programs must adhere Core - All programs must adhere Detail – Considered mandatory for new programs and those that fail to meet core requirements. Allows high-performing programs to innovate. The focus in the NAS is on educational outcomes. The common and specialty programs requirements were categorized, with the expectation that programs that demonstrate good educational outcomes will not be assessed for compliance with the “detail” requirements. “Detail” requirements will be considered mandatory for new programs and for programs that have failed to meet expectations for outcomes (and have an accreditation status of “Probation” or “Continued Accreditation with Warning”), and are intended to offer these programs added guidance.   Allowing high-performing programs the freedom to meet the detailed requirements with alternatives will provide such programs the opportunity to innovate. From : ACGME – NAS FAQs Source: Implementing The Next Accreditation System ACGME Webinar John R. Potts, III, M.D.: 4 November 2013

1. Understand Your Program’s New Requirements Example Program Requirement: VI.B. Transitions of Care (Core) (Core) (Outcome)

1. Understand Your Program’s New Requirements Example Program Requirement: VI.B. Transitions of Care When core and outcome not in compliance, then: Details

U - R - IT! Understanding RRC program requirements Requirements applied to evaluation methods/process Linking milestones/EPAs and objectives to evaluation questions Utilizing milestone scales Implementing new evaluation system Tracking completion and accuracy (outliers) for data aggregation

2. Requirements Specific to CCC Review of Trainee Aggregating/compiling multiple evaluations of individual trainees (V.A.1. Formative Evaluation) Tracking trainee participation in conferences, journal clubs, didactics (IV.A.3. Didactic Sessions) Monitoring duty hour compliance (VI.G. Duty Hours) Reviewing involvement in quality improvement and patient safety activities (IV.A.5.c. PBLI) Reviewing scholarly work (IV.B. Scholarly Work) Monitoring and reporting procedure logs (IV.A.5.a)

U - R - IT! Understanding RRC program requirements Requirements applied to evaluation methods/process Linking milestones/EPAs and objectives to evaluation questions Utilizing milestone scales Implementing new evaluation system Tracking completion and accuracy (outliers) for data aggregation

3. Implementing Evaluation systems Milestone-based/EPAs Rotation-specific Patient handovers Define evaluator groups (faculty, staff, patients) Set up and timing of delivery systems

3. Implementing Documentation and reporting systems for: Conference attendance Scholarly work (Learning Portfolios) Quality Improvement and Patient Safety (Learning Portfolios / Safety reporting systems) Duty Hours (recording, monitoring, reporting) Case Logging (if applicable)

U - R - IT! Understanding RRC program requirements Requirements applied to evaluation methods/process Linking milestones/EPAs and objectives to evaluation questions Utilizing milestone scales Implementing new evaluation system Tracking completion and accuracy (outliers) for data aggregation

4. Tracking and Reporting… Start with the end in mind: CCC biannual reporting windows to ACGME November 1- December 31 / May 1 - June 15 Back track and set calendar events for: Periodic monitoring of evaluation completion Running aggregate reports and reviewing milestone evaluation data Reviewing case logs, learning portfolios, duty hours

Pulling the Data Together Quality Improvement Activities In-service training exams Clinical Competency Committee End-of-Rotation Evaluations Safety Incident Reports Case Logs Patient/ Family Evaluations Clinical Skills Assessment Nursing and Staff / Techs Evaluations Progress on Milestones Sim Lab

Managing it all: How will I pull this off?

The Toolbox

Creating a Resident Performance Profile Goals to support your CCC Resident performance data that is: Comprehensive Consolidated / Aggregated Easy for CCC to identify strengths, areas for improvement, opportunities for advancement

Creating a Resident Performance Profile: Compiling and centralizing data Complete with auto-fill colors

Creating a Resident Performance Profile: Apply visual formatting for trends Complete with auto-fill colors

Creating a Resident Performance Profile Step 1 – Defining what to track

Creating a Resident Performance Profile Step 1 – Defining what to track

Creating a Resident Performance Profile Step 1 – Defining what to track

Creating a Resident Performance Profile Step 1 – Defining what to track

Creating a Resident Performance Profile Step 1 – Defining what to track

Creating a Resident Performance Profile Step 1 – Defining what to track

Creating a Resident Performance Profile Step 2 - Link data sources to milestones

Creating a Resident Performance Profile Step 3: CCC defines performance ranges Example: For all aggregate milestone evaluation scores for a PGY 3, the CCC has defined these ranges by PGY level in advance of the meeting: At or Above Expectation: 2.8 and higher Below Expectation: 1.7 – 2.7 Remediation: Below 1.7 Conditional formatting is a super helpful tool to use for visually presenting color coded data that “at a glance” can provide a general trend over a residents’ progress. STRENGTH WATCH AT RISK

Creating a Resident Performance Profile Step 4 – Set conditional formatting Conditional formatting is a super helpful tool to use for visually presenting color coded data that “at a glance” can provide a general trend over a residents’ progress.

Creating a Resident Performance Profile Step 4 – Set conditional formatting Example: Aggregate milestone evaluation data cells Conditional formatting is a super helpful tool to use for visually presenting color coded data that “at a glance” can provide a general trend over a residents’ progress. Highlight cells to apply the conditional formatting

Creating a Resident Performance Profile Step 4 – Set conditional formatting Set Ranges: > , < , between

Creating a Resident Performance Profile Step 4 – Set conditional formatting Select, “Greater Than” “Less Than” or “Between” to Set Value Ranges Choose the corresponding fill color (e.g., red, yellow, green) Conditional formatting is a super helpful tool to use for visually presenting color coded data that “at a glance” can provide a general trend over a residents’ progress.

Resident Performance Profile: Step 5: Enter in data Complete with auto-fill colors

Creating a Resident Performance Profile Visual trends and detailed data Complete with auto-fill colors

More tools…

Leveraging Resident Management System (RMS)Tools, if Available RMSs – becoming more feature rich Curriculum Goals and Objectives and learning outcomes by rotation Teaching and Assessment methodologies Evaluation tool development Sharing between programs and institutions

Leveraging Resident Management System (RMS)Tools, if Available Conference attendance statistics Core competencies linked to specified conferences Attaching conference materials for later reference Procedures and levels; linked procedure evaluations

Leveraging Resident Management System (RMS)Tools, if Available Resident portfolio tools QI participation and outcomes Scholarly Activity logs

Leveraging Resident Management System (RMS)Tools, if Available Aggregate reporting and graphic summaries Peer or departmental average, individual average, minimum and maximum scores, standard deviation or listing of all scores

Leveraging Calendaring and Task Management Software Set “data gathering and reporting” appointments with yourself Remember to start with the end in mind (e.g., CCC meeting dates) Break down large tasks into smaller tasks to keep it manageable

Leveraging Calendaring and Task Management Software

Learning through Experience

When a CCC Meeting… Does go well Doesn’t go well Data complete organized accurate Cooperative, collaborative decision making Efficient use of time Sound valid conclusions aligned with data Data not complete not organized not accurate PD or faculty member dominates meeting Prolonged inefficient decision making with inability to gain consensus Unsubstantiated/unreliable conclusions

Successful Resident Ranking PGY1- 4: Ready to graduate

PGY 1 Ranked at Graduation Level Milestone range for a PGY1 should not be a 4.0, 4.5 or 5.0 … 1 ?

Improvement evident

We Should not be at this Point Tracker can avoid this situation – PGY 7 being passed along although aggregate scores show areas for concern.

Beyond data…Creating a climate of CCC Success Gentle Words of Wisdom Tight efficient meetings Ground Rules Beware of Negative Group Think Schedule firm standing meeting dates in advance Reserve room of appropriate size with required audio-visual tools if needed …..and have snacks

Use Technology to Your Advantage… You can be a ‘Rock Star’

Session Recap in a Nutshell… Know your program requirements and follow them unconditionally Use simple spreadsheet, calendaring and task organizational tools to manage, track and present resident performance data to your CCC Resident education is a cyclical process – revisit and revise tools and processes each year

Questions

Contacts Kim Walker - kwalker5@stanford.edu Ann Dohn - adohn1@stanford.edu Nancy Piro - npiro@stanford.edu