Creating a Competency- informed Learning Environment Tina Foster MD, MPH Associate Program Director DHLPMR Dartmouth-Hitchcock Medical Center Lebanon, NH

What I Hope To Do Briefly describe the Dartmouth-Hitchcock Leadership Preventive Medicine residency Briefly describe the Dartmouth-Hitchcock Leadership Preventive Medicine residency Give some examples of things that feel innovative to residents, faculty, staff (and patients?) Give some examples of things that feel innovative to residents, faculty, staff (and patients?) Reflect on the learning environment(s) we are creating Reflect on the learning environment(s) we are creating

What is DHLPMR? Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program (DHLPMR) Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program (DHLPMR) Combined training in LPM and any other DHMC residency/fellowship Combined training in LPM and any other DHMC residency/fellowship First graduate in 2005 First graduate in 2005 Focus on the improvement of patient care Focus on the improvement of patient care

Why DHLPMR? To attract and develop physicians capable of leading the change and improvement of the systems where people and health care meet. In conjunction with existing clinical residency and fellowship programs, participants' academic, applied leadership and practicum experiences in preventive medicine will focus on measuring outcomes and improving the technical, service and cost excellence of care for patients and populations. To attract and develop physicians capable of leading the change and improvement of the systems where people and health care meet. In conjunction with existing clinical residency and fellowship programs, participants' academic, applied leadership and practicum experiences in preventive medicine will focus on measuring outcomes and improving the technical, service and cost excellence of care for patients and populations.

Another Way of Looking at It… Our residents Our residents Focus on a defined population of patients served by DHMC Focus on a defined population of patients served by DHMC Understand their outcomes and processes of care; identify opportunities for improvement Understand their outcomes and processes of care; identify opportunities for improvement Lead change for the improvement of care for these patients Lead change for the improvement of care for these patients Develop specific competencies Develop specific competencies

DHLPMR Core Competencies Leadership—including design and redesign—of small systems in health care. Leadership—including design and redesign—of small systems in health care. Measurement of illness burden in individuals and populations. Measurement of illness burden in individuals and populations. Measurement of the outcomes of health service interventions. Measurement of the outcomes of health service interventions. Leadership of change for improvement of quality, value and safety of health care of individuals and of populations. Leadership of change for improvement of quality, value and safety of health care of individuals and of populations. Reflection on personal professional practice & linkage of that reflection to ongoing personal and professional development. Reflection on personal professional practice & linkage of that reflection to ongoing personal and professional development.

Core Concept: The Clinical Microsystem Small group of doctors, nurses, other clinicians Small group of doctors, nurses, other clinicians Administrative and support staff Administrative and support staff Patients Patients Information and information technology Information and information technology Working together for common clinical and business aims Working together for common clinical and business aims Using shared information Using shared information Producing clinical outcomes Producing clinical outcomes

Which system is the unit of practice, intervention, measurement? Community, Market, Social Policy System Macro- organization System Microsystem Individual care-giver & patient System Self- care System

The Work: Science-based Improvement “Generalizable Scientific Evidence” + “Particular Context” “Measured Performance Improvement” control for context generalize across contexts sample design I understand system “particularities” learn structures, processes, patterns II balanced outcome measures III certainty of cause & effect shared importance IV strategy operations people V P. Batalden

Why Preventive Medicine? Populations Populations Measurement Measurement Systems Systems Leadership Leadership

Luxuries We Enjoyed… Able to design residency “from scratch” – building on PM program requirements and the idea of “competency-driven” GME Able to design residency “from scratch” – building on PM program requirements and the idea of “competency-driven” GME Deeply committed team with incredible experience, knowledge, skills Deeply committed team with incredible experience, knowledge, skills Time to develop a shared mental model of what “it” would look like Time to develop a shared mental model of what “it” would look like

Where Are We Now? Five graduates to date Five graduates to date Currently have nine first year and eight second year residents, plus three who have completed the first year Currently have nine first year and eight second year residents, plus three who have completed the first year Have combined with anesthesia, pain medicine, surgery, internal medicine, GI, ob-gyn, ID, pulmonary/critical care, family medicine, pathology, pediatrics, psychiatry Have combined with anesthesia, pain medicine, surgery, internal medicine, GI, ob-gyn, ID, pulmonary/critical care, family medicine, pathology, pediatrics, psychiatry DHLPMR has attracted applicants to DHMC GME programs DHLPMR has attracted applicants to DHMC GME programs

What Sorts of Things Do our Residents Do? Improve care for patients admitted with CAP Improve care for patients admitted with CAP Improve safety and efficiency of sedation for selected endoscopic procedures Improve safety and efficiency of sedation for selected endoscopic procedures Improve provision of screening services in GIM clinic Improve provision of screening services in GIM clinic Rapid Response Team implementation and outcomes Rapid Response Team implementation and outcomes Improve medication management for major depression Improve medication management for major depression Improve dx and tx of obesity in primary care clinic Improve dx and tx of obesity in primary care clinic Improve post-operative pain management Improve post-operative pain management Improve advance directive process Improve advance directive process Improve hand hygiene in perioperative areas Improve hand hygiene in perioperative areas

How Our Program is Different- the Residents All residents in combined training, all maintain presence in both programs All residents in combined training, all maintain presence in both programs No one is an intern No one is an intern Residents (and faculty) from a variety of specialties are working together and learning from each other Residents (and faculty) from a variety of specialties are working together and learning from each other

How Our Program is Different – the Learning Experience Residents design own learning experiences (with guidance and oversight) Residents design own learning experiences (with guidance and oversight) Residents generally manage their own time Residents generally manage their own time Faculty coaches and mentors—aided by a program of “coach development” Faculty coaches and mentors—aided by a program of “coach development” Clear expectation that residents will teach residents and faculty in their “home” programs Clear expectation that residents will teach residents and faculty in their “home” programs Program actively managed by a multidisciplinary team that works/meets every two weeks Program actively managed by a multidisciplinary team that works/meets every two weeks

How Our Program is Different – the Learning Environment Most work is inter-professional (doctors, nurses, clinic staff, medical records, administration, educators, care managers, etc…) Most work is inter-professional (doctors, nurses, clinic staff, medical records, administration, educators, care managers, etc…) Work is primarily microsystem-based – happens at the frontlines and involves many people as well as information and IT Work is primarily microsystem-based – happens at the frontlines and involves many people as well as information and IT

How Our Program is Different – Assessment and Accountability Explicit expectation that residents use web- based portfolio for reflection, evaluation, collecting evidence of their work Explicit expectation that residents use web- based portfolio for reflection, evaluation, collecting evidence of their work Practicum Review Board—composed of organizational leaders—provides guidance in development of Practicum year design, as well as institutional support Practicum Review Board—composed of organizational leaders—provides guidance in development of Practicum year design, as well as institutional support Nationally prominent residency advisory committee Nationally prominent residency advisory committee Clear expectation that residents will lead change and address sustainability of that change Clear expectation that residents will lead change and address sustainability of that change

Innovations Innovations Combining Preventive Medicine with a wide variety of other specialties Combining Preventive Medicine with a wide variety of other specialties Getting residents from different disciplines in the same room Getting residents from different disciplines in the same room Putting residents largely in charge of their own learning experiences Putting residents largely in charge of their own learning experiences

More... Residents develop different relationships with faculty, staff, others Residents develop different relationships with faculty, staff, others Residents begin to “see” the microsystems they work in, and bring their knowledge of how they “really” work Residents begin to “see” the microsystems they work in, and bring their knowledge of how they “really” work Attention to more than individual patient outcomes – residents love data! Attention to more than individual patient outcomes – residents love data!

More… Residents experience improvement of care as an integral aspect of provision of care Residents experience improvement of care as an integral aspect of provision of care Residents function as leaders Residents function as leaders Focus is NOT on the exceptional, but on important aspects of education and care that may seem mundane Focus is NOT on the exceptional, but on important aspects of education and care that may seem mundane

What is the Learning Environment? We often first think of “didactics” We often first think of “didactics” Then we might think about teaching on rounds, during procedures, etc Then we might think about teaching on rounds, during procedures, etc Eventually, we begin to think about the constant learning that goes on in GME – many teachers, many learners Eventually, we begin to think about the constant learning that goes on in GME – many teachers, many learners When does learning occur? And what learning are we talking about? When does learning occur? And what learning are we talking about?

What Residents Say: Some Characteristics of Good Learning Environments “Why” is clear “Why” is clear Opportunity to practice, apply learning Opportunity to practice, apply learning Immersion Immersion Dialogue, two-way communication Dialogue, two-way communication Helpful structure Helpful structure Respectful, safe Respectful, safe

Other Aspects Often feels good – but… Often feels good – but… Learning from mistakes is important Learning from mistakes is important Teaching is learning Teaching is learning “Embodiment” “Embodiment” A little anxiety may be a good thing? Finding the right degree of autonomy A little anxiety may be a good thing? Finding the right degree of autonomy

Environments for Learning Defined teaching and learning opportunities Defined teaching and learning opportunities Clinical care environment Clinical care environment Inner environment Inner environment

Preparing the “Inner” Learning Environment Desire to learn Desire to learn Curiosity Curiosity Sense of safety Sense of safety Ability to reflect and effectively use new knowledge Ability to reflect and effectively use new knowledge Sense that it matters Sense that it matters Potential for joy in learning/work Potential for joy in learning/work

DHLPMR and the “Inner” Learning Environment Residents (and faculty) asked to develop capacity for reflection Residents (and faculty) asked to develop capacity for reflection More time and space More time and space Opportunity for work in teams, groups – good way to learn about oneself Opportunity for work in teams, groups – good way to learn about oneself Knowing the work matters Knowing the work matters Feedback Feedback We often have a good time We often have a good time

Other DHLPMR Learning Environments Classroom experiences (MPH) and relationship to rotations/practicum Classroom experiences (MPH) and relationship to rotations/practicum Defined learning opportunities Defined learning opportunities Microsystems and learning Microsystems and learning Awareness of assumptions and what is being/has been learned Awareness of assumptions and what is being/has been learned Learning from patients and others Learning from patients and others Learning during all aspects of patient care Learning during all aspects of patient care

Supports for the DHLPMR Learning Environment Portfolio as a living record of work and a way to share Portfolio as a living record of work and a way to share Competencies and expected developmental “pathway” clearly spelled out and regularly reviewed Competencies and expected developmental “pathway” clearly spelled out and regularly reviewed Opportunities to practice new ways of working Opportunities to practice new ways of working Connections outside one’s own discipline Connections outside one’s own discipline Visibility and support – public acknowledgment that resident work MATTERS Visibility and support – public acknowledgment that resident work MATTERS

Innovation and Improvement in the Learning Environment Our residents’ work is really about CHANGING the learning environment Our residents’ work is really about CHANGING the learning environment Learning about particular microsystems Learning about particular microsystems Learning about our current processes of care and outcomes Learning about our current processes of care and outcomes Thinking about how to connect the best evidence to the work of microsystems Thinking about how to connect the best evidence to the work of microsystems Leading change within microsystems to improve those processes and outcomes Leading change within microsystems to improve those processes and outcomes Our work is really about supporting that change and continuing to understand what we are learning Our work is really about supporting that change and continuing to understand what we are learning

Competence in the Learning Environment Our work is really about assessing the competence of learners in an environment that exemplifies competence Our work is really about assessing the competence of learners in an environment that exemplifies competence AND a key component of learner competence is the ability to help create an increasingly competent environment for learning and patient care AND a key component of learner competence is the ability to help create an increasingly competent environment for learning and patient care