10 th Annual Program Directors Retreat Program Director and Coordinator Faculty Development

Welcome

What was LLU named between 1915 and 1963? A.American Medical Missionary College B.Burden Memorial College C.College of Medical Evangelists D.Mound City College

College of Medical Evangelists »Medical ~Medical Knowledge ~Patient Care ~Problem-based Learning and Improvement »College ~Interpersonal and Communication Skills ~Systems-based Practice »Evangelists ~ Professionalism ~Global and Local

GME 2013

Graduate Medical Education Business Model »Hertz hires and trains workers »At the end of training, 80% of them will go to work for competitors

Graduate Medical Education is Inherently a Community Benefit »Among MD’s practicing in San Bernardino County ~One third did their residency at LLUMC ~Half trained or teach (or both) at LLU.

Business of Medical Education »UME is profitable to very profitable ~Hence, there has been a steep increase in the numbers of medical school seats being offered in LCME, AOA and off-shore medical schools. »GME costs teaching hospitals to break even ~Hence, no significant increase in the numbers of PGY-1 positions since 1996.

Shortage of PGY-1 Positions

What Happens When Noticeable Numbers of LCME Graduates Cannot Get a PGY-1 Position?

Next Accreditation System Safe Care for Current and Future Patients

N ext A ccreditation S ystem: 2 Parts »C LER visits »Patient Safety »Supervision »Quality & Disparities in Healthcare »Transitions »Supervision »Duty Hours »Professionalism » A nnual Reports »Attrition »Changes »Scholarly Activity »Board Pass Rate »Clinical Experience »Resident Survey »Faculty Survey »Milestones

NAS: “Continuous accreditation model” »Annual review of the following performance indicators: ~1) Program Attrition ~2) Program Changes ~3) Scholarly Activity ~4) Board Pass Rate ~5) Clinical Experience ~6) Resident Survey ~7) Faculty Survey ~8) Milestones ~9) CLER site visit data »Collected now as part of the program’s annual ADS update. »ADS streamlined this year: 33 fewer questions & more multiple choice or Y/N »Collected now as part of annual administration of survey »Boards pass rates provide annually

1. Program Attrition »General Definition: Composite variable that measures the degree of personnel and trainee change within the program. »How measured: Has the program experienced any of the following: ~Change in PD? ~Decrease in core faculty? ~Residents withdraw/transfer/dismissed? ~Change in Chair? ~DIO Change? ~CEO Change?

2. Program Changes »General Definition: Composite variable that measures the degree of structural changes to the program. »How measured: Has the program experienced any of the following: ~Participating sites added or removed? ~Resident complement changes? ~Block diagram changes? ~Major structural change? ~Sponsorship change? ~GMEC reporting structural change?

3. Faculty & Resident Scholarly Activity »General Definition: Indicator that measures scholarly productivity within a program for faculty and for learners. »ACGME will eliminate faculty CVs and replace them with a new “table” to collect scholarly activity information. ~Primarily text that is not quantifiable ~Currently used by RC only at time of site visit ~Takes up significant amounts of space ACGME database ~35% of support calls related to faculty CVs »Expectations for faculty and learners w/ regard to scholarly activity will be different for core and subspecialty programs.

4. Board Pass Rate

5. Clinical Experience Data »Graduate Survey to final-year residents OR »Case Logs

»How well prepared are you to perform procedures without supervision? ~List from PRs »How well prepared are you to perform patient care activities without supervision? ~HCM, Newborns, Acute illness, Resus/Stabilize/Triage, Behavior/Mental Health »How satisfied are you with the patient volume, range of patient ages, variety of medical conditions, and extent of progressive responsibility in the care of patients? »How satisfied are you with the educational experiences to help you achieve competency in patient care skills? ~PC tracked sub-competencies »How satisfied are you with aspects of your longitudinal outpatient experience? »Are you well prepared to competently practice general pediatrics?

6. Resident Survey »Administered annually Jan-May »Questions on RS relate to 7 areas: ~Duty Hours ~Faculty ~Evaluation ~Educational Content ~Resources ~Patient Safety ~Teamwork

7. Faculty Survey »“Core” faculty only because they are most knowledgeable about the program ~dedicate an average of 15 hours/week ~trained in the evaluation and assessment of the competencies; ~spend significant time in the evaluation of the residents ~advise residents w/ respect to career and educational goals »Similar domains as the Resident Survey »Will be administered at same time as Resident Survey »Start in winter-spring 2013 for for Phase 1

8. Milestones »Competency Committees determine when residents reach specialty- determined milestones and the program reports this on WebADS

Two New Committees (2014) »Clinical Competency Committee (CCC) »PD Appoints 3 + Faculty +/- Residents »Focused on Individual Residents attainment of milestones »Advises PD (Milestone data sent to ACGME) »Program Evaluation Committee (PEC) »PD appoints 3 + Faculty and Residents »Focused on Residency Program improvement »Produces Annual Program Evaluation (APE) for GMEC

9. CLER »Every 18 month visit by a team of surveyors assessing the quality and educational environment of the sponsoring institution. ~Patient Safety ~Quality Improvement ~Transitions in Care ~Supervision ~Duty Hours/Fatigue ~Professionalism

Agenda »Morning: ~CCC »Afternoon ~Milestone Management ~PEC ~CLER

On a CLER day, you can see...

Clinical Learning Environment Review (CLER) »10-14 days advanced notice »CEO and DIO Must attend both initial and exit meetings »Option to pass on first scheduling attempt

5 Key Questions »Who and what form the hospital’s infrastructure designed to address the focus areas? »How integrated is the GME leadership and faculty in hospital efforts across the focus areas? »How engaged are the residents? »How does the hospital determine the success of its efforts to integrate GME into the focus areas? »What the are areas the hospital has identified for improvement?

Guess Who Is Coming? »ACGME CLER Regional VP(s) ~Tend to be former DIO’s ~Western region has not been hired yet »CLER Field Staff ~Tend to be former PDs »Volunteer Staff (4+) ~Current PDs, Patient Safety Officers, DIO’s, etc.

Schedule »Monday – visit team travels to site and meet in the evening »Tuesday – Initial visit with: ~CEO (required) ~DIO (required) ~CMO ~CNO ~CFO, COO and Dean of SOM (optional, but helpful)

“Walking Rounds” »Resident guides from different programs ~Preferably senior residents from core programs ~Not in other meetings »Guides should be comfortable navigating the site visitors to all areas »No preparation necessary »During visit may need to adjust timing of end and start of daytime walking rounds by minutes

Schedule »Patient Safety Interview ~Patient Safety Officer ~Outcomes Specialist ~Performance Improvement »Program Directors, Faculty and Residents ~Assorted individuals from various programs ~Visit team will provide guidance »Exit Conference with CEO and DIO (Wednesday)

Stated Goals »Aha’s! Experiences that inform learning »Guides for voluntary improvement efforts »A progressive set of activities for higher performance in organizational engagement in GME »A basis for empiric understanding of what is possible »Indications of areas ripe for future work »Not intended to provide: ~Gotcha’s ~New stealth accreditation requirements

PREPAREDNESS ASSESSMENT In you program, how well will senior residents consider the six elements have been met?

Supervision »Direct supervision – attending or senior resident at elbow »Indirect supervision with direct supervision immediately available – attending or senior resident in the same institution »Indirect supervision with direct supervision NOT immediately available (i.e. telephone back up) »Retrospective Review – “I’ll see you in the morning.”

Faculty & Residents recognize supervision is: A.Always direct B.Always at least immediately available C.Sometimes by phone, but readily available D.Sometimes retrospective review

Faculty & Residents recognize transitions in care process A.Standardized format and time, monitored frequently B.Assessed by supervisor intermittently C.Residents assess each other in 360 evaluations D.We’re too busy

Fatigue Education A.Supervisors send fatigued residents home enough to be noticed B.We have a lecture/video annually C.We’re too busy

A typical senior resident would say about Patient Safety A.I have been part of an institutional project B.I have done a Patient Safety project in the department C.We review data in M&M/QI Committee D.I get yelled at during M&M if anything goes wrong.

What percentage of your residents inaccurately report duty hours A.None (<5%) B.5 to 25% C.25-50% D.50-75% E.Over 75%

How would a typical senior resident view health disparities? A.I changed care patterns B.I have done a health disparities study C.I see lots of medically underserved patients D.What’s health disparities?

Quality Improvement 1.“I conducted a QI project looking at immunizations for my clinic patients last week/month.” 2.“I am working on a ‘class’ project, my role is limited to designing a short data collection form” 3.“I am working with a hospital quality improvement team to help standardize discharge planning to reduce readmissions” 4.“If I see a problem in care I report it to my department chair and he fixes it” 5.“I do not have time for that quality stuff”

A typical senior resident involvement in Quality Improvement: A.“Conducted a QI project in department.” B.“Role in a class project” C.“Working on institution QI team.” D.“Report problems to Chair.” E.“No time for QI”