Preparing Final Clerkship Performance Evaluations A Guide for Clerkship Directors and Evaluation Teams 2013-4

Table of Contents Evaluation Criteria Data collection Interpreting evaluation data: Patient Care (RIME) Professionalism and Interpersonal Communication Final grades Narrative evaluations Appeals Resources and Contacts

Evaluation Criteria

Grades and MSPE reporting Students may earn a grade of Pass or Pass with Distinction in each of three domains: Patient Care Professionalism and Interpersonal Communication Final Exam Grades for each domain are reported separately in the MSPE The School of Medicine has roughly adopted the six-competency framework used by the ACGME. Medical Knowledge is represented by the final exam for each clerkship. Systems-Based Practice is built into Patient Care. Practice-Based Learning and Improvement is addressed as part of both Patient Care and Professionalism.

Criteria for Pass Patient Care: Direct observations of clinical skills complete (2 per clerkship) RIME Interpreter* Professionalism/Interpersonal Communication: No significant or consistent concerns Patient logs, other assignments complete Exam score above clerkship passing threshold *See the CBEI website for additional details on the RIME framework.

Criteria for Pass with Distinction All Passing criteria must be met AND Patient Care: RIME Manager Professionalism and Interpersonal Communication (IPC): Multisource feedback requested: 1 non-MD staff member, 1 patient, 1 peer Consistent evidence of both Exceptional Professionalism and IPC with patients AND members of the medical team Exam score above clerkship-specific threshold for Pass with Distinction

Data Collection

Data Collection Ideally 100% of potential evaluators will complete electronic evaluation forms in E*Value. within a week of an evaluation being assigned.

Data collection In reality The minimum acceptable return rate is 50%. Final evaluations must be submitted within 6 weeks of the end of the clerkship. Some evaluators will not want to use E*Value.

Recommendations Keep an eye on return rates – start reminding and re-requesting early. Clerkships may need to tailor approaches to data-gathering to suit the needs of different groups, sites, or individual evaluators

Recommendations Avoid going into an evaluation team review or submitting final evaluations with a return rate under 50%. Evaluations based on input from fewer than 50% of potential evaluators are unlikely to stand up in an appeal. All evaluators who submit information (residents, faculty, fellows, non-MD staff, peers) should be listed as Contributing Evaluators in the final evaluation form.

Data Collection For ideas, resources, and practical support in boosting evaluation return rates, contact Jen Deitz (jdeitz@stanford.edu) Gretchen Shawver (gshawver@stanford.edu) or Elizabeth Stuart (aestuart@stanford.edu)

Interpreting Evaluation Data: Patient Care (RIME)

Two paths to distinction Performance Threshold for Distinction Time Students may earn Pass with Distinction by meeting criteria throughout the clerkship OR improving to meet criteria by the end of the rotation

Core clerkship students are expected to be in the Interpreter stage. Expected Transitions MANAGER POM Core clerkship Sub-I Residency + INTERPRETER REPORTER Core clerkship students are expected to be in the Interpreter stage. See the CBEI website for additional details on the RIME framework.

Interpreting Data from Patient Care (RIME) forms For a student in the Interpreter stage: Nearly all evaluators will select Consistently True for items in the Reporter section. Data will include a mix of Sometimes and Consistently True for items in the Interpreter section.

Reporter Items

Interpreter Items

Alert If significant number of evaluators - throughout the rotation - have selected Sometimes or Rarely True on Reporting items – the student has not met expectations for performance in a core clerkship and should receive a non-passing grade. Clerkship directors should speak directly with individual evaluators to confirm that a student is not consistently demonstrating the skills required in the Reporter stage.

Pass with Distinction MANAGER POM Core clerkship Sub-I Residency + INTERPRETER REPORTER Pass with Distinction requires consistently strong Reporting and Interpreting (solid bars) with evidence of being in the transition to the Manager stage.

Interpreting Data from Patient Care (RIME) forms For a student in the Manager stage: Nearly all evaluators will select Consistently True for items in the Reporter and Interpreter sections. Data will include a mix of Sometimes and Consistently True for items in the Manager section.

Manager/Educator Items

Broadly Students in the Manager stage are functioning above the expected level – at the level of a sub-intern or beyond.

Q & A Q: Should core clerkship students really be expected to manage patient care?

Q & A: “Manager” A: The term Manager is not meant to imply independent implementation of patient care plans. Students who are Managers demonstrate a sense of personal responsibility for knowing as much as possible about their patients and ensuring that they receive optimal care. Managers see themselves – and are seen by others – as patients’ primary providers and advocates.

Q & A: M without I? Q: The evaluators for one of my students marked Consistently True for all of the Manager items, but only Sometimes True in the Interpreter section. Does the student meet criteria for being a RIME Manager?

Q &A: M without I? A: No. Pass with Distinction requires consistently strong Reporting and Interpreting skills in addition to the skills and attitudes represented by the Manager items on the evaluation form.

Q & A: Outliers Q: What if one evaluator checked Rarely or Sometimes True on an item – when all other evaluators marked Consistently True?

Q & A: Outliers A: When reviewing data for both Patient Care and Professionalism/Interpersonal Communication, Evaluation Teams should look for trends and themes - over time and across evaluators.

Outliers In sorting through outliers, consider: Role/identity of the evaluator Setting Time the evaluator spent with the student Timing during the rotation

Interpreting Evaluation Data: Professionalism and Interpersonal Communication (IPC)

Fundamentals of Professionalism and IPC

Interpreting data from the Professionalism/IPC form To Pass, there should be a consistent trend of meeting expectations, with no significant or consistent concerns.

Exceptional Professionalism/IPC

Interpreting data from the Professionalism/IPC form For Pass with Distinction, data from multiple evaluators should show a consistent trend of exceptional Professionalism AND Interpersonal Communication with BOTH patients and members of the medical team: “Yes” answers to the yes/no question Narrative examples of exceptional professionalism AND interpersonal communication

Multisource Feedback (MSF) To meet criteria for Pass with Distinction, students must request multisource feedback from 1 non-MD staff member 1 patient 1 peer A response by peers, non-MD staff, patients is not required. Clerkships must put systems in place to record students’ MSF requests.

Q & A: Multisource Feedback Q: What if a non-MD staff member reports concerns about professionalism? Does that disqualify the student for PWD? Q: What if a patient or non-MD staff member submits a glowing description of a student’s Interpersonal Communication? Shouldn’t that information count toward Pass with Distinction?

Q & A: Multisource Feedback A: For the initial phase of CBEI, the content of multisource feedback is not considered in determining whether a student has met criteria for Pass with Distinction Positive comments from MSF content may be used as examples in the final summative evaluation.

NEW: Multisource Feedback Anonymized multisource feedback comments should be included in the formative narrative section of the final evaluation. Updated for 2013-14

Final Grades

Final grade options As of July 2012 clerkships will enter one of the following final grades for each student: N - Continuing Fail Marginal Pass Pass Pass with Distinction will be recorded separately for each performance domain

N grade N is for failed exams. N should not be used routinely for: Marginal/non-passing performance in the domains of Patient Care or Professionalism/Interpersonal Communication Missed time from the clerkship Incomplete assignments Use Marginal Pass or suspend the evaluation if a student has not completed all clerkship requirements* Submit evaluations with N grades promptly – within 6 weeks of the end of the clerkship. Do not “hold” students’ evaluations while waiting for them to re-take exams. * The Division of Evaluation is working to add an Incomplete grade option.

See MD Program Handbook for additional details. More on N Use when… Consequences N All aspects of performance meet criteria for passing, but student does not pass the final exam. Should not be used for marginal or failing performance in any other domain. Except in case of emergency, failure to attend the final exam session without prior permission from the clerkship director will result in referral to the Committee on Performance, Professionalism and Promotion (CP3) for unprofessional behavior. Must retake exam After second failed attempt, student takes oral exam or suitable alternative, to be determined by the clerkship director. N grades must be corrected within 12 months of the end of the clerkship. See MD Program Handbook for additional details.

Q & A: N grade Q: I have a student who was admitted to the hospital with appendicitis the night before the shelf exam. Should I wait to submit his evaluation until he takes the exam?

Q & A: N grade A: No. The evaluation should be submitted with an N grade within 6 weeks of the end of the clerkship. Evaluations contain important information that should be made available promptly to students. Evaluation submission should not be delayed by failed or missed exams.

See MD Program Handbook for additional details. Marginal Pass vs. Fail Use when… Consequences MP Performance fails to meet criteria in one domain (other than exam). Mild concern about Patient Care or Professionalism/Interpersonal Communication Reviewed by CP3. Remediation plan to be determined by the clerkship director. 3 Marginal Passes in clerkships may be considered grounds for dismissal. F Performance fails to meet criteria in more than one domain. Significant concern about Patient care or Professionalism/Interpersonal Communication 2 Failing grades in clerkships may be considered grounds for dismissal See MD Program Handbook for additional details.

Q & A: Evaluation Review Shortcuts? Q: Does the full evaluation team need to review files for all students, or just those who seem likely to meet criteria for Pass with Distinction in one or more domains?

Q & A: Shortcuts? A: CBEI introduced not only a new grade to recognize exceptional performance, but also a new process to ensure a fair and balanced review for each student. All students should benefit from the process of a full review.

Q & A: Evaluator Lists Q: Does the final evaluation in E*Value need to list every individual evaluator by name?

A: All contributors should be listed individually, by name. Q & A: Evaluator Lists A: All contributors should be listed individually, by name. If there is concern about protecting the identity of an individual evaluator, the clerkship may opt to list the names of all evaluator who were asked to contribute to the final evaluation. Updated for 2013-14

Guidelines for Narratives Summative vs. Formative

Guidelines for Summative Narratives Summative narratives should be: 100-200 words long Framed as cohesive paragraphs (not lists of quotes) reflecting student performance in each of the key domains: Patient Care Medical Knowledge Professionalism and Interpersonal Communication

Formative vs. Summative Summative evaluation involves a final judgment and description of a student's performance during a clerkship.   Formative evaluation provides ideas and recommendations for further learning and improvement.

Formative vs. Summative: An Analogy A cook asks for an evaluation of his soup Adapted from Stanford School of Medicine Clerkship Evaluation Tutorial, 2006

Summative & Formative: Analogy Summative evaluation would answer the question: Formative evaluation would answer the question: How was the soup? What might be done to improve the soup? Yuck! Pretty good. Very tasty. A culinary masterpiece! Needs a little more salt. Heat it up a bit more. Some Tabasco would round out the flavor.

Formative vs. Summative Summative narratives submitted in E*Value are intended to be cut and pasted verbatim into the MSPE. Formative narratives are not included in the MSPE. Formative comments in E*Value are seen by: Students Advising Deans Members of the Committee on Performance, Professionalism, and Promotion (CP3). Members of the Clerkship Evaluations Committee

De-identified Individual Comments Comments from individual evaluators (MD, non-MD, patients, peers) may be included in the formative section of the final evaluation as long as the identity of the individual evaluator cannot be guessed by the reader.

Q & A: Formative vs. Summative Q: I had a student who did the most amazing physical exams but who had a very hard time organizing presentations. Should I put positive comments about his exams in the summative section and leave his difficulty with presentations for the formative section? from Stanford School of Medicine Clerkship Evaluation Tutorial, 2006

Q & A: Formative vs. Summative A: No. The summative narrative is intended to provide an honest, accurate, and complete description of a student’s performance during a given clerkship. Both "positive" and "negative” aspects of performance should be included.

Should I include…? “Negative” or less than glowing comments should be included in the summative section if they reflect: Significant or consistent trends in performance over time Features of performance that did not change despite mid-rotation feedback Characteristics of performance that should be known to potential residency programs

Q & A: CBEI Wording in Narratives Q: Should the summative narrative mention whether a student’s performance met criteria for Pass with Distinction in each domain?

Q & A: CBEI Wording in Narratives A: The authors of the MSPE will add information to each narrative to indicate whether a student’s performance met criteria for PWD in each domain. Clerkship directors do not need to specifically mention Pass with Distinction in the narrative. See the next slide for examples.

MSPE format

Q & A: Concerns Q: I have concerns about a student. He responded to mid-clerkship feedback and deserves to pass the rotation – but I worry that he will have difficulty in future rotations and beyond. Should I mention the concerns I had in the formative section?

Q & A: Concerns A: Yes. The Committee on Performance, Professionalism, and Promotion (CP3) relies on information in both the formative and summative narratives in monitoring student progress. Although formative comments are not included in the MSPE, they are helpful to CP3 as a formal documentation of concerns.

Concerns The final evaluation form includes a confidential question to allow clerkship directors to report concerns about student performance. These flags are viewed by Advising Deans, Educators for CARE faculty, and the Director of Clerkship Education. They serve as tool for identifying trends in student performance.. Confidential concerns are not seen by students and not reflected any where in the MSPE.

Resources For more information on narrative evaluations, including guidance as to whether information should be formative or summative and suggestions for framing “negative” ideas, contact: Jen Deitz (jdeitz@stanford.edu) Elizabeth Stuart (aestuart@stanford.edu)

Appeals

Appeals Some students will appeal their final clerkship grades and/or the content of their narrative evaluations.

See MD Program Handbook for additional details. Appeals According to the SOM policy on evaluation appeals, the process begins with a discussion between the student and the clerkship director or Advising Dean. Unresolved disagreements are referred to the Clerkship Evaluations Committee. See MD Program Handbook for additional details.

Appeals process The CEC will initially contact the appealing student and the clerkship director to discuss the evaluation in question. The CEC will then assemble a committee to review the student’s evaluation file to determine whether: the evaluation process was conducted fairly the final evaluation was based on sufficient information the final grade and narrative warrant revision.

Appeals process For an appeal to be considered, a written request made to the Division of Evaluation within eight weeks of the date that the final evaluation was submitted in E*Value.

Appeal ≠ Failure A request for an appeal does not constitute failure on the part of the clerkship evaluation team. Appeals provide an opportunity for learning and calibration. They serve an important function in achieving the broader goal of optimizing consistency in the evaluation across clerkships and sites.

Resources & Contacts For more information, see the CBEI website: http://med.stanford.edu/md/curriculum/CBEI/index.html Or contact: Elizabeth Stuart, MD, MSEd, Director of Clerkship Education aestuart@stanford.edu Jen Deitz, MA, Director of Evaluation jdeitz@stanford.edu Gretchen Shawver, Clerkship Coordinator gshawver@stanford.edu