Titi Savitri Quality Improvement at Gadjah Mada University School of Medicine Curriculum Team Gadjah Mada University School of Medicine 17 June 2005

Titi Savitri Faculty of Medicine GMU

Implementation of PBL at GMU School of Medicine  : Community Oriented Medical Education Programme – 13 Credits from year 1-year 6  : - Hybrid PBL (20% of total Credits) - 8 PBL Symptom-based Modules for 8 Semester (pain, icterus, fever, shock, etc)

QUE Project ( ) Evaluation Results  Internal Evaluation by Ad Hoc Teams: - Tutorial discussions need to be improved - Students rely on lectures  External Evaluation by Dr. Roger Barton from New Castle University UK: - Incomplete integration - Overburdened academic staffs - Need a QA system

Follow up  Implementation of FULL INTEGRATED CURRICULUM using BLOCK System starting in 2002/2003  Using KIPDI II as the main reference to determine contents and instructional objectives  Educational Strategy: Problem-Based Learning and Lecture-Based (60-70% of total hours)

PBL Curiculum – Block/Integrated‘02/’03 knowledge skill YEAR INTERNSHIP MD/Bsc. Med MD/GP licenced

Skills Lab Curriculum 1992-now Block 1: Interpersonal Communication, Microscope Block 2: Basic Physical Diagnostic, Anthropometri Block 3: Vital sign, bandage Block 4: Lumbar Function, Aseptic Technique Block 5: Health survey, Health Promotion Block 6: Intravenous injection, Resuscitation Block 7: Denver Test, Neonatal Resuscitation Block 8: Anamnesis, Blood Smear Block 9: ENT Examination, Heteroanamnesis Block 10: Neurology examination, orthopedic examination

Skills Lab Curriculum 1992-now  Block 11: Abdominal examination, counseling  Block 12: Thorax examination, electrocardiography  Block 13: Simulated patient (anamnesis, vital sign, thorax, abdomen,blood pressure)  Block 14: Pediatrics physical exam, minor surgery  Block 15: Physiotherapy, Ascites and Cathether  Block 16: Complete physical examination, IUD insertion  Block 17: Gynaecology exam, baby delivery  Block 18: Diagnosis, Mental statement  Block 19: Eye examination, communication on sensitive case  Block 20: Simulated patient, MEQ 3-Clinical Reasoning  Block 21: CPR (ET), simulated patient (Cs 4-6)  Block 22: Paediatric life support, message and mission

Follow Up: QA System in Place Dean Vice Dean for Academic Affairs Education Committee: Curr, Ass, Tutorial, Manual Procedure Year Coordinators I-IV Block Teams I-XXII Coordinator For Clinical Rotation Clinical Coordinator 11 Depts Coord K3M Academic Audit Team

Principles of QA  Self-Evaluation by Vice Dean for Academic Affairs, Year Coordination Teams, and Block Teams  Independent Internal Evaluation by Academic Audit Team  External Evaluation by International Experts  Improvement based on evaluation by Vice Dean for Academic Affairs, Year Coordination Team, and Block Teams

Evaluation of Curriculum 2002  Internal Evaluation: Major problems in assessment, lectures (60-70%), tutorial discussions, PBL management, learning resources, clinical teaching, skills lab curriculum unmatched with block themes, contents of blocks determined by departments Caused by Incomprehensive Planning

Evaluation of Curriculum 2002  External Evaluation by Prof Arie Kruseman and Prof Albert Scherpbier from Maastricht Medical School (Feb 2004): Hybrid curriculum of lecture-based, subject-based and problem- based learning Organisation rather traditional and naturalistic and not in line with educational philosophy of student-centred (SCL) and problem-based learning (PBL) Responsibilities of staff in strategic and operational tasks unclear Learning objectives in curriculum outline and block books to detailed and directive

Evaluation of Curriculum 2002 External Evaluation by Prof Arie Kruseman and Prof Albert Scherpbier from Maastricht Medical School (Feb 2004):  Student evaluation focus on lectures, lecture notes and structured learning objectives mentioned in the block books  Skills lab is not an official unit with staff  Majority of staff not trained in concepts and objectives of SCL and PBL. Majority of students are also not aware of these objectives and educational power of tutorials  Programme too overloaded with (introductory) lectures, not enough time in programme for self-study  Majority of textbooks in library outdated[1]  Not enough computer facilities, no free access to internet [1]

May Follow up the Evaluation  Decision for Minor Revisions -continuous: assesment, tutorial discussions, learning resources, quality of blocks, clinical teaching  Decision for Major Revisions : Change the curriculum into Competency-based Curriculum - SK Mendiknas 045/U/2002

Follow up  April 2004: 4 Tim Management PBL to Maastricht  June 2004: 18 Block Coordinators and 4 Block Coordinators sent to Maastricht (new curriculum was first designed)  October 2004: 16 Clinical Instructors sent to Maastricht  July, August, Sept: Dr Pie Bartholomeus to GMU School of Medicine – Skills Lab  Oct 2004: Dr Willem de Graff to GMU SM- tutorial discussion

Follow up  Feb 2005: Prof Albert to GMU SM- PBL Management  Maret 2005: Dr. Pie Bartholomeus and Dr. Jaan Van Dallen to GMU SM – Skills Lab  May 2005: Assessment and Program Evaluation Team To Maastricht  July 2005: Dr. Erik (ass expert), Dr.Ameike Jansen (program evaluation expert) dan Dr. Marieke (skills lab) to GMU SM

June 2005-July 2006  To focus on improvement in assessment system : Task Force on Block Exam Task Force on Progress Test Task Force on OSCE Task Force on Portfolio Task Force on Clinical Rotation and Comprehensive Exam

Current practice in GMU SM End of block written test It is not easy to develop questions related to discussed topic No time to develop the questions Low quality of questions

Current practice in GMU SM End of block written test It is not easy to develop questions related to discussed topic No time to develop the questions Low quality of questions

June 2005-July 2006  To focus on improving tutorial system (tutorial discussions, management of tutors, tutor training)  To prepare the New Competency-Based Curriculum which will be implemented starting in August 2006

Titi Savitri draft Competency-based Curriculum 2006 For Undergraduate Medical Education at Gadjah Mada University School of Medicine

Outcomes (areas of competence) Competencies Knowledge, Skills, Attitudes

Competencies required for performance of roles/functions Roles and Functions of Health Professional Knowledge, skills, attitudes for acquisition of competencies Knowledge, skills, attitudes for acquisition of competencies Assessment Assessment Assessment

Educational Strategy and Approaches – Best Evidence Medical Education  Learning in context  Learning to solve patient problems  Patient-Centred, Project-Based and Problem- Based  Integration and Multidisciplinary Approach (Horizontal and Vertical; Z shape)  Collaborative Learning  Progression towards Outcome  Assessment drives students’ learning

Expertise research Organizing memory Pattern recognition Networks Context information Information retrieval

Expertise research NoviceExpert Clinical Reasoning Skills Beginner (Novice) Advanced (Expert)

C ontextual C onstructive C ollaborative What it needs to become….

How? More authentic problems Increasing complexity Real life projects Authentic assessment C ontextual C onstructive C ollaborative

How? Less direction Increasing independent learning More demand driven Portfolio assessment; self/peer assessment C ontextual C onstructive C ollaborative

How? Smaller groups Group assignments More ICT support Learning task = assessment; include group work in assessment C ontextual C onstructive C ollaborative

Progression towards Outcome Spiral Curriculum  Increased breadth  Increased utility  Increased difficulty  Increased proficiency Th 1 Th 2 Th 3 Th 4 Th 5 Competencies

Learning in Context Doctor-Patients Encounters Disease/Disorder Spectrum: Acute, Chronic, Emergency, Pregnancy Age Spectrum: Newborn-Geriatric Setting Spectrum: Individual, family, community Problems Spectrum: Clinical Behavioural Environmental

Steps to design the Competency-based Curriculum Area of Competence Primary Care Physicians Competency Components Enabling Outcome Decided At the National Level Knowledge Skills Attitude Clinical Problems Decided at the Faculty Level Level of Achievement Decided at the Faculty Level

Steps to design the Competency-based Curriculum Enabling Outcomes are distributed into phases/year in line with level of achievement Identification of Year Themes Identification of Block Themes and Distribution of Clinical Problems into Blocks Distribution of Knowledge, Skills, Attitude into Blocks Blue Print Blocks

Tasks of the Block Team  Design learning experiences for the students based on Block Blue Prints (such as tutorial discussion, field visits, lectures, skills lab, laboratory practice, etc)  Design Scenarios or other triggers  Develop Student Guide and Tutor Guide  Carry out Block Assessment  Plan, implement and evaluate

Titi Savitri Draft Structure of the Competency- Based Curriculum 2006 GMU School of Medicine 7 Areas of Competence – KIPDI III Supporting area of competence: Management of Emergency Cases

Kurikulum Fakultas Makro Meso Mikro

Progression towards A Competent Medical Doctor Th 1 Th 2 Th 3 Th 4 Th 5 Areas of Competent Fase I : Beginner Fase 2: Intermediate Fase 3: Advanced

Year Themes 1 The Human Body System 2 Life Cycle 3 Chronic disorders and Neoplasma 4 Emergency and Clinical Rotation 5 Clinical Rotation and Research 6 Internship (??) Practice Theory Independent learning Dependent learning GMU SM Competency-Based Curriculum 2006 Phase 1 Phase 2 Phase 3

Year 1: The Human Body System Block 1.1. Regulatory/ Cardiovasc ular System (First Aid) Block 1.2. Respiratory System (Cough) Block 1.3. Digestive Tract System (Diarrhoea) Block 1.4. Genitourina ry System (Disuria) Block 1.5 Sense Organs (Penurunan Visus, Pruritus, Ear Discharge) Block 1.6. Neuromuscul ar System (Paralysis and Convulsion) Block 1.7 Multisyste m (Fever) Why?: - To introduce the human body system – the foundation of medicine - Common symptoms – familiar for students – motivating students - To introduce 8 areas of competence – Level Beginner

Year 2: Life Cycle Block 2.1. Cell Growth Block 2.2. Pregnancy And Childbirth Block 2.3. Childhood Block 2.4. Puberty Block 2.5. Adulthood Block 2.6 Aging

Example:Block 1.2 Enabling Outcome  1. (Area 1)To be able to use various elements of communication principles to establish effective doctor-patient relationship, i.e.  - listen actively  - respect the patient as a person:  a. Elicits and respect patients’ values  b. Exhibits cultural sensitivity  c. Communicates empathy  2. (Area 2) Be able to perform basic clinical examination required in dealing with respiratory tract disorders  3. (Area 3) Understand the anatomy of respiratory system and surrounding  4. (Area 3) Understand the normal function of respiratory system  5. (Area 3) Understand the clinical consequences of respiratory tract disorders  6. (Area 3) able to identify the type of coughs in relation to relevant disorders  7. (Area 4) able to choose appropriate treatment for the type of coughs  8. (Area 4) carry out education needed to protect individuals against preventable respiratory tract disorders

Example: Block 1.2. Knowledge Base  Understand the anatomy of respiratory system and surrounding at cellular and organ level  - Understand the normal function of respiratory system  Biologi Sel (cellular organization and structure)  Molecular-celular defense against injury and disease: Barrier defenses Cellular immune defenses Humoral immune defenses Active and passive immunity Inflamatory response  Understand Mechanism of respiratory diseases and pathophysiological response  - pharmacology of specific drugs for respiratory system disorders

Example: Block 1.2. Skills  Active Listening  Examination of vital signs (pulse, temperature, tekanan darah,) (1,2)  - Examination of thorax (perkusi, palpasi, auskultasi) (1,2)  - Examination of nose and throat  - Assessment of thorax (perkusi, palpasi, auskultasi) (1,2)

Example of Block 1.2. Clinical Problems  ISPA (pharyngitis, bronchitis)  Tuberculosis  Asma  Pertusis  ???- check with the depts involved

Example Block 1.2. – Week 1 MondayTuesdayWednesdayThursdayFridaySaturday Overview Lecture Self- directed learning Integrated Learning Integrated Lecture Self- directed Learning - Lab Practice Integrated Lecture Tutorial Discussion Tutorial Discussion Integrated Lecture Skills Lab Health Centre Visit

Example Student Guide Block 1.2.  List of Block Team and Contact Address  List of Experts and Contact Address  Overview of Block 1.2.  Enabling Outcome  Time Table  Scenarios  Other learning activities  Learning resources

Proposal for GMU SM Blueprint Assessment Five streams Assessment

Proposal for GMU SM Knowledge End of block written test Practice session Knowledge End of block written test Practice session Skills Skills lab Practice session Skills Skills lab Practice session Professional Behavior Tutorial Other relevant activities Professional Behavior Tutorial Other relevant activities Weighting is done within each stream NOT across streams Final mark reported consists of 5 streams

Proposal for GMU SM Progress Test Starting 2x / year Progress Test Starting 2x / year Portfolio 1x / year Student choose 2 best portfolio for interview Portfolio 1x / year Student choose 2 best portfolio for interview

Proposal for GMU SM Academic Year 2005/2006 Target: 1. Improve the quality of block test 2. Modify the tutor rating form 3. Pilot project progress test 4. Socialization of portfolio