1. Shift Cards in the Resident Outpatient Clinic
How to observe and provide real time feedback to residents- and inform your Clinical Competency Committee

2. Learning Objectives
Describe the difficulty of obtaining resident observations in the outpatient clinic and ways in which residents receive feedback
Describe how the Shift card can be used by the outpatient faculty to provide real time feedback
Demonstrate how the Shift card can provide helpful information for CCC members
Analyze how a Shift card can be an EPA with associated milestones
Examine advantages of the Shift card from faculty, resident, and CCC perspective.
Your learning objectives may differ but the card is still a useful modality for capturing data real time and providing immediate feedback.
Seeing the card as an EPA with attached milestones is an important point. You can consider mentioning the card may have utility in reporting to the ACGME.
It is important to make the point that the card can be helpful to all parties. It is to be emphasized that the card can help monitor a resident’s progression over time. The more cards completed will serve to give the resident, outpatient faculty, and ultimately the Clinical Competency Committee a good understanding of a resident’s development and growth.

3. Intended Shift Card Audience
CCC members
Program director
Associate Program directors
Core faculty members
Outpatient clinic supervisory faculty

4. What is a Shift card?
A simple and easy to use tool derived, in part, from Emergency Medicine. (Bandiera 2008)
The card can:
provide feedback to learners
help faculty determine where a resident falls on the learning curve in their progression through residency based on selected milestones
be acceptable to learners and faculty
provide useful information for the CCC
It is important to emphasize that the Shift card provides the CCC with useful outpatient data that can help guide its assessment of a resident and make suggestions for improvement over time.

5. Why was the Shift Card Created?
Need for outpatient observations regarding residents
Need for outpatient data for supervising clinic faculty to help gauge learning and development over time
Need for outpatient information to feed to the CCC
Your needs may be different and you can use this slide to discuss data you need to obtain. As per the previous slide, it is important to make the point that CCC members can use card data to help them determine growth/competence in the outpatient setting.

6. Shift Card as an EPA Utilizes milestones
Applicable for all program sizes
Helpful in following performance over time
Potential use in reporting to ACGME
This point needs emphasis as the CCC requires this information in its assessment and reporting mandates.

7. What does the Shift Card Look Like?
It is a two-sided piece of paper that includes the resident’s name, date the card was completed and the preceptor’s name
It includes selected milestones to be evaluated for a new problem/acute illness on one side. On the reverse it includes milestones for chronic disease management and preventative care
On the bottom of both sides of the card is space to provide comments/specific case illustrations
This slide could be eliminated as you can pass the card out at this point (or earlier) and describe it while the audience is looking at it.
It is important to emphasize that comments/examples are extremely important. It is also important to make the point that the card does not have any numbers attached to any of the categories thus added comments are quite valuable.

8. Comments/specific cases/illustrations:
Name of Resident: __________________________________
Date of Shift Card: _________________
Preceptor:
____________________
Milestones for new problem/acute illness
Sub Competency
Critical Deficiency
Requires Direct Supervision
Requires Indirect Supervision
Ready for Unsupervised Practice
Aspirational
PC1- Gathers and Synthesizes essential and accurate information
Inaccurate history and physical
Incomplete history and physical skills or limited differential diagnosis
Can use history, physical and other data to identify central clinical problems
Hypothesis driven history and physical or appropriately prioritized differential diagnosis
Obtains subtleties and recognizes unusual clinical presentations
PC2/PC3-Develops and achieves comprehensive management plans/ Manages patients with progressive responsibility
Inappropriate care plans or
does not assume responsibility for patient management decisions
Has difficulty developing care plan without assistance
Develops appropriate care plans and/or recognizes urgent/emergent issues without preceptor assistance
Can independently manage unusual acute problems or can modify plans based on changing clinical scenario
Able to develop complete care plan even when faced with diagnostic uncertainty and uses cost conscious principles
MK1/MK2 – Clinical knowledge/knowledge of diagnostic tests
Does not have knowledge to care for patients
Incomplete knowledge of common medical conditions or treatments
Demonstrates knowledge of common medical conditions
Demonstrates and applies knowledge of complex medical problems
Demonstrates and applies knowledge of treatment or diagnosis of unusual medical problems
PROF3 – responds to each patient’s unique characteristics (culture, gender, race, ethnicity, etc…)
Unwilling to modify care plan for patient unique needs
Requires assistance to modify care for patients unique needs
Aware of patients unique needs and can modify care plan with minimal assistance
Independently and appropriately modifies care plans to accommodate patients unique needs
Role model s and teaches others (colleagues, care team) on unique needs for patients
ICS1 – communicates effectively with patients and caregivers
Makes no attempt to share decision making
Needs help to develop a shared decision making with a patient even for straight forward concerns
Can engage shared decision making for uncomplicated discussions, but might needs help for complicated problems
Independently engages patients in shared decision making for complicated problems, including caregivers when appropriate.
Role model of engaging patients in shared decision making, including caregivers, even in complicated and changing clinical situations.
Shift card side 1 (new problem/acute illness); encouraging faculty to provides comments/examples is very helpful in evaluating performance over time
Comments/specific cases/illustrations:

9. Shift card side 2 (chronic disease management and preventative care)
Name of Resident: __________________________________
Date of Shift Card: ________ _
Preceptor:
____________________
Milestones for chronic disease management and preventative care
Sub Competency
Critical Deficiency
Requires Direct Supervision
Requires Indirect Supervision
Ready for Unsupervised Practice
Aspirational
PC1- Gathers and Synthesizes essential and accurate information
Inaccurate history, physical or data review
Incomplete history and physical skills or does not review prior notes to understand purpose of visit
Uses history, physical and chart review to make complete and prioritized problem list
Efficiently uses history, physical and data review to appropriately prioritized problem list and minimize need for further testing
Obtains subtleties and recognizes unusual clinical presentations
PC2/PC3-Develops and achieves comprehensive management plans/ Manages patients with progressive responsibility
Inappropriate or inaccurate care plans or
does not assume responsibility for patient management decisions
Has difficulty developing care plan without assistance
Develops appropriate care plans for controlled problems without preceptor assistance
Can independently manage complex patients with multiple uncontrolled chronic problems
Able to independently develop complete care plan and coordinate care even when faced with complex social barriers to good care
MK1/MK2 – Clinical knowledge/knowledge of diagnostic tests
Does not have knowledge to care for patients
Lacks knowledge of common clinical guidelines
Demonstrates knowledge of common clinical guidelines
Demonstrates and applies clinical guidelines and understands appropriate times to deviate from guidelines
Demonstrates knowledge of latest literature that may not be yet included in guidelines but could influence care of the patient
SBP1 – Works effectively with an interprofessional team(Nursing, social work, pharmacy, diabetes educators)
Frustrates team members
Does not know what team members are available or how they can help patients
May need prompting from preceptor to utilize skills of other team members
Independently engages team to maximize and efficiently deliver best care to patients
Viewed as a leader of team care. Effectively and efficiently coordinates care even when away from the office.
ICS1 – communicates effectively with patients and caregivers
Makes no attempt to share decision making
Needs help to develop a shared decision making with a patient even for straight forward concerns
Can engage shared decision making for uncomplicated discussions, but might needs help for complicated problems
Independently engages patients in shared decision making for complicated problems, including caregivers when appropriate.
Role model of engaging patients in shared decision making, including caregivers, even in complicated and changing clinical situations.
Shift card side 2 (chronic disease management and preventative care)
Comments/specific cases/illustrations:

10. Shift Card Completion Have the small groups observe selected videos
SBIRT: HTN case (published 2013 on YouTube)
The Value of Non Physician Observations in Resident Assessment: Outpatient Case (1:11-2:34, published 2014 on YouTube)
The Shift card is then completed using both sides - one side for each video
Resident to patient - acute problem
Resident to attending - chronic problem
The entire card does not have to be completed - only the observed milestones
You can consider using standardized patients or create your own videos. The first case involves a hypertensive patient with the added somewhat more acute problem of excess alcohol intake. The second involves Diabetes management in a more chronic context.
The entire card does not have to be completed - only what you observe. In time, with other cards being completed by the same or other observers, a more complete picture can emerge.

11. Debrief with the Group What worked? What didn’t work?
Here you can learn more about the card in an effort to change things if needed. Getting the perspective of outpatient faculty, core program leaders, and CCC members can help you tweak things, look at other milestones, for ex.

12. Positive Aspects of a Shift Card
It allows for a snapshot of clinical performance over time and in real time
It eliminates the need for faculty to recall a resident’s performance over time-in some cases perhaps six months prior
Unlike the mini-CEX, the Shift card was developed during the NAS era and incorporates reporting milestones
Again, the use of the card is helpful as it incorporated milestones. You can use time here if needed to compare/contrast the mini-CEX and the Shift card.

13. Shift Card Beneficiaries
Residents - feedback is given in real time which can impact future performance on the path to competence
Outpatient faculty - cards completed over time can be used to follow resident progress
CCC members - the card provides information about outpatient milestones and growth
Obtaining this information is needed on an ongoing basis. Multiple parties can benefit with the use of such a simple tool.

14. Shift Card as a Tool PROS ✔ “Real-time” direct observation
Lots of performance sampling
Uses EPAs/Milestones
Easy to use
Immediate feedback for residents and data for CCCs
CONS 
Feasibility issues depending on program resources/size
Reporting milestones may not be “granular enough”
No validity data yet
You might choose to eliminate this slide or discuss it briefly. The PROS are the key points to be made. While validity data may be somewhat lacking, the card may provide all parties with useful information that previously was not being obtained.
It is anticipated the card will soon be validated.

15. With newer technologies, you can explore paperless modalities
Action Plan
Other milestones to be addressed may lead to more Shift card(s) being developed
With newer technologies, you can explore paperless modalities
You can use this slide to think toward the future—there may be innovations that the group will come up with that can lead to a more robust tool

16. References
Bandiera G, Lendrum D. Daily encounter cards facilitate competency-based feedback while leniency bias persists. CJEM 2008 Jan Vol 10 (1):44-50
SBIRT: HTN Case-average medical resident example (May 21, 2013) retrieved from https//
The Value of Non Physician Observations in Resident Assessment: Outpatient Case (Sept. 28, 2014) retrieved from https//