Using Systems Based Care to Teach the ACGME Competencies

1
Using Systems Based Care to Teach the ACGME
Competencies

• Jamie Dickey, PhD
• Donald E. Girard, MD

2
Goals

• Oregon Health Sciences Universitys Graduate
  Medical Education
• Why use System-based care to teach the ACGME
  competencies?
• The theories at work here
• Can the theories explain the OHSU experience?

3
OHSUs Graduate Medical Education

• 60 programs fully accredited occasional program
  on probationary status, but rare
• 700 fulltime faculty two major teaching
  hospitals on campus six community hospitals
• 585 residents from all medical schools in the
  country
• Approximately evenly divided between the primary
  care specialties and subspecialties
• More than 40 of Oregon physicians graduates of
  the OHSU undergraduate program, GME or both
• Virtually all become certified in their
  specialties

4
The ACGME Workshop March 2002

• PANIC will disaccreditation visit OHSU?
• Requirement to implement core curricula in three
  months
• The science of education was unclear and
  interpreted as educational jargon
• Specific methods for implementation were not
  provided

5
Implications of Implementation of the ACGME
Competencies for Faculty Team

• Learning the content and and practicing the
  skills
• Developing new teaching methods including
  curricula development
• Creating evaluation tools that measure
  application of this new information, skills, and
  attitudes
• AND, assuming additional clinical duties to
  assure successful implementation of the 80 hour
  work week.

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Meeting with the Dean

• The Dean
• Member of Institute of Medicine, author of
  Crossing the Quality Chasm
• Recognized the similarity of core competencies
  and the quality principles of the IOM Report
• Could the GME charge be a catalyst for a system
  change?

7
IOM Quality Principles vs. ACGME Core Competencies
8
The Recruitment

• Deans support of the need to bring in education
  specialist
• To interpret the requirements
• To communicate and make the requirements
  understandable to uninformed physicians
• To serve as catalyst to exchange and share ideas
  for change

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The Recruitment, contd

• Attributes counseling, team dynamics, building
  and leadership, systems theory, and advanced
  degrees in education and psychology.
• Process
• Review the ACGME toolbox literature, complimented
  with additional materials as resources for
  distribution.
• Our initial conclusion the OHSU health care team
  is central to the process and our system is the
  stage where this is to be played out.

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The Components of a Systems Based Practice

• Understanding the ripple effect of patient
  care all professionals are involved
• Understanding practices and systems of practice,
  including health care costs and resources
  allocation
• Relating these principles to quality of patient
  care
• Advocating for quality patient care
• Partnering with health care managers and
  providers for those goals

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The Real Opportunity in GME The System Change

• Institutional leadership agreement
• System is responsible and accountable, not the
  individual
• Quality of patient care can be improved and is
  ultimate goal
• The remarkable commonality between the ACGME
  competencies and IOM quality principles
• Thus, implementation of a process for teaching,
  learning and applying the competencies in GME is
  an opportunity for system change
• Vehicle for this change must be the TEAM
• Interdisciplinary team where professionalism is
  respected and understood

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Using Systems Based Practice to Guide and Teach
the Competencies
Patient Care Professionalism Communication Practic
e Based Learning Medical Knowledge System Based
Practice
Patient Care that is Safe Effective Efficient Ti
mely Patient-Centered Equitable
Systems Based Practice (as a process)
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Theoretical Principles Guiding the Chronology of
the OHSU Experience

• Complex Systems Theory
• Satir Change Process
• Congruent Systems theory
• Dreyfus Model
• Problem Based Learning
• Outcomes Based Education / Evaluation

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Complex Systems Theory

• Recognition that the consequences of individual
  behavior/choices have impact for the resident,
  team, patient, program, family, institution,
  larger health-care system, etc.
• Belief and trust in the process of teamwork
  (micro systems) to manage and create effective
  methods of education and clinical care.
• Adoption of simple rules to solve complex
  problems.
• Institutional valuing of emergent behavior
  (creative solutions).

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Satir Model for Change

• Change in any system creates chaos and that
  movement through a process of change, which
  includes integration and practice, can lead to a
  new, more effective status quo.
• Reciprocal relationship exists between
  individuals and the larger system, creating
  change for both.

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Satir Model for Change
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Congruent Systems Theory

• Effective communication, respect and valuing for
  self, other, and context are necessary
  ingredients for the provision of quality resident
  education and patient health-care.

18
Congruence
Other
Self
Context
Promotes High Self and System Esteem
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Dreyfus Model

• A knowledgeable and connected relationship to
  context, along with the struggles inherent in
  growth, leads to a process of incremental
  development with goals of achievement for each
  stage. These stages are novice, beginner,
  competent, proficient, expert, master, and
  practical wisdom.

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Chronology of Transforming Events at OHSU

• Hire a Director for Education, Leadership, and
  Evaluation
• Create Resource Notebook to Educate, Provide
  Curricula and Evaluation Tools
• Experts Panel
• Merging of School of Medicine and Hospital Goals
  (ACGME Competencies and IOM Quality Aims)
• Medical Educators Workshop (Team Focus)
• Recognizing Faculty Mentors
• Medical Educators Workshop Update

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Chronology of Transforming Events at OHSU, contd

• Interactive Website
• Interdisciplinary/Interprofessional Task Force
• Educational Task Force
• Focus Groups (Collect Qualitative Data on ACGME
  Competencies, 80-hour Workweek, IOM Quality Aims)
• Identification with Remediation of Programs
  Receiving Patient Complaints
• Creation of on-going resident learning groups
• Internet based data management for residency
  programs

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Summary

• System based care is both a competency and the
  appropriate vehicle through which to teach, learn
  and apply all the ACGME competencies