Raising the Bar

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• Raising the Bar
• Preparing for Accreditation
• Dr. Glenn D Brown, BSc, MD, CCFP(EM), FCFP, MPH
• Director of Medical Education
• Department of Family Medicine
• Queens University
• Kingston, Ontario

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Purpose of AccreditationAccording to College

• To attest to the educational quality of
  accredited programs
• To ensure sufficient uniformity and portability
  to allow residents from across Canada to qualify
  for the CFPC examination as residency candidates

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To Attest to the educational quality of
accredited programs

• I believe this is achieved
• Do you?

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To ensure sufficient uniformity and portability

• An achievement of practical significance
• An achievement of which we should all feel pride

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To ensure sufficient uniformity and portability

• Our certificants have the ability to practice in
  many areas of the world
• CCFP qualifies to write American Board exams
• New Zealand Residency CCFP allows licensure
• Australia (varies by state) Usually CCFP
  permits licensure

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Two sides to every story Its the price we pay

• Our geography is vast
• Population is diverse
• Some aspects of training will be redundant in
  certain localized areas

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Accreditation driven curriculum in Toronto

• Obstetrics
• In-patient care
• Procedural issues
• Practical fracture management

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And you thought the supreme court was activist!

• Accreditation standards partially based on some
  vision of what a family physician actually is
• Partially based on what they should be
• This should be a dynamic part of what we do as
  educators

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Must vs Should
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Musts and Shoulds

• Must
• Use of the word must indicates that meeting
  the standard is absolutely necessary if the
  program is to be accredited

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Must and Should

• Should
• Use of the word should indicates that the
  attribute is considered highly desirable
• the Committee will judge whether or not its
  absence may compromise substantial compliance
  with all the requirements for accreditation

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Heres the Nub

• the nature of the evaluation is qualitative in
  character
• it can be accomplished only through the exercise
  of professional judgment of qualified persons

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Musts that might be a challenge

• Goals
• must be a statement of the overall goals of the
  program
• must be specific educational objectives with
  respect to knowledge, skill, and attitudes for
  each rotation and on other educational
  experiences
• all residents and faculty must receive a copy of
  the current goals and objectives

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Musts

• Evaluation
• evaluation forms for all clinical rotations must
  be specific to the discipline of family medicine
  and reflect the 4 principles of family medicine
• the system must focus on both formative and
  summative evaluation
• the system must document resident learning with
  both qualitative and quantitative information

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Musts Evaluation, continued

• The system must include information collected
  from the variety of evaluation techniques and
  processes over the time of the training program.
  These should include chart reviews, direct
  observations, case discussions, and might also
  include both written and/or oral examinations
• The system must include a focus on clinical
  skills and make use of direct observations of
  clinical encounters, some of which should be
  electronically recorded (video/audio/other) and
  reviewed with residents

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Musts Evaluation - continued

• The program must ensure and be able to
  demonstrate the variety and range of patients and
  patient problems encountered by each resident
  during all their clinical family medicine
  experiences
• Observations must involve a variety of patients
  and must sample different kinds of skills
  including history taking, physical examination,
  procedural skills, doctor-patient relationship,
  and dealing with difficult patients

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Musts Evaluation - continued

• The required direct observations must be
  documented (a minimum of 32 direct observations
  over 2 years)

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Scholarly Activity
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Musts Scholarly Activity

• There must be easy access to biomedical
  information resources in print or electronic
  form, including textbooks, journals, and indexes,
  at the level of a university or major hospital
  library collection.
• There must be easy access to core biomedical
  information resources during evening and weekends.

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Musts Scholarly Activity - continued

• Residents must be given opportunities to develop
  effective teaching skills through organized
  activities focused on teaching techniques

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Continuity of Care
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Musts Continuity of Care

• Programs must demonstrate that effective
  experiential learning of continuity of patient
  care occurs within the program
• Residents must have a group of patients for whom
  they assume significant responsibility over an
  extended period of time and in different patient
  care settings.

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Musts Continuity of Care - continued

• Residents must develop an appropriate attitude
  toward the establishment of enduring
  relationships with and ongoing commitments to
  their patients.

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Musts and shoulds Continuity of Care -
continued

• Block time in family medicine must occur in both
  years
• ..at least one block should consist of four
  continuous months, in the same teaching practice

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Continuity of Care - continued

• The College of Family Physicians discourages
  family medicine block rotations of less than 2
  months as short exposure to a particular practice
  do not normally allow a resident to develop any
  meaningful level of continuity or responsibility.

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Musts Continuity of Care - continued

• Residents must maintain continuing responsibility
  for their patients in various settings such as
  a hospital, home, and long-term care institutions
• Residents must be involved in providing
  after-hours care as part of their patient care
  responsibilities during their core family
  practice experiences. After hours care must be
  limited to patients for which the family practice
  services would normally be responsible

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Musts Continuity of Care - continued

• Teaching practices must allow a resident to
  acquire the identity of a family physician
• allow the residents to observe the natural
  history of disease, and a requirement that
  residents be available to and responsible for a
  group of patients over time.

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Musts Continuity of Care

• The practice must be organized in such a manner
  that residents can build a defined panel of
  patients during their time in their primary
  teaching centre

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Shoulds Continuity of Care - continued

• Resident responsibility should be such that
  patients recognize the resident as one of their
  personal physicians, and that residents are
  directly responsible for the delivery of care to
  those patients with whom they are identified

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Other themes Practice Demographics

• The practice-based experience should have a
  reasonable balance of acute and chronic care,
  ambulatory and hospital care. It should also
  provide a breadth of age groups and have a
  variety of problems, including obstetrical
  patients

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Other themes Life Cycle

• practices should include a wide range of age
  groups and clinical problems, including care of
  dying patients.
• residents should not be limited to a practice
  that is too skewed toward any particular age
  group or special interest area. Should residents
  be assigned to such a practice, the program must
  make provisions to ensure that such residents are
  able to meet any deficiencies in learning
  opportunities

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Gender Issues

• residents must become knowledgeable about the
  special health care requirements specific to men
  and women
• The Family practicesshould have an adequate
  patient base to allow experience in these health
  areas

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Gender Issues - continued

• Residents must be well acquainted with important
  physical and psychosocial aspects of mens and
  womens health care, including occupational
  health, family planning, spousal abuse, sexual
  assault, and sexual abuse.
• Residents must become familiar with gender-based
  differences in the management of common health
  problems in men and women.

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Gender Issues - continued

• (training in gender issues)can be enhanced by a
  wide range of horizontal experiences in
  occupational health clinics, family planning
  clinics, rape crisis centers, womens shelters,
  and womens health clinics, and by other related
  experiences.

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Musts Care of the Elderly

• Residents must learn the special skills,
  knowledge, and attitudes related to care of the
  elderly.
• Residents must be able to do a comprehensive
  functional and clinical assessment of the frail
  elderly, including assessment of mental function.

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Musts Palliative Care

• Residents must learn the skills, knowledge, and
  attitude related to management of physical,
  psychological, social, and spiritual needs of
  dying patients and their families
• Residents must be familiar with medical and
  societal attitudes towards death and dying.

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Surgical and Procedural Skills
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Surgical and Procedural Skills

• Residents in family practice settings must have
  an opportunity to learn surgical and procedural
  skills that can be practiced appropriately in the
  family practice office, or in outpatient, or
  emergency department settings.

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Surgical and Procedural Skills

• See Canadian Family Physician, Defining core
  procedural skills for Canadian family medicine
  training, vol 51, October 2005
• Also, see College Website go to education
  then to resource documents then to
  educational documents - then to procedural skills

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Musts In Hospital Care

• Residents must have a minimum of 2 months
  experience maintaining clinical responsibility
  for their family medicine patients in hospital
  settings in which their family physician
  preceptors are the primary providers of inpatient
  care.

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Musts Ethics

• There must be a formal evaluation of the
  attitudes, knowledge, and skills pertinent to the
  ethics of family medicine.

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Ethics

• For guidelines about curriculum, go to College
  website education resource documents -
  educational resources - ethics

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Quality Assurance
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Musts Quality Assurance

• Family physicians must be able to assess their
  own skills, knowledge, and practices through
  practice audit and other quality assurance
  activities

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Musts Quality Assurance

• Residents must learn the basic principles of
  quality assurance, including setting standards,
  and follow-up to ensure they were met residents
  must participate in practice audit activities
  during residency training

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Approach to areas of non-compliance

• Dont have any
• There might be challenges
• Never argue about standard
• Clintons deny, deny, deny approach probably
  wont work

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Approach to areas of non-compliance-continued

• Positive framework always
• It is important to demonstrate a complete
  understanding and approach to any challenges
  and opportunities for improvement
• However, theres no need to hang out the dirty
  laundry

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The Dirty Laundry

• You do not need to share your internal
  evaluations these are old and were not
  intended for the accreditation team
• If you really have an unresolved problem,
  demonstrate your approach, what you have tried

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Approach to Challenging Issues

• It is appropriate to ask the accreditation team
  to share their insights on an issue
• It may be appropriate to use the accreditation
  visit as leverage to help resolve longstanding
  issues

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Thoughts about the Accreditation Visit

• Approach the accreditation team as honoured
  guests and colleagues
• Look after the team its a long week for them
• Give them food, breaks, realistic schedule

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The Accreditation Visit

• Make sure your faculty and residents know
  accreditation language
• Everyone should be fluent in discussing the 4
  principles, continuity of care, behavioral
  medicine, quality assurance, patient centred care

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Priming Faculty and Residents

• Isolate the ranter allow them to express their
  view but dont let it stand alone
• I have had a different experience from this
• Faculty and residents should meet to do some
  planning about what is to be said

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Priming - Continued

• Chief residents should poll the residents
  whats good and whats weak
• Faculty should also prepare ahead of time have
  a prepared statement and leave time for questions
• When there are issues, show how PGE or PD have
  been responsive to those issues

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What about changing these standards!

• The CCFP recognizes the potential for restriction
  by regulations which are too rigid and therefore
  the College promotes free communication between
  the College, the medical schools, and the
  residents as a good safeguard against undue
  rigidity.