What we noticed

1
What we noticed how we began to make sense of
it
2
Systems we noticed, heard about

• Bed availability
• Health care professionals
• Care level measurement
• Transport
• Ancillary support
• Illness prevention systems
• Triaging systems

• Housekeeping
• Insurance
• Communication
• Evidence-base of patient care
• Educational systems
• Microsystems of care
• Medication systems

3
Things we noticed that residents might need to
learn about practice-based learning and
improvement

• Importance of interdisciplinary work
• Flow of patients and ways that flow is managed
• How systems are led, managed, guided
• Exit from and entry into clinical microsystems

• Language used in carepatient stories and doctor
  stories
• Best practices and what can be learned from
  them
• Cost-benefit of alternatives when changing
  improving something
• Access systems

4
Things we noticed that residents might need to
learn about systems-based practice

• Ways of identifying patient needs from the
  systems
• Health care financing, financial resources and
  relation to things like bed allocation
• Acute problem management
• Systems impact on each other

• Social context
• Optimal support systems
• Actual data on system performanceoutcomes for
  patients
• Residents may actually want to be part of this
  learning design/change

5
Available teaching venues we noticed

• Lectures
• Role-playing
• Case-based discussions
• Patients
• Portfolio reviews
• Standardized patients

• Evidence-based medicine rounds
• Bedside teaching
• Experiential learning exercises
• Multidisciplinary teaching rounds
• Conferences
• Journal club

6
Faculty development needs include

• Best practicesteaching and patient care
• Clinical decision algorithms
• Standard literature of the relevant fields
• How to encourage residents to look at systems
• How to assess performance within a system

• Ability to make change
• Strategies, methods for resident involvement
• Teamwork strategies
• Feedback methods
• Alternative teaching methods
• Understanding of systems resources, protocols
• Evaluation alternatives

7
Assessment ideas

• Standardized patients
• Case-based vignettes/tests
• Portfolios
• Chart stimulated recall
• 360º review
• Resident self assessment
• Peer feedback

• Observation
• Global ratings
• Improvement projects
• Journal club
• Resident reflection on care
• Patient feedback
• Patient outcomes
• Data base tracking

8
What I might tell a prospective resident

• Can work on innovative projects to improve care
  here.
• We have an institution-wide curriculum based on
  the general competencies.
• We believe that as faculty we must model the
  roles you are expected to play.

• We use portfolios to allow you to see your own
  progress here.
• We teach you how to bring about improvement.
• Get exposure to different systems here.
• We study and use benchmarking to understand how
  we are doing in our patient care.

9
Yesterday afternoon

• Heard
• Modify current program vs. discard
• Faculty developmentground the intellectual
  territory, get support from deans, others
• Have residents involved
• Use ordinary venues to work more actively on
  safety, improvement
• Concordance of competencies with IOM report
• Connect to everyday patient care

• Local action
• Go back and really listen, observe
• Seek institutional help
• Work across programs
• Evaluation methods need continuitymed school,
  residency, mid-career
• Need to use what is available and document what
  we do
• Network and develop interested faculty who can
  model these changes