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Transcript of Assessing operative autonomy Combining theory and software to make evaluation easy Jonathan Fryer...
Assessing operative autonomy Combining theory and software to make evaluation easy
Jonathan Fryer MD,
Professor of Surgery,
Feinberg School of Medicine, Northwestern University
Disclosures
• I have made no financial gains from this project
• I may in the future
• I intend to continue work on this project regardless
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The Problem
There is growing concern that graduating surgical residents are not achieving operative autonomy with essential procedures.
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1. Bell RH. Why Johnny cannot operate. Surgery 146, 533–542 (2009).2. Mattar SG et al. General Surgery Residency Inadequately Prepares Trainees for
Fellowship: Results of a Survey of Fellowship Program Directors. Annals of Surgery September 2013 258, 440–449 (2013).
3. Coleman JJ et al. Early Subspecialization and Perceived Competence in Surgical Training: Are Residents Ready? Journal of the American College of Surgeons 216, 764–771 (2013).
4. Chen P. Are Today’s New Surgeons Unprepared? Well (2013). at http://well.blogs.nytimes.com/2013/12/12/are-todays-new-surgeons-unprepared
The Problem
– Currently, summative assessment of OR performance is based on:• # of cases logged by resident
– Role of resident in each case?
• Semi-annual global evaluations
– Memory decay?
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The Problem
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…asking busy surgical faculty to fill out complex assessment forms in a timely manner, doesn’t work.
The Solution
A simple assessment tool that:• Assesses operative autonomy
• Doesn’t impede surgical workflow
• Facilitates high compliance and prompt completion
Theoretical Framework
• Inter-related constructs:
– Supervision, Guidance, Autonomy, Performance
• Faculty Supervision (oversight) ≠
• Faculty guidance (physical or verbal help)
• 1
• Faculty Guidance = Resident Autonomy
• Resident Autonomy = ƒ (Resident performance)
•
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The Solution
– With every case faculty:• Provide resident supervision.
• Assess and document the level of operative autonomy achieved by the resident.
• Progressively reduce the level of operative guidance they provide to resident.
The “Zwisch” Scale
• 4 levels of operative guidance– Show & Tell
– Active Help
– Passive Help
– Supervision Only
DaRosa, D. A. et al. A Theory-Based Model for Teaching and Assessing Residents in the Operating Room. Journal of Surgical Education 70, 24–30 (2013).
Study Design: Participants and Setting
• Department of general surgery at a large academic hospital
• All teaching faculty underwent formal frame-of-reference training per published protocol1
• All general surgery residents and trained faculty raters eligible for inclusion
• IRB-approved
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1George et al, J. Surg. Educ. 2013; 70
Results: Feasibility
• A 1 hour rater training session is sufficient to achieve reliable and accurate ratings1
• 92% response rate using PASS
1George, B. C. et al. Duration of Faculty Training Needed to Ensure Reliable OR Performance Ratings. J. Surg. Educ. 70, 703–708 (2013).
Results: PASS Sample (7 mos)
Number of Residents 31
By Year of Residency
Year 1 Year 2 Year 3 Year 4 Year 5 9 6 5 5 6Number of Attendings 27
Number of Procedures 1490
Number of Types of Procedures
127
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Results: PASS Sample
Relative Case ComplexityEasiest 1/3 Middle 1/3 Hardest 1/3193 (13.0%) 895 (60.1%) 402 (27.0%)
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Results: Validity: Zwisch Levels by PGY
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p-values for sequential pair-wise
distributions
p=<.001
p=<.001
p=<.001
p=0.21
23.2%
Results: Validity: Zwisch Levels by Complexity
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p-values for sequential pair-wise
distributions
p=<.001 p=<.001
Results: Validity: Zwisch Level by Prior Experience
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p-values for sequential pair-wise
distributions
p=<.001
Study Design: Data Collection
• Sample 2: Video Sample
– 8 procedures video recorded for additional review (subset of PASS sample)
– Rated by operating faculty, in-person OR observer, and video reviewer using Zwisch scale (blinded to other scores)
– Rated by 2 additional video reviewers using other OR assessment instruments (modified OPRS and O-SCORE)
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Results: Video Sample
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Number of Residents 4 (PGY 2 to 5)
Number of Attendings 2Number of Procedures 8Number of Types of Procedures 5
2 Laparoscopic cholecystectomy2 Open inguinal hernia repair2 Parathyroidectomy1 Total thyroidectomy1 Laparoscopic ventral hernia repair
Results: Reliability
• Inter-rater reliability
– Zwisch ratings
– Operating attending, OR observer, and video rater
– ICC = .90, 95% CI = .72 - .98, p < .001.
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Item ρ p-value
Operative Performance Rating System (OPRS) Degree of prompting or direction -.92 .001 Instrument handling .94 .005 Respect for tissue .94 .005 Time and motion .94 <.001 Operation flow .95 <.001 Overall performance .95 <.001Ottawa Surgical Competency OR Eval. (O-SCORE) Knowledge of procedural steps .94 <.001 Technical performance .93 .001 Visuospatial skills .92 .001 Efficiency and flow .86 .007 Communication .92 .001
Results: Validity: Zwisch Level correlation with other OR assessment tools
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Benefits
• Faculty and residents constantly reminded of ultimate goal …. i.e. operative autonomy.
• Establishes a conceptual framework for teaching and learning in the OR.
• Data can be used to:
– Help faculty and residents to set learning goals.
– Help programs monitor operative progress and identify those who may need additional attention.
– Address regulatory requirements for OR supervision and operative performance assessment.
– Establish national norms
Limitations
• So far, studied only at a single institution
• Validity analysis based on small convenience sample
• Raters not blinded to resident PGY level
• Comparison with only selected items of OPRS and O-SCORE
• Unmeasured confounders (time of day, supervising surgeon experience, etc)
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Conclusion
• The Zwisch rating scale is a reliable and valid measure of faculty guidance and resident autonomy
• Deployed on PASS the Zwisch scale can be used to feasibly record evaluations for the vast majority of operations performed by residents
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Vision
• All surgical subspecialties.
• Other procedural specialties.
• Other medical professionals who need to learn to perform complex clinical tasks.
• Other trades or professions where trainees need to learn to independently perform complex tasks safely and effectively.
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Acknowledgements
Surgical Education Research & Development Team
Jay Zwischenberg
er
Eric HungnessShari Meyerso
n
Debra DaRosaJonathan Fryer
Ezra Teitelbau
m
Brian George
Mary Schuller
Research supported by:
Excellence in Academic Medicine Program from the State of Illinois
Augusta Webster Educational Innovation Grant from the Northwestern University
Center for Education in Medicine
Theoretical basis
• Global assessment of performance is simpler, more accurate, and more reliable than checklists1
• Faculty guidance is related to resident performance2
• Faculty can accurately and reliably rate the amount of guidance provided to residents3
1. Regehr, G., MacRae, H., Reznick, R. K. & Szalay, D. Comparing the psychometric properties of checklists and global rating scales for assessing performance on an OSCE-format examination. Acad Med 73, 993–997 (1998).
2. Chen, X. (Phoenix), Williams, R. G., Sanfey, H. A. & Dunnington, G. L. How do supervising surgeons evaluate guidance provided in the operating room? The American Journal of Surgery 203, 44–48 (2012).
3. George, B., Teitelbaum, E., DaRosa, D., Hungness, E., Meyerson, S., Fryer, J., Schuller, M., Zwischenberger, J. Duration of Faculty Training Needed to Ensure Reliable O.R. Performance Ratings. Journal of Surgical Education 70(6), 703-708 (2013).
Study Design: Rating Scales
• Zwisch
• Procedural Complexity
• Operative Performance Rating System (OPRS)1
– 6 general items only--excludes items that pertain only to specific procedures
• Ottawa Surgical Competency Operating Room Evaluation (O-SCORE)2
– 5 intra-operative items only--excludes items that did not pertain to intra-operative performance.
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1Chen et al, The American Journal of Surgery 2012; 2032Gofton et al, Acad. Med. 2012; 87
Results: Validity
• Convergent Validity for Guidance/Autonomy and Resident Performance
– Zwisch level vs. PGY
– Zwisch level vs. Complexity
– Zwisch level vs. Resident Experience
• Construct Validity for Guidance/Autonomy
– Zwisch level vs. OPRS guidance item
• Construct Validity for Resident Performance
– Zwisch level vs. OPRS performance items
– Zwisch level vs. O-SCORE performance items
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The Team
• Dr. Debra DaRosa
• Dr. Brian George
• Dr. Shari Meyerson
• Dr. Ezra Teitelbaum
• Mary Schuller
• Dr. Nathaniel Soper
• Dr. Joseph Zwischenberger
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Impact so far
• Over 1000 evaluations collected in 6 months
• Response rate > 90%
• Changes in teaching
• They love to use it!
Results: Validity
• Convergent Validity for Guidance/Autonomy and Resident Performance
– Zwisch level vs. PGY
– Zwisch level vs. Complexity
– Zwisch level vs. Resident Experience
• Construct Validity for Guidance/Autonomy
– Zwisch level vs. OPRS guidance item
• Construct Validity for Resident Performance
– Zwisch level vs. OPRS performance items
– Zwisch level vs. O-SCORE performance items
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Next Steps
• I am actively trying to bring this to MGH
• It needs additional development before it can be launched here
• Multiple other departments have already committed to supporting this project
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Current Status
Milestone Achieved Cost / time
Development of v1.0 mobile app
$200,000 / 8 months
Development of v0.9 administrative interface (beta)
$75,000 / 3 months
Integration with Northwestern EMR
$45,000 / 2 months
Development of v2.0 iOS app
$160,000 / 7 months (ongoing)
Total $480,000 + operational expenses
Road Map
Planned Technical Milestones
Target launch date
v2.0 for iOS at Northwestern February 2014
v1.0 Administrative interface at Northwestern
April 2014
v2.0 for Android at Northwestern
June 2014
System integration at MGH June 2014
v2.0 iOS at MGH July 2014
V2.0 Android at MGH October 2014
12 month budget
Expense Item Cost
Design and specification $30,000
Software Development $225,000-$300,000
QA testing $30,000
Server hosting and maintenance
$25,000
User training $5,000
Administrative $30,000
Total $345,000 - $420,000
The “Zwisch” Scale
• 4 levels of guidance
– Show & Tell
– Active Help
– Passive Help
– Supervision Only
DaRosa, D. A. et al. A Theory-Based Model for Teaching and Assessing Residents in the Operating Room. Journal of Surgical Education 70, 24–30 (2013).