Creating a Competency- informed Learning Environment Tina Foster MD, MPH Associate Program Director...
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Creating a Competency-Creating a Competency-informed Learning informed Learning
EnvironmentEnvironment
Tina Foster MD, MPHTina Foster MD, MPHAssociate Program DirectorAssociate Program Director
DHLPMRDHLPMRDartmouth-Hitchcock Medical CenterDartmouth-Hitchcock Medical Center
Lebanon, NHLebanon, NH
What I Hope To DoWhat I Hope To Do
Briefly describe the Dartmouth-Briefly describe the Dartmouth-Hitchcock Leadership Preventive Hitchcock Leadership Preventive Medicine residencyMedicine residency
Give some examples of things that Give some examples of things that feel innovative to residents, faculty, feel innovative to residents, faculty, staff (and patients?)staff (and patients?)
Reflect on the learning Reflect on the learning environment(s) we are creatingenvironment(s) we are creating
What is DHLPMR?What is DHLPMR?
Dartmouth-Hitchcock Leadership Dartmouth-Hitchcock Leadership Preventive Medicine Residency Preventive Medicine Residency Program (DHLPMR)Program (DHLPMR)
Combined training in LPM and any Combined training in LPM and any other DHMC residency/fellowshipother DHMC residency/fellowship
First graduate in 2005First graduate in 2005 Focus on the improvement of patient Focus on the improvement of patient
carecare
Why DHLPMR?Why DHLPMR?
To attract and develop physicians To attract and develop physicians capable of leading the change and capable of leading the change and improvement of the systems where improvement of the systems where people and health care meet. people and health care meet. In In conjunction with existing clinical residency conjunction with existing clinical residency and fellowship programs, participants' and fellowship programs, participants' academic, applied leadership and practicum academic, applied leadership and practicum experiences in preventive medicine will experiences in preventive medicine will focus on measuring outcomes and focus on measuring outcomes and improving the technical, service and cost improving the technical, service and cost excellence of care for patients and excellence of care for patients and populations.populations.
Another Way of Looking at Another Way of Looking at It…It…
Our residentsOur residents Focus on a defined population of patients Focus on a defined population of patients
served by DHMCserved by DHMC Understand their outcomes and Understand their outcomes and
processes of care; identify opportunities processes of care; identify opportunities for improvementfor improvement
Lead change for the improvement of care Lead change for the improvement of care for these patients for these patients
Develop specific competenciesDevelop specific competencies
DHLPMR Core CompetenciesDHLPMR Core Competencies
Leadership—including design and redesign—of Leadership—including design and redesign—of small systems in health care.small systems in health care.
Measurement of illness burden in individuals and Measurement of illness burden in individuals and populations.populations.
Measurement of the outcomes of health service Measurement of the outcomes of health service interventions.interventions.
Leadership of change for improvement of quality, Leadership of change for improvement of quality, value and safety of health care of individuals and value and safety of health care of individuals and of populations.of populations.
Reflection on personal professional practice & Reflection on personal professional practice & linkage of that reflection to ongoing personal and linkage of that reflection to ongoing personal and professional development.professional development.
Core Concept: The Clinical Core Concept: The Clinical MicrosystemMicrosystem
Small group of doctors, nurses, other Small group of doctors, nurses, other clinicians clinicians
Administrative and support staffAdministrative and support staff PatientsPatients Information and information technologyInformation and information technology
Working together for common clinical and Working together for common clinical and business aimsbusiness aims
Using shared informationUsing shared information Producing clinical outcomesProducing clinical outcomes
Which system is the unit of Which system is the unit of practice, intervention, practice, intervention,
measurement?measurement? Community, Market,
Social Policy System
Macro-organization
System
MicrosystemIndividual care-giver & patient System
Self-care
System
The Work: Science-based The Work: Science-based ImprovementImprovement
“Generalizable Scientific Evidence” + “Particular
Context”
“Measured Performance
Improvement”
• control for context• generalize across contexts• sample design
I
• understand system “particularities”• learn structures, processes, patterns
II
• balanced outcome measures
III
• certainty of cause & effect• shared importance IV
• strategy• operations• people V
P. Batalden
Why Preventive Medicine?Why Preventive Medicine?
PopulationsPopulations
MeasurementMeasurement
SystemsSystems
LeadershipLeadership
Luxuries We Enjoyed…Luxuries We Enjoyed…
Able to design residency “from Able to design residency “from scratch” – building on PM program scratch” – building on PM program requirements and the idea of requirements and the idea of “competency-driven” GME “competency-driven” GME
Deeply committed team with incredible Deeply committed team with incredible experience, knowledge, skillsexperience, knowledge, skills
Time to develop a shared mental Time to develop a shared mental model of what “it” would look likemodel of what “it” would look like
Where Are We Now?Where Are We Now?
Five graduates to dateFive graduates to date Currently have nine first year and eight Currently have nine first year and eight
second year residents, plus three who second year residents, plus three who have completed the first yearhave completed the first year
Have combined with anesthesia, pain Have combined with anesthesia, pain medicine, surgery, internal medicine, GI, medicine, surgery, internal medicine, GI, ob-gyn, ID, pulmonary/critical care, family ob-gyn, ID, pulmonary/critical care, family medicine, pathology, pediatrics, psychiatrymedicine, pathology, pediatrics, psychiatry
DHLPMR has attracted applicants to DHMC DHLPMR has attracted applicants to DHMC GME programsGME programs
What Sorts of Things Do our What Sorts of Things Do our Residents Do?Residents Do?
Improve care for patients admitted with CAPImprove care for patients admitted with CAP Improve safety and efficiency of sedation for Improve safety and efficiency of sedation for
selected endoscopic proceduresselected endoscopic procedures Improve provision of screening services in GIM clinicImprove provision of screening services in GIM clinic Rapid Response Team implementation and outcomesRapid Response Team implementation and outcomes Improve medication management for major Improve medication management for major
depressiondepression Improve dx and tx of obesity in primary care clinicImprove dx and tx of obesity in primary care clinic Improve post-operative pain managementImprove post-operative pain management Improve advance directive processImprove advance directive process Improve hand hygiene in perioperative areasImprove hand hygiene in perioperative areas
How Our Program is Different-How Our Program is Different-the Residentsthe Residents
All residents in combined training, all All residents in combined training, all maintain presence in both programsmaintain presence in both programs
No one is an internNo one is an intern Residents (and faculty) from a Residents (and faculty) from a
variety of specialties are working variety of specialties are working together and learning from each together and learning from each otherother
How Our Program is Different –How Our Program is Different – the Learning Experience the Learning Experience
Residents design own learning experiences Residents design own learning experiences (with guidance and oversight)(with guidance and oversight)
Residents generally manage their own timeResidents generally manage their own time Faculty coaches and mentors—aided by a Faculty coaches and mentors—aided by a
program of “coach development”program of “coach development” Clear expectation that residents will teach Clear expectation that residents will teach
residents residents and facultyand faculty in their “home” programs in their “home” programs Program actively managed by a Program actively managed by a
multidisciplinary team that works/meets every multidisciplinary team that works/meets every two weekstwo weeks
How Our Program is Different – How Our Program is Different –
the Learning Environmentthe Learning Environment Most work is inter-professional Most work is inter-professional
(doctors, nurses, clinic staff, medical (doctors, nurses, clinic staff, medical records, administration, educators, records, administration, educators, care managers, etc…)care managers, etc…)
Work is primarily microsystem-based Work is primarily microsystem-based – happens at the frontlines and – happens at the frontlines and involves many people as well as involves many people as well as information and ITinformation and IT
How Our Program is Different – How Our Program is Different – Assessment and AccountabilityAssessment and Accountability
Explicit expectation that residents use web-Explicit expectation that residents use web-based portfolio for reflection, evaluation, based portfolio for reflection, evaluation, collecting evidence of their workcollecting evidence of their work
Practicum Review Board—composed of Practicum Review Board—composed of organizational leaders—provides guidance in organizational leaders—provides guidance in development of Practicum year design, as well development of Practicum year design, as well as institutional supportas institutional support
Nationally prominent residency advisory Nationally prominent residency advisory committeecommittee
Clear expectation that residents will lead Clear expectation that residents will lead change and address sustainability of that change and address sustainability of that changechange
InnovationsInnovations
Combining Preventive Medicine with Combining Preventive Medicine with a wide variety of other specialtiesa wide variety of other specialties
Getting residents from different Getting residents from different disciplines in the same roomdisciplines in the same room
Putting residents largely in charge of Putting residents largely in charge of their own learning experiencestheir own learning experiences
More...More...
Residents develop different relationships Residents develop different relationships with faculty, staff, otherswith faculty, staff, others
Residents begin to “see” the Residents begin to “see” the microsystems they work in, and bring microsystems they work in, and bring their knowledge of how they “really” worktheir knowledge of how they “really” work
Attention to more than individual patient Attention to more than individual patient outcomes – residents love data!outcomes – residents love data!
More…More…
Residents experience improvement Residents experience improvement of care as an integral aspect of of care as an integral aspect of provision of careprovision of care
Residents function as leadersResidents function as leaders Focus is NOT on the exceptional, but Focus is NOT on the exceptional, but
on important aspects of education on important aspects of education and care that may seem mundaneand care that may seem mundane
What is the Learning What is the Learning Environment?Environment?
We often first think of “didactics”We often first think of “didactics” Then we might think about teaching Then we might think about teaching
on rounds, during procedures, etcon rounds, during procedures, etc Eventually, we begin to think about Eventually, we begin to think about
the constant learning that goes on in the constant learning that goes on in GME – many teachers, many learnersGME – many teachers, many learners
When does learning occur? And When does learning occur? And what learning are we talking about?what learning are we talking about?
What Residents Say: Some What Residents Say: Some Characteristics of Good Characteristics of Good Learning Environments Learning Environments
““Why” is clearWhy” is clear Opportunity to practice, apply Opportunity to practice, apply
learninglearning ImmersionImmersion Dialogue, two-way communicationDialogue, two-way communication Helpful structureHelpful structure Respectful, safeRespectful, safe
Other AspectsOther Aspects
Often feels good – but…Often feels good – but… Learning from mistakes is importantLearning from mistakes is important Teaching is learningTeaching is learning ““Embodiment”Embodiment” A little anxiety may be a good thing? A little anxiety may be a good thing?
Finding the right degree of autonomyFinding the right degree of autonomy
Environments for LearningEnvironments for Learning
Defined teaching and learning Defined teaching and learning opportunitiesopportunities
Clinical care environmentClinical care environment Inner environmentInner environment
Preparing the “Inner” Learning Preparing the “Inner” Learning EnvironmentEnvironment
Desire to learnDesire to learn CuriosityCuriosity Sense of safety Sense of safety Ability to reflect and effectively use Ability to reflect and effectively use
new knowledgenew knowledge Sense that it mattersSense that it matters Potential for joy in learning/workPotential for joy in learning/work
DHLPMR and the “Inner” DHLPMR and the “Inner” Learning EnvironmentLearning Environment
Residents (and faculty) asked to Residents (and faculty) asked to develop capacity for reflectiondevelop capacity for reflection
More time and spaceMore time and space Opportunity for work in teams, groups Opportunity for work in teams, groups
– good way to learn about oneself– good way to learn about oneself Knowing the work mattersKnowing the work matters FeedbackFeedback We often have a good timeWe often have a good time
Other DHLPMR Learning Other DHLPMR Learning EnvironmentsEnvironments
Classroom experiences (MPH) and Classroom experiences (MPH) and relationship to rotations/practicumrelationship to rotations/practicum
Defined learning opportunitiesDefined learning opportunities Microsystems and learningMicrosystems and learning
Awareness of assumptions and what is Awareness of assumptions and what is being/has been learnedbeing/has been learned
Learning from patients and othersLearning from patients and others Learning during all aspects of patient Learning during all aspects of patient
carecare
Supports for the DHLPMR Supports for the DHLPMR Learning EnvironmentLearning Environment
Portfolio as a living record of work and a way Portfolio as a living record of work and a way to shareto share
Competencies and expected developmental Competencies and expected developmental “pathway” clearly spelled out and regularly “pathway” clearly spelled out and regularly reviewedreviewed
Opportunities to practice new ways of workingOpportunities to practice new ways of working Connections outside one’s own disciplineConnections outside one’s own discipline Visibility and support – public Visibility and support – public
acknowledgment that resident work MATTERSacknowledgment that resident work MATTERS
Innovation and Improvement in Innovation and Improvement in the Learning Environmentthe Learning Environment
Our residents’ work is really about CHANGING Our residents’ work is really about CHANGING the learning environmentthe learning environment Learning about particular microsystemsLearning about particular microsystems Learning about our current processes of care and outcomesLearning about our current processes of care and outcomes Thinking about how to connect the best evidence to the work Thinking about how to connect the best evidence to the work
of microsystemsof microsystems Leading change within microsystems to improve those Leading change within microsystems to improve those
processes and outcomesprocesses and outcomes
Our work is really about supporting that Our work is really about supporting that change and continuing to understand what change and continuing to understand what we are learningwe are learning
Competence in the Learning Competence in the Learning EnvironmentEnvironment
Our work is really about assessing the Our work is really about assessing the competence of learners in an competence of learners in an environment that exemplifies environment that exemplifies competencecompetence
AND a key component of learner AND a key component of learner competence is the ability to help create competence is the ability to help create an increasingly competent environment an increasingly competent environment for learning and patient carefor learning and patient care