Ignorance Is Not Bliss: A Practical Solution to ACGME Competency #6 Richard W. Schwartz, MD, MBA...

Ignorance Is Not Bliss: A Practical Ignorance Is Not Bliss: A Practical Solution to ACGME Competency #6Solution to ACGME Competency #6

Richard W. Schwartz, MD, MBAProfessor of Surgery/Associate Chief of StaffCommonwealth Professor of SurgeryDepartment of SurgeryUniversity of Kentucky

Shawn A. Ryan, BS, M3University of Kentucky, College of Medicine

ObjectivesObjectives

Review ACGME competency #6 requirements

Current issues and strategies Strategies and deficits: coalescence

and synergies A practical solution

ACGME Outcome ProjectACGME Outcome Project

Understand how patient care/practice affects other health care professionals, the health care organization and the larger society

Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources

Practice cost-effective health care and resource allocation that does not compromise quality of care

Advocate for quality patient care and assist patients in dealing with system complexities

Know how to partner with health care managers and heath care providers in order to assess, coordinate and improve health care/system performance

ACGME Competency #6 ACGME Competency #6 Summary/TimelineSummary/Timeline

“Residents [need to] demonstrate an awareness of and responsiveness to the larger context and system of health care and [have] the ability to effectively call on system resources to provide care that is of optimal value.”

June 2002-July 2006 (Phase 2) Provide learning opportunities in all six competency domains Improve evaluation processes as needed to obtain accurate resident

performance data Provide aggregated resident data for the program’s GMEC internal review

July 2006-June 2011 (Phase 3) Full integration of the competencies and assessment of learning/clinical

care Various RRCs are mandating 30-60 hours per residency term (3-5 years) Progress to date????

www.acgme.org/outcome

The ACGME Mandate and The ACGME Mandate and Academic MedicineAcademic Medicine

Systems based practice vs business of medicine: an issue of semantics

To term the 4th largest economy in the world (US healthcare) anything other than a business/industry is not realistic

Sends a false message to students and residents: results in organizational dysfunction

The American healthcare system (HCS) is a service-based industry (the largest in the world)

Unfortunately, it is arguably the most poorly managed service system in the world

Roger W. BabsonRoger W. Babson

“If things are not going well with you, begin your effort at correcting the situation by carefully examining the service you are rendering, and especially the spirit in which you are rendering it.”

The Role of Faculty/HCSThe Role of Faculty/HCS

As faculty/HCS, we should model both the micro and macro aspects of a properly functioning HCS

Our responsibility: to teach this model to the residents in order that they may understand and properly utilize its assets

Milton Friedman Milton Friedman

“Fundamentally, there are only two ways of coordinating the economic activities of millions. One is central direction involving the use of coercion – the technique of the army and of the modern totalitarian state. The other is voluntary cooperation of the individuals – the technique of the marketplace.”

The OpportunityThe Opportunity

Residents: lower savings and higher debts than general public (lifestyle a major factor) Surgery residents the most “profligate” of all specialties Lack of budgeting correlates with indebtedness

GME programs should provide: Budgeting expenses Credit/debt management Long-term financial planning

The teachable moment Personal interest/need to know necessary Systems performance will improve with individual change

Teichman, et al. “How do residents manage personal finances?”. American Journal of Surgery. 2005; 189:134-139

Residents Currently Lack Training Residents Currently Lack Training in the Mandated Subjectsin the Mandated Subjects

78% response rate: importance of topic 63%: business/practice management necessary during

the teachable moment (years 2-5) 34%: no exposure to subjects 6%: 8-12 hours per academic year RRC: 30-60 hours per residency term Program directors survey conclusions

87%: necessity for education in areas 70%: residents inadequately trained in areas

Lusco, V., Martinez, S., and Polk, H. “Program directors is surgery agree thatresidents should be formally trained in business and practice management”. American Journal of Surgery. 2005; 189:11-13

Residency Directors Agree: mandates Residency Directors Agree: mandates not met and residents not educatednot met and residents not educated

Surgeons in PracticeSurgeons in Practice

133 surgeons surveyed in the midwest Knowledge rated in 11 business topics relevant to the

business practice of medicine Survey demonstrated that on average, they felt poorly

equipped to understand: basic financial accounting principles financial markets economics of healthcare tools for evaluating purchases marketing and budgets antitrust, fraud, and abuse regulations risk and return on investments

Satiani, B. “Business Knowledge in Surgeons”. American Journal of Surgery. 2004;188(1):13-16.

Conclusion and RecommendationConclusion and Recommendation

“Development of simple curricula aimed at preparing surgical residents for business and practice management could promote the contemporary education of surgeons.”

Lusco, Martinez, and Polk. American Journal of Surgery. 2005; 189:11-13

An Obligation to Repair the An Obligation to Repair the Current Health Care Situation Current Health Care Situation After WWII, the government became

involved in American healthcare: professional managers were hired and physicians began to relinquish control of the system

70 years later, all constituents are paying the price for this abrogation of responsibility

Physicians have as much fiscal responsibility to American healthcare as professional managers (if not more)

T. W. Nolan, 1998T. W. Nolan, 1998

“The prominence of physicians in highly interdependent medical systems confers tremendous power on them, individually and as a profession. With this power comes an ethical responsibility to be deeply concerned about medical systems as a whole.”

Physicians are in a unique position of knowledge and leadership that will allow us to effect/affect necessary change, if we are properly educated in how to use these competencies

Physicians Can No Longer Claim Physicians Can No Longer Claim Ignorance to Their Lack of Business Ignorance to Their Lack of Business CompetenceCompetence

“Very few doctors understand what is happening to the health care system in which they practice, why the system is changing so rapidly, and what they can do about it”

Relman, 1998

Obstacles to Implementing the Obstacles to Implementing the Mandates/RecommendationsMandates/Recommendations

Time Surgical residents are already having

difficulty including all of their clinical, administrative and educational duties in the 80 hour work week

This leaves very little opportunity for sheltered educational time to be increased

Cost No increased governmental funding has been

allocated to assist with the development/implementation of these competencies

Most AMC/private programs do not have the necessary intellectual or monetary capital Financial resources not available internally or via

outsourcing Intellectual capital not present in most AMC or private

practice residencies


Views of program directors Michigan State program directors view the

execution of the ACGME competencies as, “extremely labor-intensive without guaranteeing a productive outcome”

This is probably a widely held perspective

Taylor, D.K. et al. “Doing it well: demonstrating general competencies for residenteducation utilizing the ACGME Toolbox of Assessment Methods as a guide forimplementation of an evaluation plan.” Medical Education. 2002; 36(11);1102-03.


Program directors at the University of Arkansas believe that they are not well prepared to meet the requirements of the competencies

They site such barriers as: Amount of available program director time Amount of residency protected time for curriculum Amount residency support staff Lack of expertise in curriculum development and evaluation

and lack of funding for resources other than personnel

Heard, J.K. et al. “Assessing the needs of residency programdirectors to meet the ACGME general competencies.” Academic Medicine. 2002: 77(7)


Views of Residents In one of the few trials of a suggested assessment method

(360-degree assessment), cardiothoracic residents were despondent about the experience They expressed irritation about the method and its role in their

education They also devalued the feedback from non-physician raters and

were reluctant to accept it as meaningful Higgins, et al. “Implementing the ACGME general competencies in a

cardiothoracic surgery residency program using 360-degree feedback.”Annals of Thoracic Surgery. 2004;77(1):12-17.

Residents need motivation to learn/utilize novel educational principles/tools: provide them with practice management/personal finance training


AssessmentAssessment

According to the ACGME key considerations, assessments should: Provide valid (internally and externally) and

reliable data Feasible approaches: correlated to the time,

training, technology and cost necessary to implement the assessment

Provide valuable information and impart new and useful data that facilitates learning, teaching and modification of the the method, if necessary

ACGME: Best Methods of ACGME: Best Methods of Assessment for Competency #6Assessment for Competency #6

360 degree assessment Very time consuming and expensive

CT resident example: development cost of $500 and cost per resident $300 (Higgins: 2 surveys per year)

Although this type of assessment is beneficial (because it includes the residents’ sphere of influence) it is really only feasible as an online model (Dyne et al)

ACGME Toolbox of Assessment Methods: an electronic system could make this feasible for the individual resident and the program in terms of time and monetary commitments

Higgins et al. Annals of Thoracic Surgery. 2004;77(1):12-17.

Dyne, P.L. et al. “Systems-Based Practice: The Sixth Core Competency”. Department of Emergency Medicine, UCLA. 2002

Written Examination (MCQ) These tests are developed by a panel of

experts on a certain subject Development and inter-program reliability

difficult to achieve at each program Should be web-based with flexible testing

times, completion monitoring and rapid score return


Checklists: major issues Require trained evaluators to observe performance Time [needed] to complete a checklist can vary greatly

Portfolios and OSCEs: major issues Expensive Time-consuming

acgme.org/outcome


Competency # 6: Strategies to DateCompetency # 6: Strategies to Date

The ACS Education Task Force has chosen to focus on patient safety

This initiative addresses one of four important foci for healthcare systems

Market demand increasing for outcome measures (Leapfrog, etc)

Healthcare system report cards: THE FOUR ISSUES Safety (and clinical outcomes) Internal/external customer satisfaction Financial performance Organizational performance

Course: "Health Care Leadership: An Adaptation of Aviation Team Training to Surgery”

Course: “Surgeons as Leaders” Internet-based educational program on

morbidity and mortality conferences Internet-based educational program to

address systems-based practice in surgery using a case-based approach

ACS Leadership Efforts: Current ACS Leadership Efforts: Current Courses and ProgramsCourses and Programs

University of Miami School of Medicine Medical student curricula: didactic sessions and practical

experiences about the clinical, managerial, financial and ethical aspects of systems-based care

3rd year: students in administrative offices for day-long series of presentation/discussions and experiential tours in a private, tax-sheltered healthcare entity

Currently, this can only be achieved through a partnership with private healthcare corporations (understanding that profit is “healthy”/necessary)

O'Connell, M.T. et al. “A curriculum in systems-based care: experiential learningchanges in student knowledge and attitudes.” Family Medicine. 2004;36:S99-104.

A Unique Approach: The A Unique Approach: The Beginning of a SolutionBeginning of a Solution

Winston ChurchillWinston Churchill

“It is a socialist idea that making profits is a vice; consider the real vice is making losses” W.C.

Without profit, healthcare systems erode (from many different perspectives) and, therefore, will deliver increasingly poor/less service

Southern Illinois University Department of Surgery

12 months were spent by each resident on one of the hospital quality improvement/patient safety committees

Outcomes residents were resistant to this method benefit/cost ratio was only moderate very time consuming for the residents

Williams, R.G and Dunnington,G.L. “ACGME core competenciesinitiative: the road to implementation the surgical specialties”.Surgery Clinics of North America. 2004;84:1621-46.

Safety as the Initial Approach: A Safety as the Initial Approach: A Part of the SolutionPart of the Solution

CHESS (Clinical Health Economics System Simulation): Voss, UVA

a computerized team-based quasi-competitive simulator delivers the principles of health economics Provides practical application of principles learned

Voss, J.D. et al. “The Clinical Health Economics System Simulation(CHESS): A Teaching Tool for Systems- and Practice-Based Learning.”Academic Medicine. 2005; 80(2)129-34.

CHESS: One More Part of the CHESS: One More Part of the SolutionSolution

Simulates treatment costs to patients and society , and reimbursement to physician

Residents are asked to explain findings and may change treatment options and other variables to conduct sensitivity analyses in real time

Resident and faculty participants at 19 U.S. residency programs preferred CHESS to a traditional lecture-and-discussion format

98% reported increased knowledge of health economics CHESS demonstrates the potential of computer

simulation to teach health economics, practice-based/systems-based competencies

CHESS: One part of the SolutionCHESS: One part of the Solution

Efforts to Date: Pointing Towards Efforts to Date: Pointing Towards a Solutiona Solution

These novel approaches both incur major investments of time and capital University of Miami: how feasible? Southern Illinois: major resident time involvement CHESS (UVA): $50,000 to develop a short web-based

interactive program

Neither approach satisfies ACGME curricular mandates Systematic coverage of necessary topics Assessment/documentation of performance

ResidencyResidency Program Obligations Program Obligations

Effective and efficient training in these areas Safety and clinical outcomes Internal/external customer satisfaction Financial performance Organizational performance

Performed with realistic time and availability commitments

Achieved in the most cost effective way possible

A Practical Solution to These A Practical Solution to These Major IssuesMajor Issues

Sachdeva: web-based evaluations the future measure the competencies of the residents didactic education consistently fails to change physician

behaviorSachdeva, A.K. “Acquisition and maintenance of surgical

competence.” Seminar in Vascular Surgery. 2002; 15(3):182-90

Solution: combine the aforementioned simulation/teaching programs/evaluations into a 24/7, comprehensive web-based course

24/7 web-based 24/7 web-based education/evaluationeducation/evaluation

Most efficient for residents because it can be accessed anywhere, anytime

Online evaluations provide constant feedback on fulfillment of requisites and performance to residency directors

Basic curricula can be developed for every type of residency, with program specific customization

PetroniusPetronius

We trained hard – but it seemed that every time we were beginning to form into teams, we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and what a wonderful method it can be for creating the illusion of progress while producing inefficiency and demoralization

High Performance Teams and High Performance Teams and Expert Cultures: A Major ProblemExpert Cultures: A Major Problem

Surgical clinical care delivery/outcomes are based on team performance: do they perform like industry standard high-performance teams?

Expert cultures: academics (organized anarchy) and medicine

These two cultures yield HCS/AMC: a synergism of organized, rewarded dysfunction

Local Experiential Training: A Local Experiential Training: A NecessityNecessity

An important part of the educational experience that should be linked with a generic 24/7 curriculum

Needs to be incorporated in residency years 2-5

Performed in a service line which correlates with the residents interests/specialty

Should be coordinated with the healthcare system at-large in order to address organizational and leadership issues

The Solution: Partnership with The Solution: Partnership with Necessary CapitalNecessary Capital Find an entity with the necessary intellectual and monetary capital

Foundations Corporations Government

For-profit healthcare corporations have already developed similar programs for other uses (primarily employee education) Financial services Pharmaceuticals

Partnership could fund/provide/modify web-based courses to meet stated needs at no cost to healthcare systems/residency programs Cost: $15,000-$20,000 to develop one hour of an interactive educational

module on-line Developed programs can be customized for 10-20% above cost

The Invisible Hand – Adam SmithThe Invisible Hand – Adam Smith

“…self-interest guides the most efficient use of resources in a nation’s economy, with public welfare coming as a by-product”

“…state and personal efforts, to promote social good are ineffectual compared to unbridled market forces”

Motivation for All Constituents: Motivation for All Constituents: The “Invisible Hand” at WorkThe “Invisible Hand” at Work

AMC/ residency programs RRC requirements/obligations met Health systems performance improved

Residents Obtain practice/personal finance training Provided during the teachable moment

For-profit Companies Communication/marketing with Physicians Vested interest in proper resource usage

Government/Foundation: improves healthcare systems performance for all market constituents in a value-added manner

The ProposalThe Proposal

The ACS, APDS, ASE and Surgery RRC take the lead and partner with a for-profit corporation, foundation or government entity to build such a platform

This consortium then systematically enlists all the other specialties/colleges/RRCs in the effort

Ignorance Is Not Bliss: A Practical Solution to ACGME Competency #6 Richard W. Schwartz, MD, MBA...

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