Creating a Competency-informed Learning Environment

1. Creating a Competency-informed Learning Environment Tina Foster MD, MPH Associate Program Director DHLPMR Dartmouth-Hitchcock Medical Center Lebanon, NH

3. What I Hope To Do • Briefly describe the Dartmouth-Hitchcock Leadership Preventive Medicine residency • Give some examples of things that feel innovative to residents, faculty, staff (and patients?) • Reflect on the learning environment(s) we are creating

4. What is DHLPMR? • Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program (DHLPMR) • Combined training in LPM and any other DHMC residency/fellowship • First graduate in 2005 • Focus on the improvement of patient care

5. Why DHLPMR? • To attract and develop physicians capable of leading the change and improvement of the systems where people and health care meet. In conjunction with existing clinical residency and fellowship programs, participants' academic, applied leadership and practicum experiences in preventive medicine will focus on measuring outcomes and improving the technical, service and cost excellence of care for patients and populations.

6. Another Way of Looking at It… • Our residents • Focus on a defined population of patients served by DHMC • Understand their outcomes and processes of care; identify opportunities for improvement • Lead change for the improvement of care for these patients • Develop specific competencies

7. DHLPMR Core Competencies • Leadership—including design and redesign—of small systems in health care. • Measurement of illness burden in individuals and populations. • Measurement of the outcomes of health service interventions. • Leadership of change for improvement of quality, value and safety of health care of individuals and of populations. • Reflection on personal professional practice & linkage of that reflection to ongoing personal and professional development.

8. Core Concept: The Clinical Microsystem • Small group of doctors, nurses, other clinicians • Administrative and support staff • Patients • Information and information technology • Working together for common clinical and business aims • Using shared information • Producing clinical outcomes

9. Which system is the unit of practice, intervention, measurement? Community, Market, Social Policy System Self-care System Macro-organization System Individual care-giver & patient System Microsystem

10. strategy • operations • people • certainty of cause & effect • shared importance IV V • balanced outcome measures III • understand system “particularities” • learn structures, processes, patterns II The Work: Science-based Improvement “Measured Performance Improvement” “Generalizable Scientific Evidence” “Particular Context” + • control for context • generalize across contexts • sample design I P. Batalden

11. Why Preventive Medicine? • Populations • Measurement • Systems • Leadership

12. Luxuries We Enjoyed… • Able to design residency “from scratch” – building on PM program requirements and the idea of “competency-driven” GME • Deeply committed team with incredible experience, knowledge, skills • Time to develop a shared mental model of what “it” would look like

13. Where Are We Now? • Five graduates to date • Currently have nine first year and eight second year residents, plus three who have completed the first year • Have combined with anesthesia, pain medicine, surgery, internal medicine, GI, ob-gyn, ID, pulmonary/critical care, family medicine, pathology, pediatrics, psychiatry • DHLPMR has attracted applicants to DHMC GME programs

14. What Sorts of Things Do our Residents Do? • Improve care for patients admitted with CAP • Improve safety and efficiency of sedation for selected endoscopic procedures • Improve provision of screening services in GIM clinic • Rapid Response Team implementation and outcomes • Improve medication management for major depression • Improve dx and tx of obesity in primary care clinic • Improve post-operative pain management • Improve advance directive process • Improve hand hygiene in perioperative areas

15. How Our Program is Different-the Residents • All residents in combined training, all maintain presence in both programs • No one is an intern • Residents (and faculty) from a variety of specialties are working together and learning from each other

16. How Our Program is Different – the Learning Experience • Residents design own learning experiences (with guidance and oversight) • Residents generally manage their own time • Faculty coaches and mentors—aided by a program of “coach development” • Clear expectation that residents will teach residents and faculty in their “home” programs • Program actively managed by a multidisciplinary team that works/meets every two weeks

17. How Our Program is Different – the Learning Environment • Most work is inter-professional (doctors, nurses, clinic staff, medical records, administration, educators, care managers, etc…) • Work is primarily microsystem-based – happens at the frontlines and involves many people as well as information and IT

18. How Our Program is Different – Assessment and Accountability • Explicit expectation that residents use web-based portfolio for reflection, evaluation, collecting evidence of their work • Practicum Review Board—composed of organizational leaders—provides guidance in development of Practicum year design, as well as institutional support • Nationally prominent residency advisory committee • Clear expectation that residents will lead change and address sustainability of that change

19. Innovations • Combining Preventive Medicine with a wide variety of other specialties • Getting residents from different disciplines in the same room • Putting residents largely in charge of their own learning experiences

20. More... • Residents develop different relationships with faculty, staff, others • Residents begin to “see” the microsystems they work in, and bring their knowledge of how they “really” work • Attention to more than individual patient outcomes – residents love data!

21. More… • Residents experience improvement of care as an integral aspect of provision of care • Residents function as leaders • Focus is NOT on the exceptional, but on important aspects of education and care that may seem mundane

22. What is the Learning Environment? • We often first think of “didactics” • Then we might think about teaching on rounds, during procedures, etc • Eventually, we begin to think about the constant learning that goes on in GME – many teachers, many learners • When does learning occur? And what learning are we talking about?

23. What Residents Say: Some Characteristics of Good Learning Environments • “Why” is clear • Opportunity to practice, apply learning • Immersion • Dialogue, two-way communication • Helpful structure • Respectful, safe

24. Other Aspects • Often feels good – but… • Learning from mistakes is important • Teaching is learning • “Embodiment” • A little anxiety may be a good thing? Finding the right degree of autonomy

25. Environments for Learning • Defined teaching and learning opportunities • Clinical care environment • Inner environment

26. Preparing the “Inner” Learning Environment • Desire to learn • Curiosity • Sense of safety • Ability to reflect and effectively use new knowledge • Sense that it matters • Potential for joy in learning/work

27. DHLPMR and the “Inner” Learning Environment • Residents (and faculty) asked to develop capacity for reflection • More time and space • Opportunity for work in teams, groups – good way to learn about oneself • Knowing the work matters • Feedback • We often have a good time

28. Other DHLPMR Learning Environments • Classroom experiences (MPH) and relationship to rotations/practicum • Defined learning opportunities • Microsystems and learning • Awareness of assumptions and what is being/has been learned • Learning from patients and others • Learning during all aspects of patient care

29. Supports for the DHLPMR Learning Environment • Portfolio as a living record of work and a way to share • Competencies and expected developmental “pathway” clearly spelled out and regularly reviewed • Opportunities to practice new ways of working • Connections outside one’s own discipline • Visibility and support – public acknowledgment that resident work MATTERS

30. Innovation and Improvement in the Learning Environment • Our residents’ work is really about CHANGING the learning environment • Learning about particular microsystems • Learning about our current processes of care and outcomes • Thinking about how to connect the best evidence to the work of microsystems • Leading change within microsystems to improve those processes and outcomes • Our work is really about supporting that change and continuing to understand what we are learning

31. Competence in the Learning Environment • Our work is really about assessing the competence of learners in an environment that exemplifies competence • AND a key component of learner competence is the ability to help create an increasingly competent environment for learning and patient care