ARCHIE : Achieving Resident Competence & Humanism through Innovative Education .

1. ARCHIE: Achieving Resident Competence & Humanism through Innovative Education. Aurora Internal Medicine Residency Milwaukee, Wisconsin

2. Welcome to Milwaukee!

3. Project Planning: Advisory Board • Representatives from various Aurora entities for feedback & input. • Various professional perspectives on training modification. • Develop training opportunities and mentors in Aurora settings. • “Top 10” list generated.

4. “Top Ten” • Ability & confidence to care for spectrum of disease without referring, knowing when to consult specialists, manage multiple illnesses. • Use resources, tests, and specialists judiciously. • Efficiently and effectively use information in clinical decision making. • Solid communication/interview skills. • Self-assessment and self awareness.

5. Top Ten cont’d • Understand and consider patient’s culture & preferences. • Knowledge & understanding of quality improvement processes. • Effectively work as a team member with nursing, social services, pharmacy. • Understanding financial issues of practice (coding, billing, efficiency). • Procedural skills, derm skills, outpatient procedures

6. Project Goals • Development of PGY1 “immersion months” in ambulatory medicine, hospital medicine & interdisciplinary care. • Implementation of a resident report card that tracks clinical performance on inpatient & outpatient indicators. • Modify our core curricula to a competency-based format. • Develop a flexible “phase 2” of resident education with individualized learning.

7. Goal 1: Apprenticeship Experiences Opportunity in which interns work closely with faculty mentors for establishment and assessment of foundational skills Ambulatory month: intern will work closely with attending physician in outpatient setting. Inpatient month: intern will work closely with attending hospitalist physician.

8. Apprenticeship Experiences Interdisciplinary care month • Interns will spend a month working with nursing and social services to learn critical elements of hospital care. • Spend 2 weeks with unit nursing staff & pharmacy staff. • Spend 2 weeks with social services staff • Goal is to understand the team nature of health care and how to effectively work as part of the team.

9. Goal 2: Resident “Report Card” • Track residents’ patient “indicators” through our EMR for ongoing monitoring & quality improvement. • Uses our care management system (ambulatory & inpatient). • Includes other practice habits… problem lists, med lists

10. Diabetes Cholesterol in coronary artery disease Congestive Heart failure Asthma Influenza Advanced directives Osteoporosis Colorectal CA screening Breast & Cervical CA screening. Smoking Cessation Ambulatory Patient Indicators

11. Inpatient Indicators AHC tracks performance on inpatient conditions as part of Premier and the CMS demonstration project: • Acute Myocardial Infarction • Congestive heart failure • Community acquired pneumonia • Stroke

12. Medical Record “Integrity” • Track “practice” variables such as: • Tests ordered • Test cost • Problem lists on clinic patients • Medication lists for clinic patients • Time to dictation

13. Goal 3: Modification of Core Training Shift to a competency-based process rather than completion a proscribed amount of time. Define core skills for each venue of practice (i Refine evaluation methods to assess competence. Pair clinical indicator performance with educational assessment.

14. Sample Ambulatory Competencies Patient Care: Conduct focused & relevant exam, obtain appropriate history. Medical Knowledge: Appropriately diagnosis/treat common acute and chronic conditions. Communication: Efficiently & effectively determine patient’s priorities for visit. Use point of care evidence/information appropriately and effectively. .

15. Ambulatory Competencies cont’d • Efficiently use the resources of the system to provide ambulatory care. • Work as an effective member of the care team. • Review practice data and identify areas for improvement

16. Goal 4: Individual Learning Plans • “Second phase” after completion of core training and achievement of competency • Residents select experiences to meet career goals. • Optimize training for best “fit” into desired practice. • Acquire specific procedural competence for planned practice. adeptness in area of career interest and need.

17. Evaluation& Assessment Learner Assessment: • Direct observation of performance (CEX, mini-CEX) • Videotaping—standardized format • Simulation exercises • Clinical performance indicator review • QI project performance assessment

18. Program Evaluation • Gathering baseline data now. • Focus groups before & after implementation (patients, nurses, social services). • Longitudinal tracking of inpatient and outpatient indicators. • Resident perceptions and feedback are critical. • Feedback from fellowship directors & employers. • Annual reporting of progress and outcome indicators.

20. Project Barriers and Challenges • Impact on recruitment • Decrease in resident service coverage • Changing evaluation processes • Budgetary issues • Flexibility & adaptability • Maintaining focus and achieving progress • Increased IS support & data collection infrastructure

21. ARCHIE Questions?