Residents In Difficulty

2. Residents In Difficulty LTC Douglas Maurer, DO, MPH, FAAFP Faculty Development Fellowship Program Director

3. Is this resident’s performance below the line??

4. Discuss a resident in difficulty that you have worked with What were the issues? How did you deal with the problem? What would you do differently? Be prepared to share With Your Neighbor

5. Discussed your experiences Listed common resident problems Categorized those problems Reviewed a model for dealing with residents in difficulty Applied that modelto cases Objectives

6. Act swiftly… investigate and remediate Document, document, document Focus on program requirements Use a model to guide you Follow your due process policy Take Home Points

7. 1. Academic – learning difficulty Knowledge Skills Attitudes 2. Disciplinary Usually breaking rules or laws 3. Impairment/Disability Avoid temptation to diagnose Three Kinds of Difficulty

8. Academic 53 Behavior/attitude 20 Knowledge base 28 Others 5 Discipline 13 Impairment/disability 11 Past PD Responses

9. Examples • Timely documentation/completion of annoying but necessary admin tasks • Gen Y provides challenges in their attitude towards service above self • Unprofessional • Severe time management difficulties • “Ownership" of patient, rather than rushing to leave at the end of the day

10. Identified problem earlier Documented earlier Started remediation earlier Acted earlier I Wish I Would Have…

11. Warning Signs • Avoidance, no interest • Poor performance, task completion • Poor or inappropriate interactions • Tardiness, poor time management • Falling behind in charting • Excessive griping – moody • Complaints by others

12. Be Careful Saying… “Just ignore it” “They’ll grow out of it” “They’re having personal problems” “It might be just this once”

13. Barriers and Pitfalls • Fear of being the “bad guy” • No staff consensus on “The Line” • Personality conflict with resident • Personal attacks • Fear avoidance of conversations • Time • Amount of documentation required

14. Other Pitfalls Big hearts Trying to be a provider Halo effect Being a fixer Conspiracy of silence

15. What would you do now? Dr. White Cloud

16. Above the line vs. below the line… Resident prerogative vs. Program prerogative Nancy Stevens MD, Univ. of Wash. A Model to Guide You

17. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action

18. For problems that remain the resident’s prerogative to resolve Work-up Cycle

19. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives “The Line” PROBATION CYCLE Program/Faculty Prerogatives

20. Regular opportunities for: Assessing, guiding, and reassuring Identify problems for further “work-up” Acting early Verbal feedback Documenting Routine Resident Evaluation

21. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize “The Line” PROBATION CYCLE Program/Faculty Prerogatives

22. Discuss with resident ONLY Ask, Tell, Ask, Act Possible causes of situation? Respect resident’s perspective Document conversation Task 1: Problem Focus& Hypothesize

23. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? YES Provide assistance Concern Remains? YES NO “The Line” Probation Justified? PROBATION CYCLE Program/Faculty Prerogatives

24. Focus only on area of agreed need Plan help jointly with the resident Be specific in comments Monitor plan for effectiveness Inform resident when done A good situation for a learning contract?! Task 2: Provide Assistance

25. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Resident Agrees? Gather data & evaluate for Perception / Value differences YES YES NO Provide assistance Concern Remains? Concern Remains? YES YES NO NO “The Line” Probation Justified? PROBATION CYCLE Program/Faculty Prerogatives

26. Differences in perception Assist resident to collect data on future events Differences in values Help resident articulate value positions Identify behaviors likely to result in conflict Communicate the likely consequences Task 3: Gather InformationAround Differences

27. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Resident Agrees? Gather data & evaluate for Perception / Value differences YES YES NO Provide assistance Concern Remains? Concern Remains? YES YES NO NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives

28. For problems that become the program’s prerogative to resolve Probation Cycle

29. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES Monitor performance, Recommend interventions PROBATION CYCLE Program/Faculty Prerogatives

30. Program level remediation Hospital level probation Requirements clearly identified Assistance/remediation plan explained Objective criteria to assess improvement Timeline for resolution Task 4: Probationary Monitoring

31. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action

32. End remediation & begin routine evaluation Begin probation End probation Extend probation Terminate Task 5: Administrative Action

33. In groups discuss the cases… Performance above or below the line? What course of action would you take? How would you document this? Appoint a spokesperson Share your plan with the larger group Cases

34. The Tardy Resident Case 1

35. The Inefficient Resident Case 2

36. The Depressed Resident Case 3

37. The Severely Ill Resident Case 4

38. Reduced Knowledge Resident Case 5

39. The Administratively Challenged Resident Case 6

40. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action

41. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action

42. Act swiftly…investigate and remediate Document, document, document Focus on program requirements Use a model to guide you Follow your due process policies Take Home Points

43. Document early Document at the time of the event Document during the work up cycle Document during the probation cycle Document, document, document Documentation

44. Thank You