1	“Crouching Tiger, Hidden Dragon”: Managing the ACGME competency mandate
2	I have no financial interest in the contents of this talk
3	Iowa population Kinnick Stadium Des Moines 196,093 Cedar Rapids 122,542 Davenport 97,512 Sioux City 83,876 KINNICK STADIUM 71,000 (on game day) Waterloo 67,054 Iowa City 63,807 Council Bluffs 58,656 Dubuque 57,204 Ames 53,284
4	Nyle Kinnick 1939 Heisman Trophy Phi Beta Kappa Senior class president Turned down NFL Accepted to law school
5	Multiple awards Heisman Trophy 1939 Walter Camp Award 1939 Maxwell Award 1939 All-America 1939 Big Ten MVP 1939 No. 24 Iowa jersey retired College Football Hall of Fame 1951 Kinnick Stadium named 1972 Named Iowa’s greatest player 1989
6	Nyle Kinnick Killed in WW 2 (1943 training mission)
7	7 steps to finding your “Crouching Tiger” & releasing your “Hidden Dragon! Accept reality & end denial Inventory your current teaching resources Teach & Assess simultaneously Start small but start now Pick low hanging fruit first Show success over time Be a champion
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9	Nothing is impossible…. Yeah, for those who don’t have to do it I was angry I was afraid I was staring at an empty toolbox I was having to look up the definitions of competencies every time I was wondering what the heck is “systems based practice”
10	The ACGME competencies Medical knowledge Patient care Communication & interpersonal skills Professionalism Practice based medicine Systems based care
11	Vision vs. Action Unfunded mandate Program Directors: “How are we going to do this?” ACGME: “Bring us something and we will tell you if it is right”
12	Vision vs. Action Vision without Action = Daydream Action without “Vision” = Nightmare Action with vision = Outcomes project
13	Rationale for change: Why should you care? Public wants it: 100K lives campaign Industry wants it: GM $1700 per car on healthcare (not competitive) Government wants it: P4P Hospital wants it: QA, PI, TQM ACGME wants it: Proof of competence Board wants it: Proof of quality Learners need it: Credentialing, Accreditation, Licensure, Certification You need it:…wait a minute? Did he just say I need it?....We’ll come back to that….
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15	Competency based pathway
16	Competency-Based Accreditation-Certification
17	The real message of this talk on the Competencies… It’s not just about the residents…. It’s about YOU and future of medicine
18	Who is ACGME?....Depending on your perspective
19	Update: Refusal This is an invalid option….
20	Anger….not helpful at this point
21	RRC competency requirements: “They’re here….” RRC requirements related to methods Competency Assessment Forms (CAF) RRC program requirements (PIF) site visit RRC resources, Board requirements
22	Immobilization Just hanging on isn’t good enough either
23	Take this warning seriously: The Competencies are here to stay
24	Hiding from the problem wont work in this setting
25	Kubler Ross in action
26	Acceptance = End Denial
27	Also = Fight apathy
28	Self-reflection exercise: Which of the following animals best describes your systems “Competency” readiness Lizard Tiger Elephant Dolphin Puppy Dog Ostrich Bigfoot
29	Lizard Skittish, small, meek Tries to blend in & hide Runs away when threatened Might never it see again If you grab it by tail, tail might shed & you with it
30	Elephant Big, lumbering Bureaucratic, difficult to change direction Can be trained If you grab the tail, ignores you Might still be able to hitch a ride
31	Puppy dog Excitable Enthusiastic Trainable May run in circles for hours chasing its tail …but clueless
32	Ostrich Seen the competencies But in denial Doesn’t want to talk about it Tail feathers for show only Hopes it will go away
33	Bigfoot Elusive, rarely seen Hidden Big Scary Has no known tail Might not exist
34	Tiger Powerful Can not be told what to do Might be trainable but still dangerous Might get angry and eat you …but a powerful ally if on your side Grabbing the tail is usually a bad idea
35	Dolphin Intelligent Gregarious Cheerful Willing to help If you grab the tail will take you where you need to go
36	Self-reflection exercise: Which of the following animals best describes your systems “Competency” readiness Lizard Tiger Elephant Dolphin Puppy Dog Ostrich Bigfoot
37	Inventory your educational resources You don’t know what you don’t know Time for self-reflection Do you want to see you hidden dragon? Describe your current teaching curriculum
38	Your hidden curriculum: the crouching tiger Lectures Medical knowledge Rotations Role modeling professionalism Journal club Practice based learning Resident research Practice based learning Grand rounds Communication Morning report Interpersonal skills Team rounds Systems based practice Morbidity conference Root cause analysis Talking about cases Chart stimulated recall
39	In other words…. You are teaching these competencies now! You know this implicitly You just don’t call it the same thing that ACGME speak calls it
40	Your hidden curriculum: the hidden dragon Current ACGME speak modifications Lectures Pre- & post-test, grade speakers Rotations 360 evaluation (peer, patient) Journal club Structured checklist, chart audit Resident research Structured checklist, portfolio Grand rounds Portfolio, attendee evaluation Morning report Structured checklist-observation Team rounds Self-reflection projects Morbidity conference Chart audit, practice improvement Chart rounds Chart stimulated recall
41	In other words… You are doing these things now You just aren’t collecting the data! Teach & Assess at the same time
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43	More detailed example: Morbidity & Mortality conference Old paradigm Attendance Presentation Drink coffee “Interesting case!” See you next week New paradigm Pre-test/Post-test Evaluate presenters Review literature Link with journal club Chart audit Self-reflection project Root cause analysis Systems based repair Portfolio
44	Hidden pictures (Hidden curriculum, hidden dragon)
45	How many competencies can you find? (Hidden curriculum) Medical knowledge Patient care Communication & interpersonal skills Professionalism Practice based medicine Systems based care
46	Practice-based learning Self-reflection Quality or practice improvement Self-reflection on practice Quality improvement project for portfolio
47	Integration of SBL Clinical teaching (payer mix, billing, coding, resource utilization, cost) Mock financial reports Patient bill (cost) analysis Pharmacy print out (prescribing patterns, formulary choices, generics)
48	Professionalism Mentoring/role modeling Discussions of respect, compassion, integrity, ethics via case based learning Self reflection narrative (portfolio) Reflection on best practices (best mentors, role models) Hospital Ethic’s Committee
49	Resident-system based measures to reduce medical errors Simulation/rehearsal of potential responses in safe (non-live) setting Coordination of team effort to reduce variation in care & ensures standard of care Transparency of system to reduce exposure of inexperienced or duty-fatigued resident to critical patient care Institutional culture that encourages “asking for help” & eliminates stigma of asking Leach and Philbert. JAMA 296:1132.
50	You say “tomatah” I say “tomahto” (ACGME-speak) Quality & safety Clinicians, staff, engineers Waste reduction, flow, throughput Reduce medical error Evidence based medicine Performance benchmarks ACGME-speak Residents in system Systems based care Communication skill Interpersonal skill Practice based care
51	360 degree evaluation Faculty (beware Hawthorne effect) Peer review Patient satisfaction Nurses, staff, medical students Informed consent observation Residents as teachers
52	360 degree evaluation
53	Sometimes “unprofessionalism” = “problem resident” because resident has other problems (substance abuse, fatigue, marital, stress, illness)
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55	Start small: Don’t bite off more than you can chew!
56	Pick low hanging fruit first
57	You need a matrix…Neo!
58	ACGME: What is the matrix?…what will your answer be??….
59	ACGME: PIF What is the matrix?…what will your answer be??….
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61	Making the hospital matrix work for you… Quality measurements Sentinel events Near misses (clusters of events) 100,000 lives campaign Infection control Disaster preparedness Patient satisfaction
62	Show small success…you have to crawl before you walk (celebrate small steps)!
63	Sometimes only one tool will do the job
64	But you cant over rely upon one tool either
65	You cant overwork your faculty…You can not ask everyone to do everything
66	What do I mean…. Ask more people to do less Ask fewer questions of more people Only ask people questions that they can answer Answer the question with multiple observations & multiple times
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68	Be the local champion!
69	Hand holding, back patting, wrist slapping
70	Jagger et al… You cant always get what you want but if you try sometimes you might find…. You get what you need
71	Self-reflection exercise part 2: How do you convert your current system to “Competency” ready? Lizard Tiger Elephant Dolphin Puppy Dog Ostrich Bigfoot
72	Waiting for the green light from above is futile
73	Waiting for perfect conditions is not an option
74	Experimental innovation requires some risk
75	Success is not possible without the some risk of failure
76	“Anyone who has not made a mistake has not tried anything new.” Albert Einstein
77	Sometimes novel solutions are required
78	You have to be flexible
79	We have to make the message understandable to our target audience
80	Some things don’t need to be said
81	We all need encouragement sometimes
82	Incentives need to be aligned with objectives
83	If it is too long, no one will read it
84	We need alignment of our curriculum goals, teaching plan, assessment tools, & outcomes
85	All the signs need to point the same direction Hospital College of Medicine GME office Departments Chairs PDs Faculty Residents
86	Your ACGME intergalactic decoder ring has arrived (*Schmidt C, Residency Assistance Page 2006)
87	We’re all talking about same things & if we don’t use same language…. Professionalism Medical ethics Risk management Managing conflict of interest The “problem resident” Practice based learning Evidence based medicine Quality markers & Pay for performance Performance benchmarks Systems based learning Patient safety (near miss analysis) Reducing medical error (root cause) Electronic medical record
88	No one is as smart as us all
89	Summary: 7 steps to find your crouching tiger and release your hidden dragon! End Denial Inventory your current teaching resources Teach & Assess simultaneously Start small Pick low hanging fruit first Show success over time Be a champion
90	ACGME: “Nothing is impossible?” A story about “Why” we are doing this? Nyle Kinnick Desmond Doss 300 Spartans
91	PFC Desmond Doss
92	April 1945 Okinawa
93	Maeda Escarpment Okinawa May 5, 1945 400 foot high jagged escarpment Company B: 75 men wounded Trapped at top of the cliff Doss under fire lowered 75 wounded down cliff He did not stop until he was done 12 hours & multiple wounds to himself later!
94	Desmond Doss received Medal of Honor
95	Desmond Doss…the cool part… Doss was a conscientious objector!!!! Carried no weapon on Okinawa Refused to kill But did not refuse to serve He volunteered in fact
96	Courage “Courage is not the absence of fear but the judgment that something else is more important than fear”
97	It only takes a few with courage to make a difference ….300 Spartans at Thermopylae King Leonidas (480 BC) 300 Spartans! Held Persian advance 250K to 1 million Persians
98	Nothing is impossible for those with a strong enough “Why!” Desmond Doss knew that Nyle Kinnick knew it too So did the 300 Spartans How strong is your Why?
99	“We have to balance time/money against this competency thing”
100	An inconvenient truth: Earth in the balance
101	What is at stake? Our residents, you, & the future of education are in the balance
102	Rationale for change: Why should you care? Public wants it: 100K lives campaign Industry wants it: GM $1700 per car on healthcare (not competitive) Government wants it: P4P Hospital wants it: QA, PI, TQM ACGME wants it: Proof of competence Board wants it: Proof of quality Learners need it: See above You need it…MOC, CME, P4P, QAC….all the same competencies at play!
103	I wish all of you could convert your system to “the Dolphin” … at the very least you should Find your crouching tiger….Release your hidden dragon
104	Thank you for your time and attention