Creating a Competency-Creating a Competency-informed Learning informed Learning

EnvironmentEnvironment

Tina Foster MD, MPHTina Foster MD, MPHAssociate Program DirectorAssociate Program Director

DHLPMRDHLPMRDartmouth-Hitchcock Medical CenterDartmouth-Hitchcock Medical Center

Lebanon, NHLebanon, NH

What I Hope To DoWhat I Hope To Do

Briefly describe the Dartmouth-Briefly describe the Dartmouth-Hitchcock Leadership Preventive Hitchcock Leadership Preventive Medicine residencyMedicine residency

Give some examples of things that Give some examples of things that feel innovative to residents, faculty, feel innovative to residents, faculty, staff (and patients?)staff (and patients?)

Reflect on the learning Reflect on the learning environment(s) we are creatingenvironment(s) we are creating

What is DHLPMR?What is DHLPMR?

Dartmouth-Hitchcock Leadership Dartmouth-Hitchcock Leadership Preventive Medicine Residency Preventive Medicine Residency Program (DHLPMR)Program (DHLPMR)

Combined training in LPM and any Combined training in LPM and any other DHMC residency/fellowshipother DHMC residency/fellowship

First graduate in 2005First graduate in 2005 Focus on the improvement of patient Focus on the improvement of patient

carecare

Why DHLPMR?Why DHLPMR?

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

Another Way of Looking at Another Way of Looking at It…It…

Our residentsOur residents Focus on a defined population of patients Focus on a defined population of patients

served by DHMCserved by DHMC Understand their outcomes and Understand their outcomes and

processes of care; identify opportunities processes of care; identify opportunities for improvementfor improvement

Lead change for the improvement of care Lead change for the improvement of care for these patients for these patients

Develop specific competenciesDevelop specific competencies

DHLPMR Core CompetenciesDHLPMR Core Competencies

Leadership—including design and redesign—of Leadership—including design and redesign—of small systems in health care.small systems in health care.

Measurement of illness burden in individuals and Measurement of illness burden in individuals and populations.populations.

Measurement of the outcomes of health service Measurement of the outcomes of health service interventions.interventions.

Leadership of change for improvement of quality, Leadership of change for improvement of quality, value and safety of health care of individuals and value and safety of health care of individuals and of populations.of populations.

Reflection on personal professional practice & Reflection on personal professional practice & linkage of that reflection to ongoing personal and linkage of that reflection to ongoing personal and professional development.professional development.

Core Concept: The Clinical Core Concept: The Clinical MicrosystemMicrosystem

Small group of doctors, nurses, other Small group of doctors, nurses, other clinicians clinicians

Administrative and support staffAdministrative and support staff PatientsPatients Information and information technologyInformation and information technology

Working together for common clinical and Working together for common clinical and business aimsbusiness aims

Using shared informationUsing shared information Producing clinical outcomesProducing clinical outcomes

Which system is the unit of Which system is the unit of practice, intervention, practice, intervention,

measurement?measurement? Community, Market,

Social Policy System

Macro-organization

System

MicrosystemIndividual care-giver & patient System

Self-care

System

The Work: Science-based The Work: Science-based ImprovementImprovement

“Generalizable Scientific Evidence” + “Particular

Context”

“Measured Performance

Improvement”

• control for context• generalize across contexts• sample design

I

• understand system “particularities”• learn structures, processes, patterns

II

• balanced outcome measures

III

• certainty of cause & effect• shared importance IV

• strategy• operations• people V

P. Batalden

Why Preventive Medicine?Why Preventive Medicine?

PopulationsPopulations

MeasurementMeasurement

SystemsSystems

LeadershipLeadership

Luxuries We Enjoyed…Luxuries We Enjoyed…

Able to design residency “from Able to design residency “from scratch” – building on PM program scratch” – building on PM program requirements and the idea of requirements and the idea of “competency-driven” GME “competency-driven” GME

Deeply committed team with incredible Deeply committed team with incredible experience, knowledge, skillsexperience, knowledge, skills

Time to develop a shared mental Time to develop a shared mental model of what “it” would look likemodel of what “it” would look like

Where Are We Now?Where Are We Now?

Five graduates to dateFive graduates to date Currently have nine first year and eight Currently have nine first year and eight

second year residents, plus three who second year residents, plus three who have completed the first yearhave completed the first year

Have combined with anesthesia, pain Have combined with anesthesia, pain medicine, surgery, internal medicine, GI, medicine, surgery, internal medicine, GI, ob-gyn, ID, pulmonary/critical care, family ob-gyn, ID, pulmonary/critical care, family medicine, pathology, pediatrics, psychiatrymedicine, pathology, pediatrics, psychiatry

DHLPMR has attracted applicants to DHMC DHLPMR has attracted applicants to DHMC GME programsGME programs

What Sorts of Things Do our What Sorts of Things Do our Residents Do?Residents Do?

Improve care for patients admitted with CAPImprove care for patients admitted with CAP Improve safety and efficiency of sedation for Improve safety and efficiency of sedation for

selected endoscopic proceduresselected endoscopic procedures Improve provision of screening services in GIM clinicImprove provision of screening services in GIM clinic Rapid Response Team implementation and outcomesRapid Response Team implementation and outcomes Improve medication management for major Improve medication management for major

depressiondepression Improve dx and tx of obesity in primary care clinicImprove dx and tx of obesity in primary care clinic Improve post-operative pain managementImprove post-operative pain management Improve advance directive processImprove advance directive process Improve hand hygiene in perioperative areasImprove hand hygiene in perioperative areas

How Our Program is Different-How Our Program is Different-the Residentsthe Residents

All residents in combined training, all All residents in combined training, all maintain presence in both programsmaintain presence in both programs

No one is an internNo one is an intern Residents (and faculty) from a Residents (and faculty) from a

variety of specialties are working variety of specialties are working together and learning from each together and learning from each otherother

How Our Program is Different –How Our Program is Different – the Learning Experience the Learning Experience

Residents design own learning experiences Residents design own learning experiences (with guidance and oversight)(with guidance and oversight)

Residents generally manage their own timeResidents generally manage their own time Faculty coaches and mentors—aided by a Faculty coaches and mentors—aided by a

program of “coach development”program of “coach development” Clear expectation that residents will teach Clear expectation that residents will teach

residents residents and facultyand faculty in their “home” programs in their “home” programs Program actively managed by a Program actively managed by a

multidisciplinary team that works/meets every multidisciplinary team that works/meets every two weekstwo weeks

How Our Program is Different – How Our Program is Different –

the Learning Environmentthe Learning Environment Most work is inter-professional Most work is inter-professional

(doctors, nurses, clinic staff, medical (doctors, nurses, clinic staff, medical records, administration, educators, records, administration, educators, care managers, etc…)care managers, etc…)

Work is primarily microsystem-based Work is primarily microsystem-based – happens at the frontlines and – happens at the frontlines and involves many people as well as involves many people as well as information and ITinformation and IT

How Our Program is Different – How Our Program is Different – Assessment and AccountabilityAssessment and Accountability

Explicit expectation that residents use web-Explicit expectation that residents use web-based portfolio for reflection, evaluation, based portfolio for reflection, evaluation, collecting evidence of their workcollecting evidence of their work

Practicum Review Board—composed of Practicum Review Board—composed of organizational leaders—provides guidance in organizational leaders—provides guidance in development of Practicum year design, as well development of Practicum year design, as well as institutional supportas institutional support

Nationally prominent residency advisory Nationally prominent residency advisory committeecommittee

Clear expectation that residents will lead Clear expectation that residents will lead change and address sustainability of that change and address sustainability of that changechange

InnovationsInnovations

Combining Preventive Medicine with Combining Preventive Medicine with a wide variety of other specialtiesa wide variety of other specialties

Getting residents from different Getting residents from different disciplines in the same roomdisciplines in the same room

Putting residents largely in charge of Putting residents largely in charge of their own learning experiencestheir own learning experiences

More...More...

Residents develop different relationships Residents develop different relationships with faculty, staff, otherswith faculty, staff, others

Residents begin to “see” the Residents begin to “see” the microsystems they work in, and bring microsystems they work in, and bring their knowledge of how they “really” worktheir knowledge of how they “really” work

Attention to more than individual patient Attention to more than individual patient outcomes – residents love data!outcomes – residents love data!

More…More…

Residents experience improvement Residents experience improvement of care as an integral aspect of of care as an integral aspect of provision of careprovision of care

Residents function as leadersResidents function as leaders Focus is NOT on the exceptional, but Focus is NOT on the exceptional, but

on important aspects of education on important aspects of education and care that may seem mundaneand care that may seem mundane

What is the Learning What is the Learning Environment?Environment?

We often first think of “didactics”We often first think of “didactics” Then we might think about teaching Then we might think about teaching

on rounds, during procedures, etcon rounds, during procedures, etc Eventually, we begin to think about Eventually, we begin to think about

the constant learning that goes on in the constant learning that goes on in GME – many teachers, many learnersGME – many teachers, many learners

When does learning occur? And When does learning occur? And what learning are we talking about?what learning are we talking about?

What Residents Say: Some What Residents Say: Some Characteristics of Good Characteristics of Good Learning Environments Learning Environments

““Why” is clearWhy” is clear Opportunity to practice, apply Opportunity to practice, apply

learninglearning ImmersionImmersion Dialogue, two-way communicationDialogue, two-way communication Helpful structureHelpful structure Respectful, safeRespectful, safe

Other AspectsOther Aspects

Often feels good – but…Often feels good – but… Learning from mistakes is importantLearning from mistakes is important Teaching is learningTeaching is learning ““Embodiment”Embodiment” A little anxiety may be a good thing? A little anxiety may be a good thing?

Finding the right degree of autonomyFinding the right degree of autonomy

Environments for LearningEnvironments for Learning

Defined teaching and learning Defined teaching and learning opportunitiesopportunities

Clinical care environmentClinical care environment Inner environmentInner environment

Preparing the “Inner” Learning Preparing the “Inner” Learning EnvironmentEnvironment

Desire to learnDesire to learn CuriosityCuriosity Sense of safety Sense of safety Ability to reflect and effectively use Ability to reflect and effectively use

new knowledgenew knowledge Sense that it mattersSense that it matters Potential for joy in learning/workPotential for joy in learning/work

DHLPMR and the “Inner” DHLPMR and the “Inner” Learning EnvironmentLearning Environment

Residents (and faculty) asked to Residents (and faculty) asked to develop capacity for reflectiondevelop capacity for reflection

More time and spaceMore time and space Opportunity for work in teams, groups Opportunity for work in teams, groups

– good way to learn about oneself– good way to learn about oneself Knowing the work mattersKnowing the work matters FeedbackFeedback We often have a good timeWe often have a good time

Other DHLPMR Learning Other DHLPMR Learning EnvironmentsEnvironments

Classroom experiences (MPH) and Classroom experiences (MPH) and relationship to rotations/practicumrelationship to rotations/practicum

Defined learning opportunitiesDefined learning opportunities Microsystems and learningMicrosystems and learning

Awareness of assumptions and what is Awareness of assumptions and what is being/has been learnedbeing/has been learned

Learning from patients and othersLearning from patients and others Learning during all aspects of patient Learning during all aspects of patient

carecare

Supports for the DHLPMR Supports for the DHLPMR Learning EnvironmentLearning Environment

Portfolio as a living record of work and a way Portfolio as a living record of work and a way to shareto share

Competencies and expected developmental Competencies and expected developmental “pathway” clearly spelled out and regularly “pathway” clearly spelled out and regularly reviewedreviewed

Opportunities to practice new ways of workingOpportunities to practice new ways of working Connections outside one’s own disciplineConnections outside one’s own discipline Visibility and support – public Visibility and support – public

acknowledgment that resident work MATTERSacknowledgment that resident work MATTERS

Innovation and Improvement in Innovation and Improvement in the Learning Environmentthe Learning Environment

Our residents’ work is really about CHANGING Our residents’ work is really about CHANGING the learning environmentthe learning environment Learning about particular microsystemsLearning about particular microsystems Learning about our current processes of care and outcomesLearning about our current processes of care and outcomes Thinking about how to connect the best evidence to the work Thinking about how to connect the best evidence to the work

of microsystemsof microsystems Leading change within microsystems to improve those Leading change within microsystems to improve those

processes and outcomesprocesses and outcomes

Our work is really about supporting that Our work is really about supporting that change and continuing to understand what change and continuing to understand what we are learningwe are learning

Competence in the Learning Competence in the Learning EnvironmentEnvironment

Our work is really about assessing the Our work is really about assessing the competence of learners in an competence of learners in an environment that exemplifies environment that exemplifies competencecompetence

AND a key component of learner AND a key component of learner competence is the ability to help create competence is the ability to help create an increasingly competent environment an increasingly competent environment for learning and patient carefor learning and patient care