Patient Care: A Model for Measurement of Competence

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Patient CareA Model for Measurement of
Competence

• F. Daniel Duffy
• ACGME-ABMS Conference
• November 9, 2006
• Rosemont, IL

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Clinical Microsystem
Leadership/citizenship - Quality Innovation
Patients with needs Acute, Chronic, Prevention
care
Patients needs met Clinical, Satisfaction,
Economic
Treatment Monitoring
Access to Practice
Diagnostic Work-up
Self-Care Support
Teamwork Care Management
Clinical Information Management
Tests Consults Referrals - Rx
Community
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Clinical Microsystem
Leadership/citizenship - Quality Innovation
Patients with needs Acute, Chronic, Prevention
care
Patients needs met Clinical, Satisfaction,
Economic
Treatment Monitoring
Access to Practice
Diagnostic Work-up
Self-Care Support
Teamwork Care Management
Clinical Information Management
Competence in Patient Care
Tests Consults Referrals - Rx
Community
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Clinical Microsystem
Competence in System-Based Practice
Leadership/citizenship - Quality Innovation
Patients with needs Acute, Chronic, Prevention
care
Patients needs met Clinical, Satisfaction,
Economic
Treatment Monitoring
Access to Practice
Diagnostic Work-up
Self-Care Support
Teamwork Care Management
Clinical Information Management
Tests Consults Referrals - Rx
Community
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Clinical Microsystem
Leadership/citizenship - Quality Innovation
Patients with needs Acute, Chronic, Prevention
care
Patients needs met Clinical, Satisfaction,
Economic
Treatment Monitoring
Access to Practice
Diagnostic Work-up
Self-Care Support
Competence in Practice-Based Learning
Improvement
Teamwork Care Management
Clinical Information Management
Tests Consults Referrals - Rx
Community
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Tasks in Patient Care

• Prepare
• Diagnose
• Treat
• Support

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Prepare

• Commit to serve patients
• Prioritize scheduled time
• Manage interruptions
• Coordinate work
• Communicate goals and needs
• Negotiate hand-offs
• Assure seamless steps in care
• Plan for care beyond limits
• Use technology

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Diagnose

• Clinical skills
• History writing
• Interview
• Data analysis and synthesis
• Physical Examination
• Diagnostic procedures for fluid/tissue
• Use of diagnostic testing consultation network
• Diagnosis
• Differential diagnosis drives management strategy
• Select useful disease (illness) category
• Prognosis
• Probability of altering natural history
• Risk stratify for future events
• Uncertainty

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Treat

• Establish Goals
• Treatment based on scientific evidence,
• Available resources
• Patient preferences
• Prescribe
• Medications and treatments
• Patient self-care and lifestyle changes
• Operate perform therapeutic procedures
• Follow-up
• To achieve therapeutic goal
• Coordinate care for whole patient

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Support

• Relational
• Available
• Trustworthy
• Educational
• Information to provide consensual participation
• Information and skill to execute plan
• Emotional
• Relieve emotional symptoms
• Encourage
• Motivate self-efficacy to engage in therapy

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Involves All Competencies
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Patient Care and Other Competencies

• Professionalism - Self-Monitoring
• Act with appropriate confidence
• Act within limits of competence
• Persist with challenging situations
• Communications
• Respect, compassion, motivation
• Skilled advocacy
• Systems-based practice
• anticipating and arranging for help beyond
  competence

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System-Based Practice in Patient Care

• Technology
• Decision support at point of care
• Transfer of information
• Diagnostic testing
• Therapy
• Teamwork
• Network of consultants referrals
• Microsystem team
• Clinical crews

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Self-Assessment

• Self-assessment is a complicated, multifaceted,
  multipurpose phenomenon that involves a number of
  interacting cognitive processes.
• It functions as a monitor, a mentor, and a
  motivator through processes such as evaluation,
  inference, and prediction.

Eva KM, Regehr G.. Academic Medicine, Vol. 80,
No. 10 / S46 October 2005 Supplement
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Self- Assessment Balances Values

• Sets Self-limitations balances
• Confidence and caution
• Persistence and flexibility
• Experimentation and safety
• independence and collaboration
• Sets learning goals - balances
• Learning enough but not too much
• Starting neither too high nor too low
• Knowing what to tackle and what to abandon
• Reflects on accomplishments - balances
• Satisfaction and incentive
• Self reward without self delusion

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Self-Assessment of Competence
Confidence
Competence
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Stages of Competence
Expert
Proficient
Competent
Advanced Beginner
Confidence
Novice
Competence
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Development of Competence in Patient Care
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Measures of Patient Care Competence

• Case log of doctors experience (volume)
• Outcome process measures of doctors care
• Expert ratings of observations of doctors
  technical competence

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Measures of Patient Care Knowledge
MCQ Clinical Vignette Examination
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Measure of Patient Care Professionalism
Communications
Peer Staff survey of experience of doctors
care for specific problem
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Measure of Patient-Centered Care
Patient rating of experience of doctors care
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Measure of System-based Care
Quality, cost, patient and staff satisfaction of
expectation for care outcome measures
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Measure of Competence in Learning and Improving
Patient Care
Peer (staff) Assessment of doctors contribution
to innovation and improvement in quality of care
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Measurement Strategy
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Does the Model Fit All Specialties?
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Intra-operative Decisions

• Make accurate snap decisions
• Turkeys get lost in trivia
• Cant appreciate big picture
• Never in doubt, but frequently wrong
• Treat errors/mistakes as great learning
  experience
• Have to make mistakes to learn
• New surgeons dont want to take action on
  clinical signs
• MM
• Normal appendix vs no normal
• No normal have high rate of rupture
• No or low abnormal poor diagnostic accuracy
• Attempt stuff they had no training to do

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Patient Care Measurement Tools

• Patient survey outcomes report
• For diabetes disease specific
• CAHPS general communication SBP
• Peer Survey outcomes report
• PAS overall patient care competence
• Consultant SBP, usefulness
• Expert Observation
• Mini-CEX
• ACLS check list
• Experience log
• ACGME Ortho or plastic surgery
• Procedure log
• Quality of care measures
• PIM Practice Performance reports

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Thank You