Shift Cards in the Resident Outpatient Clinic - PowerPoint Presentation

1. Shift Cards in the Resident Outpatient ClinicHow to observe and provide real time feedback to residents-and inform your Clinical Competency Committee

2. Learning ObjectivesDescribe the difficulty of obtaining resident observations in the outpatient clinic and ways in which residents receive feedback Describe how the Shift card can be used by the outpatient faculty to provide real time feedbackDemonstrate how the Shift card can provide helpful information for CCC membersAnalyze how a Shift card can be an EPA with associated milestonesExamine advantages of the Shift card from faculty, resident, and CCC perspective.

3. Intended Shift Card AudienceCCC membersProgram directorAssociate Program directorsCore faculty membersOutpatient clinic supervisory faculty

4. What is a Shift card?A simple and easy to use tool derived, in part, from Emergency Medicine. (Bandiera 2008)The card can:provide feedback to learnershelp faculty determine where a resident falls on the learning curve in their progression through residency based on selected milestonesbe acceptable to learners and facultyprovide useful information for the CCC

5. Why was the Shift Card Created?Need for outpatient observations regarding residentsNeed for outpatient data for supervising clinic faculty to help gauge learning and development over timeNeed for outpatient information to feed to the CCC

6. Shift Card as an EPAUtilizes milestonesApplicable for all program sizesHelpful in following performance over timePotential use in reporting to ACGME

7. What does the Shift Card Look Like?It is a two-sided piece of paper that includes the resident’s name, date the card was completed and the preceptor’s nameIt includes selected milestones to be evaluated for a new problem/acute illness on one side. On the reverse it includes milestones for chronic disease management and preventative careOn the bottom of both sides of the card is space to provide comments/specific case illustrations

8. Sub CompetencyCritical DeficiencyRequires Direct SupervisionRequires Indirect SupervisionReady for Unsupervised PracticeAspirationalPC1- Gathers and Synthesizes essential and accurate informationInaccurate history and physicalIncomplete history and physical skills or limited differential diagnosisCan use history, physical and other data to identify central clinical problemsHypothesis driven history and physical or appropriately prioritized differential diagnosisObtains subtleties and recognizes unusual clinical presentationsPC2/PC3-Develops and achieves comprehensive management plans/ Manages patients with progressive responsibilityInappropriate care plans ordoes not assume responsibility for patient management decisionsHas difficulty developing care plan without assistanceDevelops appropriate care plans and/or recognizes urgent/emergent issues without preceptor assistanceCan independently manage unusual acute problems or can modify plans based on changing clinical scenarioAble to develop complete care plan even when faced with diagnostic uncertainty and uses cost conscious principlesMK1/MK2 – Clinical knowledge/knowledge of diagnostic testsDoes not have knowledge to care for patientsIncomplete knowledge of common medical conditions or treatmentsDemonstrates knowledge of common medical conditions Demonstrates and applies knowledge of complex medical problemsDemonstrates and applies knowledge of treatment or diagnosis of unusual medical problemsPROF3 – responds to each patient’s unique characteristics (culture, gender, race, ethnicity, etc…)Unwilling to modify care plan for patient unique needsRequires assistance to modify care for patients unique needsAware of patients unique needs and can modify care plan with minimal assistanceIndependently and appropriately modifies care plans to accommodate patients unique needsRole model s and teaches others (colleagues, care team) on unique needs for patientsICS1 – communicates effectively with patients and caregiversMakes no attempt to share decision makingNeeds help to develop a shared decision making with a patient even for straight forward concernsCan engage shared decision making for uncomplicated discussions, but might needs help for complicated problemsIndependently engages patients in shared decision making for complicated problems, including caregivers when appropriate.Role model of engaging patients in shared decision making, including caregivers, even in complicated and changing clinical situations.Milestones for new problem/acute illnessComments/specific cases/illustrations:Name of Resident: __________________________________ Date of Shift Card: _________________ Preceptor: ____________________

9. Sub CompetencyCritical DeficiencyRequires Direct SupervisionRequires Indirect SupervisionReady for Unsupervised PracticeAspirationalPC1- Gathers and Synthesizes essential and accurate informationInaccurate history, physical or data reviewIncomplete history and physical skills or does not review prior notes to understand purpose of visitUses history, physical and chart review to make complete and prioritized problem listEfficiently uses history, physical and data review to appropriately prioritized problem list and minimize need for further testingObtains subtleties and recognizes unusual clinical presentationsPC2/PC3-Develops and achieves comprehensive management plans/ Manages patients with progressive responsibilityInappropriate or inaccurate care plans ordoes not assume responsibility for patient management decisionsHas difficulty developing care plan without assistanceDevelops appropriate care plans for controlled problems without preceptor assistanceCan independently manage complex patients with multiple uncontrolled chronic problems Able to independently develop complete care plan and coordinate care even when faced with complex social barriers to good care MK1/MK2 – Clinical knowledge/knowledge of diagnostic testsDoes not have knowledge to care for patientsLacks knowledge of common clinical guidelinesDemonstrates knowledge of common clinical guidelines Demonstrates and applies clinical guidelines and understands appropriate times to deviate from guidelinesDemonstrates knowledge of latest literature that may not be yet included in guidelines but could influence care of the patientSBP1 – Works effectively with an interprofessional team(Nursing, social work, pharmacy, diabetes educators)Frustrates team membersDoes not know what team members are available or how they can help patientsMay need prompting from preceptor to utilize skills of other team membersIndependently engages team to maximize and efficiently deliver best care to patientsViewed as a leader of team care. Effectively and efficiently coordinates care even when away from the office.ICS1 – communicates effectively with patients and caregiversMakes no attempt to share decision makingNeeds help to develop a shared decision making with a patient even for straight forward concernsCan engage shared decision making for uncomplicated discussions, but might needs help for complicated problemsIndependently engages patients in shared decision making for complicated problems, including caregivers when appropriate.Role model of engaging patients in shared decision making, including caregivers, even in complicated and changing clinical situations.Milestones for chronic disease management and preventative careComments/specific cases/illustrations:Name of Resident: __________________________________ Date of Shift Card: __________ Preceptor: ____________________

10. Shift Card CompletionHave the small groups observe selected videosSBIRT: HTN case (published 2013 on YouTube)The Value of Non Physician Observations in Resident Assessment: Outpatient Case (1:11-2:34, published 2014 on YouTube)The Shift card is then completed using both sides - one side for each videoResident to patient - acute problem Resident to attending - chronic problemThe entire card does not have to be completed - only the observed milestones

11. Debrief with the GroupWhat worked?What didn’t work?

12. Positive Aspects of a Shift CardIt allows for a snapshot of clinical performance over time and in real timeIt eliminates the need for faculty to recall a resident’s performance over time-in some cases perhaps six months priorUnlike the mini-CEX, the Shift card was developed during the NAS era and incorporates reporting milestones

13. Shift Card BeneficiariesResidents - feedback is given in real time which can impact future performance on the path to competenceOutpatient faculty - cards completed over time can be used to follow resident progressCCC members - the card provides information about outpatient milestones and growth

14. Shift Card as a ToolCONS Feasibility issues depending on program resources/sizeReporting milestones may not be “granular enough”No validity data yetPROS ✔“Real-time” direct observationLots of performance samplingUses EPAs/MilestonesEasy to useImmediate feedback for residents and data for CCCs

15. Action PlanOther milestones to be addressed may lead to more Shift card(s) being developedWith newer technologies, you can explore paperless modalities

16. ReferencesBandiera G, Lendrum D. Daily encounter cards facilitate competency-based feedback while leniency bias persists. CJEM 2008 Jan Vol 10 (1):44-50 SBIRT: HTN Case-average medical resident example (May 21, 2013) retrieved from https//www.youtube.com/watch?v=NAHJRdKY4dI The Value of Non Physician Observations in Resident Assessment: Outpatient Case (Sept. 28, 2014) retrieved from https//www.youtube.com/watch?v=1N3muSELSeE