Why Competencies Why These Competencies How Shall We Do This

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Why Competencies?Why These Competencies?How
Shall We Do This?

• David C. Leach, M.D.
• Executive Director
• ACGME
• December 7, 2002

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ACGME Mission

• to improve the quality of health care by
  improving the quality of GME

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Why worry about competence?

• Public concerns with safety
• Variability in patterns of care that are not
  based on science
• Poor customer service
• Public wants
• competence and kindness Gawande
• Professional responsibility

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The crucial question for medical education is
whether it will passively accommodate itself to
market imperatives or will act affirmatively,
vigorously, and quickly to create new forms of
practice to which it will be linkedsuch that
medical professionalism can survive and
flourish.
From Frankford Conrad, Acad Med, 1998
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ACGME Outcome Project

• The Project A long term initiative
• The Vision to enhance residency education
• The Process through educational outcome
  assessment

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Why these competencies?
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The General Competencies

• Patient care
• Medical Knowledge
• Practice-based Learning and Improvement
• Interpersonal and Communication Skills
• Professionalism
• Systems-based Practice

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From ACGME Interviewees, 1998
The public would be shocked to know that health
care professionals do not come together to talk
about needs of the patient.

Physicians are not outcome oriented enough and
not using best practices.
When residents go into group practice, They
dont see the organization as a professional and
business enterprise that relies on performance
measures to monitor and legitimize itself to the
community.
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From ACGME Interviewee, 1998
There will be pressure for physicians to place
themselves in a systems context of professional
performanceThis focus (on individual-patient
relationship) needs to be broadened to understand
health and community in a systems context.
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From ACGME Interviewee, 1998

There is a need to get into a more effective
organizational mode, that provides to patients a
seamless web from prevention, curing, chronic,
end-of-life and this will require a whole new
level of organization, e.g. like VISA
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Skills for Health Professionals
From Crossing the Quality Chasm, 2000

• Find new knowledge evaluate its significance
  effectiveness decide how to incorporate it
• Synthesize the evidence base
• Combine the evidence base, knowledge about
  population outcomes, patient preferences
• Use decision support systems

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Skills for Health Professionals
From Crossing the Quality Chasm, 2000

• Identify errors and hazards in care implement
  basic safety design principles
• Continually measure quality of care, both
  processes and outcomes
• Work collaboratively in teams with shared
  responsibility

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Bridging the Competencies to
Responsive Medical Professionalism
From Frankford et al, Acad Med, 2000
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How shall we do this?
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Phases in Outcome Initiative

• Forming the initial response
• Sharpening the focus and definition of the
  competencies
• Integrating good learning with good clinical care
• Ongoing benchmarking

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Conversations about Competencies

• ACGME We invite you to respond to the
  challenge of assessing the competence of your
  residents.
• Program Directors What would you like us to
  do?
• ACGME We dont really know. Do something and
  well let you know if you did the right thing.
• Program Directors Youve got to be kidding.

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Conversations about Duty Hours

• ACGME We will tell you exactly what to do to
  reform duty hours.
• Program Directors That wont work for my
  program.
• ACGME Every program must do the same thing.
• Program directors Youve got to be kidding.

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Glouberman and Zimmerman

• Simple cookbook
• Complicated sending a rocket to the moon
• Complex raising a child

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Fundamental differences between the two
initiatives

• Competence was framed as a complex problem and an
  invitation.
• Duty hours was framed as a complicated problem
  requiring a prescription.

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Duty Hours vs. Competencies

• Complicated
• Linear
• Solution external to system
• Adaptation to static environment
• Designed outcomes
• Analysis

• Complex
• Nonlinear
• Solution as part of system
• Interaction with dynamic environment
• Emergent outcomes
• Synthesis

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Outcome Initiative Principles

• Whatever we measure we tend to improve
• Programs need flexibility to adapt to their
  particular environment
• Public accountability

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Principles Discovered after the Fact

• Competencies allow conversations about the work
  of medicine across all specialties.
• Competencies have invited a surprising amount of
  creativity.
• Competencies help distinguish substance from form.

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Substance is enduring form is ephemeral.
Preserve substance modify form know the
difference.

• Dee Hock

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Why were you invited to be here today?
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What one book would you like to have with you if
you were stranded on a desert island?

• Asked of G. K. Chesterton

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A Practical Guide to Shipbuilding
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Assessing competence is hard

• And yet can be immensely satisfying.

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Reasons this is hard

• Competence is a habit.
• Medicine is a cooperative not productive art.
• The important things are hard to measure.
• Residents need to prepare for the unknown.
• Residents seek practical wisdom.
• To become competent you have to feel bad.
• Learning occurs in microsystems.
• Becoming competent is a complex process.

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Whatever we measure we tend to improve.
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Useful Concepts about Measurement

• Life is not condensable
• We use models to understand life
• All models are limited, some are useful
• Measurements are applied to models
• Both measurements and models must be constantly
  reassessed
• We need structured dialogue about measurement

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Characteristics of good assessment

• Measures actual performance
• Identifies areas for improvement
• Satisfies reasonable request for accountability
• Is practical
• Is done over time to discern growth

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To Date

• 700 programs have completed PIF addendum
• Site visit confirmation of data
• Will make data public

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Common Approaches

• More than one assessment approach for each
  competency
• Usually global plus 1-3 others
• Movements to make global forms national (by
  specialty)
• Focused assessment in about half
• Portfolios on rise
• Written/oral exams in about 75

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Model Assessment System
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To teach is to create a space in which obedience
to truth is practiced.

• Abba Felix
• Desert Father

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What we attend to and how we attend to it defines
who we are.
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A Community of Practice

• General Competencies
• Open data systems
• Celebrate benchmarks across disciplines
• Build knowledge about medical education
• Build knowledge about improving patient care
• Enhance public accountability

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To Teach/Learn is to create a Space/Community in
which obedience to truth is practiced.