Assessment of a Health Systems Rotation for Orthopaedic
Residents Learning of the Systems Based Practice Competency AOA
Annual Meeting June 15, 2013
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Funded by the Woodward Endowment for Medical Science
Education
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Core Competencies
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Systems Based Practice Requires residents to demonstrate an
awareness of and responsiveness to the larger health care system
and the ability to effectively call on system resources to provide
care that is optimal and effective
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Systems Based Practice Expectations l Work effectively in
various health care delivery settings and systems relevant to their
clinical specialty l Coordinate patient care within the health care
system relevant to their clinical activity l Incorporate
considerations of cost awareness and risk-benefit analysis in
patient and/or population-based care
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Systems Based Practice Expectations l Advocate for quality
patient care and optimal patient care systems l Work in
interprofessional teams to enhance patient safety and improve
patient care quality l Participate in identifying system errors and
implementing potential systems solutions
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Systems Based Practice l Care not provided in a vacuum l
Internal and external factors influence the health of their
patients and the care they receive n Familiarity with various
factors n Ability to interact with various facets and participants
in health care system
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Evaluation Methods
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Systems Based Practice Wasnick: Academic Medicine, 2010 l
73/193 4 th year medical students reported having no knowledge of
any of the core competencies l 10% reported knowledge of SBP
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Systems Based Practice David: Mt Sinai J Med, 2005 Residents
focus more on medical knowledge and patient care; SBP viewed as
less important
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Systems Based Practice Harris: Int J Radiat Oncol Biol Physics,
2009 l Lack of knowledge among educators l Uncomfortable with
content, teaching and assessment
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Chairs Question l COBRA violations l RBRVS l SNF vs. LTACH l
Informed consent l DRG Not perfect! Important for the resident to
know Measurable Recordable
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360s and SBP? l Does the resident demonstrate an appreciation
for the role of all members of the health care team, and
communicate the plan of care to them appropriately? l Does the
resident demonstrate an understanding of treatment options in the
post acute continuum of care, and work with nursing, care
coordination and social services to identify the most appropriate
location for the patient?
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360s and SBP l Is the resident active in the discharge planning
process and do they complete their discharge responsibilities
accurately and in a timely manner?
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Key Questions l What must be learned? l How to teach it? l
Optimal delivery method? l How to assess resident performance?
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Literature Review
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Previous SBP Research l Lecture (ARS): Mitchell, Varkey l
Morbidity/Mortality Conferences: Davison l Group Projects: Delphin,
Patterson l Simulation: Larkin, Wang and Volzenilek l Experiential
Systems: Eiser, Buchmann, Sutkin, Turley
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Previous SBP Research Web Based Eskildsen: J Am Geriatr Soc,
2010 Ideally, this product should be used in the context of a
clinical rotation so that learners can expand their learning and
acquire transferable skills using this online tool as a starting
point.
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Systems Based Practice: Is It Being Taught?, How Is It Being
Taught?, and How Is It Being Assessed? Focus Group Sessions Survey
Data JBJS, 2012
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Is It Being Taught?
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How Is It Being Taught?
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How Is It Being Assessed?
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Focus Group Sessions Orthopaedic l Ortho residents l Ortho
faculty l Community ortho Non-Orthopaedic l Nursing l Allied
health, Support l Administrative Leadership l Quality/Safety
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Focus Groups Faculty demonstrated poor understanding and
frustration with this competency and largely focused upon
efficiency in task completion
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SBP: Taught and Assessed? The most commonly reported method for
teaching Systems Based Practice was clinical observation.
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Focus Groups Excluding Orthopaedic Surgeons and Residents l
Communication l Collaboration l Understanding complex processes l
Hospital operations l Finance l Law l Medical error l Systems
impact on patient care
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Focus Groups Strong consensus to provide a standardized,
experiential, learning experience for resident with assessment of
knowledge and performance
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The Penn State Hershey Orthopaedic Residency Experience
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Next Step l Need to prepare our residents and students to
provide health care in the 21 st century n Quality and safety n
Collaboration in multidisciplinary team n Managing disease in large
populations n Continuous improvement beyond your own individual
care
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SBP Education and Penn State Hershey l Two, one week rotations
during orthopaedic months in PGY-1 year l Reading assignments l
Focus on experiential learning l Patient assignments as an observer
of health care through the eye of the patient l What can be done,
individually and collectively, to provide a safer, better and more
efficient experience?
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SBP and Penn State Hershey Focus Areas l Weeks one and two:
Quality/Safety l Week two: E&M coding, IP documentation,
Finance l Week two: Analysis of DRG report for 4 surgeons on the
joint arthroplasty service n Supplemental reading: Medicare and
Hospital Prospective Payment System How DRG Rates are Calculated
and Updated
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SBP at Penn State Hershey Week One l Interview and follow
patients l Morning nursing report l Risk/Quality Conference l
Interview care coordinators, therapists, utilization review l
Operating room processes l Transitions to OP care
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How to measure the outcome?
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Resident Feedback I am hopeful that with more courses such as
this, and the training of new interns about the pitfalls and
dangers of the system, that we can, with time, create overdue and
necessary changes to our healthcare system.
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Resident Feedback The other two interns and I have already
spoken amongst ourselves regarding ways in which we, as individuals
and a small group who will progress through the ranks of the
orthopaedic residency program at Penn State, can affect the
necessary changes to our system.
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Holy Grail?
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Challenges The Faculty and More Senior Residents
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Challenges Labor Intensive
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Challenges If the ultimate outcome is improvement in patient
safety, quality and efficiency, there are countless other
confounding variables
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Summary SBP has evolved from a peripheral and frustrating
nuisance to an integral component of resident education.
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Systems Based Practice
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Summary RVUs, coding, insurance, malpractice are each important
topics to understand, but
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Summary 21 st century health care requires the application of
individual knowledge and skills to the excellence of a
multidisciplinary team
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Summary l Based upon our two years of experience with this
rotation we believe: n This rotation is valued by the residents n
They are developing an improved understanding of the health care
system in which they work n They are developing an improved
understanding of the roles of other members of the health care
team
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Summary l Based upon our two years of experience with this
rotation we believe: n They are developing an improved
understanding of issues pertaining to patient safety, quality and
efficiency relative to health care n They are developing an
improved understanding of the need for efficient, consistent
communication within the team
