CHAMP Teaching on Today’s Wards Session 1 – Improving the Process Chad Whelan, MD Julie Johnson, PhD Paula Podrazik, MD

CHAMPCHAMPTeaching on Today’s WardsTeaching on Today’s WardsSession 1 – Improving the Session 1 – Improving the ProcessProcess

Chad Whelan, MDChad Whelan, MD

Julie Johnson, PhD Julie Johnson, PhD

Paula Podrazik,Paula Podrazik, MDMD

Today’s AgendaToday’s Agenda

10:00 – 10:1010:00 – 10:10 Overview of Teaching on Today’s Overview of Teaching on Today’s Wards, Sessions 1-5 andWards, Sessions 1-5 and

Introduction to Session 1Introduction to Session 1

10:10 – 10:3010:10 – 10:30 Introduction to Mapping the Process Introduction to Mapping the Process

10:30 – 11:1510:30 – 11:15 Small Group ExerciseSmall Group Exercise

11:15 – 11:2511:15 – 11:25 BreakBreak

11:25 – 11:4511:25 – 11:45 Debriefing from Small Group ExerciseDebriefing from Small Group Exercise

11:45 – 12:0011:45 – 12:00 Take Home Points and Take Home Points and Homework Assignment for Session 2Homework Assignment for Session 2

Teaching on Today’s WardsTeaching on Today’s WardsOverall ObjectivesOverall Objectives

• Recognize teaching as a processRecognize teaching as a process• Review & affect barriers to teaching Review & affect barriers to teaching • Link to Clinical Teaching courseLink to Clinical Teaching course• Link to ACGME competenciesLink to ACGME competencies• Develop Strategies for Develop Strategies for

– Improving teaching on today’s wardsImproving teaching on today’s wards– Teaching ACGME competenciesTeaching ACGME competencies

• Learn some new tools for applying these Learn some new tools for applying these strategiesstrategies

Clinical Teaching CourseClinical Teaching CourseImproving Your TeachingImproving Your Teaching

• Learning ClimateLearning Climate• Control of SessionControl of Session• Communication of GoalsCommunication of Goals• Promoting Understanding and Promoting Understanding and

RetentionRetention• EvaluationEvaluation• FeedbackFeedback• Promoting Self-Directed LearningPromoting Self-Directed Learning

ACGME CompetenciesACGME CompetenciesWhat are they?What are they?

• Patient CarePatient Care• Medical KnowledgeMedical Knowledge• Practice-based Learning & Practice-based Learning &

ImprovementImprovement• Interpersonal & Communication SkillsInterpersonal & Communication Skills• ProfessionalismProfessionalism• Systems-based PracticeSystems-based Practice

Teaching on Today’s WardsTeaching on Today’s WardsSession Outline Session Outline

Sessions #1-2Sessions #1-2• Review your teaching process — Review your teaching process —

successes and barriers successes and barriers • Recognize how your process influences the Recognize how your process influences the

decisions you makedecisions you makeSessions #3-5Sessions #3-5• Teaching Teaching systems-basedsystems-based learning learning• Teaching Teaching practice-basedpractice-based learning learning• Teaching lifelong learningTeaching lifelong learning

Teaching On Today’s WardsTeaching On Today’s WardsSession #1 ObjectivesSession #1 Objectives

• Learn generalizable process mapping Learn generalizable process mapping skills skills

• Recognize teaching as a processRecognize teaching as a process• Map your teaching processMap your teaching process

– Link to communicationLink to communication– Link to professionalismLink to professionalism– ID successes and problem areasID successes and problem areas

Teaching on Today’s WardsTeaching on Today’s WardsSession #1Session #1

• Intro. –teaching process on the wardsIntro. –teaching process on the wards• Overview of the month-long processOverview of the month-long process

– Setting goalsSetting goals– Setting expectationsSetting expectations– When can teaching occur?When can teaching occur?– Preventing burn-outPreventing burn-out


• Overview of the day on the wardsOverview of the day on the wards– Setting goalsSetting goals– Setting expectationsSetting expectations– ID the teachable momentID the teachable moment– Incorporate the clinical triggerIncorporate the clinical trigger

• Maintaining Balance!!!?!!!?Maintaining Balance!!!?!!!?

What is your Primary Goal What is your Primary Goal when on the Wards?when on the Wards?

• Achieving Excellence in Clinical Care Achieving Excellence in Clinical Care and Teachingand Teaching

• Providing outstanding teaching and Providing outstanding teaching and clinical care, getting your work done, clinical care, getting your work done, getting residents home, and getting residents home, and maintaining balancemaintaining balance


• Intro. to mapping the teaching Intro. to mapping the teaching processprocess

• Demonstration of sample teaching Demonstration of sample teaching mapsmaps– Link to teaching Link to teaching professionalismprofessionalism– Link to teaching Link to teaching communicationcommunication

• Small Group exerciseSmall Group exercise

Process MappingProcess Mapping

• A process map or flowchart is a picture of A process map or flowchart is a picture of the sequence of steps in a processthe sequence of steps in a process

• Useful forUseful for– Planning a projectPlanning a project– Describing a processDescribing a process– Documenting a standard way for doing a jobDocumenting a standard way for doing a job– Building consensus about the process (correct Building consensus about the process (correct

misunderstandings about the process)misunderstandings about the process)


• Ovals are beginnings and endingsOvals are beginnings and endings

• Boxes are steps or activitiesBoxes are steps or activities

• Diamonds are questionsDiamonds are questions

• Arrows show sequence and chronology Arrows show sequence and chronology

““The first step is to draw a flow The first step is to draw a flow diagram. Then everyone diagram. Then everyone understands what his job is. If people understands what his job is. If people do not see the process, they cannot do not see the process, they cannot improve it.”improve it.”

W.E. Deming, 1993W.E. Deming, 1993


• Can be “high-level” to get an Can be “high-level” to get an overview of the processoverview of the process

Go to see patient

Go to next patient

Team meets in

work room

Rounds complete

Bedside teaching?

No

Yes

Make teaching

point


• Can also be very detailed and “drilled Can also be very detailed and “drilled down” to show the details and rolesdown” to show the details and roles

Team has test results

to review

Team meets in

work room

Team leaveswork room

Team prioritizes order to see patients

Team Discusses routine

patients


• Detailed process maps are especially Detailed process maps are especially helpful to standardize and improve helpful to standardize and improve processesprocesses

• For use as an improvement tool, it is For use as an improvement tool, it is important to map the current important to map the current process, not the desired processprocess, not the desired process


• The teaching process The teaching process – Sample maps in handoutSample maps in handout

• Disclaimer before looking at mapsDisclaimer before looking at maps– The evidence about how to teach/where The evidence about how to teach/where

to teach is mixedto teach is mixed– There isn’t a wrong or right way – they There isn’t a wrong or right way – they

are just differentare just different

Process of TeachingProcess of TeachingPost Call Day – Case Study 1Post Call Day – Case Study 1

Meet in hallway . .Attending asks any

news on oldpatients? Who

should we see first?

Team prioritizespatients to see first

Team goes topatient's room

Intern/studentgoes in first to tell

patient that theteam is coming in

for rounds

Intern/studentpresents history

Attending askspatient if he/shehas anything to

add

Attending starts physicalexam and points out

relevant findings("this helps focus me on

the patient")

Tell patient thatthe team is goingout to review test

results

Outside the patientdoor, results from

all studies arepresented and

reviewed

Attending bringsup any points ofdisagreement

Team discussesassessment and

plan

Process repeats,patient-by-patient,until all patientshave been seen

Attendingcompletes notesfor new patient

Team takes anyroad trips needed

to reviewadditional study

results

Rounds complete;House staff returns tothe floor to finish anypatient care activities

Team decidestime for rounds

and tells attending(around 7 a.m.)

Attendingcompletes noteson old patients

after rounds(around 10 a.m.)

Process of TeachingProcess of TeachingPost Call Day – Case Study 2Post Call Day – Case Study 2

Team has testresults they want

to discuss forindividual patients

Attendingcompletes noteson patients after

rounds

Team prioritizespatients to see,

based on urgency,sickest patients, andtoday's discharges

Teamdiscusses

straightforward,routine patients

Team goes tosee more

complicatedpatients

Intern/studentintroduces

attending topatient

Attending explainsto patient about

rounds and invitespatient to join in withcomments/questions

Intern/studentpresents case,physical examfindings, andassessment

Attending asksany questions

needed to clarifythe presentation

Attending askspatient

questions, evenif just to interact

with patient

Attendingconducts physicalexam and makes

any relevantteaching points

Talk aboutplan withpatient

Process repeats,patient-by-

patient, until allpatients have

been seen

Leave room anddo teachingoutside the

patient's room

Attending sees all other,straightforward patients. (If

student's patient, takestudent; if intern's patient,take resident or go alone)

Rounds completearound 10 am.

Attendingsummarizes all

patients with resident

Does attendingagree with plan?

yes

Go outsidethe room todiscuss plan

No

Team meets inthe conferenceroom (7 a.m.)

1:30 pm Team reconvenesbefore interns leave at 2 pm to

discuss anything that haschanged since morning

How Are These Processes How Are These Processes Similar/Different?Similar/Different?

• What, if anything, surprises you about the What, if anything, surprises you about the maps?maps?

• What are some similarities between the What are some similarities between the maps?maps?

• What are some differences between the What are some differences between the maps?maps?

• Where are links to Where are links to communicationcommunication and and professionalismprofessionalism

Small Group ExerciseSmall Group ExerciseMapping Your ProcessMapping Your Process

• The Goals of this exercise are toThe Goals of this exercise are to– Learn how to create a process mapLearn how to create a process map– Recognize teaching as a processRecognize teaching as a process– Recognize the differences in our teaching Recognize the differences in our teaching

processesprocesses

• InstructionsInstructions– Form a dyadForm a dyad– Interview each other to create the first draft of Interview each other to create the first draft of

the process map of your post call daythe process map of your post call day

DemonstrationDemonstration

• Mapping Chad’s process (a Mapping Chad’s process (a hypothetical process for example hypothetical process for example purposes)purposes)

Small Group ExerciseSmall Group ExerciseDebriefingDebriefing

• Re-group discussion sessionRe-group discussion session– What insights do you have about your What insights do you have about your

teaching process?teaching process?– Where in your process does teaching Where in your process does teaching

occur?occur?– Where does teaching not happen Where does teaching not happen

because of clinical care needs?because of clinical care needs?

What are some of the barriers to What are some of the barriers to teaching on the wards?teaching on the wards?

Some of the barriers we came up Some of the barriers we came up with . . .with . . .

• Time constraintsTime constraints• MisdiagnosisMisdiagnosis• Maintaining resident interestMaintaining resident interest• Power strugglesPower struggles• When can I call it a day? When can I call it a day? • ??????

Take Home Points from Take Home Points from Process MappingProcess Mapping

• Everyone has his/her own style for Everyone has his/her own style for teaching teaching

• Being explicit about your process for Being explicit about your process for teaching will provide insight into how to teaching will provide insight into how to improve the process / overcome some of improve the process / overcome some of the barriersthe barriers

• This type of exercise can be applied to any This type of exercise can be applied to any issue that you want to understand and issue that you want to understand and improve – the method can be generalizedimprove – the method can be generalized

Homework AssignmentHomework Assignment

• Finalize your process mapFinalize your process map• Review your process teaching map Review your process teaching map

– ID the successful portions of your mapID the successful portions of your map– ID the problem areas of your mapID the problem areas of your map– Link your process to the best places to teach Link your process to the best places to teach

communicationcommunication and and professionalismprofessionalism– Where does your process serve you well?Where does your process serve you well?– Where does your process start to interfere with Where does your process start to interfere with

the ultimate goal of achieving excellence in the ultimate goal of achieving excellence in teaching? How will these teaching activities teaching? How will these teaching activities affect providing clinical care?affect providing clinical care?

Documents

CHAMP Teaching on Today’s Wards Session 1 – Improving the Process Chad Whelan, MD Julie Johnson, PhD Paula Podrazik, MD