Innovation guide final web version

Monday, August 2, 2010

INNOVATIVE ADVANCESIN MEDICAL EDUCATION AND TRAINING

ABIM FOUNDATION FORUM

n About the FormAt 2

n Assessment Processes 3

n comPetencies beyond Knowledge 9

n overAll redesign 23

n ProFessionAlism/culture 31

n settings 37

n reFerences 42

Table of Contents

Dear Forum Participants:As part of day 2 of the 2010 Abim Foundation Forum, we are pleased to welcome you to a special plenary session,entitled “description of early Adopters and Presentations.” is session will feature the work of 20 early adopters of innovation in medical education and training. e term “early adopters” originates from everett roger’s book Diffusion of Innovations which describes those individuals who are among the first to adopt a new idea or process.

to identify these early adopters, the staff of the American board of internal medicine and Abim Foundation drew on the expertise of the Forum Planning committee, Abim Foundation trustees and directors, medical board and society leaders, and other education and training experts. ese innovations span both undergraduate and graduate medical education and training, and represent internal medicine, family medicine, pediatrics, surgery and anesthesiology, as well as interprofessional collaborations. ese innovations also span a wide range of topics: Assessment Processes, competencies beyond Knowledge, overall redesign, Professionalism/culture, and settings.

we would encourage you to read the guide prior to the session so that you can familiarize yourself with these impressive innovations and make the most effective use of your time. Page 2 provides further explanation of the session format. Following the explanation of the session format, innovation categories are arranged alphabetically, and within each category, the innovation abstracts are listed alphabetically by title. Abstracts are accompanied by biographies of the early adopters. relevant references for each category can be found on pages 42-44. copies of all of the articles listed are provided on your usb key.

we look forward to your active engagement in a stimulating session.

Sincerely,

2010 Abim FoundAtion Forum 1

DANIEL WOLFSONABIM Foundation

ERIC HOLMBOESession Speaker

BEVERLY WOOSession Facilitator

About the FormatPLENARY – DESCRIPTION OF EARLY ADOPTERS10:00 - 11:30 amFacilitator: beverly wooeric holmboe

After introductory remarks, the early adopters will present in two 30-minute rounds. Forum participants will select one earlyadopter per round (two total) whom they wish to hear present,and coordinate with other table members to ensure that each early adopter is heard by at least one table member.

Goals:n introduce typology and framework of early adopters

of innovations in medical education and training.

n invite participants to explore multiple innovations through small group presentations.

each early adopter will deliver a brief presentation about their poster and then engage in discussion with their audiencemembers. After 30 minutes, participants will rotate to hear theirsecond early adopter present. At the end of these two rounds,participants will return to their tables and share their observationswith fellow attendees. e next session will involve reflecting on the presentations related to the “spread” of innovations andintegration along the continuum.

REFLECTIONS ON PRESENTATIONS BY EARLYADOPTERS: SMALL GROUP DISCUSSION11:30 am – 12:35 pmFacilitator: barry egener

Goals:n explore how to integrate innovations across the

continuum of education and training and promote collaboration among organizations working on reform.

n examine how to promote and spread new ideas.

n discuss how to ensure accountability for education and training goals.

n identify ways to continue to advance the state of the art in teaching and assessment.

2 innovAtive AdvAnces in medicAl educAtion And trAining

Assessment Processes

Evaluation of Core Competencies at Baseline: How Can This Information be Used?

Presented by monica lypson

BACKGROUNDin order to determine competence or assess milestone achieve-ment, baseline measures of performance must be established. the university of michigan developed a Post-graduate orientation Assessment (PoA) to determine intern baseline proficiency.

OBJECTIVESsince 2002 there have been 1,342 residents who have taken thePoA, of which 1,255 were interns. the PoA focuses on know-ledge and skills needed during the first six to 18 weeks of theirresidency and emphasizes clinical situations that are often encountered without formal supervision.

METHODSAssessments include verbal/written handoff (university ofchicago model), informed consent, geriatric functional assessment (or pediatric history taking), aseptic technique, evidence-based medicine, diagnostic images, critical laboratoryvalues, cross-cultural communication and Joint commission requirements such as surgical fire safety and pain assessment. Assessment measures include standardized patients as well as computer-based and multiple-choice questions.

RESULTSthe PoA overall score represents a moderate, statistically significant predictor of the American board of Pediatrics boardPercent correct score (r=0.398, p=0.044, n=26). we have identified a trend that the PoA overall score is a predictor ofperformance on the in-training examination in Physical medicine& rehabilitation, although not statistically significant (r=.546,p=0.066, n=12).

CONCLUSIONShospital orientation proves to be an ideal time to gather initialperformance data on entering post-graduate trainees, and baselineperformance on the Accreditation council on graduate medicaleducation (Acgme) general competencies maybe a predictor offuture board performance.

NEXT STEPSmany institutions/programs have adopted an intern assessment.Further work is needed on the predictive value of the PoA. curriculum efforts must be adjusted to reflect intern deficits.


Monica Lypsondr. lypson, a board certified internist, isAssociate Professor of internal medicineand Assistant dean of graduate medical education (gme) at the university ofmichigan health system (umhs). she

practices at the vA Ann Arbor healthcare system (vAAhs) andis also the Faculty Advisor for the umhs standardized PatientProgram.

dr. lypson most recently served as the sociocultural curriculumdirector and as a Faculty Facilitator in the Family centered experience program; prior to that she served as Associate chief of staff for Ambulatory care at the vAAhs from 2003 to 2005.

dr. lypson’s research interests include trainee assessment, leader-ship and the under-representation of minorities in academics.she has developed and led the implementation of an orientationobjective standardized examination for all incoming interns atumhs. she serves on the national board of medical examinersintegrated case development task Force and is active in the Association of American medical colleges (AAmc) group onresident Affairs, a member of the national steering committee,central group on educational Affairs – gme section leader andnational secretary of the society of general internal medicine.

dr. lypson received her undergraduate degree from brown university and her medical degree from case western reserveuniversity school of medicine. Following medical school, shecompleted her residency in internal medicine – primary care atthe brigham and women’s hospital followed by a robert woodJohnson clinical scholars program at the university of chicago.

she is currently pursuing her masters in health professions education at the university of illinois.


Milestones of Competency in Graduate Medical Education

Presented by richard bell and eric holmboe

BACKGROUNDwith the launch of the Accreditation council for graduate medical education (Acgme) outcomes Project in 2001, theframework of graduate medical education (gme) shifted from atime and process model to an outcomes-based model. goals forthis transition include better assessment and evaluation of traineesand reassuring the public that the gme community is trainingphysicians who are capable of providing safe and effective care to the u.s. population.

OBJECTIVESto advance the outcomes Project, the Acgme has launched a gme community-wide initiative to define milestones of competency and identify assessment tools that document theachievement of milestones. by definition, milestones identify significant points in development that should allow the trainee,the program and the certification board to identify an individual’strajectory in acquiring competencies.

METHODSthe internal medicine and general surgery gme communitieshave developed draft milestones documents and are currentlyworking on implementation strategies. while each specialty approached this task differently, their work includes common elements.

RESULTSinternal medicine initially defined 142 discrete behavioral-basedmilestones and is now exploring implementation and assessmentstrategies focused around key developmental points in training.in contrast, general surgery first identified critical domains ofpractice and then points and skills in development within thosedomains and subsequently populated those points with narrativedescriptions of milestones defining competence. both of theseapproaches include the identification of critical points for focusedassessment using more discrete behavioral milestones.

CONCLUSIONdeveloping specialty-specific milestones of competency can provide a framework for enhancing the assessment and evaluationof physicians in training and can foster the development of sharedapproaches to competency-based medical education across all specialty training programs. initial work developing milestoneshas identified potential synergies in development and implementation strategies.


Richard Bell Jr.dr. bell, a board certified general surgeon,is the Assistant executive director of theAmerican board of surgery, inc. hechairs the surgical council on surgicaleducation, founded in 2006, a consortium

of seven surgical organizations whose mission is to improve graduate surgical education.

dr. bell was the loyal and edith davis Professor and chair ofthe department of surgery at the Feinberg school of medicine of northwestern university in chicago. Prior to joining the faculty at northwestern, he served as vice-chair of surgery at the university of washington and division chief of general surgery at the university of cincinnati.

he is chair of the Accreditation council of graduate medicaleducation milestones Project working group in general surgery. he currently chairs a joint project of several surgicalboards to define competencies expected of surgeons in the care of geriatric patients. he is a member of the national Advisorycommittee for the robert wood Johnson clinical scholars Program. dr. bell has served as President of the central surgical Association and the Association for Academic surgery and vice-President of the society for surgery of the Alimentary tract.

dr. bell received his undergraduate degree at Princeton university, and he received his medical degree from northwestern university.

Eric Holmboedr. holmboe, a board certified internist, is chief medical officer and senior vice President of the American board of internal medicine and the AbimFoundation. he is also Professor Adjunct

of medicine at yale university, and Adjunct Professor at the uniformed services university of the health sciences.

Previously, he was Associate Program director, yale Primary careinternal medicine residency Program, and director of studentclinical Assessment, yale school of medicine. before joiningyale, he was division chief of general internal medicine at thenational naval medical center.

his research interests include interventions to improve quality of care and methods in the evaluation of clinical competence. A frequently-requested speaker, he is the author of more than 100 peer-reviewed articles in professional journals. dr. holmboe is a member of the boards of the national board of medical examiners and medbiquitous, and is a consultant for the drugsafety and risk management subcommittee of the Pharmaceuti-cal science Advisory committee for the u.s. Food and drug Administration. he is a Fellow of the American college ofPhysicians and an honorary Fellow of the royal college of Physicians in london.

dr. holmboe is a graduate of Franklin and marshall college and the university of rochester school of medicine. he completed his residency and chief residency at yale-new havenhospital, and was a robert wood Johnson clinical scholar atyale university.


Competencies Beyond Knowledge

Achieving the Systems-Based Practice (SBP) Competency by Implementing a Web-Based Business of Medicine Curriculum

Presented by Paul taheri

BACKGROUNDthe focus of the sbP competency is to encourage physicians toleverage health system assets to provide optimal care to patients.heath systems are complex, capital-intensive businesses that typically are poorly integrated, have diffuse governance structuresand are increasingly bottom-line focused. Physicians often manage these complex business entities with little or no formalbusiness training. Physicians are in need of an understanding ofthe fundamental principles of business applied to health care.

OBJECTIVEto assess the learning outcome and satisfaction of a web-basedbusiness curriculum specifically developed for house officers.

METHODSAccess to a curriculum of 28 web-based modules covering topicssuch as economics, finance, operations management, leadershipand other business disciplines, was provided to 99 house officersin multiple training programs across the united states. Pre- andpost-testing was performed at the outset and after curriculumcompletion. overall satisfaction with the curriculum was also assessed.

RESULTSA total of 99 residents from university of michigan, henry Fordhealth system, banner good samaritan and the American boardof surgery completed the curriculum. mean pre-test score was55+ 11 and mean post-test was 75+ 11.6. on average, residentscompleted modules in 35 minutes. the vast majority of residents(>90%) rated the curriculum well organized, relevant, an excellentlearning experience and overall a positive experience, with thecontent not taught elsewhere in training.

CONCLUSIONSthe findings of this analysis demonstrate that this business curriculum is easy to use, cost effective, demonstrates learning and provides a credible platform for achieving the systems-basedPractice competency.

NEXT STEPSthis business curriculum can be easily disseminated to any and allinterested programs. recently, the curriculum was incorporatedinto the American board of surgery online score curriculum.

Additional Authors: Deborah Harkins, RN, MBA, General Manager and Senior Consultant, MDContent; David Butz, PhD, Founder and Co-Director, Center for Health Care Economics, University of Michigan


Paul Taheri dr. taheri, a board certified general surgeon, is a Professor of surgery at theuniversity of vermont, sr. Associate deanfor clinical Affairs and President of theFaculty Practice at Fletcher Allen health

care in burlington, vt. he oversees and manages a 500 membermultispecialty practice with approximately $250 million in annualrevenue. he also holds teaching positions at the university ofmichigan ross school of business and the university of vermontschool of business.

From 1996 to 2007, dr. taheri led the university of michigandivision of trauma burn and emergency surgery. during histenure, he became the Associate dean for Academic business development. in that role, he oversaw the intellectual propertymanagement and technology transfer at the school of medicine,and he developed a comprehensive leadership development coursefor the medical school faculty with the ross school of business.he also served as vice chair, department of surgery and, as ajoint initiative between the university of michigan business and medical schools, developed the center for health care economics.

dr. taheri is President-elect for the group on Faculty Practicesof the Association of American medical colleges. he is an examiner for the American board of surgery. he has deliverednumerous presentations to hospitals and physician groups on various business topics including cost of care, physician leadershipand system optimization.

dr. taheri is a graduate of st. lawrence university and earned his medical degree from new york university. he completed hisresidency at tulane university.


An Assessment of an Educational Intervention on ResidentPhysician Attitudes, Knowledge and Skills Related to AdverseEvent Reporting Presented by david mayer

BACKGROUNDreporting and learning from patient harm, near misses and unsafeconditions is critical to improving patient safety. Programs thatengage resident physicians in adverse event reporting can enhancepatient safety and simultaneously address all six competencies of the Accreditation council for graduate medical education(Acgme). however, fewer than 60 percent of physicians knowhow to report adverse events and near misses, and fewer than 40percent know what to report.

OBJECTIVEto evaluate the effect of an educational intervention on anesthesi-ology residents’ attitudes, knowledge and skills related to adverseevent reporting and the associated follow-up.

METHODSin a prospective study, anesthesiology residents participated in a training program focused on the importance of patient event reporting in patient safety and reporting methods. Quarterly adverse event reports were analyzed retrospectively for two yearsprior to the intervention and prospectively for seven quarters following the intervention. residents also completed a surveyprior to and one year after the intervention, evaluating their attitudes, experience and knowledge regarding adverse event reporting.

RESULTSFollowing the intervention, the number of adverse event reports increased from zero per quarter to almost 30 per quarter.we identified several categories of harm events, near misses and unsafe conditions, including reports of disruptive providers. of the events associated with invasive procedures, more than half were associated with lack of attending physician supervision. we also observed significant progress in the residents’ ability toappropriately file a report, improved attitudes regarding the valueof reporting and available emotional support and a reduction inperceived impediments to reporting.

CONCLUSIONAn educational intervention with residents can result in improvedattitudes toward adverse event reporting, and increased reporting.


David Mayerdr. mayer is Associate dean for curriculum, vice-chair for safety andQuality, co-executive director of the institute for Patient safety excellence and curriculum director for the masters

in Patient safety leadership program at the university of illinoisat chicago. he is board certified in general anesthesiology.

A pioneer in patient safety curricula, dr. mayer founded the telluride, colorado invitational roundtable on designing Patient safety curricula. the annual multidisciplinary roundtablebrings together leaders from the American medical Association,American nurses Association, the Joint commission, nationalboard of medical examiners, Accreditation council of graduatemedical education, American board of internal medicine, lucian leape institute and health science education with patients, residents and students.

dr. mayer is a member of the national Quality Forum Patientsafety advisory board, a consultant to the new south wales’ national task Force addressing safety, quality and education, anda member of the lucian leape institute patient safety educationalroundtable. he is principal investigator on a number of grants including three u.s. department of education grants on the design and assessment of patient safety education for medical

schools, two Anesthesia Patient safety Foundation grants on resident training for handoffs and a local anesthetic toxicity rescuetraining program. in 2007, dr. mayer was awarded the universityof illinois American Association of medical colleges/Pfizer humanism in medicine Award for his commitment to teaching,service, patient advocacy and patient care.

dr. mayer earned his medical degree from the university of illinois and completed his residency and fellowship at michaelreese hospital in chicago.


Milestones to Teach and Evaluate Handoffs

Presented by vineet Arora and holly humphrey

BACKGROUNDwith reduced resident duty hours, improving handoffs is paramount to patient safety. tools to teach and evaluate handoffsare lacking. the university of chicago’s vertically integrated undergraduate and graduate medical education structure enablesthe development and implementation of innovative education and evaluation across the continuum of medical training.

OBJECTIVEto develop and implement handoff teaching and evaluation thataddress milestones in handoff education from medical student tofaculty.

METHODSA needs assessment was conducted to assess clinical student exposure and participation in handoffs. milestones for handoffeducation and evaluation were developed and reviewed by externalexperts for content validity. education and evaluation tools werecreated to address each milestone. working with curriculumcommittees for the medical school and internal medicine residency, education and evaluation for learner levels is being implemented.

RESULTSthird-year students receive training on how to transform clinicaldata into a written signout ensuring hiPAA compliance. risingsenior students are taught how to conduct verbal signout duringtheir subinternship orientation. using case-based workshops andsimulation, graduating students and incoming medical internspractice giving and receiving handoffs. residents receive trainingin supervising and evaluating handoffs. Faculty development inhow to incorporate handoff teaching into daily rounds is ongoing.

CONCLUSIONSusing handoff milestones, it is possible to develop and implementhandoff teaching and evaluation across learner levels from medicalstudent to faculty.

NEXT STEPSdisseminate findings via national meetings, publications, mededPortal, speaking engagements and web-based platformsto house tools (website, youtube channel, slideshare).

Additional Author: Jeanne Farnan, MD, Assistant Professor of Medicine, Department of Medicine, University of Chicago


Vineet Arora dr. Arora, a board certified internist, is an Associate Professor of medicine andthe Associate Program director for themedicine residency and Assistant deanfor scholarship and discovery at the

university of chicago Pritzker school of medicine.

dr. Arora’s scholarly work on resident duty hours, patient hand-offs, medical professionalism, and quality and safety has appearedin The Journal of the American Medical Association, Academic Medicine and Annals of Internal Medicine and has been covered byThe New York Times, cnn and Abc news. she testified to theinstitute of medicine on resident duty hours and handoffs and tocongress on the need for physician payment reform to revitalizeprimary care. dr. Arora served on the American board of internal medicine (Abim)’s hospital medicine subcommitteeand internal medicine Question writing committee. she wasthe site champion for the Abim care of the vulnerable elderlyPim study and is Principal investigator for the Abim Founda-tion’s Putting the charter into Practice project grant.

dr. Arora has received numerous awards, including the society of general internal medicine’s milton hamolsky Award and the American college of Physician’s walter J. mcdonald Award.in 2009, ACP Hospitalist named her among the top 10 hospitalistsin the united states.

dr. Arora earned her medical degree from washington universityin st. louis. she completed her residency, chief residency andmaster’s degree in public policy at the university of chicago.

Holly Humphreydr. humphrey, a board certified internist,is Professor of medicine and dean formedical education at the university ofchicago. she served as chief medicalresident before joining the faculty as an Assistant Professor in 1989.

dr. humphrey was promoted to Professor in 2000 and was the first clinician-educator at the university of chicago awardedtenure. dr. humphrey is a member of the board of trustees ofthe Abim Foundation and she previously served on the board of directors of the American board of internal medicine from2001 to 2007, including a term as chair from 2006 to 2007.

Prior to accepting her current position as dean, she spent 14 yearsas director of the internal medicine residency Program.

dr. humphrey was recently elected a master by the Americancollege of Physicians (AcP). in 2009, Crain’s Chicago Businessfeatured her as one of their “women to watch.” she is a formerPresident (1995) of the Association of Program directors in internal medicine and later received the dema c. daley FoundersAward from that same organization. dr. humphrey has authoredmore than 60 articles and edited three books, including Mentoringin Academic Medicine.

An honors graduate of the Pritzker school of medicine, dr. humphrey completed her residency and pulmonary-criticalcare fellowship at the university of chicago.


Patient Safety: Internal Medicine Residents as Agents of Change

Presented by noelle sinex

BACKGROUNDPatient safety literature offers few practical solutions on the implementation of an integrated, system-wide application of patient safety approaches to clinical practice, let alone graduatemedical education. graduate medical education seems to be acritical partner in patient safety given that residents provide direct patient care and should understand the concept of patientsafety and the institutional methods that support patient safetypractices.

OBJECTIVEto create an explicit shift in graduate medical education towardpatient safety and shared accountability while driving improve-ment in the indiana university school of medicine (iu som)hospital system. researchers sought to teach key patient safetyand quality improvement concepts to internal medicine residents,and to instill and reinforce the habit and culture of patient safety.

METHODSiu som researchers developed a curriculum to teach both keypatient safety concepts and their practical application to internalmedicine residents. A patient safety consultative rotation was developed that included key readings and didactics, participatingin hospital committees and quality improvement initiatives, andconducting “safety consultations” on patient cases. residents researched and evaluated key incidents for errors using a

standardized format, and selected one to formally present at amulti-disciplinary conference. A new chief resident position for quality improvement and patient safety was developed tochampion the curriculum and consultative rotation.

RESULTSthe success was evaluated by surveys of the patient safety cultureand evaluation of the qualitative reflections of participating residents. Quantitative data including the number and nature of safety consults was collected and processed. chief residentsand faculty provided evaluation of the end-of-rotation safety conference presentations. Patient outcomes data related to safetyand quality demonstrated positive change from resident-drivenimprovement projects. the chief resident for Quality and safetycompleted multiple projects and presented three posters and twoworkshops from her work.

CONCLUSIONSinvolving residents in the process of analyzing errors and criticalincidents and then enlisting them to find solutions to prevent future events is a powerful tool. Providing a focused experience in patient safety and appropriate mentorship produces outcomesthat residents identify as valuable and important to their career.

NEXT STEPSthe team plans to launch this service in their county hospital beginning July 2010 and make this rotation a graduation require-ment for residents in the iu som’s internal medicine residencyprogram.


Noelle Sinexdr. sinex, a board certified internist, serves as Associate Program director forAmbulatory care and as medical directorof the women’s health Program at therichard l. roudebush veterans Affairs

medical center (roudebush vAmc), in indianapolis. there, sheparticipates in the educational innovations collaborative throughthe office of Academic Affiliations. Previously, she served asAmbulatory chief resident at the roudebush vAmc from 2003 to 2004, and worked in the dedicated teaching clinic.

dr. sinex is also Associate Program director for the internalmedicine residency program at indiana university (iu). iu is one of nineteen programs designated as an educational innovations Project (eiP) program. As a leader in this project,she has been involved in educational innovations in patient safetyand ambulatory education. dr. sinex’s participation in the eiPcollaborative is through the office of Academic Affiliations at the roudebush vAmc.

dr. sinex has a professional interest in teaching ambulatory medicine, women’s health, quality improvement and patient safety. she has received multiple teaching awards from iu’s department of medicine and its internal medicine residency program, including the indiana school of medicine trusteeteaching Award in 2008.

dr. sinex received her bachelor’s degree from centre college, and she earned her medical degree from indiana universityschool of medicine.


Training Interprofessional Teams of Students and Health Professionals in Quality Improvement

Presented by leslie hall

BACKGROUNDin 2006, university of missouri health care began jointly training health care students and professionals in quality improve-ment (Qi) skills, as members of interprofessional teams.

OBJECTIVEto determine (1) if health care students perceive value from participating in interprofessional Qi team training and (2) ifhealth care improvement skills increase as a result of this experience.

METHODSeach team included health care workers, students and at least one Qi facilitator. large group interactive learning sessions,which focused on fundaments of Qi process, were complementedby small group work on an improvement project over a five-month period. improvement project results were presented tohealth system leaders at the end of training.

RESULTStwenty-four teams comprised of 147 unique individuals (81health care workers and 66 students) completed this training from 2006 to 2010. satisfaction with the training was high, with participants expressing agreement that the training developedtheir Qi skills, helped them gain a greater understanding of

teamwork in health care and helped them appreciate contributionsof other health professionals. student skills in Qi, as assessed bythe Quality improvement Knowledge Assessment tool (QiKAt), increased as a result of the training, and were significantly betterthan Qi skills in control groups of students who did not completethe Qi training.

CONCLUSIONShealth care students trained in the improvement of health care aspart of interprofessional teams view the process as valuable. theirQi skills improve significantly following the experience.

NEXT STEPSreplication of this model at other academic health centers shouldbe considered.


Leslie Halldr. hall, a board certified internist, is the senior Associate dean for clinical Affairs at the university of missouri –columbia school of medicine, and thechief medical officer for university

of missouri health care.

From 2002 to 2008, dr. hall served as the director of the officeof clinical effectiveness, overseeing quality improvement and patient safety initiatives throughout university of missourihealth care. he has led several curricular innovations in theareas of quality improvement, patient safety and teamwork inhealth care. he co-leads the university of missouri Performanceimprovement leadership development course.

For the past two years, dr. hall has served as co-chair of theAcademy for healthcare improvement Professional educationresource committee. he served as a physician advisor for Quality and safety education in nursing, a national robertwood Johnson initiative, from 2005 to 2008. From 2004 to 2008, dr. hall served as the primary investigator at the universityof missouri for the Achieving competence today program,

teaching quality improvement skills to medical and nursingtrainees who were imbedded within system improvement teams.in 2007, he received the distinguished Quality ProfessionalAward of the missouri Association for healthcare Quality. hereceived the national Award for excellence in teaching from thenational Association of inpatient Physicians (now society ofhospital medicine) in 2001.

dr. hall received his medical degree from washington universityin st. louis, and completed his internal medicine residency atbethesda naval hospital in bethesda, maryland.


Patients and Families as Advisors: Enhancing Medical Education Curricula

Presented by Janice hanson

BACKGROUNDPatients and caregivers bring a perspective to medical educationthat informs the development of curriculum activities and helpsbuild a patient-centered, family-centered approach to care amongmedical students.

OBJECTIVEby using patients and families as advisors, the group sought to enhance the medical education curricula at the uniformed services university of the health sciences in bethesda, md.

METHODSinitially, 12 parents of children with chronic health conditionswere convened to describe physicians who had been most helpfulto their families. the group met for four months to learn about medical school, describe physician behaviors and attitudes,group behaviors and attitudes in categories, and draft curriculumactivities.

Following the initial effort, the patient and family advisory program was expanded. small groups of advisors meet to address focused topics and specific curricular materials. with a facilitator, they share experiences, write behavioral descriptors,draft materials and develop activities. Advisors with relevant experience teach with other medical school faculty.

RESULTSthe parents in the initial group described physician behaviors andattitudes in four categories: self-awareness (e.g., acknowledgementof limits, attitudes about people with disabilities), communication(with patients, families and health professionals), shared medicaldecision-making and advocacy (for individuals and at the systemlevel).

to date, a diverse group of more than 200 patients and familymembers have participated in the development of medical education curriculum activities and teaching over 10 years. earlycurriculum activities included a pediatric home visit with parents,children and young adults as teachers, small-group discussionsabout ethical decision-making, patients and parents coaching students in communication skills, and a workshop about advocating for patients and families.

CONCLUSIONS AND NEXT STEPSActivities from early efforts have been progressively revised to fit different places in the curriculum and adjusted curricular goals.new activities (e.g, a health supervision curriculum) have been developed with advisor participation. Activities are currently developed and co-taught with advisors in four academic departments. the advisor group provides consultation to fourcommittees that are working on curriculum reform. new focusgroups will reconsider the original four categories of physician behavior for possible revision.


Janice HansonJanice hanson, Phd, is Associate Professor of medicine, Pediatrics andFamily medicine at the uniformed services university of the health sciences(usu). with funding from the Josiah

macy, Jr. Foundation and the health resources and services Administration, dr. hanson developed a large, diverse and activegroup of patient and family advisors to co-develop and co-teachcurriculum activities in the medical education program. she nowdirects this ongoing patient and family advisor program, involvingthe advisors in courses and clerkships in four departments duringthe entire span of the medical education program.

dr. hanson’s work focuses on communication and relationshipsbetween patients, families and physicians, with a patient- and family-centered orientation. usu recently began a comprehensive curriculum reform effort, to which dr. hansonwill bring the patient’s voice. in addition to serving on the assessment committee for curriculum reform, dr. hanson has assembled a group of patient and family advisors to participate in all aspects of curriculum reform, ensuring that faculty, studentsand patient advisors will partner to design and implement the new medical school curriculum at usu. the new curriculum willmore fully integrate science and clinical learning, with curricularthemes that include patient-centered care and patient safety.

in 2002, dr. hanson, along with other members of the Pediatriceducation section at usu, received the Ambulatory PediatricsAssociation 2002 national teaching Award. in 2010, she was elected as the Putnam scholar by the American Academy on communication in healthcare to further her work in assessmentand teaching of communication skills in medical education.

dr. hanson holds degrees in education from western michigan university and east carolina university, as well as both educational specialist and doctor of philosophy degrees from the university of michigan.


Overall Redesign

Innovations in Residency Training – Mid-Stride Findings fromthe P4 Project

Presented by larry green and James Puffer

BACKGROUNDthe Preparing the Personal Physician for Practice (P4) project is a six-year (2006 to 2012) national demonstration initiative of aspectrum of innovations in family medicine residency education.the 14 participating programs form a comparative case study of experiments that include changes in the length, structure, content and location of training, and expanded measurements of competency.

OBJECTIVEto answer questions such as how best to align residency training with the new model of practice and to clarify which educational methods are most effective in producing skilled personal physicians for the Patient centered medical home.

METHODSevaluation of the innovations in the P4 project uses a mixedmethod approach. the core data collected annually from all programs are (1) Program data, (2) resident survey, (3) continuity clinic data, (4) grad survey and (5) online diarydata. each program is using additional measures designed to test their specific hypotheses.

even though analysis of the project is still underway, we sharemid-stride results and lessons based on what the P4 evaluationteam has learned from site visits, standardized core data and a survey of the P4 programs concerning accreditation requirements.

CONCLUSIONSthe P4 project will assist educators in preparing personal physicians to practice in the evolving models of advanced primarycare and help guide necessary changes in the next set of revisionsin the accreditation requirements for family medicine.

NEXT STEPScontinue to disseminate important findings from the P4 Projectto foster educational innovation and vital synergies in primarycare residency redesign.


Larry Green dr. green, a board certified family physician, is Professor of Family medicine and the epperson-Zorn chair for innovation in Family medicineand Primary care at the university of

colorado, denver.

Previously, he practiced medicine in van buren, Ariz., in the national health service corps. he joined the university of colorado faculty in 1977 and has served in various roles, including department chair. he has championed practice basedresearch for decades. in 1999, he became the founding directorof the robert graham center, a research policy center sponsoredby the American Academy of Family Physicians.

dr. green served on the steering committee of the Future ofFamily medicine Project and directed the robert wood JohnsonFoundation’s Prescription for health national program. he is afounding board member for Partnership 2040, and is chair of the council overseeing the community engagement component ofthe colorado clinical translational sciences institute, funded bythe national institutes of health. dr. green is a member of thenational committee on vital and health statistics, and co-chairof the steering committee for Preparing the Personal Physicianfor Practice. he is the immediate past chair of the board of directors of the American board of Family medicine, a memberof the board of directors of the American board of medical specialties and a member of the institute of medicine.

dr. green is a graduate of the university of oklahoma. heearned his medical degree at baylor college of medicine andcompleted his family medicine residency at highland hospitaland the university of rochester.

James Puffer dr. Puffer is President and ceo of theAmerican board of Family medicine(AbFm) in lexington, Ky. he is boardcertified in family medicine and sportsmedicine.

Previously, dr. Puffer served as a faculty member of the universityof california, los Angeles for over 23 years. during his tenure,he was Professor and chief of the division of sports medicine in the department of Family medicine. he also served as Familymedicine residency director, chief of the division of Familymedicine and interim chair of the department of Family medicine, which he was instrumental in establishing.

dr. Puffer was President of the Association of departments of Family medicine. he was elected to the board of directors of American board of Family Practice, where he served as vice President and on its executive committee. dr. Puffer was also on the board of directors of the Pisacano leadershipFoundation. he was editor-in-chief of Sports Medicine Digest,and Associate editor of Medicine and Science in Sports and Exercise. he serves or has served on the editorial board of morethan 10 journals. dr. Puffer has published a book and multiple research articles and book chapters and has presented more than 750 lectures.

dr. Puffer completed his undergraduate, medical school and family medicine residency training at uclA.


Structured Career-Centered Block Time in a Pediatric Residency Program

Presented by m. douglas Jones Jr.

BACKGROUNDFour consecutive months in Pgy-3 are set aside to improvepreparation for four different careers: primary care with and without convenient access to subspecialty care, hospitalist medicine and subspecialty medicine. All residents are individuallymentored and monitored during the four-month block. blocksinclude mentored, practice-based learning and improvement projects.

PRIMARY CAREthese blocks take place at the children’s hospital (tch) indenver and metropolitan or non-metropolitan community sites.residents are able to schedule appointments according to patientneed rather than resident availability. All receive supplementary experiences in health maintenance, telephone triage and advice,concepts of the medical home, practice management, billing andcoding, and child advocacy. they are exposed to subspecialtiesmost relevant to primary care (mental health, sports medicine,dermatology, allergy). those intending to practice in non-metropolitan sites experience practice in such sites to acquaintthem with the particular blend of procedural and practice skills needed for those sites.

HOSPITALISTthis block includes inpatient experiences at both tch and community hospitals with special instruction in conscious sedation and common procedures. it also includes experiencewith ambulatory care of children with special health care needs to provide a sense of the role of hospitalists in a medical home,i.e., the importance of continuity between hospital and routineand emergency ambulatory care. time is also set aside for instruction in principles of medical education.

SUBSPECIALTYthis block occurs at tch and varies by subspecialty. the intentis to supplement rather than duplicate later training. it includesinstruction in principles and practice of medical education, and either a quality improvement or research project.

Additional Author: Adam Rosenberg, MD, Professor of Pediatrics, Director of PediatricResidency Program, University of Colorado-Denver


M. Douglas Jones Jr.dr. Jones is Professor of Pediatrics at the university of colorado school ofmedicine. he is involved with medicaleducation at this institution as well as nationally through the new initiative for

innovation in Pediatric education (iiPe). dr. Jones is board certified in pediatrics and neonatal-perinatal medicine.

until 2005, he was Professor and chair of the department of Pediatrics at the university of colorado school of medicine and Pediatrician-in-chief and l. Joseph butterfield chair of Pediatrics at the children’s hospital in denver. Previously, whileat the Johns hopkins university school of medicine, dr. Jonesserved as Professor of Pediatrics and Associate Professor of Anesthesiology and critical care medicine and of gynecologyand obstetrics.

he is the immediate past chair of the board of directors of the American board of Pediatrics and was recently chair of theAccreditation council for graduate medical education reviewcommittee for Pediatrics. he has been a leader of two major initiatives sponsored by the American board of Pediatrics Foundation: one resulted in revision of pediatric subspecialtytraining, and the other was the recently completed three-year residency review and redesign in Pediatrics (r3P) project, acomprehensive self-study and strategic planning project that has continued as the iiPe.

dr. Jones received his master’s and medical degrees from the university of texas southwestern medical school at dallas. he completed his internship and residency in pediatrics at theuniversity of colorado health sciences center and a fellowshipin neonatal-perinatal medicine at the university of coloradohealth sciences center and the children’s hospital in denver.


Impact of an Interprofessional Central Venous Catheter InsertionTraining Program

Presented by elliot sussman

BACKGROUNDevidence suggests that central venous catheter (cvc) insertiontraining (barsuk 2009; evans 2009), the use of ultrasound guidance (leung 2006; milling 2005), and compliance with theinstitute for healthcare (ihi) central line bundle (Pronovost2006; team stePPs 2010) improve patient outcomes.

OBJECTIVEto reduce cvc complications including central line associatedbloodstream infections (clAb).

METHODSthe cvc course is required of all residents who place centrallines at lehigh valley health network (lvhn) upon entry intoresidency. A pre-course e-learning module with video vignettessets behavioral and collaborative expectations among all providerssurrounding the procedure. the course includes: a half-day practical portion with manikin practice, ultrasound for target vessel verification and a checklist based competency evaluation.nurses participate in the course and ensure that the bedsidechecklist, which includes the ihi bundle, is used as it would be at the bedside. Assessments included post-course surveys, focusgroups, pre-/post-/delayed- knowledge tests and registry data that tracks compliance with the ihi bundle and clAb.

RESULTSFocus groups confirmed the need for a check-off run and thatnurses are helping ensure sterile conditions and challenging residents on the number of needle stick attempts. statistical quality control measures were used to track the effect of the training process on the clAb rate for cvcs (peripherally inserted central catheters, Picc lines, excluded), which improvedfrom 3.4 to 0.8 per 1,000 line days (P=0.001). reduced variabilityin the downward trending rate was reflected by the standard deviation decreasing from 1.45 pre-training to 0.40 post-training.

CONCLUSIONSthe clAb rate was successfully reduced. check-off competency runs and nurse collaboration in the checklist are plausible contributing factors to success.

NEXT STEPScentral line training paradigms, including bedside checklists, interprofessional training protocols and registry methods for performance tracking require refinement and broader application.

Additional Authors:James P. Orlando, EdD, Director, Medical Education Development;

Andrew Miller, DO, Emergency Medicine Physician; William Bond, MD,

MS, Director of Research; Valerie Rupp, RN, MSN, Clinical Trial

Investigator; Bryan Kane, MD, Emergency Medicine Physician; Cindy

Umbrell, RN, MSN, Director, Trauma Neuro Intensive Care Unit; Michael

Pasquale, MD, Trauma Director; Elizabeth Verheggen, PhD, Researcher


Elliot Sussmandr. sussman, a board certified internist,serves as President and chief executiveofficer of lehigh valley health network(lvhn). under dr. sussman’s leadershipsince 1993, lvhn evolved into one of the

nation’s leading academic community hospitals. he is also theleonard Parker Pool Professor of health systems management,and Professor of medicine at the university of south Floridacollege of medicine.

From 1989 to 1993, dr. sussman was Associate dean and Associate Professor of medicine at the university of chicago, division of the biological sciences, Pritzker school of medicine.he also served as executive director for clinical Practices and Associate Professor of medicine for the university of Pennsylvania, and Associate Administrator and director of theclinical effectiveness Program at the hospital of the universityof Pennsylvania.

he is the immediate past chair of the board of directors of theAssociation of American medical colleges. dr. sussman serveson the boards of the Allentown Art museum, lehigh university,lehigh valley Pbs/wlvt tv, the ceo education 2010 leadership group and the lehigh valley Partnership.

dr. sussman holds a masters degree in business from the wharton school at the university of Pennsylvania, a medical degree from harvard university and a bachelor’s degree from yale university. he completed residency at the hospital of theuniversity of Pennsylvania. he completed a fellowship in general medicine and was a robert wood Johnson clinicalscholar at the university of Pennsylvania.


Professionalism/Culture

The Miller-Coulson Academy of Clinical Excellence at Johns Hopkins Bayview Medical Center

Presented by scott wright

BACKGROUNDAcademic medical centers (Amcs) are committed to the tripartite missions of research, education and patient care. Promotion decisions are focused predominantly on research accomplishment, and there continues to be concern about how to recognize clinicians who spend a majority of their time andexcel in caring for patients.

OBJECTIVEto define “clinical excellence in academia,” to develop an instrument to identify the physicians who are outstanding in the delivery of patient care, and to launch an academy dedicatedto promoting excellence in patient care.

METHODSthrough meetings with institutional and national leaders, a systematic review of the literature and research (both qualitativeand quantitative), a definition for clinical excellence in academiawas developed. this definition was then operationalized into ameasurement tool, the “clinical portfolio.” the portfolios (30+pages), assembled by those nominated by peers for membership in the Academy, were evaluated and scored by an external reviewboard (erb; akin to a study section) that is made up of nationalleaders in clinical performance.

RESULTSthe definition of “excellence in patient care in academia” has beenpublished. the clinical portfolio has proven to be discriminativeand reliable. there was excellent agreement among members ofthe erb, and with the internal committee, about which of thenominees would be accepted for membership in the Academy(nine of the 18 faculty physicians were admitted in 2010).through interdisciplinary collaboration, the 15 members of theAcademy are producing and planning innovative educational, advocacy and clinical programs that “promote excellence in patient care for the benefit of the patients and communities that we serve.”

CONCLUSIONStransforming the definition of clinical excellence in academia into ameasurement tool has allowed us to induct exceptional physiciansinto the miller-coulson Academy of clinical excellence. the members of this “working” Academy are committed to theprimacy of patient care and to influencing institutional culture.

Additional Authors: Steven Kravet, MD, MBA, Assistant Professor of Medicine and President,Johns Hopkins Community Physicians; Colleen Christmas, MD, Assistant Professor of Medicine and Director, Johns Hopkins Bayview Internal MedicineResidency Program; Chris Durso, MD, MBA, Assistant Professor of Medicine,Johns Hopkins Bayview; Kathleen Burkhart, Manager, Miller-Coulson Academy of Clinical Excellence; David Hellmann, MD, Vice Dean, Johns Hopkins Bayview Medical Center and Chair, Department of Medicine,Aliki Perroti Professor of Medicine, Physician-in-Chief, Johns HopkinsBayview Medical Center


Scott Wrightdr. wright, a board certified internist, is Professor in the department of medicine at the Johns hopkins university school of medicine ( Jhu-som). he has been involved with

many educational programs there, as well as with several medicaleducation activities at the national level including the initiativeto transform medical education, innovative strategies for transforming the education of Physicians, and programs of the Arnold P. gold Foundation (an organization from which he was awarded a professorship).

with colleagues, he developed and launched the miller-coulsonAcademy of clinical excellence. dr. wright serves as director of the Academy, which is committed to recognizing and promoting excellence in patient care. he has been published inleading biomedical research journals including The New EnglandJournal of Medicine, The Journal of the American Medical Association,Annals of Internal Medicine and The American Journal of Medicine.in recognition of his research accomplishments, dr. wright was elected to membership in the American society for clinicalinvestigation. his achievements in teaching and patient care

were recognized by Jhusom and he was elected a member in the Alpha omega Alpha honor medical society.

dr. wright received his medical degree from mcgill university.he completed his internal medicine residency at montreal general hospital.


Transforming the Culture of a Large Academic Medical Center:Where We’ve Been, Where We Are, Where We’re Going

Presented by d. craig brater, richard Frankel and Penelope williamson

BACKGROUNDin 1999, after eight years of planning, indiana university school of medicine (iusm) adopted a competency curriculumfor undergraduate medical students. the nine competencies inthe curriculum are: effective communication; basic clinicalskills; using science to guide medical decisions; lifelonglearning; self-Awareness; social & community contexts ofhealth care; moral reasoning and ethical Judgment; Problemsolving; Professionalism & role recognition.

despite this groundbreaking step, the school faced several ongoing challenges: a large, complex, intensely bureaucratic organizational structure; students’ dissatisfaction with their educational experience; significant gaps between the hidden curriculum and the formal competency curriculum; and a lack of faculty development to implement the new curriculum.

OBJECTIVEin 2003, the relationship-centered care initiative (rcci) waslaunched with the goal of changing the culture of the medicalschool to better align the hidden and formal curricula.

METHODSwith the help of two external facilitators, the rcci used principles of emergent design and appreciative inquiry to guidethe change process. over the course of five years, 175 faculty and students initiated more than 30 change projects, including admissions criteria, faculty development, coaching for senior administrators and developing new faculty hiring practices.

RESULTSsignificant cultural change has occurred as evidenced by AAmc exit questionnaire data, faculty vitality surveys and student narratives.

CONCLUSIONSlarge-scale cultural change is possible using emergent design, an appreciative approach and belief in the positive potential forchange. such change depends upon creating opportunities for individuals at all levels of the organization to create and sustainchange over time.

NEXT STEPSmany senior leaders have already, or will soon retire. rcci principles in operation to ensure a smooth transition includemindfulness about succession planning and continued evolution of appreciative practices that facilitate the change process.


D. Craig Braterdr. brater, a board certified internist, is dean and walter J. daly Professor atindiana university school of medicine,where he is responsible for the second-largest medical student body in the

united states. in 2006, dr. brater was appointed vice Presidentof indiana university with additional responsibility for life sciences at the university level.

dr. brater was selected to chair the department of medicine atindiana university (iu) in 1990. he joined the faculty in 1986where he began the division of clinical Pharmacology. Prior tojoining iu, he spent nine years on the faculty at the university of texas southwestern medical school in dallas after a year as a junior faculty member at university of california, san Francisco(ucsF).

he is currently President of the Alliance for Academic internalmedicine and a member of the board of directors and the executive committee of biocrossroads, an indiana consortium of business, industry and academic organizations dedicated toeconomic development through advancements in the life sciences.he also serves on the boards of directors of clarian health Partners and the riley children’s Foundation. in 2000, he wasawarded the duke medical Alumni Award in recognition of hiscontributions to academic medicine. in 2008, he was awarded anhonorary doctorate from Purdue university. in 2005, dr. braterbecame a member of the ethics committee of the united statesolympic committee.

dr. brater attended undergraduate and medical school at duke university. he completed his internship at duke and his residency at ucsF, followed by a fellowship in clinical pharmacology.

Richard Frankelrichard Frankel, Phd, is Professor ofmedicine and geriatrics and a senior research scientist at the regenstrief institute, indiana university school ofmedicine (iusm). he is also a senior

scientist in the center for implementing evidence based Practiceat the roudebush veterans Association medical center, where hedirects the patient safety fellowship. currently, dr. Frankel is thestatewide director of the professionalism competency at iusm.

dr. Frankel previously co-directed the internal medicine residencyprogram at highland hospital/university of rochester. while he was at wayne state university, he developed and directed the behavioral medicine curriculum in the internal medicine residency program.

he has served on numerous national boards and committees, including the national board of medical examiners, the Pew-Fetzer task Force on Psychosocial education and the nationalcommittee for Quality Assurance. A longtime member of thesociety of general internal medicine, he has served as co-chairof the research committee, is currently a deputy editor, and sitson the editorial board of the Journal of General Internal Medicine.dr. Frankel has been a Fulbright Fellow. he has been the


recipient of the george engel Award and co-recipient of thelynn Payer Award for outstanding contributions to research andteaching given by the American Academy on communication inhealthcare.

dr. Frankel earned his doctoral degree in sociology at the graduate school of the city university of new york. he did a post-doctoral fellowship at boston university and is afounding Fellow of the American Academy on communicationin healthcare.

PenelopeWilliamsonPenelope williamson, scd, is an internationally recognized facilitator, educator and coach. she is a foundingconsultant of relationship centeredhealth care and a part-time Associate

Professor of medicine at the Johns hopkins university school of medicine. she is also a founding Facilitator and Advisor forthe national center for courage and renewal. she co-directs two leadership programs: leading organizations to health, a 10-month institute for health care leaders who wish to create and sustain relational cultures in their organizations, and courage to lead®, an 18-month program for the personal and professional development of leaders in health care and other serving professions.

dr. williamson was the founding executive vice President of theAmerican Academy on communication in healthcare, a nationalorganization devoted to enhancing the doctor-patient relationshipthrough improved teaching and clinical skills and promotion ofresearch. she also served as executive director of the nationalsudden infant death syndrome Foundation and as AssistantProfessor of Family medicine at the university of washingtonmedical school.

dr. williamson brings to her work an ecological worldview; belief in and attention to the inner life; expertise in the disciplinesof Appreciative inquiry, world café, open space and skilled dialogue; and incorporation of the work of powerful creativemodalities including poetry, music and art.

she received her doctorate in behavioral science and ecology fromthe Johns hopkins university school of hygiene and Publichealth and completed a one-year post-doctoral fellowship at theuniversity of rochester, departments of medicine and Psychiatry.


Settings

Florida International University Herbert Wertheim College of Medicine

Presented by david brown

BACKGROUNDcoinciding with the 100th anniversary of the Flexner report and sweeping health care reform legislation, the Florida inter-national university (Fiu) herbert wertheim college of medicine (hwcom) is the first medical school to open in a major metropolitan area in 25 years. this occurs at a time of an increased understanding of how the social determinants of health and illness are at the root of deeply ingrained health inequities.

OBJECTIVEthe curriculum is intended to transform medical education tomeet the needs of patients, medically underserved communitiesand society, based on the Accreditation council for graduatemedical education (Acgme) general competencies and an additional competency – social accountability.

METHODSthe curriculum includes an enhanced emphasis on primary care,behavioral and social sciences, and public health and incorporatesearly community and clinical experiences that are integrated longitudinally over the four years. the curriculum includes fivethematic strands that span the four years: human biology; disease, illness and injury; medicine and society; Professionaldevelopment; and clinical medicine. to fulfill the implicit

social contract of medicine, the curriculum is designed to integrate students into medically underserved communities. the medicineand society strand includes neighborhoodhelPtm (health education learning Program). this signature program organizesmedical, nursing, social work and other students into inter-professional teams assigned longitudinally to neighborhoods andhouseholds in medically underserved communities. neighbor-hoodhelPtm incorporates community-based participatory bestpractices and a multi-method outcome evaluation. the goal is to educate students to form inter-professional, inter-cultural, collaborative partnerships to improve the health of patients,households and communities.


David Brown dr. brown is Founding chief of Family medicine in the department ofhumanities, health and society at theherbert wertheim college of medicine at Florida international university

(Fiu). he oversees the four-year Family medicine curriculum, integrated with the novel “medicine & society” curricula and its community component neighborhoodhelP™ (health education learning Program).

before joining Fiu, dr. brown practiced and taught at Jeffersonreaves, sr. health center in miami. As a board certified familypractitioner, he practices a full spectrum of health care for men,women and children of all ages. Previously, he held faculty appointments at the university of hawaii, the university of california at san Francisco and the university of miami.

his research employs educational, qualitative, epidemiologic, participatory and mixed methods. he has been published in the American Journal of Public Health, American Journal of Obstetrics and Gynecology and MedEdPORTAL, and has publications in press at The Qualitative Report and Medical Teacher.

dr. brown attended the massachusetts institute of technologyand received his medical degree from boston university school of medicine. he trained at the salinas Family Practice residencyin california.


The Ambulatory Long Block

Presented by eric warm

BACKGROUNDhistorical bias toward service-oriented inpatient graduate medicaleducation experiences has hindered both resident education andcare of patients in the ambulatory setting.

OBJECTIVEto describe and evaluate a residency redesign intended to improvethe ambulatory experience for residents and patients.

METHODSthe ambulatory long block was created as part of the Accreditation council for graduate medical education(Acgme)’s educational innovation Project. the long block occurs from the 17th to the 29th month of residency and is ayear-long continuous ambulatory group-practice experience involving a close partnership between the residency and a hospital-based clinical practice. long block residents follow approximately 120 to 150 patients, have office hours three half-days per week and are responsive to patient needs (by answeringmessages, refilling medications, etc.) daily. otherwise, longblock residents rotate on electives and research experiences withminimal overnight call. residents receive extensive instruction in chronic illness care, quality improvement and inter-professional teams.

RESULTSthe long block has resulted in significant improvement in multiple clinical process and outcome measures, as well as improved satisfaction among residents and patients. there hasalso been a trend toward decreased emergency department visitrates and no show rates. Additionally, the long block resulted in a robust multi-source evaluation that identified high, intermediateand low performing residents, and suggested specific formativefeedback for each.

CONCLUSIONSAn ambulatory long block can be associated with improvementsin quality measures, resident and patient satisfaction, no-showrates and evaluation.

NEXT STEPSFurther research should be done to determine which aspects of the long block most contribute to clinical and educational improvement.


Eric Warmdr. warm, a board certified internist, isAssociate Professor of internal medicineand the categorical internal medicineProgram director at the university ofcincinnati. there, he developed the

Accreditation council for graduate medical education educational innovations Project, including the creation of the Ambulatory long block.

dr. warm is the immediate past chair for the national educational innovations Project council and recently completeda term as vice President for the ohio chapter of the Americancollege of Physicians. he is interested in the interface betweeneducation and quality improvement, as well as improving doctor-patient communication skills.

currently the clinical management subcommittee chair for the society of general internal medicine’s (sgim) Patient centered medical home initiative, he has served as a member of the advisory board for the society of hospital medicine’s better outcomes for older adults through safe transitions

(boost) program, and as a faculty member for the national-residency education Project in improving end-of-life caresponsored by the robert wood Johnson Foundation. he has received numerous teaching awards, most recently the clinicalPractice innovation Award from sgim.

dr. warm earned his medical degree from the university ofcincinnati, where he also completed his residency and chief residency.


References

ASSESSMENT PROCESSES

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COMPETENCIES BEYOND KNOWLEDGE

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OVERALL REDESIGN

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PROFESSIONALISM/CULTURE

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