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1. ACGME’s Role in Ensuring and Promoting Patient Safety The Accreditation Standards and New Perspectives and Approaches September 16, 2005 VA Patient Safety Teleconference David C. Leach, MD, ACGME Executive Director Ingrid Philibert, MHA, MBA, Director, Field Activities

3. ACGME’s Primary Goals High quality resident education Educational attainment toward competence = safe care for the next generation Safe and effective patient care Safe involvement of residents in patient care = safe care for current group of patients Resident safety and well-being Attentiveness to residents as learners in formal education programs

4. Safety and the ACGME Standards The ACGME’s promotes patient safety through: Requirements for educational curricula Standards for appropriate supervision of residents Requirements that residents be observed and certified in procedures Requirements for evaluation and feedback Limits on resident duty hours => moving to a broader focus on the quality of the learning environment

5. ACGME Efforts to Foster Patient Safety Collaboration with the American College of Surgeons to develop patient safety curriculum for surgical residents Identify issues specific to resident education/teaching settings Promote concepts through ACGME Bulletin and Annual Conference VA Patient Safety Curriculum (ACGME Bulletin, Aug. 2004) University of Minnesota’s SYMPAL (Bulletin, Nov. 2004) University of New Mexico’s M&M report (Bulletin, Aug. 2004) Volpp, Grande. Residents’ Suggestions for Reducing Errors in Teaching Hospitals (Bulletin, Aug. 2004)

6. ACGME/ACSPatient Safety and Competencies Matrix

7. What These Efforts Have in Common Focus on the system around the resident (“the learning environment”) SYMPAL is a tool for learning and applying the competency of systems-based practice An M & M conference is “practice-based learning and improvement” and “systems-based” practice in action Residents must learn about systems of care, within systems that are conducive to that learning

8. What These Efforts Have in Common (2) Safety is a systems issue – no safe care or safety learning without safety at the system/learning environment level How the system around the learner addresses supervision, guidance, feedback, and follow-up on adverse events is important to physician competence and patient safety Increases the importance of the competencies as organizing principles for curricula and measures of educational attainment

9. ACGME’s Role in Ensuring and Promoting Patient Safety David C. Leach, MD

10. Objectives To clarify the roles of competent individuals and competent institutions in patient safety To understand a frame that may be useful To clarify the role of improvisation in safety

11. A Premise Improvisation engages both rules and values; physician and institutional formation must pay attention to both.

12. “Teaching makes the organic inorganic”

13. Forms of Education Curricular Dialogical (Conversational) Dialogue involves respect Praxis Action that is informed by certain values Not just action, but informed action Community and Social Capital

14. Whatever we measure, we tend to improve.

15. Four Types of Assessment Cognitive Exams Direct Observation 360 Evaluations Learning Portfolios

16. Lessons About Competence Learned to Date Competence is a habit. Competence develops along a continuum. It is more than just knowledge and skill. It is not enough to know the rules. Ask yourself how many of these lessons apply to institutional learning and competence.

17. Competence: The Continuum Novice Advanced Beginner Competent Proficient Expert Master Dreyfus Brothers

18. To become competent, you have to feel bad.

19. Knowing the rules is not enough. Residents (and institutions) need to prepare for the unknown. How they think is as important as what they think. (and may be more important over time)

21. Phronesis

22. Good Work Why is it that experts primarily teach techniques to young professionals, while ignoring the values that have sustained the quests of so many creative geniuses?

23. The Problem Some have assumed that resident education and patient care are merely complicated phenomena.

24. Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Future of Healthcare in Canada Glouberman and Zimmerman July, 2002

25. Simple, Complicated, Complex

26. Duty Hours vs. Competencies Complicated Linear Solution external to system Adaptation to static environment Designed outcomes Analysis Rules helpful Complex Nonlinear Solution is part of system Interaction with dynamic environment Emergent outcomes Synthesis Values helpful

27. Improvisation and Safety An Example

28. The Work: Science-based Improvement Batalden Knowledge system 1: Traditional scientific evidence Knowledge system 2: knowledge of the particular Knowledge system 3: Measurement knowledge. Creating measures we haven’t had before. Looking at balanced measures over time. Interpreting measures over time. Knowledge system 4: Connecting and planning knowledge. Knowing what types of models of linkage will work best under the circumstances. Knowledge system 5: Executing change. What goes into successful execution. How top organizational leadership views execution of change in such a way that it happens, that stays and that it spreads as appropriate.Knowledge system 1: Traditional scientific evidence Knowledge system 2: knowledge of the particular Knowledge system 3: Measurement knowledge. Creating measures we haven’t had before. Looking at balanced measures over time. Interpreting measures over time. Knowledge system 4: Connecting and planning knowledge. Knowing what types of models of linkage will work best under the circumstances. Knowledge system 5: Executing change. What goes into successful execution. How top organizational leadership views execution of change in such a way that it happens, that stays and that it spreads as appropriate.

29. Physicians: Commodities or Unique;Rules vs. Values Performance Measures Science Rules Easier to measure Evidence-based Present or absent Stacey control zone Little improvisation Competence Art and science Values Hard to measure Context and evidence-based Continuum Stacey control, complex, and chaos zones Depends on improvisation

30. Institutions: Qualified or Competent? Qualified Graduate of ACGME accredited program Board certified Emphasis on medical knowledge No warrants Useful to doctors Competent Habit Actual performance Balanced set of measures and attributes Implied warrant Trust Useful to patients

31. When should we… Improvise? Take discretionary judgment out of the equation? …given that our work is characterized by great uncertainty and ambiguity.

32. Community leads to clarity; Clarity leads to courage.

33. Substance is enduring; form is ephemeral; preserve substance; modify form; know the difference.

34. Values are enduring; rules are ephemeral; preserve values; modify rules; know the difference.

35. Improvisation enables both rules and values to be expressed.

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

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