Ignorance Is Not Bliss: A Practical Solution to ACGME Competency #6

1. Ignorance Is Not Bliss: A Practical Solution to ACGME Competency #6 Richard W. Schwartz, MD, MBA Professor of Surgery/Associate Chief of Staff Commonwealth Professor of Surgery Department of Surgery University of Kentucky Shawn A. Ryan, BS, M3 University of Kentucky, College of Medicine

2. Objectives • Review ACGME competency #6 requirements • Current issues and strategies • Strategies and deficits: coalescence and synergies • A practical solution

3. ACGME Outcome Project • Understand how patient care/practice affects other health care professionals, the health care organization and the larger society • Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources • Practice cost-effective health care and resource allocation that does not compromise quality of care • Advocate for quality patient care and assist patients in dealing with system complexities • Know how to partner with health care managers and heath care providers in order to assess, coordinate and improve health care/system performance

4. ACGME Competency #6 Summary/Timeline • “Residents [need to] demonstrate an awareness of and responsiveness to the larger context and system of health care and [have] the ability to effectively call on system resources to provide care that is of optimal value.” • June 2002-July 2006 (Phase 2) • Provide learning opportunities in all six competency domains • Improve evaluation processes as needed to obtain accurate resident performance data • Provide aggregated resident data for the program’s GMEC internal review • July 2006-June 2011 (Phase 3) • Full integration of the competencies and assessment of learning/clinical care • Various RRCs are mandating 30-60 hours per residency term (3-5 years) • Progress to date???? www.acgme.org/outcome

5. The ACGME Mandate and Academic Medicine • Systems based practice vs business of medicine: an issue of semantics • To term the 4th largest economy in the world (US healthcare) anything other than a business/industry is not realistic • Sends a false message to students and residents: results in organizational dysfunction • The American healthcare system (HCS) is a service-based industry (the largest in the world) • Unfortunately, it is arguably the most poorly managed service system in the world

6. Roger W. Babson • “If things are not going well with you, begin your effort at correcting the situation by carefully examining the service you are rendering, and especially the spirit in which you are rendering it.”

7. The Role of Faculty/HCS • As faculty/HCS, we should model both the micro and macro aspects of a properly functioning HCS • Our responsibility: to teach this model to the residents in order that they may understand and properly utilize its assets

8. Milton Friedman • “Fundamentally, there are only two ways of coordinating the economic activities of millions. One is central direction involving the use of coercion – the technique of the army and of the modern totalitarian state. The other is voluntary cooperation of the individuals – the technique of the marketplace.”

10. The Opportunity • Residents: lower savings and higher debts than general public (lifestyle a major factor) • Surgery residents the most “profligate” of all specialties • Lack of budgeting correlates with indebtedness • GME programs should provide: • Budgeting expenses • Credit/debt management • Long-term financial planning • The teachable moment • Personal interest/need to know necessary • Systems performance will improve with individual change Teichman, et al. “How do residents manage personal finances?”. American Journal of Surgery. 2005; 189:134-139

13. Residency Directors Agree: mandates not met and residents not educated Residents Currently Lack Training in the Mandated Subjects • 78% response rate: importance of topic • 63%: business/practice management necessary during the teachable moment (years 2-5) • 34%: no exposure to subjects • 6%: 8-12 hours per academic year • RRC: 30-60 hours per residency term • Program directors survey conclusions • 87%: necessity for education in areas • 70%: residents inadequately trained in areas Lusco, V., Martinez, S., and Polk, H. “Program directors is surgery agree that residents should be formally trained in business and practice management”. American Journal of Surgery. 2005; 189:11-13

14. Surgeons in Practice • 133 surgeons surveyed in the midwest • Knowledge rated in 11 business topics relevant to the business practice of medicine • Survey demonstrated that on average, they felt poorly equipped to understand: • basic financial accounting principles • financial markets • economics of healthcare • tools for evaluating purchases • marketing and budgets • antitrust, fraud, and abuse regulations • risk and return on investments Satiani, B. “Business Knowledge in Surgeons”. American Journal of Surgery. 2004; 188(1):13-16.

15. Conclusion and Recommendation • “Development of simple curricula aimed at preparing surgical residents for business and practice management could promote the contemporary education of surgeons.” Lusco, Martinez, and Polk. American Journal of Surgery. 2005; 189:11-13

16. An Obligation to Repair the Current Health Care Situation • After WWII, the government became involved in American healthcare: professional managers were hired and physicians began to relinquish control of the system • 70 years later, all constituents are paying the price for this abrogation of responsibility • Physicians have as much fiscal responsibility to American healthcare as professional managers (if not more)

19. T. W. Nolan, 1998 • “The prominence of physicians in highly interdependent medical systems confers tremendous power on them, individually and as a profession. With this power comes an ethical responsibility to be deeply concerned about medical systems as a whole.” • Physicians are in a unique position of knowledge and leadership that will allow us to effect/affect necessary change, if we are properly educated in how to use these competencies

20. Physicians Can No Longer Claim Ignorance to Their Lack of Business Competence “Very few doctors understand what is happening to the health care system in which they practice, why the system is changing so rapidly, and what they can do about it” Relman, 1998

23. Obstacles to Implementing the Mandates/Recommendations • Time • Surgical residents are already having difficulty including all of their clinical, administrative and educational duties in the 80 hour work week • This leaves very little opportunity for sheltered educational time to be increased

24. Obstacles to Implementing the Mandates/Recommendations • Cost • No increased governmental funding has been allocated to assist with the development/implementation of these competencies • Most AMC/private programs do not have the necessary intellectual or monetary capital • Financial resources not available internally or via outsourcing • Intellectual capital not present in most AMC or private practice residencies

25. Obstacles to Implementing the Mandates/Recommendations • Views of program directors • Michigan State program directors view the execution of the ACGME competencies as, “extremely labor-intensive without guaranteeing a productive outcome” • This is probably a widely held perspective Taylor, D.K. et al. “Doing it well: demonstrating general competencies for resident education utilizing the ACGME Toolbox of Assessment Methods as a guide for implementation of an evaluation plan.” Medical Education. 2002; 36(11);1102-03.

26. Obstacles to Implementing the Mandates/Recommendations • Program directors at the University of Arkansas believe that they are not well prepared to meet the requirements of the competencies • They site such barriers as: • Amount of available program director time • Amount of residency protected time for curriculum • Amount residency support staff • Lack of expertise in curriculum development and evaluation and lack of funding for resources other than personnel Heard, J.K. et al. “Assessing the needs of residency program directors to meet the ACGME general competencies.” Academic Medicine. 2002: 77(7)

27. Obstacles to Implementing the Mandates/Recommendations • Views of Residents • In one of the few trials of a suggested assessment method (360-degree assessment), cardiothoracic residents were despondent about the experience • They expressed irritation about the method and its role in their education • They also devalued the feedback from non-physician raters and were reluctant to accept it as meaningful Higgins, et al. “Implementing the ACGME general competencies in a cardiothoracic surgery residency program using 360-degree feedback.” Annals of Thoracic Surgery. 2004;77(1):12-17. • Residents need motivation to learn/utilize novel educational principles/tools: provide them with practice management/personal finance training

29. Assessment • According to the ACGME key considerations, assessments should: • Provide valid (internally and externally) and reliable data • Feasible approaches: correlated to the time, training, technology and cost necessary to implement the assessment • Provide valuable information and impart new and useful data that facilitates learning, teaching and modification of the the method, if necessary

30. ACGME: Best Methods of Assessment for Competency #6 • 360 degree assessment • Very time consuming and expensive • CT resident example: development cost of $500 and cost per resident $300 (Higgins: 2 surveys per year) • Although this type of assessment is beneficial (because it includes the residents’ sphere of influence) it is really only feasible as an online model (Dyne et al) • ACGME Toolbox of Assessment Methods: an electronic system could make this feasible for the individual resident and the program in terms of time and monetary commitments Higgins et al. Annals of Thoracic Surgery. 2004;77(1):12-17. Dyne, P.L. et al. “Systems-Based Practice: The Sixth Core Competency”. Department of Emergency Medicine, UCLA. 2002

31. ACGME: Best Methods of Assessment for Competency #6 • Written Examination (MCQ) • These tests are developed by a panel of experts on a certain subject • Development and inter-program reliability difficult to achieve at each program • Should be web-based with flexible testing times, completion monitoring and rapid score return

32. ACGME: Best Methods of Assessment for Competency #6 • Checklists: major issues • Require trained evaluators to observe performance • Time [needed] to complete a checklist can vary greatly • Portfolios and OSCEs: major issues • Expensive • Time-consuming acgme.org/outcome

33. Competency # 6: Strategies to Date • The ACS Education Task Force has chosen to focus on patient safety • This initiative addresses one of four important foci for healthcare systems • Market demand increasing for outcome measures (Leapfrog, etc) • Healthcare system report cards: THE FOUR ISSUES • Safety (and clinical outcomes) • Internal/external customer satisfaction • Financial performance • Organizational performance

34. ACS Leadership Efforts: Current Courses and Programs • Course: "Health Care Leadership: An Adaptation of Aviation Team Training to Surgery” • Course: “Surgeons as Leaders” • Internet-based educational program on morbidity and mortality conferences • Internet-based educational program to address systems-based practice in surgery using a case-based approach

35. A Unique Approach: The Beginning of a Solution • University of Miami School of Medicine • Medical student curricula: didactic sessions and practical experiences about the clinical, managerial, financial and ethical aspects of systems-based care • 3rd year: students in administrative offices for day-long series of presentation/discussions and experiential tours in a private, tax-sheltered healthcare entity • Currently, this can only be achieved through a partnership with private healthcare corporations (understanding that profit is “healthy”/necessary) O'Connell, M.T. et al. “A curriculum in systems-based care: experiential learning changes in student knowledge and attitudes.” Family Medicine. 2004;36:S99-104.

36. Winston Churchill • “It is a socialist idea that making profits is a vice; consider the real vice is making losses” W.C. • Without profit, healthcare systems erode (from many different perspectives) and, therefore, will deliver increasingly poor/less service

37. Safety as the Initial Approach: A Part of the Solution • Southern Illinois University Department of Surgery • 12 months were spent by each resident on one of the hospital quality improvement/patient safety committees • Outcomes • residents were resistant to this method • benefit/cost ratio was only moderate • very time consuming for the residents Williams, R.G and Dunnington,G.L. “ACGME core competencies initiative: the road to implementation the surgical specialties”. Surgery Clinics of North America. 2004;84:1621-46.

38. CHESS: One More Part of the Solution • CHESS (Clinical Health Economics System Simulation): Voss, UVA • a computerized team-based quasi-competitive simulator • delivers the principles of health economics • Provides practical application of principles learned Voss, J.D. et al. “The Clinical Health Economics System Simulation (CHESS): A Teaching Tool for Systems- and Practice-Based Learning.” Academic Medicine. 2005; 80(2)129-34.

39. CHESS: One part of the Solution • Simulates treatment costs to patients and society , and reimbursement to physician • Residents are asked to explain findings and may change treatment options and other variables to conduct sensitivity analyses in real time • Resident and faculty participants at 19 U.S. residency programs preferred CHESS to a traditional lecture-and-discussion format • 98% reported increased knowledge of health economics • CHESS demonstrates the potential of computer simulation to teach health economics, practice-based/systems-based competencies

40. Efforts to Date: Pointing Towards a Solution • These novel approaches both incur major investments of time and capital • University of Miami: how feasible? • Southern Illinois: major resident time involvement • CHESS (UVA): $50,000 to develop a short web-based interactive program • Neither approach satisfies ACGME curricular mandates • Systematic coverage of necessary topics • Assessment/documentation of performance

42. Residency Program Obligations • Effective and efficient training in these areas • Safety and clinical outcomes • Internal/external customer satisfaction • Financial performance • Organizational performance • Performed with realistic time and availability commitments • Achieved in the most cost effective way possible

43. A Practical Solution to These Major Issues • Sachdeva: web-based evaluations the future • measure the competencies of the residents • didactic education consistently fails to change physician behavior Sachdeva, A.K. “Acquisition and maintenance of surgical competence.” Seminar in Vascular Surgery. 2002; 15(3):182-90 • Solution: combine the aforementioned simulation/teaching programs/evaluations into a 24/7, comprehensive web-based course

44. 24/7 web-based education/evaluation • Most efficient for residents because it can be accessed anywhere, anytime • Online evaluations provide constant feedback on fulfillment of requisites and performance to residency directors • Basic curricula can be developed for every type of residency, with program specific customization

45. Petronius • We trained hard – but it seemed that every time we were beginning to form into teams, we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and what a wonderful method it can be for creating the illusion of progress while producing inefficiency and demoralization

46. High Performance Teams and Expert Cultures: A Major Problem • Surgical clinical care delivery/outcomes are based on team performance: do they perform like industry standard high-performance teams? • Expert cultures: academics (organized anarchy) and medicine • These two cultures yield HCS/AMC: a synergism of organized, rewarded dysfunction

47. Local Experiential Training: A Necessity • An important part of the educational experience that should be linked with a generic 24/7 curriculum • Needs to be incorporated in residency years 2-5 • Performed in a service line which correlates with the residents interests/specialty • Should be coordinated with the healthcare system at-large in order to address organizational and leadership issues

48. The Solution: Partnership with Necessary Capital • Find an entity with the necessary intellectual and monetary capital • Foundations • Corporations • Government • For-profit healthcare corporations have already developed similar programs for other uses (primarily employee education) • Financial services • Pharmaceuticals • Partnership could fund/provide/modify web-based courses to meet stated needs at no cost to healthcare systems/residency programs • Cost: $15,000-$20,000 to develop one hour of an interactive educational module on-line • Developed programs can be customized for 10-20% above cost

49. The Invisible Hand – Adam Smith • “…self-interest guides the most efficient use of resources in a nation’s economy, with public welfare coming as a by-product” • “…state and personal efforts, to promote social good are ineffectual compared to unbridled market forces”

50. Motivation for All Constituents: The “Invisible Hand” at Work • AMC/ residency programs • RRC requirements/obligations met • Health systems performance improved • Residents • Obtain practice/personal finance training • Provided during the teachable moment • For-profit Companies • Communication/marketing with Physicians • Vested interest in proper resource usage • Government/Foundation: improves healthcare systems performance for all market constituents in a value-added manner