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As noted in Tufts Health Care Institute's July-August
2002 Topic of the Month, the Accreditation Council for
Graduate Medical Education (ACGME) is now requiring
programs to train and assess residents in six competencies.
The two competency categories of Systems-Based Practice
and Practice-Based Learning and Improvement comprise
knowledge, skills, and attitudes that complement physicians'
clinical responsibilities. Mastery in these areas can
improve performance at multiple levels: systems of care,
physician practices, patient panels, and single episodes
of care.
The descriptions of learning objectives and assessment
standards issued and developed by the ACGME, academic
organizations, and individual programs help to clarify
the content of training in these two competencies. Below
are some phrases used by these sources.
Systems-Based Practice
The overall goal of Systems-Based Practice, as defined
by the ACGME, is that "residents must demonstrate
an awareness of and responsiveness to the larger context
and system of health care and the ability to effectively
call on system resources to provide care that is of
optimal value." Topics that contribute to this
goal include the systems context of care, delivery and
financing systems, cost-effective care and medical management,
patient advocacy, and collaborative and multidisciplinary
care.
Systems Context Of Care
- apply knowledge of systems to reduce errors and
improve patient care
- elicit system resources to provide care of optimal
value
- understand, access, and utilize the multidisciplinary
resources, providers and systems necessary to provide
optimal care
- understand how their patient care and other professional
practices affect other health care professionals,
the health care organization, and the larger society
and how these elements of the system affect their
own practice
- understand the reciprocal impact of personal professional
practice, health care teams, and the health care organization
on the community/society
- understand interaction of their practices with the
larger system
- recognize resource limitations within the health
care system
- identify ways in which the physician may interact
with health-care professionals, health administrators,
and community groups to positively impact the health
and well being of one's community
- gather information about the community in which
one works (e.g., demographics, and sociocultural beliefs
and practices that affect health and disease)
- identify the natural history and epidemiology of
major health problems in the community being served
(e.g., discussing the literature on incidence, prevalence
and epected course of common conditions encountered
in the discipline)
- identify factors that contribute to rising health
care costs and strives to lessen where appropriate
Delivery and Financing Systems
- know how types of medical practice and delivery
systems differ from one another, including methods
of controlling health care costs and allocating resources
- understand the limitations and opportunities inherent
in various practice types and delivery systems, and
develop strategies to optimize care for the individual
patient
- understand principles of managed care
- evaluate health benefits
- differentiate between various medical practices,
including hospital and community-based models, PPO,
and HMO health care delivery systems
- describe the methods by which individuals or hospitals
can be reimbursed, including fee-for-service, capitation,
hospital drgs, etc.
- become familiar with documentation criteria for
different levels of care
Cost-Effective Care and Medical Management
- practice cost-effective health care and resource
allocation that does not compromise quality of care
- demonstrates commitment to the practice of cost-effective
medical care
- considers cost/benefit analysis in providing clinical
care
- apply systematic, evidence-based, cost-conscious
and cost-effective strategies to prevention, diagnosis
and treatment in a way that does not compromise quality
of care
- contains costs and conserves resources, allocating
them using a lean, thoughtful practice style without
compromising quality
- use fiscal and human resources efficiently
- minimize redundant or unnecessary care
- use clinical practice guidelines when available
and appropriate
- provide attention to discharge planning beginning
at admission
- utilize hospital, community, and clinic resources
for appropriate and successful patient care
- understand coordination of current inpatient and
subsequent outpatient care
- admit patients (when appropriate) to correct level
of patient care / acuity
- appropriately order radiographs, laboratory studies,
other studies (e.g., EKG, etc.)
- practice cost-effective inpatient medicine, with
appropriate utilization of subacute care facilities
and home care services
- understand the full range of living options for
elderly persons and the cognitive and functional abilities
required for successful living in these various settings
Patient Advocacy
- advocate for quality patient care and assist patients
in dealing with system complexities
- negotiate the system to ensure optimal patient care;
patient advocacy
- help patients through health care system complexities
- collaborate with payers to ensure that patients
receive required care
- refer patients who need financial assistance
- recognize potential conflicts of interest between
the individual patients and their health care organizations
Collaborative and Multidisciplinary Care
- know how to partner with health care managers and
health care providers to assess, coordinate, and improve
health care and know how these activities can affect
system performance
- collaborate with other members of the health care
team to assist patients in dealing effectively with
complex systems and to improve systematic processes
of care
- use medical and surgical specialists as consultants
appropriately
- delineate relationships between the consulting service
and the primary service
- work effectively with nursing staff and ancillary
health care personnel
- work with case managers, discharge coordinators,
utilization review personnel, social workers, and
others to assess, coordinate, and improve patient
care
- function as the coordinator of a health-care team
to manage complex patient issues
Practice-Based Learning and Improvement
The overall goal of Practice-Based Learning and Improvement,
as defined by the ACGME, is that "residents must
be able to investigate and evaluate their patient care
practices, appraise and assimilate scientific evidence,
and improve their patient care practices." Topics
that contribute to this goal include evidence-based
medicine, information technology, quality improvement,
and educating one's self and others.
Evidence-Based Medicine and Scientific Methods
- understand and use an evidence-based approach in
providing patient care
- locate, retrieve, appraise, assimilate and apply
evidence from scientific studies related to their
patients' health problems
- apply knowledge of study designs and statistical
methods to the appraisal of clinical studies and other
information on diagnostic and therapeutic effectiveness
- use scientific evidence and methods to investigate,
evaluate, and improve patient care practices.
- discuss and research relevant literature to support
decision-making processes
- obtain and use information about their own population
of patients and the larger population from which their
patients are drawn
Quality Improvement
- analyze practice experience and perform practice-based
improvement activities using a systematic methodology
- identify, acknowledge, and fill gaps in personal
knowledge and skills in the care of patients
- develop real-time strategies for filling knowledge
gaps that will benefit patients
- learn from prior mistakes and do what is needed
to improve practice
- admit to and seek help in remedying errors
- seek and incorporate formative feedback on performance
- keep a log of unique cases, to self-assess performance
patterns
- use self-assessments of knowledge, skills and attitudes
to develop plans for addressing areas for improvement
- participate actively in quality improvement practices
pertaining to patient care
- suggest data-driven modification of protocols
- follow up on admitted and discharged patients
Information Technology
- use information technology to manage information,
access on-line medical information; and support their
own education
- access appropriate reference material for current
patients
- use information technology to support patient care
decisions and enhance both patient and physician education
- use technology to manage information for patient
care and self-improvement
Educating Other Professionals
- facilitate the learning of students and other health
care professionals
- use interactions with nursing staff and other professionals
as two-way educational opportunities
- teach junior colleagues or peers at the level of
research and preparation expected by the program
- involved in teaching, with skills highly regarded
by others
- active and positive participant in educational experiences
- participate in journal club
All residency programs must now be developing and implementing
learning experiences and assessment tools in these content
areas. Tufts Health Care Institute has been creating
related courseware and training applications; information
is available on the website, www.thci.org.
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