Clinical supervision walkthrough - American Board of Internal Medicine

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This module will help you as a supervising attending to improve the quality of care your …

This module will help you as a supervising attending to improve the quality of care your
trainees provide to their patients and help trainees to improve their clinical skills. A large
body of research evidence has demonstrated trainees lack competence in the important
clinical skills of medical interviewing, physical examination and informed decision making. http://www.abim.org/

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  • 1. Clinical Supervision Practice Improvement Module®IntroductionThis module will help you as a supervising attending to improve the quality of care yourtrainees provide to their patients and help trainees to improve their clinical skills. A largebody of research evidence has demonstrated trainees lack competence in the importantclinical skills of medical interviewing, physical examination and informed decision making.For example, poor communication and physical examination skills often lead to diagnosticand/or management errors. In addition, many basic quality and safety processes of careare not adequately performed.To complete this module, follow the steps described in the following slides. The first step isto access the module instructions page.Page 1 of 13
  • 2. Clinical Supervision Practice Improvement Module®Module InstructionsAt the bottom of the instructions page you will be able to acknowledge that you have readand understand the instructions. Clicking on the button will enable the observation andmedical record audit sections of the module.Page 2 of 13
  • 3. Clinical Supervision Practice Improvement Module®Status PageAfter acknowledging that the instructions have been read, the Observation/Audit sectionof the module becomes available as indicated above. To complete this section you mustdocument a minimum of 10 trainee observations and corresponding medical record audits.The following pages illustrate the Observation/Audit section of the module.Page 3 of 13
  • 4. Clinical Supervision Practice Improvement Module®Data Collection: Trainee ObservationTo begin the Observation/Audit section you must enter a trainee ID. Although you mayenter the trainee’s name in the ID box, the ABIM will automatically convert any informationprovided in this box to a number so as to protect trainee confidentiality. You may thenbegin to work on the first observation by clicking on the Work on Observation link.Page 4 of 13
  • 5. Clinical Supervision Practice Improvement Module®Trainee Observation FormIn either the inpatient or outpatient setting, perform a direct observation of a clinicalinteraction between your trainee and a patient. You can observe as many different traineesas you wish; however, we strongly recommend that you observe each trainee with at leasttwo different patients to see if the trainee made improvements after receiving feedbackfrom you.An observation can involve a complete outpatient visit, portions of an outpatient visit, ahospital admission history and physical, a daily inpatient assessment, an end-of-lifediscussion, discharge counseling or an informed consent discussion. You are required toobserve the trainee for a minimum of 5 minutes, and then provide the trainee with yourassessment and feedback. Be attentive to the implications of the trainees level ofperformance on the quality of care the patient is receiving. We recommend using anassessment tool during the observation exercise such as the mini Clinical EvaluationExercise (mini-CEX) form and make brief notes to guide your feedback. You will completea mini-CEX for all observations as part of the module.Answer the basic demographic characteristics about the trainee. Nothing you enter will beused by the ABIM regarding the trainee’s performance. It will be your decision as towhether to share your assessments with the program, but these observations could bevery useful for both the trainee and program to help meet the competency assessmentrequirements.Page 5 of 13
  • 6. Clinical Supervision Practice Improvement Module®Data Collection: Work on AuditOnce the Trainee Observation Form has been completed the link to the Medical RecordAudit (Work on Audit) will become active. Since the audit form relies on information youenter into the Trainee Observation Form, you must complete the Trainee ObservationForm first and it cannot be changed once complete. Clicking the Work on Audit link willtake you to the next page.Page 6 of 13
  • 7. Clinical Supervision Practice Improvement Module®Medical Record AuditThe next step is to review the medical record note of the encounter you just observed. Ifthe observation did not require a note, then review the appropriate sections of the medicalrecord. You will be prompted to evaluate the note for accuracy and internal consistency.To complete the Medical Record Audit, you will be required to review the chart forimportant quality performance measures involving preventive care (e.g. immunizations),discharge planning and safety (e.g. medications, urinary catheters and falls). Thesemeasures have all been tested and validated by national quality organizations. You shouldprovide feedback to your trainee about the results of your medical record review.Page 7 of 13
  • 8. Clinical Supervision Practice Improvement Module®Data Collection CompleteAfter you have completed at least 10 observation and audit combinations, the SummaryReport link will become available in the navigation section on the left. Clicking theSummary Report link will prompt you to indicate that you have finished recording allobservations and audits. Once you proceed to view the report you will no longer have theoption to add additional trainees to the list.Page 8 of 13
  • 9. Clinical Supervision Practice Improvement Module®Summary Report: Section 1The Summary Report consists of two sections. The first is a review of each traineeobservation and includes the ratings on the mini-CEX form and the action plan that youspecified for each trainee. There is also summary level data for all of your observations(minimum of 10 required) as seen on the next page.Page 9 of 13
  • 10. Clinical Supervision Practice Improvement Module®Summary Report: Section 2Section two of the report provides summary results for the medical record audit form.Page 10 of 13
  • 11. Clinical Supervision Practice Improvement Module®Develop Improvement PlanAfter reviewing and reflecting on the report you can use the Develop Improvement Planlink to document your learning gained from the module. This is the first section of theimprovement plan form.Page 11 of 13
  • 12. Clinical Supervision Practice Improvement Module®Supervisor Self-assessmentThe second section of the improvement plan form asks you to perform an assessment ofyour performance as an attending physician before starting the module and aftercompleting it. Completing all fields on this form is required. Once the form is completelyfilled out, you can return to the Main Menu to submit your module for credit.Page 12 of 13
  • 13. Clinical Supervision Practice Improvement Module®Submit Completed ModuleWhen all Improvement Plan questions have been answered and you are satisfied with theresults of the module, you may click the Submit Completed Module button to receive MOCcredit. You will then be directed to a post-module survey where your responses will helpinform our product planning and development processes in the future.Page 13 of 13