Creating a Competency-Creating a Competency-
informed Learninginformed Learning
EnvironmentEnvironment
Tina Foster MD, MPH...
What I Hope To DoWhat I Hope To Do
 Briefly describe the Dartmouth-HitchcockBriefly describe the Dartmouth-Hitchcock
Lead...
What is DHLPMR?What is DHLPMR?
 Dartmouth-Hitchcock LeadershipDartmouth-Hitchcock Leadership
Preventive Medicine Residenc...
Why DHLPMR?Why DHLPMR?
 To attract and develop physicians capableTo attract and develop physicians capable
of leading the...
Another Way of Looking at It…Another Way of Looking at It…
 Our residentsOur residents
 Focus on a defined population of...
DHLPMR Core CompetenciesDHLPMR Core Competencies
 Leadership—including design and redesign—of smallLeadership—including d...
Core Concept: The ClinicalCore Concept: The Clinical
MicrosystemMicrosystem
 Small group of doctors, nurses, other clinic...
Which system is the unit ofWhich system is the unit of
practice, intervention,practice, intervention,
measurement?measurem...
The Work: Science-based ImprovementThe Work: Science-based Improvement
“Generalizable
Scientific Evidence” +
“Particular
C...
Why Preventive Medicine?Why Preventive Medicine?
 PopulationsPopulations
 MeasurementMeasurement
 SystemsSystems
 Lead...
Luxuries We Enjoyed…Luxuries We Enjoyed…
 Able to design residency “from scratch” –Able to design residency “from scratch...
Where Are We Now?Where Are We Now?
 Five graduates to dateFive graduates to date
 Currently have nine first year and eig...
What Sorts of Things Do ourWhat Sorts of Things Do our
Residents Do?Residents Do?
 Improve care for patients admitted wit...
How Our Program is Different-How Our Program is Different-
the Residentsthe Residents
 All residents in combined training...
How Our Program is Different –How Our Program is Different –
the Learning Experiencethe Learning Experience
 Residents de...
How Our Program is Different –How Our Program is Different –
the Learning Environmentthe Learning Environment
 Most work ...
How Our Program is Different –How Our Program is Different –
Assessment and AccountabilityAssessment and Accountability
 ...
InnovationsInnovations
 Combining Preventive Medicine with aCombining Preventive Medicine with a
wide variety of other sp...
More...More...
 Residents develop different relationshipsResidents develop different relationships
with faculty, staff, o...
More…More…
 Residents experience improvement ofResidents experience improvement of
care as an integral aspect of provisio...
What is the Learning Environment?What is the Learning Environment?
 We often first think of “didactics”We often first thi...
What Residents Say: SomeWhat Residents Say: Some
Characteristics of Good LearningCharacteristics of Good Learning
Environm...
Other AspectsOther Aspects
 Often feels good – but…Often feels good – but…
 Learning from mistakes is importantLearning ...
Environments for LearningEnvironments for Learning
 Defined teaching and learningDefined teaching and learning
opportunit...
Preparing the “Inner” LearningPreparing the “Inner” Learning
EnvironmentEnvironment
 Desire to learnDesire to learn
 Cur...
DHLPMR and the “Inner” LearningDHLPMR and the “Inner” Learning
EnvironmentEnvironment
 Residents (and faculty) asked to d...
Other DHLPMR LearningOther DHLPMR Learning
EnvironmentsEnvironments
 Classroom experiences (MPH) andClassroom experiences...
Supports for the DHLPMR LearningSupports for the DHLPMR Learning
EnvironmentEnvironment
 Portfolio as a living record of ...
Innovation and Improvement in theInnovation and Improvement in the
Learning EnvironmentLearning Environment
 Our resident...
Competence in the LearningCompetence in the Learning
EnvironmentEnvironment
 Our work is really about assessing theOur wo...
Creating a Competency-informed Learning Environment
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Creating a Competency-informed Learning Environment

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  • 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.
  • Creating a Competency-informed Learning Environment

    1. 1. Creating a Competency-Creating a Competency- informed Learninginformed Learning EnvironmentEnvironment Tina Foster MD, MPHTina Foster MD, MPH Associate Program DirectorAssociate Program Director DHLPMRDHLPMR Dartmouth-Hitchcock Medical CenterDartmouth-Hitchcock Medical Center Lebanon, NHLebanon, NH
    2. 2. What I Hope To DoWhat I Hope To Do  Briefly describe the Dartmouth-HitchcockBriefly describe the Dartmouth-Hitchcock Leadership Preventive Medicine residencyLeadership Preventive Medicine residency  Give some examples of things that feelGive some examples of things that feel innovative to residents, faculty, staff (andinnovative to residents, faculty, staff (and patients?)patients?)  Reflect on the learning environment(s) weReflect on the learning environment(s) we are creatingare creating
    3. 3. What is DHLPMR?What is DHLPMR?  Dartmouth-Hitchcock LeadershipDartmouth-Hitchcock Leadership Preventive Medicine Residency ProgramPreventive Medicine Residency Program (DHLPMR)(DHLPMR)  Combined training in LPM and any otherCombined training in LPM and any other DHMC residency/fellowshipDHMC residency/fellowship  First graduate in 2005First graduate in 2005  Focus on the improvement of patient careFocus on the improvement of patient care
    4. 4. Why DHLPMR?Why DHLPMR?  To attract and develop physicians capableTo attract and develop physicians capable of leading the change and improvement ofof leading the change and improvement of the systems where people and health carethe systems where people and health care meet.meet. In conjunction with existing clinicalIn conjunction with existing clinical residency and fellowship programs, participants'residency and fellowship programs, participants' academic, applied leadership and practicumacademic, applied leadership and practicum experiences in preventive medicine will focus onexperiences in preventive medicine will focus on measuring outcomes and improving themeasuring outcomes and improving the technical, service and cost excellence of care fortechnical, service and cost excellence of care for patients and populations.patients and populations.
    5. 5. Another Way of Looking at It…Another Way of Looking at It…  Our residentsOur residents  Focus on a defined population of patientsFocus on a defined population of patients served by DHMCserved by DHMC  Understand their outcomes and processes ofUnderstand their outcomes and processes of care; identify opportunities for improvementcare; identify opportunities for improvement  Lead change for the improvement of care forLead change for the improvement of care for these patientsthese patients  Develop specific competenciesDevelop specific competencies
    6. 6. DHLPMR Core CompetenciesDHLPMR Core Competencies  Leadership—including design and redesign—of smallLeadership—including design and redesign—of small systems in health care.systems in health care.  Measurement of illness burden in individuals andMeasurement of illness burden in individuals and populations.populations.  Measurement of the outcomes of health serviceMeasurement of the outcomes of health service interventions.interventions.  Leadership of change for improvement of quality, valueLeadership of change for improvement of quality, value and safety of health care of individuals and ofand safety of health care of individuals and of populations.populations.  Reflection on personal professional practice & linkage ofReflection on personal professional practice & linkage of that reflection to ongoing personal and professionalthat reflection to ongoing personal and professional development.development.
    7. 7. Core Concept: The ClinicalCore Concept: The Clinical MicrosystemMicrosystem  Small group of doctors, nurses, other cliniciansSmall group of doctors, nurses, other clinicians  Administrative and support staffAdministrative and support staff  PatientsPatients  Information and information technologyInformation and information technology  Working together for common clinical andWorking together for common clinical and business aimsbusiness aims  Using shared informationUsing shared information  Producing clinical outcomesProducing clinical outcomes
    8. 8. Which system is the unit ofWhich system is the unit of practice, intervention,practice, intervention, measurement?measurement? Community, Market, Social Policy System Macro- organization System MicrosystemIndividual care-giver & patient System Self- care System
    9. 9. The Work: Science-based ImprovementThe Work: Science-based Improvement “Generalizable Scientific Evidence” + “Particular Context” “Measured Performance Improvement” • control for context • generalize across contexts • sample design I • understand system “particularities” • learn structures, processes, patterns II • balanced outcome measures III • certainty of cause & effect • shared importance IV • strategy • operations • people V P. Batalden
    10. 10. Why Preventive Medicine?Why Preventive Medicine?  PopulationsPopulations  MeasurementMeasurement  SystemsSystems  LeadershipLeadership
    11. 11. Luxuries We Enjoyed…Luxuries We Enjoyed…  Able to design residency “from scratch” –Able to design residency “from scratch” – building on PM program requirements andbuilding on PM program requirements and the idea of “competency-driven” GMEthe idea of “competency-driven” GME  Deeply committed team with incredibleDeeply committed team with incredible experience, knowledge, skillsexperience, knowledge, skills  Time to develop a shared mental model ofTime to develop a shared mental model of what “it” would look likewhat “it” would look like
    12. 12. Where Are We Now?Where Are We Now?  Five graduates to dateFive graduates to date  Currently have nine first year and eight secondCurrently have nine first year and eight second year residents, plus three who have completedyear residents, plus three who have completed the first yearthe first year  Have combined with anesthesia, pain medicine,Have combined with anesthesia, pain medicine, surgery, internal medicine, GI, ob-gyn, ID,surgery, internal medicine, GI, ob-gyn, ID, pulmonary/critical care, family medicine,pulmonary/critical care, family medicine, pathology, pediatrics, psychiatrypathology, pediatrics, psychiatry  DHLPMR has attracted applicants to DHMCDHLPMR has attracted applicants to DHMC GME programsGME programs
    13. 13. What Sorts of Things Do ourWhat Sorts of Things Do our Residents Do?Residents Do?  Improve care for patients admitted with CAPImprove care for patients admitted with CAP  Improve safety and efficiency of sedation for selectedImprove safety and efficiency of sedation for selected endoscopic proceduresendoscopic procedures  Improve provision of screening services in GIM clinicImprove provision of screening services in GIM clinic  Rapid Response Team implementation and outcomesRapid Response Team implementation and outcomes  Improve medication management for major depressionImprove medication management for major depression  Improve dx and tx of obesity in primary care clinicImprove dx and tx of obesity in primary care clinic  Improve post-operative pain managementImprove post-operative pain management  Improve advance directive processImprove advance directive process  Improve hand hygiene in perioperative areasImprove hand hygiene in perioperative areas
    14. 14. How Our Program is Different-How Our Program is Different- the Residentsthe Residents  All residents in combined training, allAll residents in combined training, all maintain presence in both programsmaintain presence in both programs  No one is an internNo one is an intern  Residents (and faculty) from a variety ofResidents (and faculty) from a variety of specialties are working together andspecialties are working together and learning from each otherlearning from each other
    15. 15. How Our Program is Different –How Our Program is Different – the Learning Experiencethe Learning Experience  Residents design own learning experiencesResidents design own learning experiences (with guidance and oversight)(with guidance and oversight)  Residents generally manage their own timeResidents generally manage their own time  Faculty coaches and mentors—aided by aFaculty coaches and mentors—aided by a program of “coach development”program of “coach development”  Clear expectation that residents will teachClear expectation that residents will teach residentsresidents and facultyand faculty in their “home” programsin their “home” programs  Program actively managed by a multidisciplinaryProgram actively managed by a multidisciplinary team that works/meets every two weeksteam that works/meets every two weeks
    16. 16. How Our Program is Different –How Our Program is Different – the Learning Environmentthe Learning Environment  Most work is inter-professional (doctors,Most work is inter-professional (doctors, nurses, clinic staff, medical records,nurses, clinic staff, medical records, administration, educators, care managers,administration, educators, care managers, etc…)etc…)  Work is primarily microsystem-based –Work is primarily microsystem-based – happens at the frontlines and involveshappens at the frontlines and involves many people as well as information and ITmany people as well as information and IT
    17. 17. How Our Program is Different –How Our Program is Different – Assessment and AccountabilityAssessment and Accountability  Explicit expectation that residents use web-Explicit expectation that residents use web- based portfolio for reflection, evaluation,based portfolio for reflection, evaluation, collecting evidence of their workcollecting evidence of their work  Practicum Review Board—composed ofPracticum Review Board—composed of organizational leaders—provides guidance inorganizational leaders—provides guidance in development of Practicum year design, as welldevelopment of Practicum year design, as well as institutional supportas institutional support  Nationally prominent residency advisoryNationally prominent residency advisory committeecommittee  Clear expectation that residents will lead changeClear expectation that residents will lead change and address sustainability of that changeand address sustainability of that change
    18. 18. InnovationsInnovations  Combining Preventive Medicine with aCombining Preventive Medicine with a wide variety of other specialtieswide variety of other specialties  Getting residents from different disciplinesGetting residents from different disciplines in the same roomin the same room  Putting residents largely in charge of theirPutting residents largely in charge of their own learning experiencesown learning experiences
    19. 19. More...More...  Residents develop different relationshipsResidents develop different relationships with faculty, staff, otherswith faculty, staff, others  Residents begin to “see” the microsystemsResidents begin to “see” the microsystems they work in, and bring their knowledge ofthey work in, and bring their knowledge of how they “really” workhow they “really” work  Attention to more than individual patientAttention to more than individual patient outcomes – residents love data!outcomes – residents love data!
    20. 20. More…More…  Residents experience improvement ofResidents experience improvement of care as an integral aspect of provision ofcare as an integral aspect of provision of carecare  Residents function as leadersResidents function as leaders  Focus is NOT on the exceptional, but onFocus is NOT on the exceptional, but on important aspects of education and careimportant aspects of education and care that may seem mundanethat may seem mundane
    21. 21. What is the Learning Environment?What is the Learning Environment?  We often first think of “didactics”We often first think of “didactics”  Then we might think about teaching onThen we might think about teaching on rounds, during procedures, etcrounds, during procedures, etc  Eventually, we begin to think about theEventually, we begin to think about the constant learning that goes on in GME –constant learning that goes on in GME – many teachers, many learnersmany teachers, many learners  When does learning occur? And whatWhen does learning occur? And what learning are we talking about?learning are we talking about?
    22. 22. What Residents Say: SomeWhat Residents Say: Some Characteristics of Good LearningCharacteristics of Good Learning EnvironmentsEnvironments  ““Why” is clearWhy” is clear  Opportunity to practice, apply learningOpportunity to practice, apply learning  ImmersionImmersion  Dialogue, two-way communicationDialogue, two-way communication  Helpful structureHelpful structure  Respectful, safeRespectful, safe
    23. 23. Other AspectsOther Aspects  Often feels good – but…Often feels good – but…  Learning from mistakes is importantLearning from mistakes is important  Teaching is learningTeaching is learning  ““Embodiment”Embodiment”  A little anxiety may be a good thing?A little anxiety may be a good thing? Finding the right degree of autonomyFinding the right degree of autonomy
    24. 24. Environments for LearningEnvironments for Learning  Defined teaching and learningDefined teaching and learning opportunitiesopportunities  Clinical care environmentClinical care environment  Inner environmentInner environment
    25. 25. Preparing the “Inner” LearningPreparing the “Inner” Learning EnvironmentEnvironment  Desire to learnDesire to learn  CuriosityCuriosity  Sense of safetySense of safety  Ability to reflect and effectively use newAbility to reflect and effectively use new knowledgeknowledge  Sense that it mattersSense that it matters  Potential for joy in learning/workPotential for joy in learning/work
    26. 26. DHLPMR and the “Inner” LearningDHLPMR and the “Inner” Learning EnvironmentEnvironment  Residents (and faculty) asked to developResidents (and faculty) asked to develop capacity for reflectioncapacity for reflection  More time and spaceMore time and space  Opportunity for work in teams, groups –Opportunity for work in teams, groups – good way to learn about oneselfgood way to learn about oneself  Knowing the work mattersKnowing the work matters  FeedbackFeedback  We often have a good timeWe often have a good time
    27. 27. Other DHLPMR LearningOther DHLPMR Learning EnvironmentsEnvironments  Classroom experiences (MPH) andClassroom experiences (MPH) and relationship to rotations/practicumrelationship to rotations/practicum  Defined learning opportunitiesDefined learning opportunities  Microsystems and learningMicrosystems and learning  Awareness of assumptions and what isAwareness of assumptions and what is being/has been learnedbeing/has been learned  Learning from patients and othersLearning from patients and others  Learning during all aspects of patient careLearning during all aspects of patient care
    28. 28. Supports for the DHLPMR LearningSupports for the DHLPMR Learning EnvironmentEnvironment  Portfolio as a living record of work and a way toPortfolio as a living record of work and a way to shareshare  Competencies and expected developmentalCompetencies and expected developmental “pathway” clearly spelled out and regularly“pathway” clearly spelled out and regularly reviewedreviewed  Opportunities to practice new ways of workingOpportunities to practice new ways of working  Connections outside one’s own disciplineConnections outside one’s own discipline  Visibility and support – public acknowledgmentVisibility and support – public acknowledgment that resident work MATTERSthat resident work MATTERS
    29. 29. Innovation and Improvement in theInnovation and Improvement in the Learning EnvironmentLearning Environment  Our residents’ work is really about CHANGINGOur residents’ work is really about CHANGING the learning environmentthe learning environment  Learning about particular microsystemsLearning about particular microsystems  Learning about our current processes of care and outcomesLearning about our current processes of care and outcomes  Thinking about how to connect the best evidence to the work ofThinking about how to connect the best evidence to the work of microsystemsmicrosystems  Leading change within microsystems to improve thoseLeading change within microsystems to improve those processes and outcomesprocesses and outcomes  Our work is really about supporting that changeOur work is really about supporting that change and continuing to understand what we areand continuing to understand what we are learninglearning
    30. 30. Competence in the LearningCompetence in the Learning EnvironmentEnvironment  Our work is really about assessing theOur work is really about assessing the competence of learners in an environmentcompetence of learners in an environment that exemplifies competencethat exemplifies competence  AND a key component of learnerAND a key component of learner competence is the ability to help create ancompetence is the ability to help create an increasingly competent environment forincreasingly competent environment for learning and patient carelearning and patient care
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