Exploring Innovative Learning Sites: The ACGME�s Learning

							Exploring Innovative Learning Sites:
 The ACGME’s Learning Innovation
  and Improvement Project (LIIP)




 A Summary

 March 2007
          ACGME Mission and Vision

Mission:
We improve health care by assessing and advancing the
quality of resident physicians‟ education through
accreditation
Vision:
Exemplary Accreditation


                   Approved ACGME Board, September, 2005
              Presentation Outline

I. Background, Objective and Rationale
II. Project Description
III. Very Early Results
              Presentation Outline

I. Background, Objective and Rationale
II. Project Description
III. Very Early Results
              Strategic Priorities

1) Foster innovation and improvement in the learning
   environment
2) Increase the accreditation emphasis on educational
   outcomes
3) Increase efficiency and reduce burden in accreditation
4) Improve communication and collaboration with key
   internal and external stakeholders
          Aim: Improve the Learning
                 Environment
The learning environment enables resident physicians
to learn the art and the science of the practice of
medicine, in an institutional setting committed to:

•   continuous quality improvement
•   competency-based education and practice
•   support for learners and faculty for their personal and
    professional development
•   educational excellence and innovation
•   clinical excellence and safe patient care(1)

(1) ACGME Committee on Innovation in the Learning Environment, September 2005
        Aim: Improve the Learning
               Environment

To date, there has been relatively little research to
identify examples of innovation in teaching
institutions that seek to improve resident education
and patient care in order to understand the
conditions that create a fertile environment for
innovation and change in the learning environment.
        Aim: Improve the Learning
               Environment

Challenges:
• Understanding processes and attributes that
  support innovation and improvement
• Understanding the impact of the institutional
  setting
• Understanding how to measure impacts of
  changes and innovation
        The Context: Societal Issues

• Concerns with quality and safety of patient care
• IHI initiative: 100,000 Lives Campaign (more than 2,000
  hospitals signed up) and new 5 Million Lives
  Campaign
• Growing interest by public and purchasers of health
  care about quality, safety and competency
• Can education improve care? How? Can we measure
  it?
• In education: Focus on measuring and improving
  outcomes, demonstrating link between high-quality
  education and good care
      The Learning Innovation and
       Improvement Project (LIIP)


Explore why some sponsoring institutions innovate in
  and improve their learning environment, in ways that
  meet the dual objectives of high-quality patient care
  and resident learning and professional development.
    Desired Outcomes of Leaning and Care

Three things are inextricably linked:
•   Quality of patient care (Health)
•   Quality of resident formation (Learning)
•   Quality of system performance (Care)
     Why Focus on Sites that Improve and
     Innovate their Learning Environment


The quality of resident formation depends on a stable,
 integrated clinical environment that uses practice-based
 learning and improvement
The quality of patient care depends on the collective work
 of many individuals including residents
The quality of system performance depends on institutional
 commitment and a culture that supports innovation and
 improvement
Good Learning for Good Health Care


 is not an idealized concept
 It uses the work to form people rather than just using
 people to get the work done.
  Good Health Care for Good Learning


“The ABIM exams can be successfully rescored to
assess trainees„ ability to practice conservatively - that
is, to practice efficiently and avoid unnecessary
interventions. High intensity training programs may
foster an inappropriately interventional practice style.”
                              Sirovich, Lipner, Holmboe, Poniatowski, Fisher
                                           J Gen Internal Medicine, 2006;21
         What has ACGME said?

Move away from process toward outcome measures,
  competencies.
Promote quality improvement efforts.
Enhance professional development of the learner.
“…innovation and experimentation are essential to
  improving professional education…”
              Presentation Outline

I. Background, Objective and Rationale
II. Project Description
III. Very Early Results
   An Example: RC for Internal Medicine
    Educational Innovation Project (EIP)

Purpose is to facilitate innovations in GME
   • Integrate medical education and quality improvement
     in patient care. (“Quality Agenda”)
   • Advance competency-based education and outcomes-
     based assessment. (“Outcomes Agenda”)
Objectives are to advance safe, high-quality patient-
centered care and competency based residency education.
    Educational Innovation Project (EIP)

RFP to facilitate change in the educational environment
Facilitate development of educational and evaluative tools
   that can be disseminated
Develop training models that better serve the professional
  needs and ultimate career goals of the residents.
Less restrictive accreditation standards, with up to ten year
   review cycle
          EIP Eligibility Requirements

Evidence of Institutional commitment by formal resolution
   of governing board to provide sufficient resources,
   including IT systems
Willingness to modify systems to enhance the quality of
    care and education, support faculty, and foster inter-
    disciplinary teamwork
Two accreditation cycles for at least 8 years, 4 years at
  most recent cycle, ABIM pass rate >80%
Annually submit annual program information, resident
   questionnaires, and summary of outcomes
EIP Focus on Dissemination of Knowledge

Dissemination of knowledge required
To RC, at its annual meeting
To APDIM, in a special session for EIP; meeting of
   leadership at annual APDIM meeting also required
Publication, presentation, poster or abstract for at least
   one additional meeting each year (SGIM, ACP,
   others)
         The Learning Innovation and
          Improvement Project (LIIP)

Explore why some sponsoring institutions innovate in and
  improve their learning environment, in ways that meet
  the dual objectives of high-quality patient care and
  resident learning and professional development.
Study institutions that are successful in innovating in their
   learning environment and selected
   programs/initiatives at these institutions.
Disseminate the findings and use them to inform the
   ACGME‟s accreditation standards and processes.
                    LIIP Goals

Gather base-line observations on processes and common
  attributes of institutions and programs that succeed in
  innovation and improvement in their learning
  environment.
Disseminate this information for adoption and adaptation
   with the goals of facilitating better linkages between
   graduate medical education and clinical care and
   informing the accreditation standards and processes.
                  LIIP Pilot: 2007

Select three to four test sites, based on IRC evaluations,
   that have the potential to act as models for this pilot
   study.
Conduct screening interviews with test sites‟ DIO and two
  to three added staff members.
Conduct on-site visits at two to three test sites to assess
  common attributes that create a favorable environment
  for innovation and improvement.
 Sampling the LIIP Approach: Selected
    Screening Interview Questions

How do education and clinical care interact and affect
  one another in your settings?
What formal or informal mechanisms currently stimulate
  change and improvement in your program?
How do you, your office or the programs in your
  institution foster interest in and implementation of
  innovation and improvement in education and
  patient care?
Do you share lessons learned among your programs?
   Do you share with other institutions?
            LIIP Roll Out: ~ 2007/08

Conduct screening telephone calls with a larger set of
  institutional candidates to select institutions for second
  set of site visits.
Conduct site visits candidate institutions, and provide
  consultative feedback reports under larger beta pilot of
  LIIP.
Collect and analyze information from the participating
  institutions.
Report findings
    Interrelated Themes Fostering LIIP

Competency-based education in a system that provides
  competent, patient-centered care
Innovation and quality improvement in teaching settings
Educational links and commitment to patient safety and
   excellence in clinical care
Professional development of learners and teachers
    Thoughts About a Possible Future

Competencies, quality improvement and innovation
  will drive the educational model.
Education across the continuum may be less time-
  based and more competency-based.
Institutions will be responsible and accountable for
   educational and clinical quality.
Performance excellence will drive the accreditation,
   licensing and certification models.
    Thoughts About a Possible Future:
        LIIP Long-Range Goals
Understand the learning environment and excellent
    educational practice at the institutional level.
Inform accreditation standards and process.
Create a systems framework for Graduate Medical Education.
Focus on innovation, change, results.
Focus on sustainable performance.
Emphasize organizational/personal learning and knowledge
   sharing.
Incorporate organizations‟ mission, values and goals, within a
   (validated) framework.
Promote benchmarking beyond the local program/institution.
Exploring Exemplary Learning Sites as
            “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?


              Gardner, Csikszentmihalyi, Damon, “Good
              Work” 2001
              Presentation Outline

I. Background, Objective and Rationale
II. Project Description
III. Very Early Results
              LIIP Pilot Early Results
            Observed Common Attributes

I.    An integrated vision of education, research & patient care
II.   A belief that patient care is improved because of graduate
      medical education
III. A centralized structure that is tight and cohesive
IV. Inclusiveness and involvement across organizational units
    and levels
V.    A learning organization with a learning culture
            LIIP Pilot Early Results
      Observed Common Attributes (cont.)

VI.   Alignment of resources with organizational goals
VII. Comfort with change and improvement
VIII. Accountability, facilitated through the use of data
IX.   Interest in collecting new information for local adoption
      and adaptation
               Notable Practices
• A GME dashboard of indicators that tracks
  performance against goals : match rates, USMLE,
  in-training exams, accreditation decisions,
  publications
• A dashboard of quality measures to identify areas
  for improvement
• Expanded GME report to the Governing Body,
  including data on GME quality improvement.
• Surveys of graduates and their employers, focusing
  on the six competencies, used for program
  improvement
                Notable Practices
• Multidisciplinary collaborative rounding with a focus
  on discharge planning, communication with primary
  physicians, prevention
• When a new requirement introduced, it is made a
  standing item for the GMEC. Every program must
  address it, which allows sharing of what works and
  what does not.
• An internal competitive grant program to promote
  innovations in education and clinical care
      Personal Statements of Participants
“I love what I do.”
“If we don‟t get our educational mission correct, then the rest
  cannot and will not follow.”
“The care to our patients is outstanding because of GME.”
“I know the administration is behind me.”
“I would not be there if for not for GME, without residency program
  I would not know half of the individuals I know.”
“GME allows us to focus our energies on something important to
 all of us.”
“Education is extremely rewarding to us, we want to do it; many of
 us have made financial sacrifices.”
“I could not envision doing anything else.”
Learning – learning together – is the thing for all
of us.

                                        Parker Palmer
                               “The Courage to Teach”