Educational Innovation
The
In the summer of 2007, the Internal Medicine residency submitted a proposal to the Internal Medicine RRC. The proposal described an innovation to help restructure the resident inpatient experience and the continuity clinic experience. This innovation was one of two granted a waiver from some of the RRC regulations under the Experimentation and Innovation section of the common program requirements.
Traditionally, by RRC mandate, all residents had to participate in a weekly half-day continuity clinic over their three years. Residents had to meet a minimum of 108 continuity sessions during their residency. This required residents to be pulled each week from the rotations to participate in clinic. This was extremely difficult for the residents given their obligations to both the clinic and their inpatient rotations. Subsequently, it was very disruptive to faculty precepting these rotations. Additionally, the care at the clinic was understandably disjointed as residents were only present four hours per week. This system led to a lack of continuity, significant dissatisfaction, and limited access for patients.
Improvements to the system were difficult as the current model provided limited flexibility due to restrictive regulations. We proposed that if the requirement to have a weekly half-day clinic session were waived, we could develop a better model for residency education. In our model, residents would do week-long blocks of ambulatory medicine in which they would have six continuity sessions plus other learning venues. Residents sole clinical responsibility would be to the clinic during this time. These one-week blocks would be followed by four-week blocks of traditional internal medicine rotations. The difference, however, would be that during these four-week rotations, resident would no longer be pulled to participate in a half-day clinic session each week. The four week rotations would alternate with one week rotations in a 4:1:4:1 format. This model provides the opportunity for improved continuity of care, more ambulatory sessions, more focus on the importance of ambulatory education, and subsequently improved patient access.
The RRC approved this innovation and as of June 24, 2008, this scheduling format has begun. The new scheduling template is also compliant with the 2009 RRC Regulations (which will include the mandate for >150 clinic sessions). While many programs will be struggling with how to meet these new requirements, our model presents a novel solution that will likely be presented in a national forum.
The other area that has been reviewed and developed is the actual Ambulatory Curriculum and continuity clinic experience. The 4:1 schedule has allowed the clinic population to be divided into three main teams. The Residency has also been able to fully staff the clinic with three dedicated faculty preceptors that will oversee each of these teams. With renewed ownership through the team model, many processes and systems have been reviewed and redesigned. The new scheduling scheme has allowed us to identify dysfunctional processes in the clinic and start working on their solutions. Through process improvement, the goal is to create a residency ambulatory site that efficiently and effectively provides medical care to an underserved population while at the same time provides a meaningful educational platform for learners.
Coupled with the internal LVPP practice changes, a novel Ambulatory Curriculum has been developed for the residency. This curriculum consists of regular didactics and procedural modules coupled with sessions devoted to videotape review, quality and process improvement, billing and coding, and self-directed learning opportunities. These sessions will be facilitated by the core teaching attendings in addition to the private preceptors. An improved expectation and evaluation process has also been developed to include a full-day ambulatory orientation for the interns, a curriculum text and consistent quarterly feedback from preceptors, nursing staff and LVPP administration. Eventual goals also include individualized clinical performance feedback and active participation in QI initiatives.
All of these changes and initiatives are meant to aid in improved focus and dedicated time for ambulatory education, as well as a better outpatient experience and training for our residents.
The Exemplary Care and Learning Site
The concept of an Exemplary Care and Learning Site (ECLS) was born out of the IHI Health Professions Educational Collaborative.
Since its beginning, the collaborative has sought to pioneer ways to teach medical students/residents about quality/process improvement.
The idea behind the ECLS is to have each site function as a clinical micro-system that incorporates the dual aims of both patient care and professional development. The ECLS is designed to be a place where exemplary care and learning come together to create something truly special.
Goals of the ECLS are to help medical (and other) professional students/residents learn about the improvement of healthcare, help foster faculty development, and allow collaboration to speed educational change.
In addition to
