Educational Purpose and Goals

Healthcare in the 21st century extends well beyond the immediate patient-physician relationship, and includes a vast array of healthcare professionals, business organizations, special interest groups, numerous governmental and private sector personnel.  Resource allocation, cost, quality measurement, systems improvement, systems communication and organization management all impact on healthcare.During our training program residents are taught to understand these systems, function effectively within them, assume leadership roles in updates and improvements of the system, and advocate for and assist patients with the successful navigation of these systems.

Principle Teaching Methods
Supervised Direct Patient Care Activities

• During clinical activities, residents work closely with attending physicians and case managers who guide and assist residents in discharge planning and appropriate utilization of multidisciplinary patient care.
•  Teams rotating on the Geriatrics Service experience daily interdisciplinary rounds on the acute geriatric in-patient unit.  Nurses, dieticians, pharmacists, case managers are all present with the team to discuss on-going issues and plans.
• Preceptor faculty and clinic staff promote resident systems-based practice during ambulatory rotations and continuity clinic sessions. 

Small group discussions
       The system of Firms allows members of a clinic "practice" to meet regularly to discuss the business of medicine including E&M coding, office management and provider information.  In addition, the members of the Firms work on performance improvement projects some of which include topics on SBP. 

Medical Death Chart Review
       Senior residents gather to review all of the charts of patients who died during the previous month on the Medicine Service.  This group peer review process includes an assessment of healthcare quality, physician performance, healthcare cost/value decisions.

Core Curriculum Conferences
       Didactic lectures on particular elements of systems-based practice are part of the core curriculum series, and include, among others:

• Law and Public Policy
• M&M conferences focused on system errors
• Palliative Care
• Patient safety
• Resources for alcoholic, drug dependent disabled and terminally ill patients.
  

Mentoring
       The resident will discuss systems-based practice at their quarterly meeting with the Program Director or mentor as the Portfolios are reviewed.

Standing Medical Staff Committee Assignments
Residents are assigned to committees of the medical staff where they participate in the business of the respective committee.
 
Portfolios
       Residents are required to keep portfolios of their activities as a part of the development of all the ACGME competencies including systems-based practice.  This includes pre and post-rotation goal setting and self-assessment in each of the competencies.

Teamwork
       In fulfillment of their duties, residents must work with personnel at a variety of levels within the system, both as a team member and leader and will have the opportunity to develop a keen sense of systems-based practice in that arena.
   
Educational Content

 Patient Diversity and Variety
       The wide variety of patients under the care of residents at St. Vincent's assures exposure to every type of situation that the resident must think about in the system-based care of the patient.
 
Learning Venues 

• Direct patient care (66% in-patient and 33% out-patient)
• Ancillary services
  • Case Managers
  • Nursing staff
  • Laboratory and Radiology staff
  • Physical Therapy
  • Respiratory Therapy
  • Administrative staff

Structure of the rotation(s)
      Direct patient care rotations throughout the years of training
 
 
Principle Ancillary Educational Materials

 Role modeling
       Throughout the residency, emphasis will be placed on observation of role models, especially attending physicians, for systems-based practice skills.

Methods of Evaluation

• Resident Performance will be monitored by attending faculty who will complete web-based resident evaluation forms assessing systems-based practice skills.  All evaluations are available for on-line review by the resident at their convenience, and are sent to the residency office for internal review.  The evaluations are kept as part of the resident file and are reviewed with the resident at the 6 month interviews.
• Resident self-assessment in regard to systems-based practice is made after each patient discharge and at the end of a rotation in their portfolio.
• Program and Faculty performance are completed  by the residents anonymously on a web-based form and are reviewed with the faculty once a year.  These include an evaluation of the faculty in regard to their systems-based practice.
• Clinical Competence Committee meets every six weeks to evaluate residents in a cyclic fashion and to review any residents whose performance is sub-par.  The committee will recommend appropriate measures to remediate any deficiencies in systems-based practice.

Systems-based Practice Competency-Specific Objectives

• Residents must demonstrate awareness and responsiveness to the larger context and system of healthcare, and the ability to effectively call on resources to provide patient care that is of optimal value. 
• Residents must recognize how the types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
• Residents must practice cost-effective healthcare and resource allocation that does not compromise quality of patient care.
• Residents must advocate for quality patient cae and assist patients in dealing with system complexities.
• Residents must know how to partner with health care managers and providers to assess, coordinate and improve healthcare

PGY 1 residents must

• Display ability to work well with their core team which includes other physicians, nurses, therapists and other healthcare professionals to assess, coordinate and improve patient care
• Display sensitivity to costs and be able to incorporate fundamental cost-effective analysis into care approaches, minimizing unnecessary care.
• Identify, implement, document and monitor patient care plans
• Be dedicated to high quality patient care

 PGY 2 residents should additionally

• Be able to coordinate multi-specialty care
• Be able to effectively lead family meetings and large team discussions
• Demonstrate an understanding of medical delivery systems, including alternative care resources, ambulatory care resources, rehabilitation resources and continuing care resources
• Demonstrate a basic understanding of the methods of controlling healthcare costs and appropriate allocation of resources
• Demonstrate ability to effectively guide patients and families through the complex healthcare environment
• Demonstrate the ability to utilize the talents of utilization review personnel, physician assistants, office manager and other providers.

 PGY 3 residents should additionally

• Demonstrate ability to effectively coordinate care with other healthcare providers as needed.
• Provide a leadership role in the management of complex care plans
• Provide improvement opportunities for the healthcare system