170605 Titi Savitri

Quality Improvementat Gadjah Mada University School of Medicine

Curriculum Team

Gadjah Mada University School of Medicine

17 June 2005

170605 Titi Savitri

Faculty of Medicine GMU

Implementation of PBL at GMU School of Medicine

1985-1992 : Community Oriented Medical Education Programme – 13 Credits from year 1-year 6

1992-2002:

- Hybrid PBL (20% of total Credits)

- 8 PBL Symptom-based Modules for 8 Semester (pain, icterus, fever, shock, etc)

QUE Project (1998-2003)Evaluation Results

Internal Evaluation by Ad Hoc Teams:- Tutorial discussions need to be improved

- Students rely on lectures External Evaluation by Dr. Roger Barton

from New Castle University UK:- Incomplete integration

- Overburdened academic staffs - Need a QA system

Follow up Implementation of FULL INTEGRATED

CURRICULUM using BLOCK System starting in 2002/2003

Using KIPDI II as the main reference to determine contents and instructional objectives

Educational Strategy: Problem-Based Learning and

Lecture-Based (60-70% of total hours)

6

Internship

E2 GP

5

Internal Medicine

Pediatric

Obgyn

Surgery

P.H

Elective

Local Exam.

E1 MD/BSc Rotation Exam.

4

Res. Method Biostat

Int. Health Manag,

New.Em.Dis

Emergency & Trauma

Electives and Research Activity

MF

DV

Rad.

Anes.

Ent.

Opt.

Ne

Psy

4 Blocks + Rotation

Research Seminar Patient – doctor Com. 3

3

Hemato Bleeding Lymph tissue

Nephro Urology

& Body fluid

Endocrine & Metabol

Reproduct Health

& Diseases

Neuro Behavior

Psychiatry

Sense organ &

Integument

6 Blocks

Patient – doctor Com. 2

2

Life – Cycle & Elderly-Geriatrics

Immuno. Inflam. Infection Trop.

Med.

Degener Regener

& Neoplasm

Locomotion

& Musculo Skelet

Digestion (Gastro)

& Absorb. (Nutrition)

CVS &

Lungs

6 Blocks

Patient – doctor Com. 1

1

Learn. Comp. & IT

Premed

Sci

Biomed

I

Biomed

II

P.H. Com. Med.

Entrepr.

Bioethics &

Humanities

6 Blocks

Fig.Gadjah Mada Curriculum in Basic Medical Education, Institutional Programme 2002, ( 5 years)

PBL Curiculum – Block/Integrated‘02/’03

knowledge

skill

YEAR

INTERNSHIP

MD/Bsc. Med

MD/GP

licenced

Skills Lab Curriculum1992-now

Block 1 : Interpersonal Communication, MicroscopeBlock 2 : Basic Physical Diagnostic, AnthropometriBlock 3 : Vital sign, bandageBlock 4 : Lumbar Function, Aseptic TechniqueBlock 5 : Health survey, Health PromotionBlock 6 : Intravenous injection, ResuscitationBlock 7 : Denver Test, Neonatal Resuscitation Block 8 : Anamnesis, Blood SmearBlock 9 : ENT Examination, HeteroanamnesisBlock 10: Neurology examination, orthopedic examination

Skills Lab Curriculum1992-now

Block 11 : Abdominal examination, counseling Block 12 : Thorax examination, electrocardiography Block 13 : Simulated patient (anamnesis, vital sign, thorax,

abdomen,blood pressure) Block 14 : Pediatrics physical exam, minor surgery Block 15 : Physiotherapy, Ascites and Cathether Block 16 : Complete physical examination, IUD insertion Block 17 : Gynaecology exam, baby delivery Block 18 : Diagnosis, Mental statement Block 19 : Eye examination, communication on sensitive case Block 20 : Simulated patient, MEQ 3-Clinical Reasoning Block 21 : CPR (ET), simulated patient (Cs 4-6) Block 22 : Paediatric life support, message and mission

Follow Up: QA System in Place

Dean

Vice Dean for Academic Affairs

Education Committee:Curr, Ass, Tutorial,Manual Procedure

Year CoordinatorsI-IV

Block TeamsI-XXII

CoordinatorFor Clinical Rotation

Clinical Coordinator11 Depts

CoordK3M

AcademicAudit Team

Principles of QA

Self-Evaluation by Vice Dean for Academic Affairs, Year Coordination Teams, and Block Teams

Independent Internal Evaluation by Academic Audit Team

External Evaluation by International Experts Improvement based on evaluation by Vice Dean

for Academic Affairs, Year Coordination Team, and Block Teams

Evaluation of Curriculum 2002

Internal Evaluation: Major problems in assessment, lectures (60-70%),

tutorial discussions, PBL management, learning resources, clinical teaching, skills lab curriculum unmatched with block themes, contents of blocks determined by departments

Caused by

Incomprehensive Planning

Evaluation of Curriculum 2002 External Evaluation by Prof Arie Kruseman and Prof

Albert Scherpbier from Maastricht Medical School (Feb 2004):

Hybrid curriculum of lecture-based, subject-based and problem-based learning

Organisation rather traditional and naturalistic and not in line with educational philosophy of student-centred (SCL) and problem-based learning (PBL)

Responsibilities of staff in strategic and operational tasks unclear

Learning objectives in curriculum outline and block books to detailed and directive

Evaluation of Curriculum 2002

External Evaluation by Prof Arie Kruseman and Prof Albert Scherpbier from Maastricht Medical School (Feb 2004):

Student evaluation focus on lectures, lecture notes and structured learning objectives mentioned in the block books

Skills lab is not an official unit with staff Majority of staff not trained in concepts and objectives of SCL and PBL.

Majority of students are also not aware of these objectives and educational power of tutorials

Programme too overloaded with (introductory) lectures, not enough time in programme for self-study

Majority of textbooks in library outdated[1] Not enough computer facilities, no free access to internet [1]

May 2004- Follow up the Evaluation

Decision for Minor Revisions -continuous: assesment, tutorial discussions, learning resources, quality of blocks, clinical teaching

Decision for Major Revisions 2005-2006:

Change the curriculum into Competency-based Curriculum

- SK Mendiknas 045/U/2002

Follow up April 2004: 4 Tim Management PBL to

Maastricht June 2004: 18 Block Coordinators and 4 Block

Coordinators sent to Maastricht (new curriculum was first designed)

October 2004: 16 Clinical Instructors sent to Maastricht

July, August, Sept: Dr Pie Bartholomeus to GMU School of Medicine – Skills Lab

Oct 2004: Dr Willem de Graff to GMU SM- tutorial discussion

Follow up Feb 2005: Prof Albert to GMU SM- PBL

Management Maret 2005: Dr. Pie Bartholomeus and Dr. Jaan

Van Dallen to GMU SM – Skills Lab May 2005: Assessment and Program Evaluation

Team To Maastricht July 2005: Dr. Erik (ass expert), Dr.Ameike

Jansen (program evaluation expert) dan Dr. Marieke (skills lab) to GMU SM

June 2005-July 2006

To focus on improvement in assessment system : Task Force on Block Exam Task Force on Progress Test Task Force on OSCE Task Force on Portfolio Task Force on Clinical Rotation and

Comprehensive Exam

Current practice in GMU SMEnd of block written test

It is not easy to develop questions related to discussed topicNo time to develop the questions

Low quality of questions

Bloom’s Taxonomy (n/%)

No Source Code Number of

Question C1 C2 C3 C4 C5 C6 1 Regular, Block 4 Session 1 7 April 2004 75 60

(80%) 15 (20%)

2 Regular, Block 4 Session 2 10 April 2004

75 55 (73,33%)

20 (26,67%)

3 Regular, Block 8 Session 1 14 Des 2004 75 57 (76%)

18 (24%)

- - - -

4 Regular, Block 8 Session 2 17 Des 2004 75 62 (82,67%)

13 (17,33)

- - - -

5 International, Block 4 Session 1

10 March 2004 75 56 (74,67%)

19 (25,33%)

- - - -

6 International, Block 4 Session 2

12 March 2004 75 62 (82,67%)

13 (17,33)

- - - -

7 International, Block 8 Session 1

30814 75 73 (97,33)

2 (2,67)

- - - -

8 International, Block 8 Session 2

30824 75 61 (81,3%)

13 (17,3%)

1 (1,3%)

- - -

9 International, Block 15 Session 1

51515 75 35 (46,67%)

36 (48%)

4 (5,33%)

- - -

10 International, Block 15 Session 2

51525 75 22 (29,33)

47 (62,67%)

3 (4%)

3 (4%)

- -

Current practice in GMU SMEnd of block written test

It is not easy to develop questions related to discussed topicNo time to develop the questions

Low quality of questions

Recall / Application

No

Source Code Number of

Question R A 1 Regular, Block 4 Session 1 7 April 2004 75

2 Regular, Block 4 Session 2 10 April 2004

75

3 Regular, Block 8 Session 1 14 Des 2004 75 75 (100%)

-

4 Regular, Block 8 Session 2 17 Des 2004 75 75 (100%)

-

5 International, Block 4 Session 1 10 March 2004 75 75 (100%)

-

6 International, Block 4 Session 2 12 March 2004 75 75 (100%)

-

7 International, Block 8 Session 1 30814 75 75 (100%)

-

8 International, Block 8 Session 2 30824 75 74 (98,67%)

1 (1,33)

9 International, Block 15 Session 1 51515 75 69 (92%)

6 (8%)

10 International, Block 15 Session 2 51525 75 69 (92%)

6 (8%)

June 2005-July 2006 To focus on improving tutorial system

(tutorial discussions, management of tutors, tutor training)

To prepare the New Competency-Based Curriculum which will be implemented starting in August 2006

170605 Titi Savitri

draft

Competency-based Curriculum 2006For Undergraduate Medical Education at Gadjah Mada University

School of Medicine

OutcomesOutcomes(areas of competence)(areas of competence)

CompetenciesCompetencies

Knowledge, Skills, AttitudesKnowledge, Skills, Attitudes

Competencies required for performance of roles/functionsCompetencies required for performance of roles/functions

Roles and Functions of Health ProfessionalRoles and Functions of Health Professional

Knowledge, skills, attitudes for acquisition of competenciesKnowledge, skills, attitudes for acquisition of competencies

AssessmentAssessment

AssessmentAssessment

AssessmentAssessment

Educational Strategy and Approaches – Best Evidence Medical Education

Learning in context Learning to solve patient problems Patient-Centred, Project-Based and Problem-

Based Integration and Multidisciplinary Approach

(Horizontal and Vertical; Z shape) Collaborative Learning Progression towards Outcome Assessment drives students’ learning

Expertise research

Organizing memory

Pattern recognition

Networks

Context information

Information retrieval

Expertise research

Novice Expert

Clinical Reasoning Skills

Beginner(Novice)

Advanced(Expert)

Contextual

Constructive

Collaborative

What it needs to become….

How?

More authentic problems

Increasing complexity

Real lifeprojects

Authentic assessment

Contextual

Constructive

Collaborative

How?

Less direction

Increasing independent learning

More demand driven

Portfolioassessment;self/peerassessmentContextual

Constructive

Collaborative

How?

Smaller groups

Group assignments

More ICT support

Learning task = assessment;include group work in assessmentContextual

Constructive

Collaborative

Progression towards OutcomeSpiral Curriculum

Increased breadth Increased utility Increased difficulty Increased proficiency

Th 1

Th 2

Th 3

Th 4

Th 5

Competencies

Competencies

Learning in Context

Doctor-PatientsEncounters

Disease/Disorder Spectrum:

Acute, Chronic, Emergency, Pregnancy

Age Spectrum:Newborn-Geriatric

Setting Spectrum:Individual, family,

community

Problems Spectrum:Clinical

BehaviouralEnvironmental

Steps to design the Competency-based Curriculum

Area of CompetencePrimary Care Physicians

Competency Components

Enabling Outcome

DecidedAt theNational Level

Knowledge Skills AttitudeClinical

Problems

Decided at the Faculty Level

Level of Achievement

Decided at the Faculty Level

Steps to design the Competency-based Curriculum

Enabling Outcomes are distributedinto phases/year in line with level of achievement

Identification ofYear Themes

Identification of Block Themesand Distribution of Clinical Problems into Blocks

Distribution of Knowledge, Skills, Attitude into BlocksBlue PrintBlocks

Tasks of the Block Team Design learning experiences for the

students based on Block Blue Prints (such as tutorial discussion, field visits, lectures, skills lab, laboratory practice, etc)

Design Scenarios or other triggers Develop Student Guide and Tutor Guide Carry out Block Assessment Plan, implement and evaluate

170605 Titi Savitri

Draft Structure of the Competency-Based Curriculum 2006GMU School of Medicine

7 Areas of Competence – KIPDI IIISupporting area of competence: Management of Emergency Cases

Kurikulum Fakultas

Makro

Meso

Mikro

Progression towards A Competent Medical Doctor

Th 1

Th 2

Th 3

Th 4

Th 5

Areas of Competent

Areas of Competent

Fase I : Beginner 1 2 34

5678

12 3 4

567

8

Fase 2: Intermediate

Fase 3: Advanced

Year Themes1 The Human Body SystemThe Human Body System

2 Life CycleLife Cycle

3 Chronic disordersChronic disorders and Neoplasma and Neoplasma

4 Emergency and Emergency and Clinical RotationClinical Rotation

5 Clinical Rotation and Clinical Rotation and ResearchResearch

6 Internship (??)Internship (??)

Practice Theory

Independent learning Dependent learning

GMU SM Competency-Based Curriculum 2006

Phase 1

Phase 2

Phase 3

Year 1: The Human Body System

Block 1.1.

Regulatory/

Cardiovascular

System

(First

Aid)

Block 1.2.

Respiratory

System

(Cough)

Block 1.3.

Digestive

Tract

System

(Diarrhoea)

Block 1.4.

Genitourinary System

(Disuria)

Block 1.5

Sense Organs

(Penurunan Visus, Pruritus,

Ear Discharge)

Block 1.6.

Neuromuscular System

(Paralysis and Convulsion)

Block 1.7

Multisystem

(Fever)

Why? : - To introduce the human body system – the foundation of medicine - Common symptoms – familiar for students – motivating students

- To introduce 8 areas of competence – Level Beginner

Year 2: Life Cycle

Block 2.1.

Cell Growth

Block 2.2.

Pregnancy

And

Childbirth

Block 2.3.

Childhood

Block 2.4.

Puberty

Block 2.5.

Adulthood

Block 2.6

Aging

Example:Block 1.2Enabling Outcome

1. (Area 1)To be able to use various elements of communication principles to establish effective doctor-patient relationship, i.e.

- listen actively - respect the patient as a person: a. Elicits and respect patients’ values b. Exhibits cultural sensitivity c. Communicates empathy 2. (Area 2) Be able to perform basic clinical examination required in dealing

with respiratory tract disorders 3. (Area 3) Understand the anatomy of respiratory system and surrounding 4. (Area 3) Understand the normal function of respiratory system 5. (Area 3) Understand the clinical consequences of respiratory tract

disorders 6. (Area 3) able to identify the type of coughs in relation to relevant disorders 7. (Area 4) able to choose appropriate treatment for the type of coughs 8. (Area 4) carry out education needed to protect individuals against

preventable respiratory tract disorders

Example: Block 1.2.Knowledge Base

Understand the anatomy of respiratory system and surrounding at cellular and organ level

- Understand the normal function of respiratory system Biologi Sel (cellular organization and structure) Molecular-celular defense against injury and disease:

Barrier defenses Cellular immune defenses Humoral immune defenses Active and passive immunity Inflamatory response

Understand Mechanism of respiratory diseases and pathophysiological response

- pharmacology of specific drugs for respiratory system disorders

Example: Block 1.2.Skills

Active Listening Examination of vital signs (pulse,

temperature, tekanan darah,) (1,2) - Examination of thorax (perkusi, palpasi,

auskultasi) (1,2) - Examination of nose and throat - Assessment of thorax (perkusi, palpasi,

auskultasi) (1,2)

Example of Block 1.2.Clinical Problems

ISPA (pharyngitis, bronchitis) Tuberculosis Asma Pertusis ???- check with the depts involved

Example Block 1.2. – Week 1

Monday Tuesday Wednesday Thursday Friday Saturday

07.00-09.0 Overview

Lecture

Self-directed

learning

Integrated

Learning

Integrated

Lecture

Self-directed

Learning

-

Lab Practice

Integrated

Lecture

09.00-11.00 Tutorial

Discussion

Tutorial

Discussion

Integrated

Lecture

13.00-15.00 Skills Lab Skills Lab Skills Lab Health Centre Visit

Example Student Guide Block 1.2. List of Block Team and Contact Address List of Experts and Contact Address Overview of Block 1.2. Enabling Outcome Time Table Scenarios Other learning activities Learning resources

Proposal for GMU SMBlueprint Assessment

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Knowledge MCQ ES S A Y KF

Skills

O S C E

Professional Behaviour

Knowledge PROGRESS TEST

Integrated

P O R T F O L I O

e.g.

T U T O R

R A T I N G

Five streams Assessment

Proposal for GMU SM

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Knowledge MCQ ES S A Y KF

Skills

O S C E

Professional Behaviour

Knowledge PROGRESS TEST

Integrated

P O R T F O L I O

e.g.

T U T O R

R A T I N G Knowledge

• End of block written test

• Practice session

Knowledge

• End of block written test

• Practice session

Skills

• Skills lab

• Practice session

Skills

• Skills lab

• Practice session

Professional Behavior

• Tutorial

•Other relevant activities

Professional Behavior

• Tutorial

•Other relevant activities

• Weighting is done within each stream NOT across streams

• Final mark reported consists of 5 streams

Proposal for GMU SM

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Knowledge MCQ ES S A Y KF

Skills

O S C E

Professional Behaviour

Knowledge PROGRESS TEST

Integrated

P O R T F O L I O

e.g.

T U T O R

R A T I N G

Progress Test

Starting 2x / yearProgress Test

Starting 2x / year

Portfolio

• 1x / year

• Student choose 2 best portfolio for interview

Portfolio

• 1x / year

• Student choose 2 best portfolio for interview

Proposal for GMU SMAcademic Year 2005/2006

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Block Test

Knowledge MCQ ES S A Y KF

Skills

O S C E

Professional Behaviour

Knowledge PROGRESS TEST

Integrated

P O R T F O L I O

e.g.

T U T O R

R A T I N G

Target:

1. Improve the quality of block test2. Modify the tutor rating form3. Pilot project progress test4. Socialization of portfolio