Presenters: •Dr. Rae Wright, Family Medicine of

Southwest Washington•Dr. Zinna Johns, East Pierce Family

Medicine

Hosted by: Family Medicine Residency Network

Webinar: October 1, 2014

CCC: Lessons Learned

– Two Programs,

Two Case Examples

Structure

Program 1: Family Medicine of Southwest Washington

Developing the CCC Team Developing and Determining Evaluation

Tools Case: Resident Profile

Program 2: East Pierce Family Medicine CCC Background Case: Resident Profiles – CCC Discussion

and Response Outcome

Discussion

CCC and Case 1Family Medicine of Southwest Washington

Presented By: Dr. Rae Wright

Strategically Select CCC Members

Start with a champion

Respected and trusted by faculty and residents

Active in teaching and evaluating residents in a variety of settings

Interested in learning Milestones lingo

History of being collaborative in meetings, etc.

FMSW has 6 members, 5 full spectrum FM faculty and one BH faculty

Develop a Milestones Based Evaluation System

Collect aggregate date on Milestones over time

Tools should be easy to interpret

New Innovations has built-in tools Direct vs. indirect evaluations Shift cards Milestones reports

Gradually integrate new evaluations

Periodic Meetings for CCC

Discussion of residents of concern

Use Competencies and Milestones based language for discussion

FMSW Style CCC meets 1-2 times per month Must have at least 3 members present for interim

meeting. Usually 4-5. Pre-biannual meeting with other faculty including

advisors

Case 1: Concern

“Working to improve documentation – some uncertainty about what is needed.”

“Still struggling on nights to get work done by [themself], as well as learning about all the small extra tasks that are required, but once [resident] is shown will then consistently perform them. Visible improvement over the few days I was with [resident].”

“Needs some improvements in organizational skills to prioritize and perform duties as needed for care of patients.”

“Presentations are a work in progress. I encourage [resident] to avoid extraneous comments and questions during presentations. Presentations were initially difficulty to follow due to the lack of structure, but they improved in the week we had together.”

“Presentations not yet polished, can be scattered.”

“Does not consistently carry pager when on call.”

Discussion

Competencies/Milestones of Concern Patient Care

(PC-1) Professionalism (Prof-

1,2) Communication (C-

3,4)

Plan for Improvement Seek out feedback to

improve performance real time.

Carry pager as required.

Focus on task at hand before moving to next tasks.

Practice oral presentations as part of active precepting and with senior residents.

Semi-Annual Meetings

Preparation Use support staff to gather all data beforehand Pre-meet with advisors and other available faculty for

Resident Review

Meeting Consider splitting into 2 groups Use a time keeper

Case 1: Resident Profile

“Enthusiastic, energetic, and always eager to learn.”

“Actively seeks out feedback and takes suggestions well.”

After the CCC Semi-Annual Review

Milestones information completed in NI

Email sent to advisors with instructions and meeting time

Advisors review all information with advisees, including Milestones info on NI

Informal vs. formal feedback to CCC after advisors meet with advisees

What did we do with our resident?

Interim meetings with advisor

Active precepting in clinic

Fine tune presentations when in clinic

Shadow senior residents in the inpatient setting to see the other side

Resident received all feedback well and has made some progress

CCC and Case 2East Pierce Family Medicine

Presented By: Dr. Zinna Johns

CCC Background

3 CCC meetings per class broken up into specific teams: Pine, Oak, and Maple.

Thus a total of 9 CCC meetings biannually at EPFM.

Advisor(s) for each team must be at the CCC for their advisees. Other faculty members may attend if schedule allows.

Program Director, Program Coordinator and Behavioral Health Specialist present for all CCC meetings.

CCC EPFM Style

Case 2: Resident Profile: Above or Below the Bar?

SA is one of 6 residents in the 1st class of residents at EPFM

At time of CCC, is half way through her 2nd year of residency

In general, performance is “meets” or “exceeds expectations”

Had a reputation as a resident that “sets the bar”

Case 2: Resident Profile: Above or Below the Bar?

Spring 2014 CCC for R2s on average took about 35-42 minutes.

The outlier was the CCC evaluation for SA, which took 75 minutes.

Areas of concern were: SBP4, Prof1-4, and Com3.

Tools used for evaluation include: Faculty observation, 360 evaluations, ITEs, Rotation evaluations that were mapped to Milestones

Case 2: Resident Profile

Case 2: Concern

Through out residency, SA has had cyclical episodes of interactions that were concerning for lack professional conduct.

Behaviors such as explosive response to changes to a previously established policy; inappropriate selection of time and modality of giving negative feedback (to med students, peers, and faculty); repeated inflexibility with changes that are perceived as unfair

Resident is effectively isolating self from fellow residents because of lack of willingness to be a team player.

Case 2: Mock CCC Discussion

Case 2: Outcomes

Resident was given Milestones feedback, after completing self assessment with the Milestones packet.

On average scored 2.5. except for the areas of concern.

On self assessment, scored self at 3.5.

Areas of weakness were reviewed with resident.

Resident was informed that the behavior was problematic and needed to change.

Case 2: Outcomes

Reviewed the cyclic pattern with resident and outlined correlation with stressful schedules such as night float.

Resident was directed to Behavioral Health Specialist for tools and/or reading a book about professionalism and communication.

2 follow-up meetings have occurred since.

SA never met with BH (now 4-5 months later). Resident chose a book about spirituality at the workplace and felt overall improvement.

Planned pre-CCC meeting with SA to revisit areas of weakness, which persist with clarification that persistence these behaviors could lead to formal process.

Lessons Learned

CCC Meetings increase in value with higher number of faculty members.

The more faculty members, the longer the CCC meetings.

If there is a prolonged discussion on a specific Milestone for a certain resident, that person is possibly struggling in that area.

CCC’s task is simply to evaluate the data and assign the resident’s progress for the Milestones.

This must be separated from identification of whether a resident is in difficulty.

CCC is not intended for problem solving and the tendency to do so will limit efficiency.

Questions & Discussions