simulation: an inclined plane in the nas
TRANSCRIPT
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Simulation: An Inclined Plane in the NAS
John R. Potts, III, MD, FACS Senior Vice President, Surgical Accreditation
ACGME
Consortium of ACS-Accredited Education Institutes 8th Annual Meeting
Chicago 14 March 2015
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Disclosures
• In recovery • DIO • Program director in surgery • Practicing general surgeon
• I believe that surgical training in the United States is the best in the world
• No financial disclosure • In this talk, I do not represent ACGME
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
• GME is a public trust
• ACGME accountable to the public
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
• Patients & payers expect doctors to be:
• Health information technology literate
• Able to use HIT to improve care
• Sensitive to cost-effective care
• Involve patients in their own care
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
• Public expects GME to produce doctors who:
• Possess these skills, and
• Requisite clinical and professional attributes
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
MedPAC
COGME
Robert Wood Johnson Foundation
Macy Foundation Institute of Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
• Help produce physicians for 21st century
• Accredit programs based on outcomes
• Provide public accountability for outcomes
• Reduce administrative burden of accreditation
Next Accreditation System: Goals
©2015 Accreditation Council for Graduate Medical Education (ACGME)
The Next Accreditation System Continuous
observations
Identify opportunities for
improvement
Program makes
improvement(s)
Assess program
improvement(s)
Promote Innovation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
Definition: A flat supporting surface tilted at an angle, with one end higher than the other, used as an aid for raising or lowering a load.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane • Moving an object up an inclined plane
requires less force than lifting it straight up, at a cost of an increase in the distance moved.
Fw MA = Fi
MA = Mechanical Advantage Fw = Gravitational force of the load object (weight) Fi = Force exerted on the object, parallel to the plane, to move it up the plane.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
• Probably used building: • Stonehenge • Egyptian pyramids
• Sloping roads and causeways by Romans • During the Renaissance the inclined plane
was classed with the other simple machines (lever, wheel, pulley, wedge, and screw)
• 1856 Simon Stevin (Flemish) derived the mechanical advantage of the inclined plane
Inclined Plane
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Hypothesis
Simulation is a tool that can be used to “smooth” the path over many of the obstacles to: learning, assessment and, ultimately, to desired outcomes for GME programs.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Obstetrics & Gynecology
II.D.3. There must be space and equipment for the educational program, including meeting rooms and classrooms with audiovisual and other educational aids, simulation capabilities, and office space for staff members. (Core)
IV.A.3.b) [Regularly scheduled didactic] sessions should consist of patient rounds, case conferences, simulation training, journal clubs, and protected time for educational activities covering all aspects of obstetrics and gynecology, including basic sciences pertinent to the specialty. (Detail)
Simulation in PRs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Otolaryngology
IV.A.3.b).(3).(a) [Didactics in] Anatomy should include the study and dissection of anatomic specimens, including the temporal bone, and procedural skills laboratories, along with appropriate lectures and other formal sessions. (Detail)
Simulation in PRs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Surgery
II.D.2. Resources must include simulation and skills laboratories. These facilities must address acquisition and maintenance of skills with a competency-based method of evaluation. (Core)
Simulation in PRs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Thoracic Surgery
V.C.2.d).(2).(a) Programs must use the results of assessments to provide program improvement (e.g., quality of the didactic and clinical curriculum, and the use of educational tools such as skills labs and other activities) (Detail)
Simulation in PRs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Simulation in Surgical PRs Simulation Skills Lab
Colorectal Surgery - - Neurological Surgery - - Obstetrics & Gynecology ++ - Ophthalmology - - Orthopedic Surgery - - Otolaryngology - + Plastic Surgery - - Surgery + + Thoracic Surgery - + Urology - -
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Anesthesiology FAQs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Emergency Medicine FAQs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
High Tech Simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
The Value Equation
Benefit Value = Cost
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
PPPPPPPPPPPPPP
© Potts
Cost-Utilization Triangle of Simulation
Component Cost
Component Utility
Basic Surgical Skills
Specialty Surgical Skills
Advanced Specialty Surgical Skills
Advanced Subspecialty Surgical Skills
Innovative & Experimental Surgical Skills
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Creation of Milestones
ABMS
Milestones
RRC PD Group Academy Residents
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Clinical Competency Committee
Clinical Competency Committee
Assessment of Milestones
Peer Evaluations
Nursing and Ancillary
Personnel Evaluations
OSCE
Operative Performance
Rating Scales
Mock Orals
ITE
End of Rotation
Evaluations
Self Evaluations Case
Logs
Sim Lab
Student Evaluations
Patient / Family
Evaluations
Clinic Work Place
Evaluations
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Miller’s1 Pyramid of Clinical Competence
Knows MCQ, Oral Examinations
Knows How MCQ, Oral Examinations, Standardized Patients
Shows How Clinical Observation, Simulation, Standardized Patients, Mini CEX
Clinical Observations, Multi-Source Feedback, Teamwork Evaluation, Operative (Procedural) Skill Evaluation, Mini CEX
van der Vleuten, CPM, Schuwirth, LWT. Assessing professional competence: from Methods to Programmes. Medical Education 2005; 39: 309–317
1Miller, GE. Assessment of Clinical Skills/Competence/Performance. Academic Medicine (Supplement) 1990. 65. (S63-S67)
Does
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Other Roles for Simulation • Non-technical
• Patient history • Physical examination • Breaking bad news • “On call calls” • Obtaining informed consent • Checklist event • Identifying / confronting impaired physician • Patient safety event
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Other Roles for Simulation
• Technical • Surgical origami • Knot board • Endoscopy • Laparoscopy • Robotics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Other Roles for Simulation
• Could become an ACGME requirement • Could become an ABS requirement • Could be used for credit for rare, high
stakes procedures (as in EM)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
PPPPPPPPPPPPPP
© Potts
Cost-Utilization Triangle of Simulation
Component Cost
Component Utility
Basic Surgical Skills
Specialty Surgical Skills
Advanced Specialty Surgical Skills
Advanced Subspecialty Surgical Skills
Innovative & Experimental Surgical Skills
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
• A flat supporting surface tilted at an angle, with one end higher than the other, used as an aid for raising or lowering a load.
• Moving an object up an inclined plane requires less force than lifting it straight up, at a cost of an increase in the distance moved.
• The mechanical advantage of an inclined plane, the factor by which the force is reduced is equal to the ratio of the length of the sloped surface to the height that it spans.
• Due to conservation of energy, the same amount of mechanical energy (work) is required to lift a given object by a given vertical distance, disregarding losses from friction but the inclined plane allows the same work to
©2015 Accreditation Council for Graduate Medical Education (ACGME)
• 3rd century BC Archimedean simple machines: Lever, pulley and screw
• 1st century AD Heron of Alexandria listed the classic five simple machines that “can set a load in motion”: Lever, windlass, pulley, wedge and screw
• It wasn't until the Renaissance that the inclined plane was classed with the other simple machines
• 1856 Simon Stevin (Flemish) derived the mechanical advantage of the inclined plane
Inclined Plane
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Component Utility
Component Cost
Basic Surgical Skills
Specialty Surgical Skills
Principles of Surgery
Advanced Specialty Surgical Skills
Advanced Subspecialty Surgical Skills
Innovative & Experimental Surgical Skills
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Component Utility
Component Cost
Basic Surgical Skills
Specialty Surgical Skills
Principles of Surgery
Advanced Specialty Surgical Skills
Advanced Subspecialty Surgical Skills
Innovative & Experimental Surgical Skills
Cost-Utilization Triangle of Simulation
Potts
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Component Utilility
Component Cost
Basic Surgical Skills
Specialty Surgical Skills
Principles of Surgery
Advanced Specialty Surgical Skills
Advanced Subspecialty Surgical Skills
Innovative & Experimental Surgical Skills
Cost-Utilization Triangle of Simulation
Potts
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
Definition: A flat supporting surface tilted at an angle, with one end higher than the other, used as an aid for raising or lowering a load.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
PPPPPPPPPPPPPP
Inclined Plane & Value Equation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
PPPPPPPPPPPPPP
Inclined Plane & Value Equation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
PPPPPPPPPPPPPP
© Potts
Cost-Utilization Triangle of Simulation
Component Cost
Component Utility
Basic Surgical Skills
Specialty Surgical Skills
Advanced Specialty Surgical Skills
Advanced Subspecialty Surgical Skills
Innovative & Experimental Surgical Skills
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Data Reviewed Annually by RC • Annual ADS Update
• Program Characteristics – Structure and resources • Program Changes – PD / core faculty / residents • Scholarly Activity – Faculty and residents • Response to active citations • Omission of data
• Board Pass Rate • Resident Survey • Faculty Survey • Clinical Experience – Case logs • Semi-Annual Resident Evaluation and Feedback
• Milestones
?
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane • Moving an object up an inclined plane
requires less force than lifting it straight up, at a cost of an increase in the distance moved.
• The mechanical advantage of an inclined plane, the factor by which the force is reduced is equal to the ratio of the length of the sloped surface to the height that it spans.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
MA = Mechanical Advantage Fw = Gravitational force of the load object (weight) Fi = Force exerted on the object, parallel to the plane, to move it up the plane.
Fw MA = Fi
Inclined Plane
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Hypothesis
Simulation is a tool that can be used to “smooth” the path over many of the obstacles to learning, assessment and, ultimately, to desired outcomes for GME programs.