December 2021 Faculty Development Tip

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How to teach Operational Excellence Techniques during clinical precepting

Elizabeth Eisenhardt, MD, FACP

Operational Excellence and Quality Improvement principles can provide ripe educational opportunities beyond the standard format of lectures or book reading. Quality Improvement/Operational Excellence principles can be taught “in the moment”, “at the bedside” or “just in time” during clinical precepting sessions. In the following article, I will give you some examples of how to achieve this.

To begin, let’s review the definitions of Quality, Improvement, and Operational Excellence. Quality can be defined as “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge AND the degree health services meet the expectations of healthcare users (the marketplace).” In the words of the famous scholar Juran, he describes quality as the following:

  • Attaining professionally agreed standards of care.
  • Something that is good, serves the purpose,
    and is worth the money that is paid for it
  • Reducing the variation around the target.

Improvement can be defined as “A change for the better (Kaizen), and not simply a change, but one which is supported by data, not a judgement call. “  Quality Improvement work tends to be proactive, continuous process improvement work to shift a culture or to exceed expectations.

Operational Excellence can be described as a philosophy that embraces problem-solving and leadership as the key to continuous improvement with the change ideas coming from the “real place of work” or Gemba.

One of the founding principles of Operational Excellence is the 8 types of waste as pictured in the waste wheel pictured below:

If you keep a copy of this wheel close by while precepting, it can be useful to pull it out and ask a learner to identify a type of waste they observed during a certain patient interaction. Perhaps the learner is running late, because the patient had excess WAITING time to be roomed, or to check-in, or to enter the building after being asked screening questions.  Perhaps they observed TRANSPORTATION waste if a certain medication or vaccine is kept only on one floor and the staff had to retrieve it. There are numerous examples of waste that can be observed and discussed.

Another quick way to keep Operational Excellence alive in the moment of clinical precepting is to ask a learner to come up with a KPI ( Key Performance Indicator) that could be applied to their patient to achieve a missing quality metric. For example, if they are telling you how their diabetic patient is missing their A1C (measurement of their blood sugar), you can pause and ask the learner, “Can you think of a KPI that might help you capture more A1C ‘s on your patients?”  The answer may be something along the lines of “100% of diabetic patients will schedule a one month follow-up at time of check-out” or “100% of diabetic patients seen in the office due for A1C will have this test ordered at time of visit.” KPIs can be applied to nearly any quality metric to help improve results. KPIs are then posted to the clinical sites’ KPI board and seen during Operational Excellence Gemba board walks.

Helping learners to develop their Quality Improvement skills can have multiple benefits for them including increased engagement, increased understanding of the “bigger picture” and increased appreciation for inter-professional teamwork. I hope you will try out some of the techniques above!

References:

Website for the Institute for Healthcare Improvement: Improving Health and Health Care Worldwide | IHI – Institute for Healthcare Improvement

MMC Canvas: Quality Improvement Science Guide: Quality Improvement Science Guide (instructure.com)

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July Faculty Development Tip

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MITE Monthly Tip

The Objective Structured Teaching Exercise (OSTE): Tips for Faculty Development

Corinn Martineau, PharmD, BCACP, CDOE

It is clear that faculty development is important to enhance clinical teaching skills, however there are few objective measures of the impact of faculty development on these skills. An Objective Structured Teaching Exercise (OSTE) is both a training modality and an assessment method for the teaching skills of faculty members, preceptors, and residents. Similar to the idea of the well-known OSCE (Objective Structured Clinical Examination), the OSTE offers opportunities to engage in and practice targeted teaching skills with a standardized student (1).

Take a moment to think, “When was the last time I was observed teaching a student or resident in my clinical setting?” Clinical educators are rarely observed teaching in their clinical environment and rarely receive feedback from peers with only minimal feedback from learners. Quality of clinical teaching is generally measured by written evaluations from learners, however these generally tend to comment on a teacher’s communication skills or interest in teaching and not concrete skills.

The OSTE’s simulated teaching scenario and utilization of the standardized learner provides the opportunity for the faculty member or preceptor to develop and practice key teaching skills while being assessed objectively with immediate feedback provided to the teacher. Some of the key benefits of this modality are the ability to adjust scenarios to provide a range of difficulties (support both your junior faculty and senior faculty), provide control over the variable clinical setting, and the chance to practice teaching skills and receive immediate feedback in a safe environment (2). Furthermore, the OSTE may offer interprofessional faculty training opportunities to engage faculty members that are involved in teaching a variety of professional learners, for example, a Clinical Pharmacist Faculty member developing skills in teaching a standardized Family Medicine Resident.

Boillat and colleagues provide wonderful insight and important tips on how to use the OSTE as a faculty and preceptor development tool. Summarized below are key tips and themes gathered from their work (2):

Clarify the Goal

  • What specific teaching skill are you looking to develop or enhance?
  • Is the teacher a seasoned faculty member or a first-year resident completing a Residents as Teachers curriculum?
  • A needs assessment may be helpful prior to this step to clarify the goal prior to the creation of the scenario.
    • If the OSTE is something to be incorporated into a faculty development curriculum, a needs assessment might help identify trends multiple faculty members hope to improve upon.

Determine Context and Target Audience

  • Will the OSTE be one component of a larger faculty development curriculum?
  • Will your target audience be junior preceptors or experienced faculty?
    • This will help to guide the level of difficulty of your scenarios.
  • Consider space restrictions and/or availability of standardized learners.

Identify the Teaching Skill to be Addressed

  • Teaching skills to be addressed should be observable behaviors that can be measured.
  • Will the scenario be focused on the ability to teach a specific procedure or focused on a specific competency such as communication?
  • The sky is the limit here! Refer to the article for many helpful examples.

Prepare the Scenario

  • Consider focusing on a scenario that is based upon real life situations.
    • Perhaps the OSTE illustrates a specific teaching challenge discovered during your needs assessment.
  • Scripts should be detailed leaving minimal room for improvisation
  • Make sure the scenario is relevant to all preceptors or faculty participating.
    • Consider altering scenarios for teachers from different disciplines

Develop the Assessment Tool

  • Assessment is key and may be formative or summative.
  • Consider an objective assessment tool that outlines the observable behaviors of the teaching skill
  • Assessment may include self-assessment, assessment by standardized student(s), and assessment by peer-teachers.

In summary, the OSTE is a unique teacher and faculty development modality that consists of a standardized teaching encounter with a standardized learner and an iterative process of feedback and practice for the teacher. OSTEs are a strong faculty development tool as they offer genuine scenarios, objective, real-time assessment, and direct feedback from peers and learners. Furthermore, OSTEs can offer opportunity for targeted faculty development based upon a needs assessment with opportunity for repeated practice.

References:

  1. Sturpe DA, Schaivone KA. A primer for objective structured teaching exercises. Am J Pharm Educ. 2014;78(5):104.
  2. Boillat M, Bethune C, Ohle E, Razack S, Steinert Y. Twelve tips for using the objective structured teaching exercise for faculty development. Med Teach. 2012;34(4):269-273.
  3. Trowbridge RL, Snydman LK, Skolfield J, Hafler J, Bing-You RG. A systematic review of the use and effectiveness of the objective structured teaching encounter. Med Teach. 2011;33(11):893-903.

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March Faculty Development Tip-The Prebrief: More than just an Orientation

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February Monthly Faculty Development Tip

Shelly Chipman, RN

The Prebrief: More than just an Orientation

Our passion and responsibility as educators is to facilitate the acquisition of knowledge and/or skills upon our students. Traditionally, this has been a rather passive process, where faculty provide information and learners absorb by listening or watching; transference of knowledge is teacher focused.  Newer modalities of teaching, such as team based learning, case based and experiential learning provide a more active learning environment, thus moving accountability of learning to the student/learner (Cheng, 2016).  Simulation is one such experiential educational activity, which allows learners to participate in a reproduction of a realistic clinical experience. A reflective discussion about that experience called the debrief follows and is facilitated by the instructor, and is a critical component of active learning. It provides an opportunity for deeper learning and translation of technical, cognitive and behavioral skills to clinical practice (Arefeh, 2010).

While the debrief is well recognized as an essential component of simulation education, the less well known “prebrief” is also important to learning, and sets the stage for the simulated experience and debrief. Several components of the prebrief are necessary in order to optimize learning and learner engagement:

Psychological Safety: This provides the foundation for the deep reflection needed for learning and translation of that learning to clinical practice. Psychological safety is established in the prebrief so learners feel comfortable discussing potential errors, gaps in knowledge or even successes that were revealed during the simulation scenario.

Review Expectations: Providing a clear description of what the learners can expect and what is expected of them is critical to a successful session.

Explain format-rational-agenda: This description of expectations should include an outline of agenda, explanation of any ground rules and clarification of any questions or preconceived notions that the learners may have.  Transparency, clarity of objectives and rationale for training (formative vs summative) prior to the scenario is key to optimal learner participation.

Basic Assumption: Part of establishing psychological safety is setting the basic assumption of healthcare simulation, an underlying belief that learners are intelligent, well trained and want to improve (Rudolph, 2006).  By setting this tone and assumption, mistakes during simulation are viewed as puzzles to be solved, rather than mistakes or faults in skill. Although this is not explicitly stated in the prebrief, it is recognized by faculty behaviors throughout the simulation session.

Review confidentiality: This includes the concept of “what happens in simulation, stays in simulation”, addressing any observers and their purpose for observing and keeping the scenarios confidential, avoiding “scenario leak” to other leaners.

Introduce Environment: This includes the space, manikin, the equipment or any other unique aspects. Introduction to the environment is critically important to provide “buy in” and prevent learners from “blaming” the lack of fidelity as an issue that may have affected their performance (Rudolph, 2014).

Encourage embracing the uncomfortable: Evidence supports the concept that some level of stress and emotion helps enhance memory (Clapper, 2014). Simulation provides an opportunity for the learners to reach that sweet spot of learning, where they are uncomfortable enough to learn, but not so uncomfortable that they cannot perform.

Fictional contract: This is where learners are asked to suspend disbelief and faculty acknowledge that it is not a perfect replica of the clinical environment must be addressed in order to make the experience more valuable.

As simulation educators, it is vitally important to provide a prebrief that sets the stage for a successful debrief and experiential learning session. By practicing each of these important components and providing a prebrief in every simulation education session, educators can provide an environment that is engaging and enhances learning. These components can be utilized in many learner-focused educational activities to promote engagement.

 

Psychological safety

Review expectations

Explain format-rational-agenda

Basic assumption

Review confidentiality

Introduce Environment

Encourage embracing the uncomfortable

Fiction contract

 

Further Reading: (attached)

Rudolph, J, Raemer D, Simon, R. Establishing a Safe Container for Learning in Simulation: The Role of the Presimulation Briefing. Simulation in Healthcare. 2014 December 9(6): 339-349.

 

References:

Arafeh,J, Hansen, S, Nichols, A. Debriefing in Simulated-Based Learning, Facilitating a Reflective Discussion. Journal of Perinatal Nursing. 2010 24(4): 302-309.

Clapper, T. C. Beyond Knowles: What those conducting simulation need to know about

adult learning theory. Clinical Simulation in Nursing. 2010 January  VOL(6), e7-e14. doi:10.1016/j.ecns.2009.07.003

 

Cheng, A. Morse, K., Rudolph, J., Abeer, A. Runnacles, J, Eppich,W. Learner-Centered Debriefing for Health Care Simulation Education: Lessons for Faculty Development.  Simulation in Healthcare. 2016 February 11(1):32-40.

Eppich, W, Cheng, A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): Development and Rationale for a Blended Approach to Health Care Simulation Debriefing. Simulation in Healthcare.  2015 April 10(2): 106-115.

Rudolph, J, Simon, R, Dufresne, R, Raemer, D. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simulation in Healthcare. 2006 1(1):49-55.

November Faculty Development Tip: Tips on Clinical Teaching and Precepting Using Telehealth

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MITE Tip November, 2020
Tips on clinical teaching and precepting using telehealth
Ruth Frydman, M.D.

Since the start of the COVID-19 pandemic in the U.S., there has been an abrupt and substantial shift to providing health care through telehealth. Staff, learners, and patients have been learning to adjust to using technology for outpatient clinical care and clinical education.

Pros of using outpatient telehealth:
-Removes geographical barriers for appointments
-Reduces spread of COVID-19
-May lower psychological barriers to seeking and receiving care for pts with anxiety and/or psychological trauma disorders
-Allows us to treat and precept remotely
-See patients in their home environment
-video platforms can improve communication for people with hearing impairments via additional hearing assistance technology, not having to use masks, and use of chat button for clarification

Cons and barriers to using outpatient telehealth:
-Lack of personal access to technology for some patients for financial, cognitive, or psychological reasons
-Poor connectivity or lack of internet access in some geographical areas
-Can be harder to develop the same rapport as with in-person visits
-Less (or different) data when not in person, especially aspects of physical exam
-Less efficient when there are technological glitches or unfamiliarity with the technology
-Loss of hallway teaching time with learners between appointments
-People may discover they have hidden hearing loss

What are some tips to creatively adapt clinical teaching when using telehealth?

Dr. Erlich’s webinar (link below), The Triumph of Teleteaching: Tips for Incorporating Students into Outpatient Telemedicine, offers a number of ways to adapt clinical teaching approaches for efficiently teleteaching with students when all are on ZOOM or other video platforms:

-Modeling:
The learner actively watches the preceptor. Prior to the appointment, ask the learner to watch how the preceptor approaches something specific in the appointment and then discuss that afterwards together. For example, the learner might be directed to observe how the preceptor shares bad news or broaches substance use.

-Pre-rooming:
The student can do typical medical assistant functions prior to your arrival at the appointment such as checking that technology is working, maintaining and editing the electronic health record, completing screenings, entering the reason for visit, medication reconciliation, or other tasks. This also builds a rapport with the patient that segues into the rest of the appointment which the student can conduct with the preceptor observing.

-Virtual Triangle Method or In-Room Precepting:
The student starts alone with the patient via phone or virtual appointment. The preceptor joins the appointment at the midway point. The student presents the patient in front of both the patient and the preceptor using patient centered language directly addressing the patient with second person grammar (you, your). The preceptor can leave the video camera off to be more of an observer. The preceptor would ideally debrief with the student by phone or ZOOM briefly after the appointment is over for feedback.

Advantages of Virtual Triangle Method:
It is more time efficient than having the student present to the preceptor away from the patient.
The patient can correct information presented by student.
Both the patient and the student can learn more about the patient’s condition with all present for discussion with the preceptor and with the preceptor modeling patient teaching and care.
The preceptor gets more face time with the patient.

Other advantages of using telehealth:
The preceptor can use private chat with students to give them
– suggestions or feedback in their interactions with patients.
– request for learner to look up evidence or educational materials for patient to give during the appointment or afterwards.
Using screen sharing for labs or other materials.

Disadvantages:
Technological glitches, although many students are technology savvy and able to help.
Patients without access to phone or internet.
Loss of time alone with student for teaching for which you can compensate by concentrating on getting across one general teaching point rather than lots of information. The preceptor can also compensate by chatting with the student in the ZOOM room after the visit or by phone at the end of the session to debrief and give feedback.

In conclusion, we all benefit from improving our clinical teaching skills in telehealth as it gets better integrated into health care and clinical teaching. Please watch the attached video for more concrete details on implementing precepting via telehealth. These same concepts apply to residents and fellows, although they can function more independently.

From Tufts CANVAS site:
The Triumph of Teleteaching: Tips for Incorporating Students into Outpatient Telemedicine
Deborah Erlich, MD, MMedEd, FAAFP

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September Faculty Development: Measuring Competency as a Clinical Teacher

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Measuring Competency as a Clinical Teacher By Elizabeth Herrle, MD

What does it mean to be competent?

  • Competence is a global assessment of an individual’s abilities as they relate to that individual’s current responsibilities. To be competent is “to possess all the required abilities in all domains in a defined context at a particular stage in clinical training”1.

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July Faculty Development: Teaching Clinical Reasoning with the Think Aloud Technique

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Teaching Clinical Reasoning with the Think Aloud Technique by Kelly M. Brooks, MD, Maine Track ‘16

“Expert clinicians frequently use automatic unconscious thinking processes as they gather and analyze clinical information to generate diagnoses. When experts use think aloud techniques, they articulate their thinking as they are reasoning and by doing so make their thinking processes clear to students.” 1 Think aloud is most commonly utilized as a research method for studying cognition, and is considered a reliable method for capturing peoples’ thought processes.

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February Faculty Develoment: The Five-Step Micro-skills Model for Clinical Teaching

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Finding time to teach can be challenging in the clinical environment and it is easy to miss valuable teaching opportunities. The Five Step micro skills tool (also known as the one-minute preceptor) is a tool originally developed for teaching in outpatient clinics that can easily be applied to any clinical environment with minimal added time or effort.

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