Systems-based Practice

AFP Systems-Based Practice Curriculum

Goals:

The ACGME Competency #5 Systems-Based Practice basically requires that residents understand the many facets of the system within which they work. In Family Medicine this competency requires that:

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

	work effectively in various health care delivery settings and systems relevant to their clinical specialty;
	coordinate patient care within the health care system relevant to their clinical specialty;
	incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate;
	advocate for quality patient care and optimal patient care systems;
	work in inter-professional teams to enhance patient safety and improve patient care quality; and
	participate in identifying system errors and implementing potential systems solutions.
	be taught to develop the skills necessary for career-long professional learning sufficient to maintain certification in the specialty. These should include:

a) knowledge sufficient to pass the ABFM certification exam;

b) ability to collect a complete initial data base and examination;

c) ability to define and expand the differential diagnoses list;

d) identification of the most likely diagnoses and the establishing of a plan for diagnostic and treatment modalities;

e) ability to educate the patient and family about the diagnoses, evaluation and treatment of the disease, to obtain informed consent, and perform appropriate procedures;

f) ability to practice in a team and with a systems-based approach;

g) ability to present data to other members of the team and consultants;

h) cost-conscious ordering of diagnostic tests and therapeutics;

i) construction of a medical record summary with accuracy and in compliance with expected format and in compliance with the hospital's medical records policies;

j) formulate short and long term goals; and,

k) the providing of guidance to patients regarding advanced directives, end-of-life issues and unexpected diagnoses/outcomes.

Objectives:

1) PGY-1 residents will be able to use insurance company formularies to select appropriate covered medications for their continuity patients.

2) PGY-2 residents will be able to request a non-formulary medication for a continuity patient when needed.

3) PGY-3 residents will rarely receive call-backs from pharmacies regarding denial of medications for continuity patients due to formulary issues.

4) PGY-1 residents will demonstrate an understanding of the function of the office staff in providing care for patients at the continuity clinic.

5) PGY-2 residents will demonstrate an understanding of documentation to support billing at all levels of complexity in the office setting.

6) PGY-3 residents are able to perform triage functions in the office setting without difficulty.

7) PGY-1 residents are able to coordinate discharge of hospitalized patients working closely with the case manager and other team members.

8) PGY-2 residents are able to make appropriate referrals to skilled nursing facilities or rehabilitation centers.

9) PGY-3 residents are able to recognize the need for hospice care and make referrals when appropriate.

Teaching Methods

At Altoona Family Physicians the Systems-Based Practice curriculum is taught longitudinally throughout the three year program by a combination of didactic lectures and educational experiences while on rotations. Some of this material is taught during the Practice Management course and during ALSO.

1) Didactic Lectures:

	The hospital experience
	Healthcare structure
	CPT and E/M coding
	Governance
	Job search
	Patient safety

2) Office-Based Systems:

	During office hours the residents learn how to use insurance formularies correctly with assistance from the faculty preceptors.
	During COFME rotations residents work with front office and clinical staff learning to receive and triage incoming telephone calls to office.
	During COFME rotations residents work with the billing staff and learn about how the bills they generate from patient encounters are processed and come to understand the part they play in the larger system of healthcare costs as well as costs to the patients.
	Residents participate in a CPI project which helps them understand how interpretation of data collected can help facilitate positive change within the office system.

3) Hospital-Based Systems:

	During in-patient rotations the residents work as part of a multi-disciplinary team with Case Managers, Social Workers and nursing staff to facilitate discharge planning.
	Residents take part in hospital committees to learn aspects of managing a hospital system such as continuous performance improvement and patient safety committees.
	During in-patient rotations the residents are taught about the use of order sets for certain conditions such as pneumonia, cerebro-vascular accident among others to try to ensure that patients are ordered and receive appropriate care.

4) Family Medicine Rounds:

During these meetings complicated cases are discussed; the faculty present highlight aspects of the cases that pertain to systems-based practice competency areas.

5) Higher-level Healthcare Systems:

During the COFME I rotation the residents have the opportunity to work at the Partnering For Health Services Clinic which provides free care from the hospital to patients who do not qualify for Medicaid but do not have any other health insurance. They learn about the provision of healthcare to the wider community and some of the implications that politics have on allocation of healthcare services.

Assessment Method

1) Staff at the continuity clinics monitor calls from pharmacies and make note of call-backs related to formulary issues. The total number of calls per month is reviewed with the residents at their evaluations with their faculty advisors. Nursing staff advise faculty if a resident has an apparently unusual number of calls from pharmacies so that appropriate feedback and teaching can be done.

2) The office staff members provide evaluations from both front desk and clinical staff regarding resident performance in terms of the office based systems for review with each resident at their periodic meetings with their Faculty Advisor.

3) Case managers and nursing staff from the hospital complete evaluations of the residents� performance in discharging patients which are reviewed with the residents by their Faculty Advisor.

4) Residents are evaluated by Attending physicians on all rotations regarding competency areas pertaining to systems-based practice. These are reviewed by Faculty at evaluation meetings with the residents.

5) Residents will complete a pre and post test at entering residency, mid cycle and at the end of residency to evaluate knowledge gained in this competency area from above teaching methods.