ACMD 615 Unit 4 Needs/Change 

Part 1: Needs:

1. Identify your most useful definition of Need

A need is an externally or internally perceived deficit in required knowledge or skill that compels the individual to act to resolve it.

2. Develop a teaching/learning case scenario that contains a need(s) assessment, a learning plan, and a learner assessment. Be sure that the learning does reflect and support the identified actual need translated to practice and that the learning method and content are reasonable for the level of the learner and the learner's practice. Please support and justify your decisions.

1. Needs Assessment: PERFORM A "GAP" ANALYSIS.

• Current situation: Determine the current state of skills, knowledge, and abilities and also examine section/departmental goals, climate, and internal and external constraints.
• Desired or necessary situation:  identify the desired or necessary conditions to achieve success. Distinguish actual needs from the perceived needs, or wants.

The difference is the "gap" between the current and the necessary and will identify needs, purposes, and objectives.

2. IDENTIFY PRIORITIES AND IMPORTANCE.

            Learner assessment:

3. IDENTIFY CAUSES OF PERFORMANCE PROBLEMS AND/OR OPPORTUNITIES.

            Learner assessment:

4.IDENTIFY POSSIBLE SOLUTIONS

Learning plan for:

Training in deficient knowledge or skill

Organizational change

1. Teaching/Learning Case Scenario:

A PGY-2 surgical resident is deficient in basic laparoscopic skills including knot-tying, tissue manipulation and bilateral hand coordination.

Needs Assessment:

            Actual -

• Routine faculty evaluation of Operating Room performance indicates insufficient manual dexterity in basic laparoscopic skills.
• Simulation laboratory exercise using standardized laparoscopic skills trainer and skill set indicates time overage and missteps, consistent with entry level surgical resident
• Review of operative log reveals deficiency in laparoscopic cases as surgeon junior (as opposed to first assistant)
• Self evaluation indicates uneasiness with laparoscopic skills resulting in case avoidance

Expected -

• PGY-2 residents are expected to demonstrate manual dexterity in basic laparoscopic skills including knot-tying, with efficiency. 

Learning Plan:

            Deficiency in laparoscopic skills will be addressed by this resident participation in:

1. Didactic DVD reviewing basic laparoscopic techniques including knot-tying
2. Proctored demonstration and practice of basic laparoscopic techniques in simulation lab
3. Independent practice of basic laparoscopic techniques in simulation lab
4. Proctored practice of basic laparoscopic techniques in simulation

Learning Assessment:

This resident’s achievement of learning basic laparoscopic techniques will be assessed by:

• Timed performance of basic laparoscopic skills in simulation lab, with comparison to peer group;

Once acceptable,

• Monthly self-evaluation of actual performance of basic laparoscopic skills in operating room
• Case by case faculty evaluation of actual performance of basic laparoscopic skills in operating room

               Reinforcement of Learning:

Quarterly simulation lab sessions with basic and then advanced laparoscopic skills proctored lessons.

 Part 2: Change:

There are many changes that can be made in the practice of medicine, but if you are a 'change leader', you need to bring the team into the concept in a productive way. Develop a case in which you institute a change and indicate how you will guide a group through the stages of change.

Fellows Clinic.

Our fellow’s clinic had not been a true continuity clinic since its inception in 1999. Fellows typically had seen a patient once and the “A,B,C”  team concept never led to the situation in which that patient would be seen again by that fellow.  At best a team member might see the patient on follow up but that was more luck than predetermination. To meet ACGME requirements that GI fellows follow a cohort of their patients over 3 years a transitional change in the clinic was required.

We have now gone through the following steps to achieve this change as per Kotter’s 8 Steps:

1. Establish a sense of urgency
1. Impending GME and ACGME reviews created a sense of urgency in our section as this was a cited problem in past. Fellows were disgruntled with the clinic ebb and flow
2. Create a guiding coalition

                    a. A new assistant PD was given charge over the fellows clinic and asked to push its’ change giving u                     a coalition of 2 (the PD included as well) which was adequate for the 14 attendings in our section

               3.   Develop a sense of vision and a strategy

                    a. A curriculum was developed specifically to push the changes in clinic to meet ACGME powered                          curricular guidelines

               4.   Communicate the change vision

                    a. The impending changes were communicated through a carve-out of time in each monthly faculty                          meeting and staff meeting over a 4-month lead in to discuss the clinic.

               5.  Empower broad-based action

                    a. Over the 4 months all concerns were heard and addressed; a few naysayers were                          marginalized/removed by general consensus and perception of need for change by majority of                          attendings. The EPIC schedule was changed to reflect fellows as the primary GI MD and chart                          system created to identify patient as "belonging" to a fellow.  Staff sessions held to get them on                          board as well.

             6. Generating short term wins

                 a. Early after inception fellow's positive comments were widely disseminated to faculty.                     Patient surveys showed no degradation of service level.

              7. Consolidating Gains

                    a. Last month's numbers show the following: Increased overall section RVU's in                          outpatient clinics, reduced wait time to see a GI physician, improved learner                          perceptions of the experience, passage with no citations of internal GME review of                          the clinic structure and function.

               8. Anchor new approach in culture 

                    a. This has been a win-win situation for our section and this approach to fellow's clinic is                          now solidly ingrained into the culture and function of the section.  Naysayers have                          begun to participate due to perceived benefits.