What indicates competency in systems based practice? An analysis of perspective consistency among healthcare team members

Abstract

In many parts of the world the practice of medicine and medical education increasingly focus on providing patient care within context of the larger healthcare system. Our purpose is to solicit perceptions of all professional stakeholders (e.g. nurses) of the system regarding the U.S. ACGME competency Systems Based Practice to uncover the extent to which there is agreement or discrepancy among key system stakeholders. Eighty-eight multidisciplinary personnel (n = 88) from two academic medical centers were invited to participate in one of 14 nominal group process sessions. Participants generated and prioritized resident characteristics that they believed were important for effective System Based Practices. Through content analysis the prioritized attribute statements were coded to identify embedded themes of resident roles and behavior. From the themes, three major resident roles emerged: resident as Self-Manager, Team Collaborator, and Patient Advocate. No one professional group (e.g., nurses, attending physicians, social workers) emphasized all of these roles. Some concepts that are emphasized in the ACGME definition like using cost-benefit analysis were conspicuously absent from the healthcare team generated list. We showed that there are gaps between the key stakeholders prioritizations about the ACGME definition of SBP and, more generally, the behaviors and roles identified by healthcare team stakeholders beyond the U.S. This suggests that within the process of developing a comprehensive working understanding of the Systems Based Practice competency (or other similar competencies, such as in CanMEDS), it is necessary to use multiple stakeholders in the system (perhaps including patients) to more accurately identify key resident roles and observable behaviors.

Systems-Based Practice Defined: Taxonomy Development and Role Identification for Competency Assessment of Residents

“…Other stakeholder groups (nursing, pharmacy, social work, physical therapy) were not included in this process because of scheduling difficulty, perceived task complexity, and simply because physicians and residents were more readily available to us because of our involvement in other projects with them. We based this methodological decision on the rationale that an entire spectrum of stakeholders-attending physicians, nurses, pharmacy, residents, social work, physical therapyconfirmed a theme structure in a previous study, 3 and all that the present group of physicians and residents was doing was confirming the structure of this previous process. Limitations of this decision and how the results may differ from Graham et al 3 are addressed in a subsequent section.…”

“…We based this methodological decision on the rationale that an entire spectrum of stakeholders-attending physicians, nurses, pharmacy, residents, social work, physical therapyconfirmed a theme structure in a previous study, 3 and all that the present group of physicians and residents was doing was confirming the structure of this previous process. Limitations of this decision and how the results may differ from Graham et al 3 are addressed in a subsequent section. The following is an example of what our consultation with physicians and residents revealed through an iterative process during the 6-month period.…”

“…3 These statements were Steps of the Process Model Employed to Derive a Performance Rating Tool in the Systems-Based Practice (SBP) Competency Area…”

“…This emphasis has evolved from a combination of factors, including (1) an increase in knowledge and technologies that require a more systems-based rather than individual-practice emphasis in patient care; (2) an increase in health care errors that are widely publicized; (3) higher levels of information and expectations of consumers in accessing a variety of services in a system of care; and (4) efforts to contain overwhelming health care costs, such as those seen in managed care, which requires scrutiny of all components of a health care system. [1][2][3][4][5][6][7][8][9] The accreditation standards for graduate medical education programs in several nations now emphasize that physicians understand and practice within a larger system of patient care (eg, the United States' ACGME Outcome Project, 10 Canada's CanMEDS, 11 and the United Kingdom General Medical Council's Good Medical Practices). [10][11][12] When physicians competently practice within larger systems of care, patients are better able to access a full range of services, and physicians can provide more coordinated care contained within the limited resources available.…”

Development of the Objective Structured System-Interaction Examination

“…7 A taxonomy of observable behaviors and a method of evaluation that allows observation of these behaviors is needed. 8 The purpose of the article is to explore the difficulties with current methods used to measure systems-based practice and to describe the development of the Objective Structured System-Interaction Examination (OSSIE). The OSSIE is patterned after the format of the Objective Structured Clinical Examination (OSCE), which is commonly used in medical schools.…”