1 Kirksville college of osteopathic medicine A T Still University of health sciences.

11

Kirksville college of Kirksville college of osteopathic medicineosteopathic medicine

A T Still University A T Still University of health sciencesof health sciences

22

A Matrix forA Matrix forQuality EnhancementQuality Enhancement

Based upon the Based upon the Seven Core Competencies of Seven Core Competencies of

the Osteopathic Professionthe Osteopathic Profession

Michael Lockwood, DO, FCA Michael Lockwood, DO, FCA AACOM June 2007AACOM June 2007

33

The Matrix for quality enhancement: The Matrix for quality enhancement: Comprised of five submatrixesComprised of five submatrixes

The Seven Core Competencies of the The Seven Core Competencies of the Osteopathic Profession Osteopathic Profession

Expectations for COMLEX-USA, Expectations for COMLEX-USA, Dimension I and IIDimension I and II

Domains of COMLEX-USA-PEDomains of COMLEX-USA-PE Physician behavior based Patient Safety Physician behavior based Patient Safety

concernsconcerns The Stillian Paradigm as enunciated in the The Stillian Paradigm as enunciated in the

Four Tenets of Osteopathic MedicineFour Tenets of Osteopathic Medicine

The Seven Core Competencies of the The Seven Core Competencies of the Osteopathic Profession Osteopathic Profession

Expectations for COMLEX-USA, Expectations for COMLEX-USA, Dimension I and IIDimension I and II

Domains of COMLEX-USA-PEDomains of COMLEX-USA-PE Physician behavior based Patient Safety Physician behavior based Patient Safety

concernsconcerns The Stillian Paradigm as enunciated in the The Stillian Paradigm as enunciated in the

Four Tenets of Osteopathic MedicineFour Tenets of Osteopathic Medicine

44

55

The Matrix for Quality enhancementThe Matrix for Quality enhancement

Allows for tracking of core competenciesAllows for tracking of core competencies Provides basis for curriculum developmentProvides basis for curriculum development Can be applied to Standardized Patient and Can be applied to Standardized Patient and

other case based formatsother case based formats Can track First and Second year encountersCan track First and Second year encounters Can be employed by preceptorsCan be employed by preceptors Regional Deans could track undergraduate Regional Deans could track undergraduate

programsprograms Can be applied to OPTIK programs Can be applied to OPTIK programs

66

Modified Bloom’s Hierarchy of Learning Modified Bloom’s Hierarchy of Learning and the Use of the Expanded Matrixand the Use of the Expanded Matrix

Learning CategoryLearning Category

Stage I Foundation fundamentalsPrototypical examplesStructure FunctionSelf-healing, Self-regulating mechanisms

Year 1InexperiencedStudent

Stage II Associations and relationshipsIntegrated concepts of body unity

Year 2NoviceStudent

Stage III Application and appreciation of treatmentmodalities on an individual to an individualbasis

Year 3 & 4Beginning/BasicCompetence

Stage IV Individualization and advancement into alldomains including an osteopathic clinicalapproach to comorbidities, inquiry intoresearch, and enhanced clinical outcomes

PostgraduateExpert/Specialist Master/Author

77

Seven Core CompetenciesSeven Core Competencies

Individual competencies were analyzed for Individual competencies were analyzed for expectations and requirementsexpectations and requirements

Each competency or required element was Each competency or required element was subdivided according to expectationssubdivided according to expectations

Subdivided expectations were made into the Subdivided expectations were made into the interogative forminterogative form

Responses were imposed upon the MATRIX grid Responses were imposed upon the MATRIX grid for analysisfor analysis

88

AN example subdivided as to AN example subdivided as to individual expectaTionsindividual expectaTions

CORE COMPETENCY 1: CORE COMPETENCY 1: Osteopathic Philosophy and Osteopathic Osteopathic Philosophy and Osteopathic

Manipulative MedicineManipulative Medicine

Students are expected to demonstrate and apply Students are expected to demonstrate and apply knowledge of accepted standards in Osteopathic knowledge of accepted standards in Osteopathic Manipulative Treatment (OMT).Manipulative Treatment (OMT). The educational The educational goal is to train a skilled and competent osteopathic goal is to train a skilled and competent osteopathic practitioner who remains dedicated to life-long practitioner who remains dedicated to life-long learninglearning and to practice habits in osteopathic and to practice habits in osteopathic philosophy and manipulative medicine.philosophy and manipulative medicine.

99

AN Example OF the Three expectations AN Example OF the Three expectations Changed to the interogative Changed to the interogative

CORE COMPETENCY 1: Osteopathic CORE COMPETENCY 1: Osteopathic Philosophy and Osteopathic Manipulative MedicinePhilosophy and Osteopathic Manipulative Medicine

DOES THE LEARNING ACTIVITY HELP, ALLOW ORDOES THE LEARNING ACTIVITY HELP, ALLOW ORREQUIRE THE STUDENT TO:REQUIRE THE STUDENT TO:1.1. Demonstrate and apply knowledge of accepted Demonstrate and apply knowledge of accepted

standards in OMT?standards in OMT?2.2. Train a skilled and competent osteopathic practitioner Train a skilled and competent osteopathic practitioner

who remains dedicated to life-long learning?who remains dedicated to life-long learning?3.3. Train a skilled and competent osteopathic practitioner Train a skilled and competent osteopathic practitioner

who remains dedicated to practice habits of who remains dedicated to practice habits of manipulative medicine?manipulative medicine?

1010

Required elements ARE ALSO Required elements ARE ALSO CHANGED PUT INTO A QUERY FORMATCHANGED PUT INTO A QUERY FORMAT

REQUIRED ELEMENT ONE REQUIRED ELEMENT ONE • Does it demonstrate competency in the Does it demonstrate competency in the

understanding and application of Osteopathic understanding and application of Osteopathic Manipulative Treatment (OMT)?Manipulative Treatment (OMT)?

• Does it integrate Osteopathic Concepts and Does it integrate Osteopathic Concepts and OMT into the medical care provided to patients?OMT into the medical care provided to patients?

• Does it advance integrating Osteopathic Does it advance integrating Osteopathic Principles and Philosophy into all clinical and Principles and Philosophy into all clinical and patient care activities?patient care activities?

1111

Matrix for Quality Enhancement Seven Core Competencies of the Osteopathic Profession

CC1Competency 1: Osteopathic Philosophy and Osteopathic Manipulative MedicineDoes the learning activity help, require or allow the student to:

Incorporated

Yes No N/A

CC1.1 Demonstrate and apply knowledge of accepted standards in Osteopathic Manipulative Treatment.

CC1.2 Train a skilled and competent osteopathic practitioner who remains dedicated to life-long learning.

CC1.3 Train a skilled and competent osteopathic practitioner who remains dedicated to practice habits of manipulative medicine.

R1.1 Required Element 1: Demonstrate competency in the understanding and application of Osteopathic Manipulative Treatment.

R2.1 Required Element 2: Integrate Osteopathic Concepts and Osteopathic Manipulative Treatment into the medical care provided to patients.

R3.1 Required Element 3: Advance integrating Osteopathic Principles and Philosophy into all clinical and patient care activities.

Comments: Total

1212

Comlex-usa

1313

COMLEX - USACOMLEX - USA

The NBOME examinations are the primary pathway The NBOME examinations are the primary pathway by which osteopathic physicians apply for licensure by which osteopathic physicians apply for licensure to practice osteopathic medicine and surgeryto practice osteopathic medicine and surgery

A passing score on these examinations ensures A passing score on these examinations ensures that the candidate’s medical knowledge and clinical that the candidate’s medical knowledge and clinical skills have met a national standardskills have met a national standard

The COMLEX-USA examination sequence is The COMLEX-USA examination sequence is accepted for licensure in 50 statesaccepted for licensure in 50 states

The Osteopathic Medical Board in seven states The Osteopathic Medical Board in seven states require COMLEX for licensurerequire COMLEX for licensure

1414

COMLEX - USACOMLEX - USA

COMLEX – USA examination sequence uses COMLEX – USA examination sequence uses a primary care approach to patient carea primary care approach to patient care

Distinctiveness of osteopathic medicine fully Distinctiveness of osteopathic medicine fully integrated throughout the examinationintegrated throughout the examination

Approximately 20% of questions have a Approximately 20% of questions have a distinct component of Osteopathicdistinct component of Osteopathic philosophy, principles, and practicephilosophy, principles, and practice

1515

Submatrix for COMLEX – USASubmatrix for COMLEX – USA

CLINICAL PRESENTATION CLINICAL PRESENTATION Dimension I lists patient Dimension I lists patient

presentations in case history format. presentations in case history format.

PHYSCIAN TASKSPHYSCIAN TASKS Dimension II ensures adequate Dimension II ensures adequate

demonstration of physician tasks. demonstration of physician tasks.

1616

Level 1, Level 2, Level 1, Level 2, Level 3Level 3

DI-ADI-A Asymptomatic & General SymptomsAsymptomatic & General Symptoms 8-16%8-16%

DI-BDI-B Symptoms & Disorders of Digestion & MetabolismSymptoms & Disorders of Digestion & Metabolism 4-10%4-10%

DI-CDI-C Symptoms & Disorders of Sensory AlterationsSymptoms & Disorders of Sensory Alterations 28-38%28-38%

DI-DDI-D Symptoms & Disorders of Motor AlterationsSymptoms & Disorders of Motor Alterations 6-12%6-12%

DI-EDI-E Symptoms & Disorders Related to Human Sexuality & Symptoms & Disorders Related to Human Sexuality & UrinationUrination

3-8%3-8%

DI-FDI-F Symptoms & Disorders of Respiration & CirculationSymptoms & Disorders of Respiration & Circulation 8-16%8-16%

DI-GDI-G Symptoms & Disorders of ThermoregulationSymptoms & Disorders of Thermoregulation 2-6%2-6%

DI-HDI-H Symptoms & Disorders of the Tissues and TraumaSymptoms & Disorders of the Tissues and Trauma 8-16%8-16%

DI-IDI-I Symptoms & Disorders of Human DevelopmentSymptoms & Disorders of Human Development 3-8%3-8%

Dimension I: Patient Presentation TypesDimension I: Patient Presentation TypesWITH DESIGNATOR ABBREVIATION WITH DESIGNATOR ABBREVIATION

1717

Dimension II: Physician Tasks with Dimension II: Physician Tasks with Designator AbbreviationDesignator Abbreviation

Level 1Level 1 Level 2 CELevel 2 CE Level 3Level 3

DII-ADII-A Health Promotion & Disease Health Promotion & Disease PreventionPrevention

1-5%1-5% 15-20%15-20% 15-20%15-20%

DII-BDII-B History & PhysicalHistory & Physical 5-15%5-15% 30-40%30-40% 10-20%10-20%

DII-CDII-C Diagnostic TechnologiesDiagnostic Technologies 1-5%1-5% 10-20%10-20% 15-25%15-25%

DII-DDII-D ManagementManagement 2-7%2-7% 10-20%10-20% 25-40%25-40%

DII-EDII-E Scientific Understanding of Scientific Understanding of MechanismsMechanisms

70-85%70-85% 5-15%5-15% 5-10%5-10%

DII-FDII-F Health Care DeliveryHealth Care Delivery 1-3%1-3% 5-10%5-10% 5-10%5-10%

1818

COMLEX-USA-Level 2-PECOMLEX-USA-Level 2-PE

COMLEX – USA Level 2 –PE is a clinical skills examination COMLEX – USA Level 2 –PE is a clinical skills examination with an examination blueprint designed to assess with an examination blueprint designed to assess osteopathic studentsosteopathic students

The blueprint reflects the distinctive practice of osteopathic The blueprint reflects the distinctive practice of osteopathic medicinemedicine

All encounters are expected to reflect Osteopathic Principles All encounters are expected to reflect Osteopathic Principles and Philosophyand Philosophy

Additionally, from Additionally, from 25% to 50%25% to 50% of the encounters, the of the encounters, the student is expected to perform appropriate osteopathic student is expected to perform appropriate osteopathic manipulative treatmentmanipulative treatment

There is an emphasis on manipulative treatment and the There is an emphasis on manipulative treatment and the neuromusculoskeletal system as appropriate for osteopathic neuromusculoskeletal system as appropriate for osteopathic medicinemedicine

1919

COMLEX -USA- PE COMLEX -USA- PE biomechanical/boimedical domainbiomechanical/boimedical domainB B

BB 1BB 1 Skills in history-takingSkills in history-taking

BB 2BB 2 Physical examination skillsPhysical examination skills

BB 3BB 3 Osteopathic palpatory skillsOsteopathic palpatory skills

BB 4BB 4 Osteopathic manipulative treatmentOsteopathic manipulative treatment

BB 5BB 5 Written communication skills in the Written communication skills in the form of a “SOAP” noteform of a “SOAP” note

BB 6BB 6 Aspects of clinical problem-solvingAspects of clinical problem-solving

BB 7BB 7 Integrated differential diagnosisIntegrated differential diagnosis

BB 8BB 8 Formulation of a therapeutic planFormulation of a therapeutic plan

2020

COMLEX-USA-PE humanistic domainsCOMLEX-USA-PE humanistic domains

H 1H 1 Skills in doctor-patient communicationSkills in doctor-patient communication

H 2H 2 Interpersonal skillsInterpersonal skills

H 3H 3 ProfessionalismProfessionalism

2121

medica safety issues with medica safety issues with designator abbreviationdesignator abbreviation

S 1S 1 ““Never-Never” Use AbbreviationsNever-Never” Use Abbreviations

S 2S 2 Universal Barrier PrecautionsUniversal Barrier Precautions

S 3S 3 HIPPA RequirementsHIPPA Requirements

S 4S 4 Legibility of the Medical RecordLegibility of the Medical Record

S 5S 5 Radiation PrecautionsRadiation Precautions

S 6S 6 Biohazard PrecautionsBiohazard Precautions

S 7S 7 HandwashingHandwashing

S 8S 8 Time Out Procedures Time Out Procedures

2222

Consider Medical Safety ErrorsConsider Medical Safety Errors

““Never Never Use” Abbreviations- ExamplesNever Never Use” Abbreviations- Examples

AbbreviationAbbreviation Potential ProblemPotential Problem Preferred TermPreferred Term

UU (for unit) (for unit) Mistaken as zero, four, or ccMistaken as zero, four, or cc Write ‘Write ‘unitunit””

Trailing zeroTrailing zero(X.0 mg)(X.0 mg)Lack of leading Lack of leading zerozero(.X mg)(.X mg)

Decimal point is missedDecimal point is missed Never write a zero by Never write a zero by itself after a decimal itself after a decimal point (Xmg) and point (Xmg) and always use a zero always use a zero before a decimal before a decimal point (0.XXmg)point (0.XXmg)

ugug (for (for microgram)microgram)

Mistaken for mg Mistaken for mg (milligrams) resulting in one (milligrams) resulting in one thousand-fold dosing thousand-fold dosing overdoseoverdose

WriteWrite “meg” “meg” or or “microgram”“microgram”

2323

Rational therapy basedupon understanding ofbody and integrationof other three tenets

Structure and Function Are reciprocally interrelated.Normal structure is essential to normal function.

The body is a unit.Mind, body, spiritinseparable.

The body possesses healing and self-regulatingmechanisms.

The Four Tenets of OsteopathyThe Four Tenets of The Four Tenets of OsteopathyOsteopathy

2424

Stillian paradigm requirementsStillian paradigm requirements

A scientific knowledge of A scientific knowledge of anatomy and physiology anatomy and physiology in the hands of a person in the hands of a person of intelligence and skillof intelligence and skill

Masterful adherence to the Masterful adherence to the process of astute, process of astute, systematic observationssystematic observations

Development of advanced Development of advanced palpatory skillspalpatory skills

Apply all skills and Apply all skills and knowledge base for knowledge base for enhancement and enhancement and promotion of health promotion of health

2525

KCOM/ATSU C Fossum, 2006

2626

Viscerosomatic considerations in Viscerosomatic considerations in osteopathic manipulative medicineosteopathic manipulative medicine

Somatic Dysfunction

Lymphatic

Sympathetics Para- sympathetics

Know Systemic Drainage PatternsPotential Obstruction to Lymph Flow Myofascial, ANS, Pathological

ThoracolumbarOutflow:T1 – L2

CraniosacralOutflow:

OA, C1-2; & S1 - 4

Know Sympathetic Chain GangliaKnow Organ Segmentation

2727

Viscerosomatic considerations in Viscerosomatic considerations in osteopathic manipulative medicineosteopathic manipulative medicine

Palpatory Clues to Lymphatic Involvement:Decreased movement of rib cage and reduced diaphragmatic excursionMyofascial tension and somatic dysfunctions in areas of transverse diaphragms and spinal junctionsFullness and bogginess palpated in areas of regional lymphatic drainagePresence of Chapman’s Reflexes

Somatic Dysfunction is impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures; and related vascular, lymphatic and neural elements

Defining Criteria:Tenderness (T)Asymmetry (A)Restricted Range of Motion (R)Tissue Texture Changes (T)

Palpatory Clues in Viscerosomatic Reflex Activity:Increased temperature and sweat (sudomotor activity: moisture on skin drag) Korr, 1962, Nicholas et al 1983

Paraspinal myofascial tissue in area of facilitation feel ‘doughy, boggy’, with predominance of bogginess in the subcutaneous tissues Denslow, 1975, Kappler, 2003 Segmental response to ‘springing’ usually not confined to just one segment: there is a tendency for two or more segments to react ‘en-bloc’ Beal, 1985, 2004

Restricted ROM is due to reflexively muscle activation which will give a springy or ropy quality or end-feel on passive motion testing KCOM/ATSU C Fossum 2006

2828

Evidence-Based MedicineEvidence-Based Medicine

……the integration of best research evidence the integration of best research evidence with clinical expertise with clinical expertise

and patient values…and patient values…

2929

The Osteopathic PhysicianThe Osteopathic Physician““The relationship between the OsteopathThe relationship between the Osteopath

and the patient is the heart of Osteopathy”.and the patient is the heart of Osteopathy”.(Podmore, 2001)(Podmore, 2001)

Figure adapted from ACP Journal Club

3030

Evidence Search IEvidence Search IA search for the best evidence is based upon A search for the best evidence is based upon

the hierarchy of studies as shown:the hierarchy of studies as shown:

Elsevier Ltd. 2005. Straus et al.: Evidence Based Medicine

3131

Evidence Search IIEvidence Search II

An appraisal of the osteopathicAn appraisal of the osteopathic

literature is critical to ensure theliterature is critical to ensure the

osteopathic paradigm is foremost osteopathic paradigm is foremost in the philosophical application in the philosophical application of information to patient care.of information to patient care.

3232

Search RequirementsSearch Requirements

Search of relevant data from the osteopathic literatureSearch of relevant data from the osteopathic literature• Ost Med (Ost Med (http://ostmed.hsc.unt.edu/ostmed/http://ostmed.hsc.unt.edu/ostmed/))• A.T. Still Library Online TextA.T. Still Library Online Text• ACOFP, JAOA, Journal of the AAOACOFP, JAOA, Journal of the AAO

Systems or synopses engines:Systems or synopses engines:• Poems (Poems (www.infopoems.comwww.infopoems.com))• Up to Date (Up to Date (www.uptodate.comwww.uptodate.com• Family Practice Inquiry Network –(Family Practice Inquiry Network –(www.fpin.orgwww.fpin.org))

Studies, synopsisStudies, synopsis• PubMed Linkout – ATSU Kirksville – PubMed plus PubMed Linkout – ATSU Kirksville – PubMed plus

links to the journals owned by ATSU/KCOM links to the journals owned by ATSU/KCOM • OVID, Google Scholar, othersOVID, Google Scholar, others

3333

Evaluation of clinical experiences using Evaluation of clinical experiences using sp’s based on seven core competenciessp’s based on seven core competencies

Competency One

Viral Disease Case CC 1 R 1 R 2 R 3 Total  Exp.

Acute Gastroenteritis

2/3 1/1 1/1 1/1 5/6  5/6 

Acute respiratory disease 2/3 1/1 1/1 1/1 5/6  5/6 

Aseptic meningitis 2/3 1/1 1/1 1/1 5/6  5/6 

Common Cold 2/3 1/1 1/1 1/1 5/6  5/6 

EBV - Mononucleosis 2/3 1/1 1/1 1/1 5/6  5/6 

Genital Warts 2/3 1/1 1/1 1/1 5/6  5/6 

Hepatitis A 2/3 1/1 1/1 1/1 5/6  5/6 

Herpes genitalis 2/3 1/1 1/1 1/1 5/6  5/6 

Herpes simplex Pharyngitis 2/3 1/1 1/1 1/1 5/6  5/6 

HIV Positive 2/3 1/1 1/1 1/1 5/6  5/6 

Influenza 2/3 1/1 1/1 1/1 5/6  5/6 

Keratoconjunctivitis 2/3 1/1 1/1 1/1 5/6  5/6 

Laryngitis 2/3 1/1 1/1 1/1 5/6  5/6 

Rubella 2/3 1/1 1/1 1/1 5/6  5/6 

Shingles 2/3 1/1 1/1 1/1 5/6  5/6 

West Nile Encephalitis 2/3 1/1 1/1 1/1 5/6  5/6 

Ost

eopa

thic

P

hilo

soph

y a

nd

Tre

atm

ent

OM

T

App

lica

tions

OM

T I

nteg

ratio

n

Inte

grat

ion

of

Ost

eopa

thic

P

rinci

ple

s

Tot

als

C

omp

ete

ncy

One

Exp

ecta

tions

for

O

MS

I M

edic

al

Mic

robi

olog

y

3434

to whom much is given, to whom much is given, much is expectedmuch is expected

LUKE THE PHYSICIANLUKE THE PHYSICIAN

3535

Your feedback is desired. Please Your feedback is desired. Please submit paper or E-commentssubmit paper or E-comments

to request templatesto request [email protected]@atsu.edu

fax660-626-2626fax660-626-2626