Assessing Procedural Assessing Procedural Competencies Competencies Amy S. Oxentenko, MD, FACP, FACG Amy S. Oxentenko, MD, FACP, FACG Associate Professor of Medicine Associate Professor of Medicine Fellowship Director, Mayo Clinic- Fellowship Director, Mayo Clinic- Rochester Rochester
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• Patient tolerance 97% Patient tolerance 97% fair to excellentfair to excellent
• 33rdrd year fellow year fellow
• 427 colonoscopies427 colonoscopies
• Cecal intubation 69%Cecal intubation 69%
• Adenoma detection 12%Adenoma detection 12%
• Withdrawal 6 minWithdrawal 6 min
• Patient tolerance 85% Patient tolerance 85% fair to excellentfair to excellent
YESYES NONO
What Needs to be What Needs to be Measured?Measured?
CompetencyCompetency
Minimum Minimum Procedure Procedure
NumberNumber
Defined Defined level of level of abilityability
The NumbersThe Numbers
Minimum Cited NumbersMinimum Cited Numbers
• Flex sigsFlex sigs 25-3025-30
• EGDsEGDs 130130
• ColonsColons 140140
– Based on goal of cecal intubation > 90%Based on goal of cecal intubation > 90%– Others found competence at 275 casesOthers found competence at 275 cases11
– Others found competence at 500 casesOthers found competence at 500 cases22
11Using Sedlack dataUsing Sedlack data22Using Spier dataUsing Spier data
Cecal Intubation RateCecal Intubation Rate
Sedlack RE. Gastrointest Endosc 2011;74:355-66.
Spier BJ, et al. Gastrointest Endosc 2010;71:319-24.
Procedure Logs: Procedure Logs: Not Just Numbers Anymore!Not Just Numbers Anymore!
• ““A skilled preceptor must be available to A skilled preceptor must be available to teach and supervise the fellows in the teach and supervise the fellows in the performance and interpretation of performance and interpretation of procedures, which must be documented procedures, which must be documented in each fellow's record, including in each fellow's record, including indications, outcomes, diagnoses, and indications, outcomes, diagnoses, and supervisor(s).”supervisor(s).”
IV.A.6.d).(2) on Page 19, GI Program Requirements, “Tracked Changes” document
The SkillsThe Skills
Procedure LoggingProcedure Logging• ““Assessment of procedural competence should include Assessment of procedural competence should include
a formal evaluation process and NOT be based solely a formal evaluation process and NOT be based solely on a minimum number of procedures performed. on a minimum number of procedures performed.
• Each program must define criteria for competence for Each program must define criteria for competence for all required and elective procedures.all required and elective procedures.
• The record of evaluation must include the fellow’s The record of evaluation must include the fellow’s logbook or an equivalent method to demonstrate that logbook or an equivalent method to demonstrate that each fellow has achieved competence in the each fellow has achieved competence in the performance of required procedures.”performance of required procedures.”
V.A.1.a).(2) and 1.b).(1).(a) on Page 20-21, GI Requirements, “Tracked Changes” document
• Compliance with completionCompliance with completion– Too easy for staff to forget or not take the timeToo easy for staff to forget or not take the time
• Differing endoscopy database systemsDiffering endoscopy database systems– No communication across programsNo communication across programs
Pros/Cons of ProVationPros/Cons of ProVation• PROS:PROS:• Compliance with completionCompliance with completion
– Automatic pop-up on all fellow EGDs and colonsAutomatic pop-up on all fellow EGDs and colons– Staff cannot sign off until completeStaff cannot sign off until complete
• CONS:CONS:• Yet another databaseYet another database
– How long with it be around?How long with it be around?– Not everyone has itNot everyone has it– Dependent on others to add features desiredDependent on others to add features desired
• Detail desiredDetail desired– Has to fit into radio buttons, brief, succinctHas to fit into radio buttons, brief, succinct
The FutureThe Future
The Game Has Changed in The Game Has Changed in the Setting of NASthe Setting of NAS
• No longer a numbers gameNo longer a numbers game
• No longer a competency yes/no gameNo longer a competency yes/no game
• Now it is all about meeting milestones Now it is all about meeting milestones on the way to becoming competenton the way to becoming competent
http://www.acgme-nas.org/assets/pdf/NEJMfinal.pdf
A Blueprint for Milestones A Blueprint for Milestones or Competency?or Competency?