How To Change Specialist Training In Singapore

Transcription

1 Transition towards a Competency Based Graduate Medical Education in Singapore: The National Healthcare Group Experience A/Prof Nicholas Chew DIO National Healthcare Group Residency

2 I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Je n ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication. Author: Nicholas Chew Date: 25 October 2014

3 Overview 1. A bit about a small country 2. Healthcare provision and challenges 3. Traditional Specialist Training System and impetus for change 4. Change Management in NHG Residency 5. Where we are now

4 Singapore Size: 718 SqKm Population: 5.4M 3.9M Singapore Citizens and Permanent Residents 7615 persons per sq Km

5 Main Healthcare Challenges Aging population and increased need for care Transformation of Primary Care Population Health - Regional Health Systems

6 The National Healthcare Group

7 History of Specialist Training in Singapore The training of specialists in Singapore started in the 1970s. Modeled after the UK system of training Featured 6 monthly rotations, with intermediate and final summative examinations. Distinct benefits of the system. Basic Spec Training 3 Years Intermediate high stakes exam Adv Spec Training 3 Years Final Exit high stakes exam Specialist Accreditation

8 History of Specialist Training in Singapore In , Ministry of Health, Singapore embarked on a review of Specialist Training and identified deficits in the system 2008 MOH systematically studied various models of specialist training and recommended adopting a competency based residency system modeled after the US based ACGME In 2009, MOH announced the intention to change the system of medical specialist training. 18 months later in 2010 we underwent Institutional and Programme Accreditation in 6 specialties.

9 Impetus for Change 1. Educational Governance and Quality Improvement 2. Educational Curriculum and Assessment 3. Faculty Management

10 Educational Governance» Ownership of learning process» Central committee, distant from the workplace» Department Heads left to balance demands of service and education. Few were informed about educational principles.» Appointed supervisors fulfilled nominal requirements to sign off training periods but had little idea what was to be taught/ learnt

11 Curriculum and Assessment» Unstructured, time based training» Variable and opportunistic educational experiences» Rotations mostly unplanned, learners competed for limited number of places» Few formative assessments and feedback» Dependent on High stakes examination system. Worried about studying for exams rather than patient care» Few formative assessments for learning» Progression through rotations determined largely by ability to deliver service

12 Faculty Management» Faculty development was not coordinated, not aligned to curriculum delivery» Few dedicated medical educators in the system» Examination boards varied in standards

13 What we needed to implement Compliance to Requirements Programme compliance to processes Faculty Prog Evaluations Resident Assessments Competency Committees Prog Eval Comm Education Peer Reviews Create systematic education governance structures, policies and processes Create great programmes Create robust and sustainable assessment systems CQI Faculty dev ACGME-I / JCST

14 Key Enablers Innovative funding support structure delivery of graduate medical education. Ministry and inter institutional engagement throughout the implementation process. Focus on Quality Improvement principles and adopting an existing ACGME-I accreditation model

15 Push Back - System Push back from our doctors: Why do we have to do this, what's wrong with our system? Stronger push back from our higher functioning programmes Why not incremental gains instead of drastic change? OK, I understand, but can we just do things the old way?

16 Push Back - Curriculum You want us to create a new curriculum and implement it in 18 months? What does "competency based" even mean? Are we "incompetency based"? So many assessments to do. What's wrong with high stakes exam? "...and you want all this to be done with duty hour restrictions?" Environment for working is fundamentally different from the environment of learning

17 Push Back - Faculty I don't have time to teach. "OK, OK, I will teach but I don't want you to pay me to teach" Model of financial remuneration helps

18 Change Management in NHG The players in the game

19 Kotter s Framework for Leading Change 1. Establishing a Sense of Urgency 2. Creating the Guiding Coalition 3. Developing a Change Vision 4. Communicating the Vision for Buy-in 5. Empowering Broad-based Action 6. Generating Short-term Wins 7. Never Letting Up 8. Incorporating Changes into the Culture

20 1. Establishing a Sense of Urgency Short implementation timeline - Decision was made by MOH, there is no turning back Education culture in NHG and need to succeed as an Academic Medical Centre Consequence of failure Hospital leadership helped deliver the message

21 2. Creating the Guiding Coalition Identification of the "Coalition of the willing" Getting the right people on the bus, dividing out the change management work, identifying successors We started with a core group of like minded potential educators. The educators we developed will be our drivers of change. Invested in a strong administrative support team

22 3. Developing a Change Vision Alignment with NHG's Vision - "Adding years of healthy life" What it meant to NHG Residency? "Improving patient care through good education" What it meant to the Faculty? "Teach Well, Treat Well, Test Well"

23 3. Developing a Change Vision Guiding principles Competency based rather than time based Empowering the Programme Directors as owners Assessment and feedback as key learning processes Quality Improvement at the heart of education systems

24 4. Communicating the Vision for Buy-in The core group needed to raise a larger workforce to help with the change efforts We focused on Faculty Development Supporting the Programme Directors when they had to communicate with faculty Publicity focused on the healthcare system leaders, medical community, potential residents.

25 5. Empowering Broad-based Action Empowering faculty to work by removing barriers Workgroups to see through implementation Graduate Medical Education Committee (internal barriers) DIO Meetings (between Institutions) MOH MEC Committee Key Activities Resources, funding, manpower etc Managing detractors Empowering PDs to decide and implement education efforts Using MOH and ACGME as levers for implementation

26 6. Generating Short-term Wins Celebrating the successful completion of the first 6 programme accreditations Feedback to leadership on small wins Improvement in duty hours In-Training Exam results

27 7. Never Letting Up Completing the Quality Improvement cycles Faculty Development at the next level Masters in Health Professions Education Expanding our capabilities Health Outcomes and Medical Education Research (HOMER) office Education Innovations

28 8. Incorporating Changes into the Culture Pushing Competency Based education into other areas of training Incorporating educators into decision making process at leadership level and in new projects (e.g. IT)

29 Results How we addressed the problems with the traditional training system» Educational Governance» Curriculum and Assessment» Faculty Management

30 Educational Governance Traditional Spec Trg Competency Based Residency» Ownership of learning process and review of programmes» Central committee» Heads of Department Institutions own the education process and quality improvement Programme directors responsible.» Appointed supervisors sign off training rotations Clinical Competency Committee Core Faculty members

31 Curriculum Traditional Spec Trg Competency Based Residency» Unstructured, time based Learning objectives for each rotation. Time is still a factor.» Variable, opportunistic learning Less variability over core elements» Learners apply for positions Common rotation structure

32 Assessment Traditional Spec Trg» High stakes exams vs Formative assessments Competency Based Residency High stakes exams are still important. Formative assessments added.» Progression assessment determined by ability to provide service more holistic assessment of 6 competencies

33 Faculty Management Traditional Spec Trg» Faculty development not systematic» Few dedicated medical educators Competency Based Residency Faculty development as a system aligned to educational roles Defined careers for medical educators, "no worse off" increased numbers

34 Where we are now» 29 Residency Programmes» 576 Residents» 189 doctors involved as core faculty» 10 completed Masters in medical education» Involved in 149 Education research projects, 55 presentations and 8 publications.» Admin team...

35 Admin team

36 The Next Phase Back to the drawing board