Efforts to redesign primary care practice using advanced models of care are transforming the delivery of primary care in the United States. The explicit goals of these models are producing better care experiences and better health outcomes at lower costs (the “Triple Aim”).1 These efforts use strategies that enhance patient relationships, provider competencies, and organizational functions in the health system.2 However, the scope and scale of developments in health care redesign have not been sufficiently adopted in the training of primary care physicians. There is an urgent need to transform primary care residency education, both to enhance capacity to produce physicians capable of effectively practicing patient-centered care on revised platforms of primary care and to train local leaders in this transformation process.
The move toward redesigning practice began for each of the three primary care disciplines separately. In family medicine, the initiative known as Preparing the Personal Physician for Practice3 was a comparative case study of 14 residencies that experimented with changes in residency education, many of which included aspects of the patient-centered medical home (PCMH).2 Two pediatrics initiatives, Residency Review and Redesign in Pediatrics4 and the Initiative for Innovation in Pediatric Education,4 were designed to initiate, facilitate, and oversee innovative change in pediatric residency education through carefully monitored, outcome-directed experimentation. The internal medicine initiative, the Education Innovation Project, targeted ambulatory redesign in several programs through training revisions.5
In 2009, the three primary care American Board of Medical Specialties boards (family medicine, internal medicine, and pediatrics) united to establish a Tri-Board Steering Committee (SC) to explore collaboration to strengthen residency training. In partnership with evaluation experts at Oregon Health & Science University, the SC engaged in a project to create and test interdisciplinary learning communities designed to better prepare graduates to practice effectively in redesigned health systems. In the fall of 2012, the Health Resources and Services Administration (HRSA) awarded an 18-month contract to Oregon Health & Science University to implement and evaluate a pilot faculty development initiative. The Primary Care Faculty Development Initiative’s (PCFDI) overarching goal is to expand the skill sets of primary care residency faculty to enhance and accelerate the transformation of residency training and create an interdisciplinary learning collaborative among the three disciplines to work within their local institutions. Here we describe the initiative, initial curriculum, and organizational approach, and report early results.
PCFDI project overview and curriculum
The SC developed a proposal, framework, and time line for the PCFDI (Figure 1) by convening additional leaders and key stakeholders and completing a robust review of the current state of ambulatory training and of policy maker and health system concerns about medical education. In addition, the SC surveyed program directors in the three disciplines in 2011 to determine faculty development needs and assessed the literature for current gaps in faculty skills. These activities identified a number of needed skills: using electronic health records (EHRs) in teaching; change management; curriculum design; evaluation; individualized learning plans; career coaching; competency-based assessment; leadership; systems-based practice; teamwork; and practice-based learning and improvement.
Using this background, patient-centered care emerged as the core of a conceptual model, and six key areas were conceptualized as interdependent modules: leadership, change management, teamwork, population management, clinical microsystems, and competency assessment. The key components were revised and validated at a January 2012 national conference of key stakeholders that included representatives of the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education (ACGME), the Agency for Healthcare Research and Quality, the Josiah Macy Jr. Foundation, the Robert Wood Johnson Foundation, the Patient-Centered Primary Care Collaborative, HRSA, consumer groups (e.g., Consumer Reports), members of the American Board of Family Medicine, the American Board of Internal Medicine, the American Board Pediatrics, and others.
Selection of participating programs
An open solicitation for participation in the PCFDI was sent to the program directors associations in family medicine, internal medicine, and pediatrics and was widely distributed to residency programs in all three disciplines. Organizations were invited to be initial participants without compensation for themselves or their residency programs. Fifty-one letters of intent and 53 full applications were received, involving 159 residency programs. Applicants were required to apply as a team of residencies from the three disciplines of family medicine, internal medicine, and pediatrics and to confirm support from their sponsoring organizations. A peer review committee, consisting of selected members of the SC, chose the four sites clustered in the Midwest in January 2013: Advocate Lutheran General Hospital (Park Ridge, Illinois); University of Minnesota Medical School; University of Nebraska Medical Center; and Ohio State University College of Medicine. These institutions identified nine clinician–educators and leaders (three from each of the three disciplines) to participate in the program.
A core group of multidisciplinary faculty were chosen to facilitate the PCFDI on the basis of their expertise and experience with modular components of the program as well as real-life experiences with practice change and transformation. This group was assembled to develop and deliver the program using a combination of didactic and small-group interactive sessions to allow participants to apply skills in their respective residency continuity practices. The educational program launched with a two-and-a-half-day training session held in Chicago, Illinois, April 18 to 20, 2013 (see Table 1). Faculty encouraged participants to apply program concepts to local interdisciplinary transformation efforts. The interdisciplinary teams from each site received content reinforcement and coaching after the training session in the form of webinars, conference calls, and visits by core faculty and members of the evaluation team.
A robust evaluation assessed the feasibility and acceptability of the program, and its initial impact on faculty and on residency program and practice redesign. The evaluation also assessed the specific impact that the learning communities had on creating and sustaining momentum for transformation. The specific measures and their timing are included in Supplemental Digital Table 1 at http://links.lww.com/ACADMED/A270.
This project, including all evaluation activities, received an exemption from Oregon Health & Science University’s institutional review board.
Evaluation of the initial training
Using carefully designed surveys, the participants completed formal assessments of the logistics, presentation quality, and usefulness of the training session, as well as their intentions to implement redesign features in their own practices. All surveys used a five-point rating scale with assessment of presentation skills: Poor (1), Adequate (2), Good (3), Excellent (4), and Outstanding (5). Usefulness of the presentations was assessed using a scale with responses ranging from Not at All Useful (1) to Exceptionally Useful (5). Intention to implement skills was scored using response scales ranging from Unlikely to Implement (1) to Absolutely Will Implement (5). We used descriptive statistics to characterize responses to the program by participants. In reporting the survey results, we collapsed responses in the final two categories (e.g., excellent and outstanding) into a single category. For presentation quality ratings, we combined presenter skills and topic materials, which were scored separately, into a single global score. Data capture was 100% for participants, and < 1% of data involved missing responses for individual variables.
In addition, four senior faculty members from three different academic institutions who were either members of the SC or part of the evaluation team and had expertise in recording field notes served as formal evaluators and took extensive field notes, which were compiled into a single document. Two members of the evaluation team used classical content analysis methods6 to identify relevant themes, which arose during discussions related to each topic area. A consensus process was used to verify theme identification and to select exemplars that reflected those themes.
Satisfaction with initial training session
Participation by selected programs was high at the initial training session in April, with 33 of 36 (91.6%) attending (3 members were unable to overcome travel difficulties). Overall, 28/32 (missing 1 response) (87.5%) participants thought the meeting logistics were excellent to outstanding. Presentation quality was rated as excellent or outstanding by 17/33 (51.5%) participants for leadership skills, 26/33 (78.8%) for teamwork skills, 25/33 (75.8%) for change management skills, 26/33 (78.8%) for systems thinking skills, 27/33 (81.8%) for population management skills, 31/33 (93.9%) for patient centeredness skills, and 32/33 (97.0%) for competency assessment skills. Usefulness scores were rated as very or exceptionally useful by 14/33 (42.5%) participants for leadership, 25/32 (missing 1 response) (78.1%) for teamwork, 21/33 (63.6%) for change management, 28/33 (84.8%) for population management, 26/33 (78.8%) for systems thinking, 28/33 (84.8%) for patient centeredness, and 28/33 (84.8%) for competency assessment. The number of participants rating their intention to implement what was learned as “very likely to” or “absolutely will” was 16/32 (missing 1 response) (50%) for leadership, 24/33 (72.7%) for change management, 23/33 (69.7%) for systems thinking, 25/32 (missing 1 response) (75.8%) for population management, 28/33 (84.9%) for teamwork, 29/33 (87.8%) for competency assessment, and 30/31 (missing 2 responses) 96.7% for patient centeredness.
Observed themes and potential contributions of the learning community
Key faculty observations noted that leadership skills are key drivers of change but that participants face challenges in changing culture and engaging other stakeholders (Table 2). Many participants noticed the value of a servant–leadership style rather than a force-of-will leadership model.7 Faculty observers also noted that the three disciplines varied in their readiness to change, even within institutions, and that targeting patient-centered redesign strengthened efforts because work that benefits patients garnered widespread support. The potential contributions of this collaborative approach included identifying the values all three disciplines share in terms of aspiring to be better teachers and physicians. Also, by unifying requests to obtain resources in funding and protected time across all three disciplines, success may be more likely. Faculty observers noted that developing teamwork skills was challenging because of different operational definitions for teamwork; thus, much time was spent rediscovering what teamwork is rather than on developing the “glue” that binds team members together.
Accessing and managing data from EHRs for population management was a universal challenge, especially retrieving data for individual residents. Consequently, residents had virtually no exposure to their own data and had little understanding of how it could be used to improve patient care. Residents tended to see the EHR as being used singularly to take care of individual patients. Faculty observers speculated that members of the learning collaborative could generate a common information technology agenda that would benefit all three disciplines. Faculty also noted the need for clarity in defining a common purpose related to Triple Aim efforts.1 Participants generally agreed that focusing patient-centered efforts around building relationships, improving service, and assuring reliability could be a unifying purpose.
Faculty observers noted the need for embedded patient-based outcome assessments in the curriculum, as well as for feedback for all residents to help them reflect on their experience and performance and avoid “arrested development,” or the inability to sustain evolving change. If the collaborating residencies were to focus on developing curriculum and measurements together for shared topics, then data on the residents in respective disciplines could be shared, and all would benefit. Patient centeredness and PCMH principles were sometimes challenging to develop because institutional missions did not always align with primary care.
Interestingly, we learned that although many faculty knew of each other at their respective institutions, they had not collaborated before. In fact, some faculty had not met prior to starting the project. Participants therefore appreciated that a majority of the two-and-a-half-day meeting was spent working within institutional teams. Indeed, we observed a natural evolution into a professional learning community, consistent with the definition as a group of educators that meets regularly, shares expertise, and works collaboratively to improve teaching skills and learner performances.8
This study was an exploratory study and is quite limited in what can be definitely concluded. The small sample size precludes generalizability. Our approach to evaluating this pilot was to learn from experience and identify relevant contextual and practical operational factors useful in transporting findings into further development of an emerging program. This is an important methodology for educational and practice transformation.
To our knowledge, this effort is the first to actively study the impact of developing a learning community among the three primary care disciplines to simultaneously transform clinical care and residency training. To date, we have learned that primary care residencies have substantial interest in transforming their programs, shared needs, and an untapped ability to collaborate across the three primary care physician specialties. Participants were generally satisfied with the initial content of the program. Participants were least satisfied with the approach to leadership and most positive about competency assessment, systems thinking, and patient centeredness skills, areas in which they likely received little training during their own education. Skills in evaluation and competency assessment were reconfirmed as a gap in current skills for faculty attempting to redesign residencies.9 This is particularly important because enhanced competency assessment is an essential component in the ACGME’s Next Accreditation System,10 and doing this well will benefit many disciplines.
Lessons learned from this pilot are still emerging and will inform further revisions and possible expansion of this initiative to help family medicine, internal medicine, and pediatric residencies better prepare the primary care workforce for the future.
Acknowledgments: The Primary Care Faculty Development Initiative (PCFDI) depended on the dedicated volunteers in residency programs at Advocate Lutheran General Hospital, University of Minnesota Medical School, University of Nebraska Medical Center, and Ohio State University College of Medicine. The authors applaud these innovators and thank them for their courage and leadership. The authors also gratefully acknowledge Charles Kilo, MD, MPH, of Oregon Health & Science University; Eric Warm, MD, of the University of Cincinnati; Perry Dickinson, MD, of the University of Colorado; Paul V. Miles, MD, of the American Board of Pediatrics; Ana-Elena Jensen, PhD, Patient Centered Medical Home Senior Consultant/Facilitator; Brad Benson, MD, and Brian Sick, MD, of the University of Minnesota; Steven Crane, MD, of Mountain Area Health Education Center; and Will Miller, MD, MA, of Lehigh Valley Health System, for their contributions to the PCFDI program.