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Systems Based Practice
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Systems-Based Practice (SBP) is defined by ACGME as
"an awareness of and responsiveness to the larger
context and system of health care and the ability to
effectively call on system resources to provide care that
is of optimal value."
Online Resource downloads include:
-
References
Tactics
Workbook
ACGME
Toolbox
Figure
One
A system is a collection or conglomerate of elements that
interrelate and interact to provide a function, product or
service (See Figure 1). Bottlenecks and disruptions in
this system are readily available examples for education
and evaluations in this domain. The Association of
American Medical Colleges has divided SBP into seven
sub-domains (Table I).
Four areas of anesthesia training and practice, in
which systems-based practice are evident, are preoperative
assessment, intra-operative management, multidisciplinary
pain team and the labor and delivery suite. Specific
content in each of these areas for education and
assessment are identified and evaluation tools are
described below. The ACGME Tool Box was modified for this
domain (Table2).
In addition, anesthesiologist can take advantage of
existing global assessment tools such as: hospital
required certification in HIPPA regulations, infectious
control standards on blood born pathogens and
tuberculosis, safety guidelines and mass casualty alerts.
Because focused observation is inherent to anesthesiology
training, many existing evaluation forms may need only
minor modifications to address these competencies. Of
note, there is much overlap between the domains of
professionalism, interpersonal communication and SBP. In
the future, a common evaluation tool could be formulated.
Preoperative Assessment
Tasks:
- Gather data from electronic or paper systems
- Identify need for consultation
- Obtain consults in timely manner
- Educate the patient
(NPO
rules, preoperative medications, necessary paper work)
Obtain consent or confirm consent obtained
Order preoperative test in cost effective manner
Coordinate preoperative therapy/treatments
Coordinate patient care with PCP, clinics, consultants
and surgeons
Promote efficient patient flow (throughput)
Communicate obtained information with anesthesia team
Assessment Tools:
- Checklist - all ten tasks accomplished
- Feedback from OR
- Checklist
- Delays 2º to inadequate preop
- Accounting of cancellations
- Patient satisfaction survey
- 360º evaluation from preoperative clinic
participants to meet the ten item expectation listed
- Time study of patient flow (portfolio)
- Chart-stimulated recall of impact preoperative
assessment
Intraoperative Management
Knowledge Areas:
- Information systems
- Supply systems
- Communication systems
- Costs vs. charges vs. value for anesthetic
medications and supplies
- Resource utilization
- "Charge" anesthesiologists role
- Attending anesthesiologist role
- Nursing role
- Anesthetic plan effect on postoperative disposition
- Room preparation and turnover
Assessment Tools:
- Portfolio Report – Resident identifies a systems
problem in OR and conducts a mini- Root Cause
Analysis. Report should include five of the seven
elements of the TACTICS paradigm
- PACU rotation (Portfolio) – The residents
identifies one patient per day in which outcome could
have been improved in written report.
- Include system-based language in existing monthly
rotation assessments.
For example: Anesthetic plan complete including
consideration of cost, efficiency and postoperative
disposition.
Interdisciplinary Pain Team
Tasks:
- Teamwork – recognizes they are a member of the
team
- Advocacy – understands and implements plan
- Coordination of services and facilitates care
- Technology aware of policies, safety standards
- Improvement –identifies and modifies existing
structures
- Cost – understand costs of pain medications and
interventions
- Safety – familiar with complications of pain
management and proposed remedies
Assessment tools:
- Portfolio
- Teamwork - list members and roles of team members
- Advocacy - write a sample letter to insurance
company or intrahospital request to obtain services
for patient
- Coordination - patient and staff’s evaluation on
resident’s explanation and education on pain team’s
role and services
- Technology – demonstrates ability to set, read
and clear pumps
- Improvement - review and revise existing policy
- Cost – cost benefit analysis for one patient’s
discharge planning
- Safety – attend QA meetings
- The "Walk in Another Person’s Shoe"
Approach – Portfolio piece
The resident spends a predetermined amount of time
with different members of the team to experience their
aspect of care. This list should included team leader,
family, patient representative, nursing, PT,
biomedical engineering, billing specialist, PI or QI
committee.
Labor and Delivery Practice
Areas of Assessment
Teamwork
- Assigns roles and responsibility
- Productively interact with obstetricians, RNs and
support staff
Advocacy
- Advocate for optimal patient care
- Involves family in patient care plans
Coordinates
- Manages patient flow through unit
- Interfaces with consults and other services
Technology
- Complies with policies
- Performs room/machine/equipment check and set up
Improvement
- Follows up on complications
- Attends QI meetings
Cost
- Identifies material and medication misuse and wastes
- Identifies cost saving ideas
Safety
- Charts accurately
- Complies with controlled substance policies
Means of Assessment
Checklist of above tasks
Portfolio report
Structured case reports
Focused Observation
General Approach
In addition to addressing specific areas and functions
were SBP can observed and evaluated, a Systems-Based
Practice workbook has been compiled.
Residents can complete the individual case based
assignments during their training and include their
completed discussions in their portfolios. A sample
workbook is attached as Appendix I.
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