Phyllis Beemsterboer and Denice Stewart, Oregon Health & Science University
Wilbert Milligan, University of Pittsburgh
ADEA Annual Session 2010Washington, DC
Sections of Clinic Administration and Business and Finance
1. Explore non-traditional methods of clinical assessment.
2. Report on the design and implementation of an OSCE.
3. Discuss comp case presentations as tool for clinical competency.
4. Present a four year approach for practice and patient management assessment.
OSCEs Dr. Beemsterboer
Senior Case Capstone Dr. MilliganPractice Management in Group Practices Dr. Stewart
Discussion Presenters and attendees
Clinic Administration and Business and Finance Sections meeting to follow.
Objective Structured Clinical Examination:
An examination using a series of stations to test clinical skills and/or competencies
Introduced in 1975 by Harden and Gleeson for medicine
Schoonheim-Klein, M. The use of the OSCE in dental education – excellent reference on topic
Goal was to design procedure stationsfor testing diagnosis and treatment planning skills for DS 4 students.◦ Accurate◦ Easy ◦ Cheap◦ Fun
1. Medical history interviewing skills2. Ability to obtain vital signs3. Communication skills4. Ability to perform head & neck exam5. Ability to give informed consent6. Radiographic interpretation7. Treatment planning8. Treatment phasing and sequencing
Set in general clinic 10 stations Duplicated 4 times 7 minutes per station Faculty and staff
served as “patients” 5 stations were paper 5 stations were
“patients”
Establishing scenarios
Creating materials Training faculty Training “patients” Training staff Establishing flow
pattern Developing eval tool
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tested diagnosis skills
tested tx planning skill
identified areas to learn
fair way to eval useful educ experience
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1. Accurate testing method. Identified gaps in learning.
2. Easy – Not. Prep was significant.
3. Cheap – cost contained in house
4. Fun – yes and no
W. H. Milligan III, PhD, DMDAssociate Dean for Clinical Affairs
University of Pittsburgh, School of Dental Medicine
440 Salk HallPittsburgh, PA 15261-1933
[email protected] 412-383-9839
Goal was to develop a tool which would allow us to:◦ determine if students could incorporate biomedical
and clinical didactic material to diagnose, treatment plan and treat patients.◦ evaluate student’s communication skills
PATIENT SELECTION:◦ Medical status PS 2 or above◦ Clinical and radiographic evidence of caries◦ Missing teeth such that the patient needs either a
removable or fixed prosthesis◦ Two or more of the following: Preventive care or periodontal disease
treatment Preparatory restorative procedures Multiple extractions Presence of endodontic lesions
Introduced near the end of student’s second year.
Three components:◦ Formal written report (no more than 8 pages)◦ Supportive documentation◦ Oral case presentation before an Examination panel
Chief complaint Medical and Dental History Clinical findings Diagnosis Treatment Plan (evidence based) Treatment provided and prognosis Patient instructions and post-treatment
follow-up
Written narrative All records properly de-identified Pre- and post-treatment:◦ Radiographs◦ Mounted articulated models and dies if fixed
restorations involved◦ Photographs if necessary
30-45 minutes in length (including oral presentation and questions by examiners and attendees)
Examiners assess presenter for knowledge, communication skills, evidence-based practices in the Diagnosis, Treatment Plan and Treatment provided.
Expectations at level of: “in depth”, “understanding”, or familiarity
Following presentation examiners meet for evaluation of student performance◦ Passing grade must be achieved in each of the
following three categories: Written report Supportive documentation Oral report presentation
Scoring:Rating Scale: Rate the quality of the performance of the student with regard to each ofthe following skills using the following rating scale.Satisfactory = SCritical Error = U
Written Report:1. Diagnosis: _______2. Etiology: _______3. Prognosis: _______4. Treatment Plan: _______ Date Submitted: _______5. Therapy: _______ Date Due: _______6. Evaluate Results: _______7. Maintenance Program: _______
Supportive Documentation Presentation:Pre-Treatment Radiographs: _______Pre-Treatment Diagnostic Mounted Casts: _______Pre-Treatment Charting: _______Treatment Plan with Options: _______ Date Submitted: _______Post Treatment Radiographs: _______ Date Due: _______Post Treatment Mounted Casts: _______
Oral & Visual Presentation: Visual Presentation: _______Oral Presentation: _______ Punctual & Present on Date of Senior Comp: _______
Primary:◦ Apply ethical and legal standards in the provision of
dental care to patients◦ Access and evaluate scientific literature to support
lifelong learning and evidence based decisions◦ Monitor and evaluate treatment outcomes and
utilize results to reassess and modify diagnosis and/or treatment.
Foundational Knowledge:◦ Develop a comprehensive, properly sequenced
treatment plan with treatment alternatives◦ Provide patient care that emphasizes prevention of
oral disease and supports the maintenance of systemic and oral health
CASTS: trimmed, lack bubbles properly mounted
PHOTOGRAPHS: de-identified in accordance with HIPAA; properly labeled and appropriately support the presentation
RADIOGRAPHS: of diagnostic quality and meet radiographic standards of the radiology section.
Evidence-based support for treatment decisions
Ethical and professional behavior◦ Presentation concise, thorough and accurate
without omissions◦ Identified and analyzed ethical considerations in
treatment plan development
ADA CODE OF ETHICS:◦ Actions consistent with ADA code of Ethics,
Professionalism and SDM standards of care◦ HIPAA, privacy and identity regulations followed◦ Demonstrated cultural sensitivity in discussion and
treatment analysis
DIAGNOSTIC FINDINGS:◦ Interpreted health history to recognize systemic
disease and deviations from normal and its impact on dental care◦ Assessed patients history to arrive at appropriate PS
designation◦ Discussed rationale for radiographs◦ Comprehensive radiographic interpretation correct
and established differential diagnosis TREATMENT PLAN / TREATMENT:◦ Presented and discussed all treatment plan options◦ Properly sequenced treatment plan based on
diagnostic data and patient interview
ASSESSMENT OF TREATMENT OUTCOMES / RISK ASSESSMENT:◦ At exit examination discussed patient’s initial
presentation◦ Discussed etiology of patient’s dental disease and
discussed preventive approaches◦ Provided recommendations for further dental care
based on outcomes.
MAINTENANCE PROGRAM ESTABLISHED:◦ Established comprehensive maintenance program
consistent with clinical findings, reassessment and treatment
MONITORING, EVALUATION AND MODIFICATION:◦ Interpreted dental examination findings to arrive
at diagnosis and management options◦ Independently identified and provided health
education needs and made the association with oral and systemic disease.
Requirements for patient selection / completion presented early.
Frequent student consultations with the supervising faculty
Encourage underclassmen to attend senior oral presentations.
Encourage non-examining faculty to attend case presentations
The presentations may identify areas for improvement in the curriculum
Foster interdisciplinary education: faculty attendance can result in a reinforcement of the applicability of biomedical science for clinicians and the clinical sciences for biomedical scientists.
An integrated group practice is a team of student practitioners, representing each of the four dental classes, providing coordinated and comprehensive patient care under the direction and guidance of a faculty group leader and their associated faculty and staff.
Implemented Fall 2008
SIX TEAMS of: 1 Group Leader - manages practice General dentistry faculty Specialty and basic science faculty 1 Care Coordinator .5 DTE – dental assistant Students from all 4 years (~12 each class)
Students In clinic earlier providing patient care Learn and provide comprehensive care Learn and apply practice management skills
Share knowledge with each other over 4 years
Ease or eliminate transition from pre to clinic
Course # Student Year
Term Course Grade
DEN730 DS1 Early fall Spring Pass/FailDEN740 DS2 Summer Spring Pass/FailDEN754; 755 DS3 Summer Winter; Spring 0.0 4.0DEN756; 757 DS4 Summer Fall; Winter 0.0 4.0DEN758 DS4 Spring Pass/Fail
DEN 730-758 courses evaluate students’ ability to provide comprehensive patient care including patient management, clinic utilization and time management, and quality of care appropriate to student’s level.
All courses in the DEN series focus on the integration of the clinical disciplines in the provision of comprehensive care to meet patient needs.
As care providers, students must ensure patient care meets the School of Dentistry Standards of Patient Care. These standards provide the foundation for the comprehensive care course objectives and evaluation mechanisms.
Student ensures Standards of Patient Care are met for all patients under his/her care.
DS1 and 2: phased care concepts, familiarity with the clinic setting, examples of professionalism, communication and protocols.
DS-3 and 4: receive list of the experiences desired for the DS1/2s to make the session more productive and meaningful.
DS1 – 88 hoursDS2 - 69 hours
Students must complete:• 3 specific observations per term during specificassigned sessions,• plus 2 endodontic assists each year;
They may come to clinic up to the number of timesavailable each term.
*additional clinical hours are in perio, restorative, andradiology
Students complete a reflective assessment of each clinic experience complete the “Clinic Observation Form”
Student notes supervising faculty, student mentor, procedure/task performed, patient disposition
Describes, assesses and reflects on the experience and treatment process
Evaluates adherence to infection control protocols
DS1 Student realizing time management and organization are important!
DS3 and DS4 years◦ Focus on aspects of
dentistry not discipline specific Professionalism and
ethics Practice management Patient management
DS3 – 1000 hours DS4 - 1200 hours
Students are primary care providers in a comprehensivecare setting. These hours include rotations to OMS,Urgent Care, community clinics.
Parallels SOD Quality Assurance
Individual and group performance evaluation follow the same elements and format; utilize the same data and reporting◦ Students, faculty & group leaders all on the same page◦ Student sees how his/her performance impacts the
practice◦ Students help manage the practice
Chart documentation – electronic tracking Medical consultation – standard case Treatment planning – patient Infection control – electronic tracking Post treatment review - patient Cross-cultural communication - reflective Medical emergency preparedness – simulation
performance
Classroom – predominately at start of DS3 yr Clinic Privileges – each term, day long Group Huddle◦ One hour each week (Monday 8 AM)◦ Specific sessions for med emerg, inf control, chart
doc, cross-cultural communication Seminars – special topics and comp care case
presentations Clinic – patient care and rotations
DS3 and DS4 years
AttendanceIn order to take advantage of available learning opportunities and to ensure
patient care is progressing in a timely manner, students must be present in the clinic and engaged in clinical activities.
DS3 & 4 - Student must achieve a MINIMUM 85% patient care activity.
Professional Development (SOD Competency 1)To develop skills needed to be a leader and professional, students are expected
to prepare and perform presentations and contribute to the group management by serving on or leading practice committees. Students are expected to uphold principles of ethics and professional conduct.
In addition to patient care: present cases, serve on practice committees, use EBD. Students are expected to be actively engaged in their own development and to work closely with their group leader in development of the professional skills and judgment.
Student interaction with patients and staff are assessed.maximum possible points 25
Student understands principles of comprehensive care and ensures patient receives and consents to a treatment plan that meets their needs.
Key elements: Comprehensive treatment plans are phased and
sequenced Post treatment review assessment after each phase of
tx
COMPETENCY (SOD 2, 3, 4, and 10) Post Treatment ReviewComp Care Case
Key elements: Timeliness of patient (axiUm overdue
manager; school policies on overdue pts) Student clears and/or explains any
unapproved treatment or treatment in process at the end of each academic term.
Note: students who do not meet timeliness of care requirements do not get new patients assigned.
Patient care is of good quality and appropriately documented in the patient record.
Key elements: Treatment plans: comprehensive and informed consent Chart documentation: accurate, current, deficiencies corrected Student participates in Group chart audit activities Student performance on competencies
COMPETENCY (SOD 3, 4, 9, 10): Chart Documentation:Diagnosis and Treatment Planning
Students treat patients with respect; ensure patients understand treatment and costs of care ensure patients know how to access afterhours care if needed. Students establish good and ongoing communication with patients.
Key elements: Ensure patients understand cost of services and pay in a timely
manner – (aged balance for patients does not exceed $500 over 60 days).
Patient complaints regarding are infrequent and appropriately handled.
Students participate in group activities to improve patient care and satisfaction.
Students facilitate patients completing satisfaction surveys. Student completes the cultural and communication competency
COMPETENCY (SOD 3 and 5): Cross cultural communication
Students understand regulations, guidelines and policies addressing security and confidentiality of patient information and ensure these are met for each patient under their care.
Student follows policies that ensure confidentiality of patient information in communications, chart management, etc.
Students understand and adhere to policies and procedures that ensure patient care is performed safely and in a safe environment.
Key elements: Student adheres to all clinic policies to ensure safety in provision
of patient care. CPR certification and prepared to handle medical emergencies Clean, organized workspace in the clinic including their own
operatory on a daily basis and the group practice as a whole. Participates in medical emergency preparedness drills and
infection control/cleanliness group inspections.
COMPETENCY (SOD 3, 4, 6, and 9): Medical EmergencyInfection Control
1) Infection Control Committee2) Service Excellence Committee3) Quality Assurance Committee4) Practice Management Committee5) Evidence Based Practice Committee
Required end of term report from Group Leader and Care Coordinator◦ Parallels student performance assessment◦ Provides quarterly review of practice performance◦ Promotes setting, assessing and attaining goals◦ Provides a means to compare across groups◦ Can be used in group leader performance
assessment Submitted to Associate Dean Clinical Affairs,
utilized in quarterly report to Dean
STUDENT PERFORMANCE – Individually and group
Attendance Assigned patients* Clinical experiences – D(R)Vs* Procedures completed, in process or planned*
PRACTICE PERFORMANCE Production and allocation report* Key procedure counts* Aged balances* Discounts and no charges*
*From axiUm report
PATIENT CARE Patient statuses*
new, active, discontinued, recall # patient appointments and fail rate
Overdue patients – timeliness of care* Chart audit outcomes*◦ # completed, key deficiencies, correction rate
Patient satisfaction survey results
PROFESSIONALISM AND ETHICS HIGHLIGHTS OF PRACTICEOPPORTUNITIES FOR IMPROVEMENT
*From axiUm report
End of term report continued
The courses do promote student adherence to standards of dental practice, compliance, policies, etc.
Student access to information through axiUm reports allows them to monitor performance and use the same data the GL is using.
Not clear if students see these skills as transferable or important in practice.
Improvements planned:◦ Practice committees◦ Closer integration with practice management didactic
courses◦ More time, credit hours!
Phyllis Beemsterboer [email protected] Stewart [email protected]
Wilbert Milligan [email protected]
Presentation is available on ADEA site or you may contact us directly
