Quality Improvementat Gadjah Mada University School of Medicine

Curriculum TeamGadjah Mada University School of Medicine17 June 2005

Faculty of Medicine GMU

Implementation of PBL at GMU School of Medicine1985-1992 : Community Oriented Medical Education Programme 13 Credits from year 1-year 61992-2002: - Hybrid PBL (20% of total Credits)- 8 PBL Symptom-based Modules for 8 Semester (pain, icterus, fever, shock, etc)

QUE Project (1998-2003)Evaluation ResultsInternal Evaluation by Ad Hoc Teams:- Tutorial discussions need to be improved - Students rely on lecturesExternal Evaluation by Dr. Roger Barton from New Castle University UK:- Incomplete integration - Overburdened academic staffs - Need a QA system

Follow upImplementation of FULL INTEGRATED CURRICULUM using BLOCK System starting in 2002/2003Using KIPDI II as the main reference to determine contents and instructional objectivesEducational Strategy: Problem-Based Learning and Lecture-Based (60-70% of total hours)

PBL Curiculum Block/Integrated02/03knowledgeskillYEARINTERNSHIPMD/Bsc. MedMD/GPlicenced

6

Internship

E2

GP

5

Internal

Medicine

Pediatric

Obgyn

Surgery

P.H

Elective

Local Exam.

E1

MD/BSc

Rotation

Exam.

4

Res. Method Biostat

Int. Health Manag, New.Em.Dis

Emergency & Trauma

Electives and Research Activity

MF

DV

Rad.

Anes.

Ent.

Opt.

Ne

Psy

4 Blocks

+

Rotation

Research Seminar

Patient doctor Com. 3

3

Hemato Bleeding Lymph tissue

Nephro Urology

& Body fluid

Endocrine

& Metabol

Reproduct Health & Diseases

Neuro Behavior Psychiatry

Sense organ & Integument

6 Blocks

Patient doctor Com. 2

2

Life Cycle & Elderly-Geriatrics

Immuno. Inflam. Infection Trop. Med.

Degener Regener & Neoplasm

Locomotion

& Musculo Skelet

Digestion (Gastro) & Absorb. (Nutrition)

CVS

&

Lungs

6 Blocks

Patient doctor Com. 1

1

Learn. Comp.

& IT

Premed

Sci

Biomed

I

Biomed

II

P.H. Com. Med.

Entrepr.

Bioethics

&

Humanities

6 Blocks

Fig.Gadjah Mada Curriculum in Basic Medical Education, Institutional Programme 2002, ( 5 years)

Skills Lab Curriculum1992-nowBlock 1: Interpersonal Communication, MicroscopeBlock 2: Basic Physical Diagnostic, AnthropometriBlock 3: Vital sign, bandageBlock 4: Lumbar Function, Aseptic TechniqueBlock 5: Health survey, Health PromotionBlock 6: Intravenous injection, ResuscitationBlock 7: Denver Test, Neonatal Resuscitation Block 8: Anamnesis, Blood SmearBlock 9: ENT Examination, HeteroanamnesisBlock 10: Neurology examination, orthopedic examination

Skills Lab Curriculum1992-nowBlock 11: Abdominal examination, counselingBlock 12: Thorax examination, electrocardiographyBlock 13: Simulated patient (anamnesis, vital sign, thorax, abdomen,blood pressure)Block 14: Pediatrics physical exam, minor surgeryBlock 15: Physiotherapy, Ascites and CathetherBlock 16: Complete physical examination, IUD insertionBlock 17: Gynaecology exam, baby deliveryBlock 18: Diagnosis, Mental statementBlock 19: Eye examination, communication on sensitive caseBlock 20: Simulated patient, MEQ 3-Clinical ReasoningBlock 21: CPR (ET), simulated patient (Cs 4-6)Block 22: Paediatric life support, message and mission

Follow Up: QA System in PlaceDeanVice Dean for Academic AffairsEducation Committee:Curr, Ass, Tutorial,Manual ProcedureYear CoordinatorsI-IVBlock TeamsI-XXIICoordinatorFor Clinical RotationClinical Coordinator11 DeptsCoordK3MAcademicAudit Team

Principles of QASelf-Evaluation by Vice Dean for Academic Affairs, Year Coordination Teams, and Block TeamsIndependent Internal Evaluation by Academic Audit TeamExternal Evaluation by International ExpertsImprovement based on evaluation by Vice Dean for Academic Affairs, Year Coordination Team, and Block Teams

Evaluation of Curriculum 2002Internal Evaluation:Major problems in assessment, lectures (60-70%), tutorial discussions, PBL management, learning resources, clinical teaching, skills lab curriculum unmatched with block themes, contents of blocks determined by departments

Caused by

Incomprehensive Planning

Evaluation of Curriculum 2002External Evaluation by Prof Arie Kruseman and Prof Albert Scherpbier from Maastricht Medical School (Feb 2004):

Hybrid curriculum of lecture-based, subject-based and problem-based learningOrganisation rather traditional and naturalistic and not in line with educational philosophy of student-centred (SCL) and problem-based learning (PBL)Responsibilities of staff in strategic and operational tasks unclearLearning objectives in curriculum outline and block books to detailed and directive

Evaluation of Curriculum 2002External Evaluation by Prof Arie Kruseman and Prof Albert Scherpbier from Maastricht Medical School (Feb 2004):

Student evaluation focus on lectures, lecture notes and structured learning objectives mentioned in the block booksSkills lab is not an official unit with staffMajority of staff not trained in concepts and objectives of SCL and PBL. Majority of students are also not aware of these objectives and educational power of tutorialsProgramme too overloaded with (introductory) lectures, not enough time in programme for self-studyMajority of textbooks in library outdated[1]Not enough computer facilities, no free access to internet [1]

May 2004- Follow up the EvaluationDecision for Minor Revisions -continuous: assesment, tutorial discussions, learning resources, quality of blocks, clinical teachingDecision for Major Revisions 2005-2006:

Change the curriculum into Competency-based Curriculum- SK Mendiknas 045/U/2002

Follow upApril 2004: 4 Tim Management PBL to MaastrichtJune 2004: 18 Block Coordinators and 4 Block Coordinators sent to Maastricht (new curriculum was first designed)October 2004: 16 Clinical Instructors sent to MaastrichtJuly, August, Sept: Dr Pie Bartholomeus to GMU School of Medicine Skills LabOct 2004: Dr Willem de Graff to GMU SM- tutorial discussion

Follow upFeb 2005: Prof Albert to GMU SM- PBL ManagementMaret 2005: Dr. Pie Bartholomeus and Dr. Jaan Van Dallen to GMU SM Skills LabMay 2005: Assessment and Program Evaluation Team To MaastrichtJuly 2005: Dr. Erik (ass expert), Dr.Ameike Jansen (program evaluation expert) dan Dr. Marieke (skills lab) to GMU SM

June 2005-July 2006To focus on improvement in assessment system : Task Force on Block ExamTask Force on Progress TestTask Force on OSCETask Force on PortfolioTask Force on Clinical Rotation and Comprehensive Exam

Current practice in GMU SMEnd of block written testIt is not easy to develop questions related to discussed topicNo time to develop the questionsLow quality of questions

Current practice in GMU SMEnd of block written testIt is not easy to develop questions related to discussed topicNo time to develop the questionsLow quality of questions

June 2005-July 2006To focus on improving tutorial system (tutorial discussions, management of tutors, tutor training)To prepare the New Competency-Based Curriculum which will be implemented starting in August 2006

draftCompetency-based Curriculum 2006For Undergraduate Medical Education at Gadjah Mada University School of Medicine

Outcomes (areas of competence)CompetenciesKnowledge, Skills, Attitudes

AssessmentAssessmentAssessment

Educational Strategy and Approaches Best Evidence Medical EducationLearning in contextLearning to solve patient problemsPatient-Centred, Project-Based and Problem-BasedIntegration and Multidisciplinary Approach(Horizontal and Vertical; Z shape)Collaborative Learning Progression towards OutcomeAssessment drives students learning

Expertise research

Organizing memory Pattern recognitionNetworksContext informationInformation retrieval

Expertise research

NoviceExpertClinical Reasoning SkillsBeginner(Novice)Advanced(Expert)

What it needs to become.

How?More authentic problemsIncreasing complexityReal lifeprojectsAuthentic assessmentContextualConstructiveCollaborative

How?Less directionIncreasing independent learningMore demand drivenPortfolioassessment;self/peerassessment

How?Smaller groupsGroup assignmentsMore ICT supportLearning task = assessment;include group work in assessment

Progression towards OutcomeSpiral CurriculumIncreased breadth Increased utility Increased difficultyIncreased proficiency

Th 1Th 2Th 3Th 4Th 5CompetenciesCompetencies

Learning in ContextDoctor-PatientsEncountersDisease/Disorder Spectrum:Acute, Chronic, Emergency, PregnancyAge Spectrum:Newborn-Geriatric

Setting Spectrum:Individual, family,communityProblems Spectrum:ClinicalBehaviouralEnvironmental

Steps to design the Competency-based CurriculumArea of CompetencePrimary Care PhysiciansCompetency ComponentsEnabling OutcomeDecidedAt theNational LevelKnowledgeSkillsAttitudeClinicalProblemsDecided at the Faculty LevelLevel of AchievementDecided at the Faculty Level

Steps to design the Competency-based CurriculumEnabling Outcomes are distributedinto phases/year in line with level of achievementIdentification ofYear ThemesIdentification of Block Themesand Distribution of Clinical Problems into BlocksDistribution of Knowledge, Skills, Attitude into BlocksBlue PrintBlocks

Tasks of the Block TeamDesign learning experiences for the students based on Block Blue Prints (such as tutorial discussion, field visits, lectures, skills lab, laboratory practice, etc)Design Scenarios or other triggersDevelop Student Guide and Tutor GuideCarry out Block AssessmentPlan, implement and evaluate

Draft Structure of the Competency-Based Curriculum 2006GMU School of Medicine7 Areas of Competence KIPDI IIISupporting area of competence: Management of Emergency Cases

Kurikulum Fakultas MakroMesoMikro

Progression towards A Competent Medical Doctor

Th 1Th 2Th 3Th 4Th 5Areas of CompetentAreas of CompetentFase I : Beginner1234567812345678Fase 2: IntermediateFase 3: Advanced

PracticeTheoryIndependent learningDependent learningGMU SM Competency-Based Curriculum 2006Phase 1Phase 2Phase 3

Year 1: The Human Body SystemWhy?: - To introduce the human body system the foundation of medicine - Common symptoms familiar for students motivating students - To introduce 8 areas of competence Level Beginner

Year 2: Life Cycle

Example:Block 1.2Enabling Outcome1. (Area 1)To be able to use various elements of communication principles to establish effective doctor-patient relationship, i.e.- listen actively- respect the patient as a person: a. Elicits and respect patients valuesb. Exhibits cultural sensitivityc. Communicates empathy2. (Area 2) Be able to perform basic clinical examination required in dealing with respiratory tract disorders3. (Area 3) Understand the anatomy of respiratory system and surrounding4. (Area 3) Understand the normal function of respiratory system 5. (Area 3) Understand the clinical consequences of respiratory tract disorders 6. (Area 3) able to identify the type of coughs in relation to relevant disorders7. (Area 4) able to choose appropriate treatment for the type of coughs8. (Area 4) carry out education needed to protect individuals against preventable respiratory tract disorders

Example: Block 1.2.Knowledge BaseUnderstand the anatomy of respiratory system and surrounding at cellular and organ level- Understand the normal function of respiratory system Biologi Sel (cellular organization and structure)Molecular-celular defense against injury and disease:Barrier defensesCellular immune defensesHumoral immune defensesActive and passive immunityInflamatory responseUnderstand Mechanism of respiratory diseases and pathophysiological response - pharmacology of specific drugs for respiratory system disorders

Example: Block 1.2.SkillsActive ListeningExamination of vital signs (pulse, temperature, tekanan darah,) (1,2)- Examination of thorax (perkusi, palpasi, auskultasi) (1,2)- Examination of nose and throat- Assessment of thorax (perkusi, palpasi, auskultasi) (1,2)

Example of Block 1.2.Clinical ProblemsISPA (pharyngitis, bronchitis)TuberculosisAsmaPertusis???- check with the depts involved

Example Block 1.2. Week 1

Example Student Guide Block 1.2.List of Block Team and Contact AddressList of Experts and Contact AddressOverview of Block 1.2.Enabling Outcome Time TableScenariosOther learning activitiesLearning resources

Proposal for GMU SMBlueprint Assessment

Five streams Assessment

Proposal for GMU SM

Knowledge End of block written test Practice sessionSkills Skills lab Practice sessionProfessional Behavior TutorialOther relevant activities Weighting is done within each stream NOT across streams

Final mark reported consists of 5 streams

Proposal for GMU SM

Progress TestStarting 2x / year

Portfolio 1x / year Student choose 2 best portfolio for interview

Proposal for GMU SMAcademic Year 2005/2006Target:

1. Improve the quality of block test2. Modify the tutor rating form3. Pilot project progress test4. Socialization of portfolio