Faculty Engagement: Helping academic medicine in a time of change

Dear Colleagues,

The introduction of Competence by Design (CBD) has been prompting a series of rich conversations about the realities of our health care system, as well as the pressures on academic medicine in Canada. Academic medicine is under stress and CBD implementation is happening amidst that current strain. Here’s how I see faculty engagement making a difference:

1. Active Leadership
   Postgraduate deans, deans and program directors are using CBD to mobilize their community of faculty as a way to distinguish their school and be a champion for change in creating a clear path for improvement.
2. Creative Solutions
   I admire those who use innovative ways to engage their faculty in CBD. Everything from posters to video snippets, grand rounds, forums for residents, or giving rewards for EPA observations and quality feedback.


A simple yet effective tool created by Queen’s University’s Dr. Damon Dagnone, CBME Faculty Lead (above) and Dr. Jena Hall, CBME Resident Lead (not shown): a “CBME Mobile Training Unit” push cart, circulated regularly to answer outstanding faculty and resident questions. With Samantha Buttemer, PGY4 Public Health and Preventive Medicine, speaking with a resident.

3. Resident Leadership
   It’s been so encouraging to hear of the momentum being built through grass-roots resident activities. When residents are invited into the process, the experience for the program is much richer. Resident leads, like Dr. Jena Hall at Queen’s University, have organized school-wide committees to help make the new curriculum a success. They include CBD- and non-CBD residents to ensure inclusiveness for all.
4. National Knowledge Transfer
   Sharing our learnings across programs and schools keeps us engaged with each other and allows us to leverage experiences and lessons learned. Don’t miss the innovative efforts of Dr. Steven Katz in Internal Medicine at University of Alberta (featured in the article below).

I also encourage you to read the advice offered by Rhonda St. Croix, change advisor at the Royal College. She guides us through steps to involve our teams in CBD implementation. A solid engagement strategy will help us not only spread success at the local level, but it is also the first step in addressing pressure points in academic medicine that originate at a systems level.

In a complex system, the more we interact to better understand the realities of the system, the better chance we have of identifying solutions that make sense at all levels.

Sincerely,

Jason R. Frank, MD, MA (Ed.) FRCPC

How to do CBD Right. Learning from program director Dr. Steven Katz

Dr. Steven Katz is director of the core internal medicine program, and associate chair, postgraduate medical education for the Department of Medicine at the University of Alberta. In this discussion, we check in with Dr. Katz about his program’s progress implementing CBD – in particular, the department’s success engaging faculty and residents.

How are the faculty and residents of the Internal Medicine program reacting to the implementation of CBD? What’s the vibe right now?
I’d say the attitude is one of cautious optimism. We definitely see the benefits of CBD. In particular, our PGY1 group that’s transitioning has engaged strongly and is doing well, which says to me that we’re on the right path. We just need to make sure we stay on it.

How are you tackling the big issue of engaging your faculty and managing their expectations?
It’s going well, but we can always do better. One issue for internal medicine is that the program is so large. We have 100 residents and hundreds of staff at multiple locations, so it’s a real challenge getting everyone to buy in.

A big part of the challenge is in getting faculty to understand the importance of being open to providing residents with feedback. We want residents to try EPAs they don’t necessarily feel confident about so that they can learn by doing. And for that to happen, we need staff to give residents the impression that it’s okay to ask questions. It’s a concern because each staff member has to want to do it. We need to find the right carrot for everyone and that takes time.

What tools are you using to engage faculty?
We’ve been to most sites and sat down with staff in group sessions to explain CBD, the benefits and what’s expected, and to hear people’s concerns and feedback. We’ve engaged regularly with the leadership at our various sites though emails and posters. We also made a La-La Land-inspired video this year as a different way to engage faculty. We thought that showing the program directors having fun and repeating two or three very straightforward messages would get our audience to engage with CBD a bit more. The feedback has been great. Whether it makes a difference, time will tell.

What are you particularly proud of?
Our residents have been amazing through this transition. We have full CBD implementation already in Edmonton. It says a lot about the residents and their character that they’ve been successful in making this work, so I give them full credit.

As one example of progress, a year ago, most residents were focussing on only doing successful EPAs. They weren’t attempting EPAs where they felt vulnerable. So, one message we’ve been fine tuning is that doing EPAs is not about jumping through hoops and “passing.” It’s about making attempts and learning. Residents are hearing the message, and now they’re not cherry picking the EPAs they know they can pass nearly as much as they used to.

What has been your biggest challenge in implementing CBD?
This is a massive change-management exercise that requires people to establish new habits and a new culture of learning. We need to make sure we understand people’s concerns and the best ways to overcome them.

What major lesson have you learned?
Don’t use the word “pilot” in the context of CBD implementation. As soon as you market something as a pilot project, your level of engagement goes down. People see pilots as not quite real – that you’re doing it for the sake of management instead of for the benefit of the participants. My advice would be to just do a project or don’t do it. But never sell CBD implementation as an experiment.

If you could pass on one piece of advice to another program director embarking on CBD implementation, what would that be?
Communication is the big thing with all our stakeholders, be it residents, staff, the department leadership, everyone. And not just communication from us about what they should be doing or what to expect, but also hearing communication from them about their concerns and ideas, and making sure great ideas are brought forward. That’s how you encourage engagement and get results.

How do you see your program, faculty and residents benefitting from CBD?
If done well, CBD creates an environment where faculty and residents are engaging in better feedback. It means residents can identify where they need to improve and, ideally, they’re doing that earlier under CBD. For faculty and administration, there’s a great benefit in identifying issues with residents earlier and giving them resources they need to get on track. The process of self-reflection and subsequent improvement makes for a better resident and a better physician down the road.

How our minds react to change, by Rhonda St. Croix

In talking to program leaders across the country about the challenges of implementing Competence by Design (CBD), the single most frequent issue that I hear about is the difficulty engaging faculty. As we know from neuroscience and psychology, we are wired to resist change as it requires us to replace our trusted standard operating procedures with new behaviours and habits. Our brains, which are ruled by two different systems — the rational and emotional —often have competing needs. As Chip and Dan Heath said in Switch: How to Change Things When Change is Hard, the rational mind wants a great beach body and the emotional mind wants an Oreo cookie.

Along comes CBD, the rationale part of most people’s brains agree with the concept, they may even see the value of the vision, but the emotional mind can take over, freaking out because it starts thinking about things like ‘how will I find the time to observe residents’ and ‘give and document feedback in an ePortfolio.’ This is the discomfort that can overwhelm any change initiative, the rational mind over analyzing and getting paralyzed by the uncertainty, while the emotional mind gets far outside its comfort zone.

So how can we overcome the discomfort and resistance, and find ourselves in a place where we can start moving forward? In Diffusion of Innovation, Everett Rogers shows that an idea for change is not embraced by everyone at first. Rather, the change is initially embraced by a small group of innovators and early adopters who start small, practise new behaviours and make their progress and learnings visible. Robert Cialdini offers six principles of influence from his book Influence. Cialdini shows that we are all influenced by those around us. Over time, change gains momentum and spreads more widely as the early adopters show their progress and others join not wanting to lose out.

So how can we apply these valuable insights to help you engage your faculty in CBD?

1. Find your faculty members who are the innovators and early adopters. Every program has them. Work with these people, rather than pushing against those who have higher resistance levels.
2. Start small with specific actions, engaging with a small group of willing faculty. The rational mind can be inspired by the long term vision and follow an action plan. But we can’t just expect people to change by hearing about lofty goals, visions and document suites, we have to involve them and work together to identify the practical everyday actions. For example, as Dr. Steven Katz said, CBD is about two to three minutes a day with your resident where you focus on one thing that they can do better. Change happens by the everyday actions. Start with one thing.
3. Involve people in how CBD is going to work at your site. Nothing empowers people more than being involved and having a say in how the change can be done. This can be a simple as saying “We are implementing CBD. Here are the three key things we are required to do to meet the standards. Who would like to be involved to figure this out for our program?” Invite people to evolve it and give them room to create the best solution to meet their context.
4. Make success visible. As early adopters in your program start to make progress and learn valuable lessons, make sure your colleagues are aware of them. Nothing influences people more than seeing how trusted peers achieve results. Cialdini calls this social proof and it is a key strategy to clone/copy successes. People do not want to be left behind and miss out on success.
5. Practice a growth mindset. This starts with expecting setbacks as a natural part of the process. Model and help people stretch and grow to be bigger than the challenge. This happens by starting small, trying it out, and taking in feedback, learning and adjusting. The change process is a U-shaped curve. We start with a compelling vision and we hope to arrive at a positive future. Everything in the messy middle is change, growth, learning and adaptation.

These simple actions are about, in the wise words of organisation change guru Peter Block, building agency and true engagement of faculty by “confronting them with their freedom” versus overpowering with compliance (“have to”). This will enable faculty, who are vital to the work of CBD, to take responsibility for making it happen.

For more reading:

• Switch, Chip and Dan Heath
• Diffusion of Innovation, Everett Rogers
• Influence, Robert Cialdini
• The Three Myths of Behaviour Change Jeni Cross TED talk
• Flawless Consulting, The Answer to How is Yes and COMMUNITY, three books by Peter Block

CBD Online Training Modules

Competence by Design for Program Directors is a practical resource designed to provide support throughout the transition to CBD and to help program directors prepare for the change.

Each online module includes practical tools and templates.

Download Lead the Change training module overview, 5 Actions to lead CBD in your program

We have developed this module on change to help program directors engage faculty and residents in CBD. The training modules are meant to complement the Royal College CBD workshops in that it helps programs get started now and keeps them going throughout the CBD implementation process. Program directors who have started early have reported better success in implementing the change. Use this module in any way that works for you; for example, you can complete it online at your own pace or use the materials in a workshop at your school or with your partners, team or program.

CanERA: Accreditation for the 21^st century launching this July!

Following many years of collaboration, Canada’s new accreditation system will officially launch on July 1, 2019. Known as CanERA (Canadian Excellence in Residency Accreditation), this new system for residency education accreditation emphasizes outcomes focused on program quality, while embodying the values of efficiency, consistency and continuous quality improvement.

Built by CanRAC, proudly Canadian

The Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada and the Collège des médecins du Québec maintain national standards for the evaluation and accreditation of Canadian postgraduate medical training institutions and their residency programs across Canada’s 17 medical schools. Together they form the Canadian Residency Accreditation Consortium (CanRAC) and the collaborative relationship has resulted in CanERA.

The aim of CanERA is to

• ensure the quality of residency education provided across Canada;
• objectively evaluate residency programs and institutions to ensure compliance with required expectations;
• facilitate and contribute to the continuous quality improvement of residency programs and institutions; and
• ensure that residency education adequately prepares residents to meet the health care needs of their patient populations upon completion of training.

CanERA introduces the following key features

Final prototype testing almost complete

CanERA was introduced through a multi-phased approach consisting of three prototypes prior to full implementation. As part of prototype 3 (P3), the regular accreditation review of Dalhousie University in November 2018 was successfully conducted using the CanERA system. McGill University, the second P3 University, will be reviewed this March. This is the final phase of testing prior to full implementation of CanERA on July 1, after which all accreditation reviews will be conducted based on this new accreditation system.

CanAMS, the new accreditation management system

As part of CanERA, implementation of the new accreditation management system called CanAMS is also well underway. It is important to note that as we transition to this new system, the Royal College is allowing time to learn and adjust, and is supporting schools and their residency programs through this transition.

Currently, CanAMS access has been provided to the two P3 Universities, as well as to Western University and the University of British Columbia. The next group release of CanAMS, which is currently in progress, includes the University of Toronto, University of Montreal, Northern Ontario School of Medicine (NOSM), University of Manitoba, and University of Calgary. The final two group releases of CanAMS are anticipated for winter and spring 2019.

Throughout the prototype testing, CanAMS has been accessed and tested by other key users including surveyors, specialty and accreditation committee members, and staff. Valuable feedback has been collected throughout this process and improvements to CanAMS (both planned and based on prototype feedback) are being incorporated, as appropriate.

Tools available at www.canera.ca

To support the transition to CanERA, including familiarization with CanAMS and the new standards, a series of stakeholder-specific training, tools, and supports have been developed, and can be found on the CanERA website.

Mark your calendars for the International Conference on Residency Education (ICRE)

ICRE 2019 will be held in Ottawa, Canada, September 26-28, 2019.

The theme for the 2019 conference, “Diversity in Residency Education: Training in a World of Differences” will inspire forward-looking programming that explores issues, innovations and research related to diversity in residency education.

Contribute to this year’s conference by submitting an abstract for presentation under one of the 21 Learning Tracks, including Competency-based Education. Deadline for submissions is March 1, 2019.

Visit www.royalcollege.ca/icre for more information.