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Roles of Assessment in the Transformation of Healthcare

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John Norcini

on 19 December 2016

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Transcript of Roles of Assessment in the Transformation of Healthcare

Roles of Assessment in the Transformation of Healthcare

John Norcini, Ph.D.

Why transformation?
Roles of assessment
Ensure quality
Enable change
Enhance learning
Improve practice
Enable change
Assess the competencies that support transformation
Ensure quality
Periodic assessment
Enhance learning
Formative assessment
Improve practice
In support of CPD, we need to learn how to better assess work
Patient outcomes (mortality, morbidity, functional status, cost effectiveness...) and process of care (general and condition-specific)
Forms the basis for
Needs assessment

Healthcare faces two challenges
Capacity of healthcare does not meet the needs of patients

Global shortfall of 13M healthcare workers by 2035 (WHO)
This is an issue in many countries but the greatest need is in Sub-Saharan Africa

11% of the world's population
24% of the world's disease burden
3% of the healthcare workers
<5% of the medical schools

Quality of healthcare is often compromised

Relationship between quality of care and mortality/morbidity
US healthcare is an example

Substantial number of hospital admissions result in harm to patients
Race and income disparities
Lack of continuity of care
Transformation of the healthcare system must address capacity and quality

Patient centered care

"Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." (IOM)

Evidence that it improves patient outcomes and efficiency

Use the assessment of work as part of a quality improvement cycle
Based on practice data
Incorporates feedback
What we know
Knowledge changes rapidly
Performance declines with time since training
It is a matter of failing to keep up, not forgetting

Significant challenges
Case mix, complexity
What we also know (IOM, 2010)
Continuing professional development changes knowledge, attitudes, skills, behavior
Incorporates needs assessments
Ongoing feedback
Multiple methods of learning
Clinically relevant
A competent workforce is the foundation of efficiency and quality
Necessary but not sufficient condition for assuring efficiency and quality
National high stakes assessment programs are central to ensuring competence

Research indicates that licensing/certifying exam performance is associated with
Process of care
Patient outcomes
For doctors, performance declines with time since medical school
Systematic review of the literature (Choudhry) ‏
Knowledge studies
Adherence to standards for diagnosis, screening, prevention
Adherence to standards of appropriate therapy
Patient outcomes
Assessment signals what is important
Can play a significant role in health systems transformation
Indicate the needed competencies
Ensure that they have been acquired
Support ongoing improvement
If it is not assessed, it will not be given priority in learning
But, assessment does not
Practice has not changed
There are not enough clinical placements that model IPLC well
What is learned, is not used
Assessment of competence in interprofessional learning and collaboration enables transformation

Written tests of roles and attitudes
Simulation of teams
Peer assessment
Formative assessment is a powerful educational force
Guides and creates learning
Could increase educational efficiency but
Most exams are summative
Observation is rare and feedback is limited
Formative assessment is poorly done
Summative assessment is used for formative purposes
Well-designed summative assessments typically
Provide a good overall estimate of learning
Lack specific information about strengths and weakness
Lack ties to educational interventions
Have an impact on trainee attitudes
Ineffective as formative assessment

Formative assessments is used for summative purposes
Common in workplace-based assessment
Trainees are told the purpose is formative but the results are used for promotion decisions
Trainees realize its summative and treat it that way
Creates the wrong environment for learning
A test designed for formative purposes is not optimal for summative purposes
Formative assessment is regarded as low stakes
Standards for good measurement are often ignored
Leads to unreliable and perhaps misleading feedback
Creates educational inefficiencies
assessment into practice
The effect is not small

At the extremes, it is a 15-25% increase in relative risk for mortality post-AMI, CHF, CABG
Represents a failure to keep up, not a cognitive decline
Patient outcomes (Norcini)
Mortality adjusted for severity of illness, hospital, and physician characteristics
Specialty Certification (voluntary)
Cardiologists, internists, family medicine (AMI): -15%
Cardiologists and internists (AMI): -19%
Cardiologists, internists, family medicine (AMI, CHF): -6%
Licensure scores: All IMGs (AMI, CHF) -4% per SD
Roles of assessment in system transformation
Ensure the quality of individual providers through periodic assessment
Enable change by assessing the full range of competencies
Enhance learning through formative assessment
Improve practice by integrating assessment
Aspirin within 24 hours of symptoms
23% reduction in 30-day mortality (ISIS-2)

"To be good is noble, but to teach others how to be good is nobler, and less trouble."

Mark Twain
"I can't tell you his age, but when he was born the wonder drug was Mercurochrome."

Milton Berle
Age. That period of life in which we compound for the vices that remain by reviling those we have no longer the vigor to commit.

A. Bierce
Interprofessional learning and collaborative practice address capacity and quality
access to health-services
appropriate use of specialists
health outcomes
patient care and safety
total patient complications
length of hospital stay
conflict among caregivers
staff turnover
hospital admissions
clinical error rates
mortality rates
"We shouldn't fear a world that is more interacted"

GW Bush
“Some cause happiness wherever they go; others, whenever they go”

O Wilde

"The way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not."

Mark Twain
Process of care (Tamblyn)
Licensing/certifying exam scores associated with
Increased consultation rates
3.8/1000 per SD
Increased mammography rates
6.6/1000 per SD
Decreased contraindicated prescribing
-2.7/1000 per SD
“It is only by getting your cases grouped…that you can make any real progress with your post-collegiate education”

W. Osler
Why do you think transformation is necessary...
What do you think assessment can do to help in the transformation of healthcare...
Long-term use of beta-blockers
23% reduction in mortality (Freemantle)
Full transcript