Dr. Abdullatif Alkhal

DIO, Director of Medical Eduction

Transforming GME in an Emerging AHC

• Change and transformation of the health care system

• Drivers for change

• Main areas of change

• Reforming GME as part of the transformation

• Challenges and opportunities

A System in Transformation Vision and Aspirations

• HMC is a major health care provider in the region

• Very ambitious vision of becoming a center of excellence in health care

• Aspiration, through partnership, to be a leading Academic Health System where strong research and education components enhance medical care

• This has led to significant transformation affecting all areas at HMC and has reshaped the way we function as a system

• To fulfill our ambitions, we partnered with leading academic institutions and health delivery systems in Qatar and worldwide

Major Transformation A Roadmap to Excellence

• The pace of change and transformation is unlike any other in the

region and perhaps in the world

• The transformation is cutting a cross all hospitals and departments of

the system and affecting everyone in it

• The rate of change is rapid; we are trying to achieve in 5 years what

took others decades to achieve

• Change can be uncomfortable, however, everyone came to accept it

as being part of everyday’s business and came to understand it is necessary for us to prosper

• Challenging; we have to go through transformation and at the same

time we need to continue to provide high quality patient care in the face of increasing demand as well as to continue to add more

hospitals and services

• All leaders and all staff members are involved in this change

Drivers for Change A Responsive System

• High quality patient care in a safe environment

• Our vision of becoming a center of excellence

• Aspiration to become an academic health system

• The vision of the leaders of the country and the increasing

expectations of our community

• The National Health Strategy

• Our aim to become highly attractive for the best health professionals

in the areas of patients’ care and health related research

• Our ambition to be a leader in health care in the region

• The changing model of funding of care; from government funding to

health insurance

• The rapidly changing demographics of the population and the rapid

growth of the economy

Areas of Change Priorities

• A traditional health care delivery system; Academic health system

• A centralized decision making; A decentralized system with integrated clinical services and strong physician networking

• QI being a corporate function; QI at the front line led by the

physicians and nurses with corporate guidance and support

• Disjointed care provided by individual clinicians; Multidisciplinary care

provided by teams

• System/self centered care; Patients’ centered care

• Paper based records; Full electronic medical records

• A government funded system; Funding mostly from health

insurance

• A local health care institution; An institution with strong regional and

international presence and renowned health partners

Areas of Change Priorities

• Passive recipient of knowledge; Contribute to the generation of

medical knowledge

• Local internal standards; Accredited institution &programs aligned

with the highest international standards (JCI, ACGMEI, Magnet, etc)

• Delivering good care; Evidence based medical care adopting clinical

pathways with continuous performance improvement

• Loose physicians’ job descriptions & subjective performance appraisals ; Specific physicians’ job plans with measurable performance and objective evaluation

• A system with limited leading role for physicians; A system that is

mostly led by physicians

• A system satisfied with the current status; A system aspiring to be a

leader in health care

• Once in a life -time certification; Revalidation of credentials and

maintenance of certification activities

Academic Health System Our Journey of Transformation

Advanced Clinical care

Education Research (Clinical)

Advanced Clinical care

Education Research (Clinical and translational)

Our Current State Our Vision for 2016

Disciplines Academic

partner

Accrediting Body

For Education

Accrediting

Body

For Health care

Services/facility

Certification/

Licensing

Physicians

Weill Cornell

Medical College-

Qatar (WCMC-Q)

ACGME-I

Nov,2012

JCI

2006,2009,2012 Boards

Nurses

University of

Calgary – Qatar

(UCQ)

•UCQ

•CNA- Canadian Nursing

Association; American

Nurses Credentialing

Center

• National League of

Nursing

JCI

Magnet

UCA CNA National League of

Nursing

Pharmacists

Qatar University

(QU)

Canadian Council for

Accreditation of

Pharmacy Program

JCI QU/Supreme Council of

Health Licensure

Medical

Radiographers

College of North

Atlantic (CNAQ)

•CMA – Canadian Medical

Association

JCI CAMRT – Canadian

Association of Medical

Radiography

Technologists

Respiratory

Therapists

College of North

Atlantic (CNAQ)

COARTE – Council on

Accreditation for

Respiratory Therapy

Education

JCI CBRC -Canadian Board

for Respiratory Care

Biomedical

Technologists

Qatar University

(QU)

American Society Clinical

Pathology (ASCP)

JCI American Society

Clinical Pathology (ASCP)

Transforming Medical Education From Inception to Realization

• In October 2004, HMC, WCMC-Q and NYPH signed an affiliation agreement whereby HMC became a primary affiliated medical center

• WCMC-Q Medical students would receive their clinical clerkship training at HMC hospitals.

• The clinical training delivered by both HMC and WCMC-Q faculty members and students work closely with residents.

• HMC was to meet the LCME requirements pertinent to teaching hospitals

• HMC to meet the ACGME institutional and advanced specialty standards such that medical students receive their clinical training in an ACGME environment

• CME requirements were already established at that time in HMC

Transforming GME

Continuous Educational Process

LCME ACGME CME

Medical School

(WCMC-Q)

Medical Students

(Learning)

Teaching Hospitals

(HMC)

GME Residency

programs

(Learning & care)

Teaching & Mentoring

Teaching & Mentoring

Teaching

Clinical Care areas

(HMC)

Staff (Faculty)

(Service, teaching,

research)

Transforming GME A Major GME Sponsor

• HMC is a major sponsoring institution of GME programs in the region

• Currently enrolling 160 new residents every year

• Residency training existed since 1983

• We aim to be the training center of choice for the best local and

foreign medical graduates

• Our mission is to train our residents and fellows to the highest international standards to prepare our future specialists

• Our vision is to have a highly qualified and homogeneous medical

manpower that provide consistent, reliable and high quality medical

care for the population of the country

Transforming GME GME Before 2005

• HMC had been a training center supporting residency since 1983,

however;

• Residents selection and enrollment was sporadic, unregulated and

did not follow specific pattern or criteria

• No protected residents positions

• No written policies governing residency training

• No officially assigned Program Directors or GME committees

• Curricula were mostly syllabus form and not necessary followed

• No distinction between “education” and “service” • Residents pulled often out of rotation to cover the service

• No graduated responsibility for the different levels of residency years

Transforming GME GME Before 2005

• Supervision was loose and inconsistent

• Evaluations mostly sporadic, subjective and paper based

• Outcomes of training were variable

• No clear exit criteria and residency often stretched way beyond

specified period

• Very low board pass rates in some programs

• Limited communication channel between programs

• Educational activities for residents were limited and no minimum

mandatory courses or orientation

• No established faculty development programs

• No fellowship programs, instead departments adopted “specialist” apprenticeship training

Transforming GME Benefits of Achieving Accreditation by ACGME-I

• Improve the Safety and quality of care provided to our patients.

• Enhance the quality of our postgraduate residency and fellowship programs to match those seen in the US.

• Attract the best residents from Qatar, the region and the rest of the world to join the residency programs at HMC.

• Create a better learning environment for medical students.

• Graduate a homogeneous, highly competent, knowledgeable, and professional future physicians who will provide reliable and consistent medical care to serve the needs of our population.

• Create an educational environment highly attractive of top tier faculty and researchers.

• Keep our faculty at the cutting edge of medical knowledge.

• Allow for reciprocity of residency programs with Sidra Research and Medical when it opens.

Transforming GME Desire for Change

• With the new direction HMC was taking there was a strong need to

change the way we prepare our future generations of specialists

• This coincided with the signing of the affiliation agreement between

HMC and Weill Cornell in 2004

• Transforming the institution and the GME programs to align with the

ACGME was a major challenge

• There were numerous institutional and program level hurdles that

had to be resolved

• The Department of Medical Education was given the task to lead this

change.

Transforming GME The Journey

• In 2005 the Department of Medical Education started its efforts on aligning the institution and the programs with the ACGME standards

• HMC approached the ACGME in 2006 to consider accrediting the institution and the residency programs

• ACGME replied that they didn’t accredit programs outside the US

• HMC continued its efforts align with the ACGME standards

• In November, 2009 – the ACGME announced its international subsidiary and appointed a Vice President for International Accreditation services (ACGME-International) which is a subsidiary organization that accredits GME programs outside of the USA.

• HMC contacted the ACGME again to come to Qatar

• The ACGME responded positively

Transforming GME Challenges

• Lack of knowledge and awareness among clinical leaders, medical

staff, residents, administrators and support departments about ACGME; significant communication required

• Faculty development; hundreds of medical staff need development in

many areas such as clinical teaching, assessment, feedback……. • Skepticism, resistance to change, additional work for busy clinicians

• Resources issues; personnel, space

• Budgetary requirements for residents posts, faculty development,

visiting faculty, GME coordinators, etc; significant spending

• Not being the center of choice for the best FMG’s • Challenge and issues with support departments

Transforming GME Opportunities

• Commitment and support of the system

• Residency training is not new to the system

• Huge resources in terms of teaching material and medical staff

• JCI accredited high quality medical care

• Availability of potential champions and educational leaders in most of

the clinical departments

• Clinical leaders and medical staff who trained in ACGME or similar

environments

• Presence of Weill Cornell medical school as an academic partner

• Partnership and close collaboration with several renowned

international medical centers

Transforming GME Important Steps & Elements for Success

• Declared commitment from the leaders of the system

• Establishing programs and committees and appointing PD’s • Creating GMEC and regulating policies and processes

• Budgetary planning

• Changing culture among physicians

• Changing culture among the support departments and administrative leaders

• Faculty development

• Residents development

• Electronic systems

• The Medical School

• Creating partnerships • Facilities

• Coordinating with other governmental institutions

Transforming GME Establishing Programs

• Seventeen residency programs were officially created, and

• Program Directors were officially appointed

• PD’s appointed Associate Directors and Site PD’s

• Champion medical faculty were identified by the programs

• Programs created “Training and Education” committees • Training committees started working on programs’ curricula

• Residents rotations’ objectives were communicated

• Mandatory residents’ educational activities with minimum attendance

• Development and implementation of assessment tools including

DOPS, CSR, MS-360, Observed Clinical Encounter, Medical Knowledge

• Assessment forms were created

Transforming GME Creating GMEC and Regulating Policies

• GME Committee was established by CEO with membership of PD’s, DIO, Medical Director, WCMCQ representative, and Director of HR

• GMEC Sub-committees for policies, internal review and competence

created

• Core programs Sub-committee created

• Creation of the Residents’ Council by election and the Chair of the Council and 2 Assistant Chairs sit as members in the GMEC

• Nearly 30 policies consistent with the ACGME standards were created

to cover the different aspects of residents’ education such as selection

and enrolment, supervision, evaluation, etc

• Some of the policies needed the involvement of several departments

e.g. Leave Policy

• Medical Bylaws modified to contain statements on residents education

the roles of residents

• Residents’ contracts were revised to meet the ACGME requirements

Transforming GME Budgetary Planning

• Residents posts needs for each program were assessed based on

beds numbers, faculty ratio and teaching material

• The required residents’ posts were included in the new year’s budget • Residents needed to exit at the end of their successful completion of

the training program to vacate the posts for the incoming residents

• Fellowship programs and positions were created to accommodate the

graduating residents

• Faculty development costs were included in the new year’s budget • ACGME-I accreditation cost was added to the new year’s budget

Transforming GME Changing the Culture Among Physicians

• Disseminate the culture of change among physicians leaders and

medical staff through numerous meetings, educational activities, events, and visiting other accredited centers

• Mobilizing clinical leaders

• Buy in and sense of ownership by the clinical departments and the

medical staff

• Creating a positive spirit of competition among programs

• Making departments feel that it is in their best interest

• Changing the concept from “service” to “training” • Active involvement of the residents in making the change and the

making them understand that it’s to their advantage • Messages from the leaders of the system to the medical staff

Transforming GME

Changing Culture: Admin

• Sending clear messages of commitment from the CEO to the lead

administrators

• Spreading the understanding of the benefits and the advantages of

being an accredited teaching institution

• Engaging the lead administrators and leaders of support departments in

making the change

• Involving lead administrators in events and meetings related to

residencies

• Recognizing their important role in making change

• Including the Director of HR as GMEC member

• Sending senior members from support departments to attend the

ACGME meeting

• Inviting lead administrators to the Annual Medical Education Day

Transforming GME Faculty Development

• HMC realized the importance of faculty in field of education

• Champions were identified and were trained to be instructors in Clinical Teaching, Communication Skills, EBM, Simulation, QI,

Evaluation, Research, etc

• Many faculty development courses related to ACGME requirements

such as curricula development, assessment, supervision, etc., were

jointly delivered by HMC, WCMC-Q and other partners

• Supported faculty to attend international meetings related to

education e.g. ACGME, Association of PD’s

• Supported faculty to visit accredited programs

• Program Directors and assistants were given priority to be developed

• Faculty development courses will be a regular activity

Transforming GME Residents Development

• New residents start their program with orientation session at

institutional and program levels

• All residents must complete mandatory courses:

• ILS

• EBM

• Basic Surgical Skills, Basic Laparoscopic Course

• Research Methodology

• QI

• Communication skills

• Clinical Teaching course (optional)

Transforming GME The Medical School

• Presence of WCMC-Q as academic partner helped create an

academic environment and expedite change

• Staff from the medical school were assigned to work closely with HMC on making the change

• Joint courses and educational activities organized

• Teaching medical students at HMC meant medical staff have to apply

for faculty titles

• Faculty promotion depends on publications and contribution to

education

• Medical staff became more interested in faculty development

educational activities

• All of these reflected positively on the residency programs

Transforming GME Electronic System

• Large number of residents makes it difficult to manage a huge amount of information

• Online residents management system was procured

• Training sessions were conducted

• Accessed by residents, coordinators, faculty and PDs,

• Allows managing all aspects of residency programs including demographics, schedules, rotations, log books, evaluations, leaves, duty hours, etc

• Facilitates communication between residents, faculty, PD, Coordinators, and Medical Education Dept

• System is consistent with ACGME-I standards

• Faculty and residents are slow to utilize it

Transforming GME Coordinating with others

• HMC recruits around 160 residents every year

• Most are international applicants

• Applicants must come to Doha for interviews conducted over one

week

• Issuing visas and residency permits done by HMC

• Requires close coordination and collaboration with Ministry of Labor and Ministry of Interior

• Ministries are responding to our needs and try their best to help

• Not without difficulties

Transforming GME Where we are now

• Enrolment occurs annually on July 1st

• Selection based on exam and interview criteria

• Annual departmental exam for residents

• Utilization of OSCE and other clinical evaluation tools

• Entry and exit criteria

• Promotion based on competency

• Progressive responsibility

• Evaluation using electronic system

• Residents evaluation of faculty

• Annual Medical Education day for graduating residents and best faculty and best residents

• Achieved ACGME-I institutional accreditation

• Seven programs are going for accreditation this year

Transforming GME

The Way Forward

JC-I ACGME-I ABMS-I

Accreditation of

facilities and services

Accreditation of

Graduate Medical Education

Certification and

MOC

Transforming GME Conclusions

• HMC is a system going through major transformation with help and

support from its partners

• Reforming health professionals education is a major component of

the transformation

• Highly organized and standardized GME programs are pivotal to high

quality and safe patients’ care and key element in an academic medical center

• Strong and reliable GME programs assure highly competent future

specialists

• Achieving ACGME-I accreditation needs a strong commitment from

all levels of leadership and involvement of every one in the system

• This can be used as model to achieve accreditation for other health

educational programs (nursing, pharmacy, allied health)

GME at HMC

Thank You