*5.2.5 Evaluation and feedback*

After the Goals and Objectives section, this is probably the most important section. Two of the most common questions residents ask at the beginning of any rotation are: "How am I being evaluated?" and "Is feedback provided during the rotation? These are important questions to address in this section of the curriculum so that the resident has a clear understanding how s/he will be evaluated [31]. Important aspects to consider including this section:


Note that the rotation evaluations for the rotation should be directly related to the goals and objectives that you define in your curriculum initially.

## **5.3 Faculty development**

The foundation for starting a residency program lies in the layering of the right faculty framework. Faculty remains one of the biggest assets for any training program. Dedication to teaching, commitment to education, and passion to share the love of learning are all aspects of academic medicine that propagate scholarly activity. Historically, there are many challenges to faculty development in any department, but most especially in new program development, in an academic setting. This issue was specifically addressed at the World Conference on Medical Education in 1988. It was intended to improve medical education worldwide. The Edinburgh Declaration made 12 recommendations, the fifth recommendation was to train forerunners as educators, not just content experts, and reward distinction in this arena as in biomedical research or clinical practice [32, 33]. This was also addressed as part of the ACGME Outcome Project initiative that faculty must be qualified to provide and evaluate education that is level-specific, competency-based, standardized, integrated, and accessible [34, 35]. The evolution of a physician into an educator does not happen overnight. The acknowledgement of the importance of faculty development cannot be overemphasized, especially in training of future physicians.

#### *Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*

There are many challenges to a sustainable faculty development curriculum. The requirement for faculty development has increased as a result of growing demands by the regulatory agencies [36–38]. American Association of Directors and Psychiatry Residency Training membership reported lack of funding and lack of time as well as excessive clinical demands as the main barriers to seeking career in graduate medical education [36]. Clinically, the concerns for excellent patient care while teaching residents or students, with the demands of RVU production can be daunting. Other barriers noted in this survey included "faculty attrition, faculty burnout, lack of recognition, and paucity of GME positions within institutions" [36].

Traditional faculty development consists of faculty development workshops, grand rounds, leadership conferences, and faculty retreats. These sessions typically require faculty to block clinical hours to be present face-to-face in one designated location. These usually occur in larger group settings due to the cohort nature of the exercises. These sessions usually address faculty development competencies including education theory. Topics can include curriculum development, competencies, milestones, and EPAs. Other helpful topics to assess teacher effectiveness would include preparation and delivery of didactic teaching skills, clinical teaching skills, specific audience targeting, and incorporation of technology into teaching sessions. Topics specific to the resident evaluation would include assessment and evaluation, giving feedback, the 1-min preceptor, small group teaching, learner styles, and flipped classroom sessions. Other models include teaching and mentoring skills. Topics to be considered under this umbrella would include advising/mentoring techniques and evaluation of any resident expressing difficulty with academic or behavioral issues. Due to new curriculum and new roles for faculty as educators, management and leadership training should also be at the foreground of new faculty training in new programs. Management and leadership styles vary greatly depending upon the physician's prior experiences, their own role models, and their own prior mentors. Useful topics under leadership areas include time management, work hours, delegation, emotional intelligence, networking, team building theory, work/life integration, communication skills, conflict management, strategic planning, and career development of an educator's portfolio.

Another important component in faculty development includes the incorporation of research, especially early in residency design. The expectation of quality and process improvement (QI/PI) projects for both residents and faculty fosters a foundation of evidence-based medicine and quality standard measures for patient safety. Faculty education on research study design, statistical methodology, utilizing the Plan-Do-Check-Act (PDCA) cycle for project implementation, presenting and writing study results, project feasibility, IRB submission, poster presentations, grants submissions, literature searches, publications, evidence-based medicine (EBM), and quality improvement are essential for propagation of scholarly environment. These faculty development workshops are all valuable resources for faculty to stimulate personal research opportunities but also ignite resident intellectual curiosity. New programs that initiate faculty development in all these areas show a commitment to education to the residents. Faculties are expected to have core knowledge in their specialties. This is maintained by board certifications, recertifications, Continue Medical Education (CME), faculty appointments, and recognition within the field of interest. However, a dedicated commitment by the residency programs to structured faculty education is essential to the success of the residency itself. Capturing all areas of research, leadership, education theory, and teaching skills will undoubtedly advance the program and the residents within it.

Innovative methods to faculty development can also be explored through other social platforms. Due to the explosive nature of technology in academic medicine, exercises in flipped classroom settings, online prep courses, Skype presentations,

and lectures further help to spread the availability of resources outside the typical face-to-face lecture/conference settings. It is essential in the busy clinical setting to have flexibility in the location and timing of training activities. 2010 I-PASS study among 11 academic institutions was launched to determine the effectiveness of patient handoffs and patient safety [39]. It required faculty at multiple institutions to first be trained on best practices on patient handoffs, which then in turn would be taught to the residents. This study prompted the development of new faculty curriculum across multiple sites and the need for standardized training. Faculty development was in the lead to advance patient safety among various institutions through innovative modules, online conferencing, combined with live training workshops [39]. Another example is video observation with guided reflection using peer review of videotaped teaching encounters [40]. Another article from Klein and associates reviewed the use of social media with excellent participation, that is, Facebook in providing online faculty development for a larger venue. Participants were involved in knowledge exchange (discussing, questioning/answering, and learning new tools and opportunities) and social capital (networking, sharing ideas, and peer learning). Outcomes showed overall positive impressions with ease of use, rapport, and community building. The biggest challenges were the asynchronous nature of participation and concerns for privacy and professionalism using social media [41]. "Online learning in general is neither superior to nor inferior to other approaches, but simply a method that overcomes some challenges while creating others." Educators should innovatively balance face-to-face and online approaches in teaching [42]. This mix of approaches offers the best combination for faculty adherence and feasibility.

Finally, the future recruitment of excellent faculty educators also lies in praising and rewarding those educators who are the role models for our new residents. These faculty members need to be recognized for the role they fulfill every day in teaching our future physicians and scholars. It will require making changes in academic policies and performance expectations, offering a well-defined career path and identity for educators, increasing faculty development programs, supporting health professions education scholarship units and academies of medical educators, and generating means to ensure high standards for all educators [32]. These resources need to be standardized and shared within the academic learning communities both in undergraduate and graduate forums. Many roles have shared responsibilities within the academic world. Professional development occurs at all levels in academic medicine with the same ultimate goals. "Ensuring that all educators receive the essential knowledge and skills for teaching should be a policy priority" [32]. Joining forces with other established programs can greatly help new program faculty development. This is evidenced in national meetings of educators who welcome shared input to advance both established and new programs for the ultimate advancement of excellent programs. The rewards of graduating a residency class with knowledgeable, compassionate, and competent future physicians remain the ultimate draw into a career of academic medicine.

#### **5.4 Collaboration between residency programs**

The benefits of collaboration in industries from information technology to professional sports have been clearly demonstrated. "We are often better served by connecting ideas than protecting them" [43, 44]. Within medical education, residency collaboration has borne fruit in several fields [45–47]. A noteworthy example is the Preparing the Personal Physician for Practice (P4) project, an initiative undertaken by 14 family medicine residency programs tasked with seeking innovation in residency education [45]. The collaboration between these programs

#### *Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*

allowed for the sharing of "best practices," while also granting participating programs latitude for experimentation that has led to significant advances in the education of residents [47, 48]. Similarly, a collaborative health advocacy training program developed by California's pediatric residency programs allowed each of the constituent residencies to demonstrate clear adherence to the ACGME's requirement on the subject [46]. In a publication that described this joint venture, the authors explain that the effectiveness of the project in accomplishing its goal has led the group to expand the scope of their collaboration [46].

New residency programs offer fertile ground for collaboration in several dimensions. First, the new residency may look at the other programs available for collaboration. Are there existing residencies of the same specialty in the health network or fellowships with ties to the new program's field? What other new residency programs are starting in the network at the same time, or within several years, of the new program? Second, a new residency program should consider what domains are best suited for collaboration with other programs. Is it feasible and mutually beneficial to create collaborative educational content in the form of didactics and workshops? Would share clinical experiences offer growth opportunities that are missing in single-specialty or single-program scenarios? What research and scholarly activity might grow from inter-program collaboration? Exploring these questions and their answers allows the new residency program to capitalize on opportunities to collaborate and enhance training for all of the residents involved.

At St. Luke's Hospital - Anderson Campus, several avenues of collaboration have been established. During the planning phase for the new family medicine and internal medicine residency programs at the Anderson Campus, the decision was made to collaborate in the implementation of a curriculum in lifestyle medicine. This approach to clinical medicine, with a focus on the modification of lifestyle as a first line for disease prevention and management, is attractive to both patients and prospective residents. Working together, with the help of lifestyle medicine-trained adjunct faculty, the family and internal medicine residencies were accepted as a pilot site for the American College of Lifestyle Medicine's "Lifestyle Medicine Residency Curriculum," (LMRC) which prepares residents for dual board eligibility in their core specialty as well as lifestyle medicine at the end of their training. Residents participate in shared lifestyle medicine didactics and will rotate together through a lifestyle medicine specialty clinic. It was the inter-specialty nature of this collaboration that distinguished St. Luke's from other programs vying for acceptance as LMRC sites.

Residents in the new residency programs at St. Luke's Hospital - Anderson Campus also participate in a scholarly activity collaborative; trainees enjoy joint sessions on foundational concepts in research and work together to develop quality improvement projects spanning inpatient and outpatient settings. In addition to the clear patient care benefits of this program, residents can enhance their skills in communicating with other health-care professionals and in considering the impact of a quality improvement initiative outside of their clinical domain.

#### **6. Marketing and recruitment**

Recruiting residents for a new program must be done in a strategic manner to allow for the best outcome for the trainees and the training institution. The first three classes of a residency program can help shape the program and the community it serves. It is important to bring in residents who will contribute to the program development and are flexible in working through the challenges a new program has to offer. Over the past decade, there have been multiple studies regarding resident selection that have seen an increasing trend that USMLE score do not correlate with

performance during residency [49–51]. Many surgical and emergency medicine programs have started to look at "GRIT" as an important aspect of being successful in residency. GRIT is defined as growth, resilience, intensity, and tenacity. Identifying residents who are passionate about medicine and are willing to go beyond the job description, thus ensuring the highest patient care [52–55]. This concept has been in existence since the conception of residency by William Halsted but has been forgotten as the field of medicine has become overburdened with an increasing number of applicants and more regulations in Graduate Medical Education (GME) [50, 55].

When recruiting future residents to a new residency program, it is vital to select candidates based on the following qualities: leadership ability, strong sense on comradery, willingness to adapt and learn, GRIT (resilience), and emotional intelligence.

Academic rigor and test scores will be a part of GRIT [55]. When evaluating candidates for a residency position, it is important to create a standardized procedure to prevent biases. In terms of resident leadership, we can use Kouzes and Posner's approach to identify those who inspire a shared vision, enable others to act, and encourage contributions and positive outcomes [56, 57]. It is also important to select individuals that work well in team; candidates that have experiences of working in a team outside of medicine should be considered an important quality. High-quality teamwork will have resulted in a candidate who has effective communication skills and demonstrates a high degree of professionalism. Willingness to adapt and learn is an important quality for candidates in a new program as it requires a great degree of flexibility and the ability to learn from challenges that will be faced as a team. A well-respected psychologist who focuses on high-functioning teams, Mihaly Csikszentmihalyi, states: "Of all the virtues we can learn, no trait is more useful, more essential for survival, and more likely to improve the quality of life than the ability to transform adversity into an enjoyable challenge."

GRIT, as previously mentioned, is defined as growth, resilience, intensity, and tenacity. This is a vital component of resident selection. It should include the resident's previous academic abilities. A form of this characteristic was used as a part of the criteria of the original Halstead resident for training academic surgeons at Johns Hopkins. Selecting the right set of candidates will create a unique sense of community. It is also important to select candidates with a high level of emotional intelligence in a new program. Residents will be put in environments with staff who are not familiar with having physician trainees and will require residents to handle those situations with poise and humility.

A final important consideration when recruiting residents is promoting diversity. This can be done by selecting an interview panel that encompasses staff from different areas of health care with whom the residents will be required to interact. This inclusive interview team will also be responsible with creating a standardized and structured interview process. Faculty should also be trained to avoid anchoring bias based on the application or resume alone prior to interview [51].

#### **7. Challenges and tips**

Aside from the "3Fs" model (faculty, finance, and facilities), starting a new teaching hospital poses challenges around reimbursement and accreditation. Once sponsorship and training sites have been identified, the new teaching program must determine if it has the regulatory right to start and develop a GME resident FTE cap and to be reimbursed for the residency training through CMS. Building a resident FTE cap large enough to support the hospital and the health network's needs, not only operationally and financially, but strategically, to

#### *Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*

provide workforce solutions in response to community health needs assessments. The Congressional Research Service (CRS) recently published an overview of how Medicare Graduate Medical Education Payments work [58]. CRS identified selected GME funding issues for the Congress to address including that Medicare GME payments do not reimburse hospitals for their up-front investment to begin new residency programs. Lack of up-front or even retro funding is a significant challenge to hospitals starting new residency programs as well as the increase in medical school enrollments and projected physician workforce shortages. As a result of absence of up-front funding, hospitals need to intertwine physician workforce initiatives into their strategic plans and business objectives rather than seeing residency training as separate from the strategy vision. By doing so, hospital executives incorporate residency training costs into their growth proformas and establish community-based recruitment, training, and retention goals as part of their growth outcomes. Hospital executives see the value of residency programs when viewing them as a workforce development initiative rather than solely an educational program that is part of a community mission.

There are many factors that determine if a hospital is eligible for Medicare GME reimbursement, which can be found at cms.gov. CMS regulations define a "new medical residency training program" simply as "a medical residency that receives initial accreditation by the appropriate accrediting body." CMS will reimburse eligible hospitals for starting new residencies albeit under challenging and sometimes ambiguous guidelines. For example, as the end of a 5-year cap building period, CMS completes a balancing test to determine if a program is new for Medicare GME reimbursement purposes during a new teaching hospital's 5-year cap-building window. In addition to obtaining ACGME initial accreditation status, CMS considers the following factors: (a) whether the program director is new, (b) whether the teaching staff is new, (c) whether residents came from an existing program, (d) relationship between hospitals, (e) degree to which hospital with an original program continues to operate its own program in the same specialty, (f) whether a program was relocated from a closed hospital and if so, whether it was part of that hospital's caps, and (g) whether a program is part of any existing hospital's caps [59]. While the balance test of "newness" might appear to be straightforward, every health-care system or entity struggles with some elements depending on their situation. There are numerous factors that could affect "newness" of a program, such as meaning all curriculum requirements, having sufficient number of qualified faculty, recruiting high quality candidates, etc. One area that programs can find challenging is recruiting residents with prior training. For a new program, this can put a damper on the depth of a recruitment pool. CMS's guidance on the "new resident" has been that in order to maintain newness, most of the residents in the program must be residents who are also new, again, with no prior training, or the resident's initial residency period (or IRP) not triggered.

Another CMS newness challenge faced by new programs is the comingling issues. As a new program, residents cannot participate in side-by-side training with other residents of the same specialty, as that is not deemed as "new." Yet another area that programs can find challenging in passing the "newness" test is using new people, resources, and sites and not from existing programs. This poses a particularly significant hurdle when an organization likes to internally promote. If a health system has one family medicine program and wants to start a new family medicine program at another campus, promoting the associate program director from the existing residency to program director of the new residency can pose a problem. The keyword in this last paragraph is "can." The CMS balance does allow for some wiggle room and, overall, much of a program should pass all elements of

the balance test, hence the name "balance" in order to qualify to receive Medicare GME reimbursement.

A few tips for mitigating the risk of losing up-front investment to failure to pass the newness assessment include but are not limited to: (1) getting a Medicare GME reimbursement consultant to conduct a "newness" assessment of your new residency programs. This should be conducted at the beginning and all throughout the 5-year cap building process. (2) Hiring a project manager to help keep new program builds in sync with the larger objective which is ensure the provision of necessary financial support for administrative, educational, and clinical resources, including personnel. A project manager will also help programs remedy obstacles to pass the balance test of newness, which inevitably require logistical support. (3) Organizing the project in terms of faculty, facility, and finance tasks and activities. Accreditation work is assumed and a significant piece of the up-front feasibility study, for example, who would be interested? What rotations would we be able to keep in-house versus out-of-house? How much will things cost? etc. Physician Leads receive accreditation standards and application and work to draft a rotation schedule prior to a planning meeting. The goal of the planning meeting is to score the department's readiness (**Table 1**). The readiness assessment will help to structure the way we launch the change and minimize the time and resources spent on implementing the changes. With the assessment, we can learn: (1) current state of department's compliance, capacity, personnel, and resource; (2) what the curriculum rotation schedule could look like; and (3) the department's experience and belief in the value of the change.
