Point-of-Care Feedback: Preceptor Cosigning Workflow Promotes Milestone Assessment

Field: Health Professions (Health Sciences)

In residency training, the Accreditation Council for Graduate Medical Education stipulates feedback from faculty should be frequent, exist in the context of routine clinical care, include multiple evaluators, emphasize competency and milestones, and be in writing so it can be shared with the Clinical Competency Committee.Collecting frequent feedback in the context of ambulatory care is an ambitious ask. Supervision of residents in clinic can be busy, if not chaotic. Assessment surveys can be quick, and they can be web-based or smartphone application-based. Still, collection rates can be lower than is needed. Faculty reminders by email, signs in the supervision area, available program links on workplace computers, and prompts submitted by residents to supervising faculty have all been used to increase assessment completion by faculty.1Oregon Health & Science University's Internal Medicine Clinic is the resident continuity clinic for 44 trainees, supervised by more than 30 part-time faculty preceptors. We tested a method to increase case-specific direct observation feedback by preceptors.We looked to thought leaders in informatics for help in our tool design. The most frequently used clinical decision support tools are directly integrated with electronic medical record (EMR) systems. To design effective point-of-care support tools, our experts stick with these informatics rules of thumb: “Speed is everything,” “Deliver in real-time,” and “Fit into the user's workflow.”2We designed a web-based rapid assessment tool. The evaluator selects content areas or processes to score and enters a narrative comment. Our innovation was to deliver this tool directly within the preceptor workflow: we embedded a link in the cosigning (preceptor attestation) template. The location of the survey link was a game changer for our collection rate.Embedding the link into the cosigning template took some care. So that our survey hyperlink would never become part of the patient chart, we needed disappearing instructional text with automated removal from the chart when the preceptor note was signed. Many EMRs enable “prompts” in templates or text blocks. Our university utilizes EpicCare, and we were able to achieve disappearing text using the function “blank, optional SmartList.” Our function displays as a single line of text at the bottom of the preceptor note in progress, with blue font that is recognized by the clinician as disappearing text. The text contains a hyperlink to our rapid assessment.Within the attestation workflow, a preceptor has a visual reminder to provide the assessment and has the option to enter the assessment survey with a single click. The survey results can be collected at any interval by the clinic medical director, who has access to survey reports.Links to our rapid assessment tool were provided in several lower yield environments before we identified a way to embed a link into the cosigning workflow (Figure). Embedding the link within the existing preceptor workflow of chart attestation resulted in an immediate, meaningful, and sustained increase in the number of submitted assessments.The feedback entered is exceptionally relevant—it is specific and contains colorful clinical performance anecdotes that inform resident competencies. This process has been popular with residents and faculty, and it has markedly enriched our resident feedback process.