Quality Improvement at Gadjah Mada University School of Medicine

1. Quality Improvementat Gadjah Mada University School of Medicine Curriculum Team Gadjah Mada University School of Medicine 17 June 2005

2. Faculty of Medicine GMU

3. Background

4. Implementation of PBL at GMU School of Medicine • 1985-1992 : Community Oriented Medical Education Programme – 13 Credits from year 1-year 6 • 1992-2002: - Hybrid PBL (20% of total Credits) - 8 PBL Symptom-based Modules for 8 Semester (pain, icterus, fever, shock, etc)

5. QUE Project (1998-2003)Evaluation Results • Internal Evaluation by Ad Hoc Teams: - Tutorial discussions need to be improved - Students rely on lectures • External Evaluation by Dr. Roger Barton from New Castle University UK: - Incomplete integration - Overburdened academic staffs - Need a QA system

6. Follow up • Implementation of FULL INTEGRATED CURRICULUM using BLOCK System starting in 2002/2003 • Using KIPDI II as the main reference to determine contents and instructional objectives • Educational Strategy: Problem-Based Learning and Lecture-Based (60-70% of total hours)

7. PBL Curiculum – Block/Integrated‘02/’03 skill MD/GP licenced INTERNSHIP MD/Bsc. Med knowledge YEAR

8. Skills Lab Curriculum1992-now Block 1 : Interpersonal Communication, Microscope Block 2 : Basic Physical Diagnostic, Anthropometri Block 3 : Vital sign, bandage Block 4 : Lumbar Function, Aseptic Technique Block 5 : Health survey, Health Promotion Block 6 : Intravenous injection, Resuscitation Block 7 : Denver Test, Neonatal Resuscitation Block 8 : Anamnesis, Blood Smear Block 9 : ENT Examination, Heteroanamnesis Block 10: Neurology examination, orthopedic examination

9. Skills Lab Curriculum1992-now • Block 11 : Abdominal examination, counseling • Block 12 : Thorax examination, electrocardiography • Block 13 : Simulated patient (anamnesis, vital sign, thorax, abdomen,blood pressure) • Block 14 : Pediatrics physical exam, minor surgery • Block 15 : Physiotherapy, Ascites and Cathether • Block 16 : Complete physical examination, IUD insertion • Block 17 : Gynaecology exam, baby delivery • Block 18 : Diagnosis, Mental statement • Block 19 : Eye examination, communication on sensitive case • Block 20 : Simulated patient, MEQ 3-Clinical Reasoning • Block 21 : CPR (ET), simulated patient (Cs 4-6) • Block 22 : Paediatric life support, message and mission

10. Follow Up: QA System in Place Dean Academic Audit Team Vice Dean for Academic Affairs Education Committee: Curr, Ass, Tutorial, Manual Procedure Year Coordinators I-IV Coordinator For Clinical Rotation Block Teams I-XXII Clinical Coordinator 11 Depts Coord K3M

11. Principles of QA • Self-Evaluation by Vice Dean for Academic Affairs, Year Coordination Teams, and Block Teams • Independent Internal Evaluation by Academic Audit Team • External Evaluation by International Experts • Improvement based on evaluation by Vice Dean for Academic Affairs, Year Coordination Team, and Block Teams

12. Evaluation of Curriculum 2002 • Internal Evaluation: • Major problems in assessment, lectures (60-70%), tutorial discussions, PBL management, learning resources, clinical teaching, skills lab curriculum unmatched with block themes, contents of blocks determined by departments Caused by Incomprehensive Planning

13. Evaluation of Curriculum 2002 • External Evaluation by Prof Arie Kruseman and Prof Albert Scherpbier from Maastricht Medical School (Feb 2004): • Hybrid curriculum of lecture-based, subject-based and problem-based learning • Organisation rather traditional and naturalistic and not in line with educational philosophy of student-centred (SCL) and problem-based learning (PBL) • Responsibilities of staff in strategic and operational tasks unclear • Learning objectives in curriculum outline and block books to detailed and directive

14. Evaluation of Curriculum 2002 External Evaluation by Prof Arie Kruseman and Prof Albert Scherpbier from Maastricht Medical School (Feb 2004): • Student evaluation focus on lectures, lecture notes and structured learning objectives mentioned in the block books • Skills lab is not an official unit with staff • Majority of staff not trained in concepts and objectives of SCL and PBL. Majority of students are also not aware of these objectives and educational power of tutorials • Programme too overloaded with (introductory) lectures, not enough time in programme for self-study • Majority of textbooks in library outdated[1] • Not enough computer facilities, no free access to internet [1]

15. May 2004- Follow up the Evaluation • Decision for Minor Revisions -continuous: assesment, tutorial discussions, learning resources, quality of blocks, clinical teaching • Decision for Major Revisions 2005-2006: Change the curriculum into Competency-based Curriculum - SK Mendiknas 045/U/2002

16. Follow up • April 2004: 4 Tim Management PBL to Maastricht • June 2004: 18 Block Coordinators and 4 Block Coordinators sent to Maastricht (new curriculum was first designed) • October 2004: 16 Clinical Instructors sent to Maastricht • July, August, Sept: Dr Pie Bartholomeus to GMU School of Medicine – Skills Lab • Oct 2004: Dr Willem de Graff to GMU SM- tutorial discussion

17. Follow up • Feb 2005: Prof Albert to GMU SM- PBL Management • Maret 2005: Dr. Pie Bartholomeus and Dr. Jaan Van Dallen to GMU SM – Skills Lab • May 2005: Assessment and Program Evaluation Team To Maastricht • July 2005: Dr. Erik (ass expert), Dr.Ameike Jansen (program evaluation expert) dan Dr. Marieke (skills lab) to GMU SM

18. June 2005-July 2006 • To focus on improvement in assessment system : • Task Force on Block Exam • Task Force on Progress Test • Task Force on OSCE • Task Force on Portfolio • Task Force on Clinical Rotation and Comprehensive Exam

19. Current practice in GMU SMEnd of block written test It is not easy to develop questions related to discussed topic No time to develop the questions Low quality of questions

20. Current practice in GMU SMEnd of block written test It is not easy to develop questions related to discussed topic No time to develop the questions Low quality of questions

21. June 2005-July 2006 • To focus on improving tutorial system (tutorial discussions, management of tutors, tutor training) • To prepare the New Competency-Based Curriculum which will be implemented starting in August 2006

22. draftCompetency-based Curriculum 2006 For Undergraduate Medical Education at Gadjah Mada University School of Medicine

23. Outcomes(areas of competence) Competencies Knowledge, Skills, Attitudes

24. Roles and Functions of Health Professional Competencies required for performance of roles/functions Knowledge, skills, attitudes for acquisition of competencies Assessment Assessment Assessment

25. Educational Strategy and Approaches – Best Evidence Medical Education • Learning in context • Learning to solve patient problems • Patient-Centred, Project-Based and Problem-Based • Integration and Multidisciplinary Approach (Horizontal and Vertical; Z shape) • Collaborative Learning • Progression towards Outcome • Assessment drives students’ learning

26. Expertise research Networks Organizing memory Context information Information retrieval Pattern recognition

27. Expertise research Clinical Reasoning Skills Advanced (Expert) Beginner (Novice) Novice Expert

28. C ontextual C onstructive C ollaborative What it needs to become….

29. How? Authentic assessment C ontextual Real life projects C onstructive Increasing complexity C ollaborative More authentic problems

30. C ontextual C onstructive C ollaborative How? Portfolio assessment; self/peer assessment More demand driven Increasing independent learning Less direction

31. C ontextual C onstructive C ollaborative How? Learning task = assessment; include group work in assessment More ICT support Group assignments Smaller groups

32. Progression towards OutcomeSpiral Curriculum Competencies • Increased breadth • Increased utility • Increased difficulty • Increased proficiency Th 5 Th 4 Th 3 Th 2 Th 1 Competencies

33. Learning in Context Disease/Disorder Spectrum: Acute, Chronic, Emergency, Pregnancy Age Spectrum: Newborn-Geriatric Doctor-Patients Encounters Problems Spectrum: Clinical Behavioural Environmental Setting Spectrum: Individual, family, community

34. Steps to design the Competency-based Curriculum Area of Competence Primary Care Physicians Decided At the National Level Competency Components Enabling Outcome Level of Achievement Decided at the Faculty Level Skills Knowledge Attitude Clinical Problems Decided at the Faculty Level

35. Steps to design the Competency-based Curriculum Enabling Outcomes are distributed into phases/year in line with level of achievement Identification of Year Themes Identification of Block Themes and Distribution of Clinical Problems into Blocks Blue Print Blocks Distribution of Knowledge, Skills, Attitude into Blocks

36. Tasks of the Block Team • Design learning experiences for the students based on Block Blue Prints (such as tutorial discussion, field visits, lectures, skills lab, laboratory practice, etc) • Design Scenarios or other triggers • Develop Student Guide and Tutor Guide • Carry out Block Assessment • Plan, implement and evaluate

37. Draft Structure of the Competency-Based Curriculum 2006GMU School of Medicine 7 Areas of Competence – KIPDI III Supporting area of competence: Management of Emergency Cases

38. Kurikulum Fakultas Makro Meso Mikro

39. Progression towards A Competent Medical Doctor Areas of Competent 2 3 4 1 8 5 6 7 Th 5 Fase 3: Advanced Th 4 Th 3 Fase 2: Intermediate Th 2 3 Fase I : Beginner 2 1 4 Th 1 8 5 7 6 Areas of Competent

40. Year Themes 1 The Human Body System 2 Life Cycle 3 Chronic disorders and Neoplasma 4 Emergency and Clinical Rotation 5 Clinical Rotation and Research 6 Internship (??) GMU SM Competency-Based Curriculum 2006 Phase 1 Phase 2 Phase 3 Practice Theory Independent learning Dependent learning

41. Year 1: The Human Body System Why? : - To introduce the human body system – the foundation of medicine - Common symptoms – familiar for students – motivating students - To introduce 8 areas of competence – Level Beginner

42. Year 2: Life Cycle

43. Example:Block 1.2Enabling Outcome • 1. (Area 1)To be able to use various elements of communication principles to establish effective doctor-patient relationship, i.e. • - listen actively • - respect the patient as a person: • a. Elicits and respect patients’ values • b. Exhibits cultural sensitivity • c. Communicates empathy • 2. (Area 2) Be able to perform basic clinical examination required in dealing with respiratory tract disorders • 3. (Area 3) Understand the anatomy of respiratory system and surrounding • 4. (Area 3) Understand the normal function of respiratory system • 5. (Area 3) Understand the clinical consequences of respiratory tract disorders • 6. (Area 3) able to identify the type of coughs in relation to relevant disorders • 7. (Area 4) able to choose appropriate treatment for the type of coughs • 8. (Area 4) carry out education needed to protect individuals against preventable respiratory tract disorders

44. Example: Block 1.2.Knowledge Base • Understand the anatomy of respiratory system and surrounding at cellular and organ level • - Understand the normal function of respiratory system • Biologi Sel (cellular organization and structure) • Molecular-celular defense against injury and disease: • Barrier defenses • Cellular immune defenses • Humoral immune defenses • Active and passive immunity • Inflamatory response • Understand Mechanism of respiratory diseases and pathophysiological response • - pharmacology of specific drugs for respiratory system disorders

45. Example: Block 1.2.Skills • Active Listening • Examination of vital signs (pulse, temperature, tekanan darah,) (1,2) • - Examination of thorax (perkusi, palpasi, auskultasi) (1,2) • - Examination of nose and throat • - Assessment of thorax (perkusi, palpasi, auskultasi) (1,2)

46. Example of Block 1.2.Clinical Problems • ISPA (pharyngitis, bronchitis) • Tuberculosis • Asma • Pertusis • ???- check with the depts involved

47. Example Block 1.2. – Week 1

48. Example Student Guide Block 1.2. • List of Block Team and Contact Address • List of Experts and Contact Address • Overview of Block 1.2. • Enabling Outcome • Time Table • Scenarios • Other learning activities • Learning resources

49. Proposal for GMU SMBlueprint Assessment Five streams Assessment

50. Proposal for GMU SM • Knowledge • End of block written test • Practice session • Skills • Skills lab • Practice session • Weighting is done within • each stream NOT across • streams • Final mark reported consists • of 5 streams • Professional Behavior • Tutorial • Other relevant activities