ICU Workplace-Based Assessment Form - FAMILY MEETING Initiated # ICU months: Name of Trainee: (Months of ICU rotation completed since beginning of ☐ assessment: CCM program) Initiated Name of Faculty: MM / DD / YY Date: ☐ assessment: ☐ ☐ ☐ ☐ Setting: ICU E.R. Ward Post-Op Unit ☐ ☐ ☐ EPA: Status Update End of life discussion Consent/Error Disclosure Complexity: ☐ ☐ ☐ Low Moderate High (e.g. language barrier, cultural Routine clinical problem, Some elements of complexity in Complex and atypical clinical challenges, complex family communication, and social clinical problem, communication, problem, communication, and/or dynamics, overt conflicts, etc.) circumstances. and/or social circumstances. social circumstances. Brief case description: CHOOSE 2 AREAS OF FEEDBACK. For each, provide: 1) narrative comments on trainee's strengths, areas for development, and improvement strategies, and 2) choose a level of autonomy on the entrustment scale. NEEDS NEEDS NEEDS AUTONOMOUS EXPERT INTERVENTIONS DIRECTIONS MINIMAL GUIDANCE Able to do without guidance; Able to do in complex Unable to do without Partially able to do with Mostly able to do with refinement possible with situations; personal others’ actions. others’ directions. minimal guidance. feedback. insight on performance. Areas of feedback Feedback Narrative Comments ☐ Building a Relationship Ability to communicate patient-centred approach that encourages trust and mutual respect. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Opening the Discussion Ability to provide clear and understandable information to patient/family and to encourage questions. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Gathering Information Ability to elicit and synthesize accurate and relevant information. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Understanding Patient/ Family's Perspectives/ Empathy Ability to show compassion, to engage, to listen, and to adapt INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT to each patient/family. ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Sharing Information
ICU Workplace-Based Assessment Form - FAMILY MEETING Name of Trainee: Initiated assessment: ☐ # ICU months: (Months of ICU rotation completed since beginning of CCM program) Name of Faculty: Initiated assessment: ☐ Date: MM / DD / YY Setting: ☐ ICU ☐ E.R. ☐ Ward ☐ Post-Op Unit EPA: ☐ Status Update ☐ End of life discussion ☐ Consent/Error Disclosure Complexity: (e.g. language barrier, cultural challenges, complex family dynamics, overt conflicts, etc.) ☐ Low Routine clinical problem, communication, and social circumstances. ☐ Moderate Some elements of complexity in clinical problem, communication, and/or social circumstances. ☐ High Complex and atypical clinical problem, communication, and/or social circumstances. Brief case description: CHOOSE 2 AREAS OF FEEDBACK. For each, provide: 1) narrative comments on trainee's strengths, areas for development, and improvement strategies, and 2) choose a level of autonomy on the entrustment scale. NEEDS INTERVENTIONS Unable to do without others’ actions. NEEDS DIRECTIONS Partially able to do with others’ directions. NEEDS MINIMAL GUIDANCE Mostly able to do with minimal guidance. AUTONOMOUS Able to do without guidance; refinement possible with feedback. EXPERT Able to do in complex situations; personal insight on performance. Areas of feedback Feedback ☐ Building a Relationship Ability to communicate patient-centred approach that encourages trust and mutual respect. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Opening the Discussion Ability to provide clear and understandable information to patient/family and to encourage questions. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Gathering Information Ability to elicit and synthesize accurate and relevant information. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Understanding Patient/ Family's Perspectives/ Empathy Ability to show compassion, to engage, to listen, and to adapt to each patient/family. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Sharing Information Narrative Comments