Faculty Evaluation of Fellow: Checklist—Systems-Based Practice
Instructions for Use
This checklist assesses Systems-Based Practice—the fellow’s awareness of and responsiveness to the larger context and system of health care
and the ability to effectively call on system resources to provide care that is of optimal value. It can be used for global assessment on an
intermittent basis; for example, once after 3 months and again at least 3 months prior to the end of the fellowship.
The checklist may also be used for an end-of-year summative evaluation. The form is completed by faculty and may also be used as a selfassessment checklist by the fellow. It is adaptable to inpatient and outpatient settings and should be accompanied by more detailed in-person
feedback where appropriate.
Instructions for Entering Data
By Hand
Print the assessment tool and fill it out.
On the Computer
 Text—type the text (eg, fellow’s name) in the shaded area, then press the Tab key to move to the next field.
 Checkbox—click in the box or press the spacebar to select it.
 Saving—Select File, Save As, and save with a new name.
 Editing—If you want to make changes to the assessment tool, you must first unlock it so that it is no longer a form. To display the
Forms toolbar in Word 2003, from the menu select View, Toolbars, Forms. Click the Protect Form icon to unlock it. Be sure to lock the
form again after you have made the edits.
Revised 7/8/2009. Eva Chittenden, MD, and Robert Arnold, MD, on behalf of the HPM Competencies Phase 3 Workgroup (Susan Block, MD; Laura Morrison, MD; Robert Arnold,
MD; J. Andrew Billings, MD; Elise Carey, MD; Eva Chittenden, MD; VJ Periyakoil, MD; Sandra Sanchez-Reilly, MD; Rodney Tucker, MD) with funding from the Arthur Vining Davis
Foundation and the Milbank Foundation for Rehabilitation.
Faculty Evaluation of Fellow: Checklist – Systems-Based Practice
Competency Domain: Systems-Based Practice
Purpose: To assess the fellow’s awareness of and responsiveness to the larger context and system of health care and the ability to effectively
call on system resources to provide care that is of optimal value.
Instructions: Rate each skill from 1 to 9. Check NA if no information is available.
Fellow:
Evaluator:
Signature:
Rotation Name:
Rotation Dates:
Evaluation Date:
Category
Cost-Effective and
Best Practices
Heathcare System
Ensuring Seamless
Transitions
Skill
NA
Unsatisfactory
1
2
3
Satisfactory
4
5
6
Superior
7
8
Describes basic methods of physician billing, current procedural
terminology coding, and reimbursement across settings in palliative care.
Uses awareness of medication cost as a factor in prescribing.
Reviews pertinent clinical or patient/family satisfaction data about
personal, team, or institutional practice patterns.
Describes key types of insurance (eg, managed care versus fee-for
service, Medicare, Medicaid) available for patients with advanced illness.
Describes philosophy, admissions criteria, range of services, and structure
of hospice care.
Distinguishes between services provided at major loci of care: hospital,
long-term acute care, rehab, skilled nursing facility, office, conventional
home care, palliative care units, and home hospice.
In concert with interdisciplinary team, communicates with appropriate
healthcare professionals across sites of care to enable seamless
transitions.
Assists and advocates for patients and families in dealing with systems
complexities, including settings of care, service options, and
reimbursement processes.
Revised 7/8/2009. Eva Chittenden, MD, and Robert Arnold, MD, on behalf of the HPM Competencies Phase 3 Workgroup (Susan Block, MD; Laura Morrison, MD; Robert Arnold, MD; J.
Andrew Billings, MD; Elise Carey, MD; Eva Chittenden, MD; VJ Periyakoil, MD; Sandra Sanchez-Reilly, MD; Rodney Tucker, MD) with funding from the Arthur Vining Davis Foundation and the
Milbank Foundation for Rehabilitation.
9