Accreditation Council for Graduate Medical Education Family Medicine Milestones & the Next Accreditation System April 2013
Overview • Next Accreditation System • Clinical Learning Environment Review • Family Medicine Milestones
Why ‘ Next Accreditation System ’ (NAS)? “Self-regulation is a fundamental professional responsibility, and the system for educating physicians answers to the public for the graduates it produces.” “The Next GME Accreditation System – Rationale and Benefits” Nasca T.J., Philibert I., Brigham T., Flynn T.C. N Engl J Med 2012; 366:1051-1056
Why ‘ Next Accreditation System ’ (NAS)? • The ACGME's public stakeholders have heightened expectations of physicians. • Patients, Payers, and the public demand -access to proper care and a good physician -information-technology literacy, -sensitivity to cost-effectiveness, -the ability to involve patients in their own care, and -the use of health information technology to improve care for individuals and populations.
Why ‘ Next Accreditation System ’ (NAS)? • Evaluate programs based on reporting of outcomes through educational milestones which is the next step for the ACGME competencies. - Patient care - Medical Knowledge - Professionalism - Systems-based practice - Practice-based learning and improvement - Interpersonal and communication skills • Foster innovation and improvement by programs.
Goals of NAS • Strengthen resident development in Professionalism, Interpersonal & Communication Skills, Systems Based Practice, & Practice Based Learning • Enhance public accountability • More explicit definition of a good physician (Milestones) • Patient safety is paramount (Clinical Learning Environment Review Program) • Improve efficiency and reduce burden required for accreditation
NAS Overview • Continuous oversight rather than episodic sampling • Milestone reports (semi-annual), Resident & Faculty questionnaires (annually), Case Logs (annually), Program & Institutional Infrastructure (annually) monitored by ACGME Review Committees • Program Site Visits at ~10 year intervals • Emphasis on program effectiveness as evidenced by resident advancement through the milestones
‘ Next Accreditation System ’ in a Nutshell • NAS allows accreditation process to advance from an episodic “ biopsy ” model to annual data collection. RRCs will measure compliance through the evaluation of annual program data elements.
Annual Program Data (Elements to Include) • RC receives data ‘ continuously ’ • RC tracks data on each program/residents • Milestone Performance • Resident Survey Results • Faculty Survey Results • Case Logs and other parameters of clinical experience • Scholarly Activity • Key Quality/Patient Safety Data • Board Certification Examination Results • Institutional/Fiscal/Faculty/Leadership, etc..
ACGME Strategy • De-emphasize the current focus on the PIF and prescriptive program requirements • Emphasize evaluation of program ’ s actual operations and implementation processes • Enhance selected elements of visit - Review of citations - Resident complaints - Resident survey (non-compliance) - Duty hour and learning environment standards - Changes since last visit - Annual program evaluation
NAS Timeline • June 2011 ACGME Board Approved NAS • July 2012 Clinical Learning Environment Review (CLER) Visits Initiated • December 2012 Draft Residency Milestones Completed • July 2013 NAS begins in 7 Specialties • 2013-14 NAS Policies & Procedures Finalized • 2014 NAS Implemented in all Specialties • 2015 Subspecialty Milestones Completed
Clinical Learning Environment Review • Institutional CLER visits ~ every 18 months for each participating institution • Entire first cycle of visits are beta testing and will not change accreditation • Initial visits will be used for feedback, learning and to establish baseline information • Site visits will be done by full-time staff and volunteer peers • Six key areas that will be focused on during the site visits 12
Clinical Learning Environment Review Visits • Integration of residents into institution’s Patient Safety programs and demonstration of impact • Integration of residents into institution’s Quality Improvement programs and efforts to reduce Disparity in Health Care Delivery and demonstration of impact • Establishment, implementation and oversight of Supervision policies Additional information available at: http://www.acgme-nas.org/CLER
Clinical Learning Environment Review Visits • Oversight of Transitions of Care • Oversight of Duty Hours Policy , Fatigue Management and Mitigation • Education and Monitoring of Professionalism Additional information available at: http://www.acgme-nas.org/CLER
FM Milestones • 14-member Committee • Committee Meetings -March, July, October 2012 -Conference calls between meetings • Comment Period -Late 2012/Early 2013 -Presentation at RPS/PDW • Final Document – Summer 2013 • Implementation – Summer 2014
FM Milestones • Milestones are specific benchmarks of skills, knowledge, and behaviors that each resident is expected to achieve at identified stages of residency training. • Milestones developed for each of the six ACGME competencies. • Stages for the FM Milestones: Has not achieved level 1, level 1, level 2, level 3, level 4 and level 5.
FM Milestones • Observable developmental steps describing a trajectory of progress from level 1 to level 5 • Provide a “roadmap” for learning • “Intuitively” known by experienced family medicine educators
FM Milestones • Designed to allow tracking of discrete and measurable educational “outcomes” • Build upon existing evaluation tools and observations of the faculty • Additional evaluation tools and techniques may be developed, as needed • Progress of each resident to be assessed by local program’s Clinical Competency Committee (CCC)
FM Milestones • FM Milestones draft document will be on the ACGME website in February 2013 • Feedback on the milestones encouraged • Revised document presented at RPS/PDW for comment • Final document – Summer 2013 • Living document that will be updated
FM Milestones • Each residency will have a clinical competency committee (CCC) • CCC should include faculty only • CCC should have at least 3 faculty members • CCC should include faculty who are active in evaluation of the residents
FM Milestones • CCC will review each resident’s progress in each competency and enter assessments on the milestones reporting form for each resident twice a year • The program will provide feedback to each resident regarding their progress in each milestone
FM Milestones • Residents do not need to achieve level 4 in every milestone to graduate but should substantially demonstrate the milestones targeted for this level as it is designed as the graduation target • Residents do not need to achieve competency at level 2 in each milestone to advance to their second year of training but should achieve that level in the majority of milestones
FM Milestones • Residents are not expected to achieve competency at level 5 during residency • Residents may achieve a level of competency in specific milestones sooner than expected
FM Milestones • Resident data will be de-identified on the semi-annual milestone form • ACGME will compile data at program level and specialty level • Milestone data will not affect accreditation cycle at this time
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FM Milestones Feedback • Common themes from general feedback: • Too long - too short • Too vague - too specific • Hard stops or pass/fail that must be met • Assessment tools • Administrative burden
FM Milestones Alpha Testing • 12 programs • Recommended: • 2 residents from each year – total 6 residents • Variety of residents – top of class, bottom of class, middle of class • Clinical Competency Committees • Survey completed about the process
FM Milestones Alpha Testing • CCC averaged 6 – 7 members • Reviewed on average 6 residents • Averaged time was 60 minutes/resident with range of 36 – 84 minutes • 8/12 programs plan to modify their curriculum because of the experience • 10/12 programs plan to modify or add new evaluation tools/methods
FM Milestones • Revised milestones online: http://www.acgme-nas.org/assets/pdf/ Milestones/FamilyMedicineMilestones.pdf • Programs to beta test the FM Milestones • If interested, please send an email to: FMMilestones@acgme.org with name of programs, name of program director and contact information
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