Measurements and MilestonesBy: Pamela Lipsett
Date: November 28, 2012
The Accreditation Council for Graduate Medical Education (ACGME) has entered Phase I of the Next Accreditation System. This building block of this new system will involve fundamental differences in how the ACGME reviews and oversees residents, residency programs and institutions. The Clinical Learning Environment Review (CLER) program whereby the sponsoring institution and its participating sites assume the responsibility for the quality and safety of the environment of learning and patient care will be a cornerstone of this program.
CLER focuses on seven areas important to the safety and quality of care in teaching hospitals and the care residents will provide in a lifetime of practice after they complete training: engagement of residents in patient safety; engagement of residents in quality improvement; enhancing practice for care transitions; identifying opportunities for reducing health disparities; promoting appropriate resident supervision; duty-hour oversight and fatigue management; and enhancing professionalism in the learning environment and in reporting to the ACGME.
Semiannually each program will report to the ACGME individual resident data focused on newly defined educational milestones, which will be aggregated to make judgments about the quality of training at the residency program. Although General Surgery is not part of Phase I implementation, we will be part of the implementation beginning in July 2014.
What are the educational milestones and why have they been developed? The milestones are observable developmental steps moving from beginning resident to the expected level of proficiency at graduation from residency, ultimately, the level of expert/master. The theoretical benefits of the milestones are that they articulate shared understanding of expectations, set aspirational goals of excellence, provide a framework and language for discussions across the continuum and ultimately track what is most important—the educational outcomes of the residency program.
The Surgery RRC and ABS have already beta-tested the milestones on which our residents will be evaluated. They consist of 16 areas within the six competencies already defined: medical knowledge, patient care, interpersonal skills and communication, professionalism, problem-based learning and improvement, and systems-based practice. They have further identified practice domains under which these competencies fall, critical deficiencies and four levels of development. Competency committees will be expected to use existing evaluations, case logs, testing and other documentation to make decisions on residents twice each year.
In early testing, the committee required approximately one hour of discussion to assess each resident’s milestones. The results of these discussions would then be transmitted to the RRC, and of course to the resident semiannually. It is expected that program directors and faculty would then use these assessments to help develop further expertise in residents and to improve program performance. Ultimately the beneficiary of these added measurements should be the patient and health care system. Hopefully, one day we will learn exactly how we can link the performance of an individual resident with the ultimate outcome of a patient. Exactly how we will separate this from faculty and team performance will in itself be a measurement milestone.
Director, Halsted General Surgery Training Program