ACGME Competencies Robert Wigton MD Associate Dean Graduate

ACGME Competencies Robert Wigton, MD Associate Dean Graduate Medical Education

Outline 1. Background: the ACGME requirements 2. What are the 6 Competencies and where did they come from? 3. How do we teach them? 4. How do we evaluate them? 5. Where do we go from here? 6. How can this help your own professional development?

ACGME (Accreditation Council for Graduate Medical Education) Predecessor = AMA Council on Medical Education Member Organizations • American Board of Medical Specialties (ABMS) • American Hospital Association (AHA) • American Medical Association (AMA) • Association of American Medical Colleges (AAMC) • Council of Medical Specialty Societies (CMSS) Residency Review Committees (RRCs) David Leach, MD Executive Director

Recent Changes at the ACGME: • Relationship of the ACGME to the Residency Review Committees (RRCs) • Common Program Requirements • Work hours regulations • The Outcomes Project – 6 Resident Competencies

“General Competencies” 1. Patient Care 2. Medical Knowledge 3. Practice-Based Learning and Improvement 4. Interpersonal and Communication Skills 5. Professionalism 6. Systems-Based Practice

Where Did the 6 Competencies Come From?

Background: Issues in Medical Practice • Government funding and regulation of health care with their complex regulations and procedures – Medicare – DRGs and billing systems: require more sophisticated charting and billing – Medicare payments to hospitals for residents (IME, DME) • HMOs and the managed care movement: – – • Systems of care affect productivity and workload New emphasis on population medicine Patient centered care Concerns about HMOs’ negative effects on professionalism Quality of care – TQI: Deming, Don Berwick and IHI, – NASA, Lucian Leape – “To Err is Human”: IOM and medical error • Resident working conditions – Libby Zion and the Bell Commission

Background: Managed Care • Systems of care • Emphasis on population medicine • Patient centered care • Concerns about professionalism

Background: Medical Errors – NASA, Lucian Leape – “To Err is Human”: IOM and medical error

Background: Quality of Care – TQI: Deming, – Don Berwick – Institute for Healthcare Improvement (IHI)

The “Meta-Curriculum” Meta- = beside, about, beyond Each is well established with national organizations, annual meetings, and body of literature and many have dedicated journals • TQI, Continuous Improvement • Medical Systems • Medical Decision Making (MDM), Cost Effectiveness • Evidence-Based Medicine (EBM) • Medical Informatics • Epidemiology, Medical Statistics • Population Medicine • Prevention • Medical Interviewing • Procedural Skills • Teaching Residents to Teach • Diversity

Minimum Requirements (Inserted in All Special Requirements) • The residency program must require its residents to obtain competencies in the 6 areas to the level expected of a new practitioner. Programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed • The residency program must demonstrate that it has an effective plan for assessing resident performance throughout the program and for utilizing assessment results to improve resident performance.

General Competencies: 1. Patient Care 2. Medical Knowledge 3. Practice-Based Learning and Improvement 4. Interpersonal and Communication Skills 5. Professionalism 6. Systems-Based Practice

6 Competencies Mostly, these are bins or groupings of related topics, not dimensions of behavior. (Except for interpersonal skills) • Bins – Earth science, 18 th century Europe, cosmology, how to fix different brands of refrigerators • Dimensions – Knowledge, friendliness, neatness, hand-eye coordination, common sense, aggressiveness

Patient Care The secret of the care of the patient is caring for the patient. . . Francis Wold Peabody 1927 Peabody FW. The care of the patient. JAMA. 1927; 88: 877 -82

1. Patient Care Residents must provide patient care that is compassionate, appropriate, and effective - • Caring and respectful behaviors when interacting with patients and their families • Interviewing (Medical Interviewing) • Informed decision making (MDM) • Develop and carry out patient management plans • Counsel and educate patients and their families • Use information technology (Informatics) • Perform competently all procedures (Procedural Skills) • Preventive health care services (Prevention) • Work in a team

2. Medical Knowledge in field, including • Investigatory and analytic thinking (MDM) • Knowledge and application of the basic and clinical sciences.

3. Practice-Based Learning and Improvement • • Analyze own practice for needed improvements (TQI, QI) Use evidence from scientific studies (EBM) Apply research and statistical methods (Statistics) Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness (Epidemiology, Cost Effectiveness) • Use information technology (Informatics) • Facilitate the learning of others (Teaching Residents to Teach)

4. Interpersonal and Communication Skills • Create therapeutic relationship with patients • Develop listening skills • Work effectively as part of a health care team.

5. Professionalism • Respectful, altruistic • Ethically sound practices • Sensitive to culture, age, disability (Diversity)

6. Systems-Based Practice • Understand interaction of their practice with larger system • Know about practice and delivery systems • Practice cost-effective health care • Advocate for patients within the health care system. • Partner with health care managers and health care providers to assess, coordinate, and improve health care

Medical Outcomes Project 10 year timeline, RWJ development grant • • • Teach the six competencies Evaluate residents’ competencies Demonstrate continuous improvement

Teaching Competencies: COM Online Courses for Residents 330. House Officer Teaching Skills 331. Medical-Legal Issues 332. Quality of Care, EBM & Stats 333. Professionalism 333 a. Strategies for Physician-Patient Communication 334. Healthcare Economics (Systems) 334 a. Personal Finance 334 b. Billing & Documentation 335. Medical Ethics

Teaching Competencies: Orientation Topics • • • Malpractice Medical Informatics Fatigue and Working Conditions (SAFER) Quality Improvement Impaired Physicians Licensure Hospital Systems Error and Safety Patient Relations

Evaluation of Competencies

Evaluation Toolbox • • • Record review Chart stimulated recall Checklist forms Global ratings Standardized patients OSCEs 360˚ Assessment Portfolios Exams Case logs

On the ACGME Website: www. ACGME. org. Go to Outcome Project

360 Degree Evaluation • Surveys of people who work with the resident – – – Nurses Other residents Students Other health professionals Staff • Given as feedback to resident to help improve (few studies of effectiveness and reliability in resident education)

Chart-Stimulated Recall • Oral exam of resident using recent patient records • Examiner probes reasoning, actions, differentials etc. • Exam procedure and scoring rules standardized (Well studied, psychometrics good)

Objective Structured Clinical Examination (OSCE) • Encounter stations lasting 10 -15 minutes • Each station designed to observe and asses specific task • Widely used (Many studies of effectiveness and generalizability)

Portfolios • Collection of “products” of education • Prepared by the resident • May include – – – Personal and professional goals Learning objectives Logs of procedures, cases Case summaries Documented achievements Etc. (Most studies are descriptive)

Tailoring Evaluation to the Competency

Strategies for Creating Evaluations • Import successful techniques, forms, protocols from other programs • Pool expertise with other program directors • Enlist other faculty in your department • Outcome research projects • Visiting experts • Grants • RIME journal club • Don’t reinvent the wheel if you don’t need to.

Issues for Designing Evaluation • Evaluation should be useful and result in measurable improvement • Evaluation emphasis should be proportional to importance of topic. (Evaluation can drive the curriculum)

Professional Development Strategies for Faculty • Faculty Educational Portfolio – Evaluation design – Project leadership – Creating online resources • Papers – Academic Med, Med. Educ. , T&L in Med. , others – General Medical Journals, JAMA etc – Journals in your specialty • Presentations – AAMC: RIME, GEA, Central GEA, GRA, ACGME – International medical education meetings: AMEE etc – Specialty meetings

References • Lists of references at the ACGME web site: ACGME. org for each of the competencies. Also -- • Berwick DM. Escape Fire : Designs for the Future of Health Care • Corrigan J, Kohn L, Donaldson, M. (eds) To Err Is Human: Building a Safer Health System. • Institute of Medicine (eds) Crossing the Quality Chasm: A New Health System for the 21 st Century • Closing the Quality Gap. AHRQ publications at http: //www. ahrq. gov/downloads/pub/evidence/pdf/qualga p 1/contents. pdf