Association of Hospital Medical Educators AHME Shaping the Future: Milestones, Portfolios, and the N

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Association of Hospital Medical Educators
(AHME)Shaping the Future Milestones,
Portfolios, and the Next Accreditation System

• Thomas J. Nasca, MD, MACP
• Chief Executive Officer

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Disclosure

• I have received no external support from any
  for-profit entity, pharmaceutical or device
  company
• The ACGME receives no funds from any corporate
  entity other than accreditation fees related to
  ACGME accreditation services
• The ACGME receives, from time to time, grants
  from non-profit foundations (for example, RWJ)
• The ACGME Annual Educational Meeting and all
  other educational ACGME sponsored meetings
  receive no support other than attendee fees
• The ACGME sponsored Journal of Medical Education
  will not accept commercial advertising

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Topics (If we have enough time!)

• Competencies/Outcomes/Portfolios and the Next
  Accreditation System
• Resident Duty Hour and Learning Environment
  Standards
• (The Pipeline)

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Our Work Produces a Social Good

• The output of this phase of the continuum of
  medical education serves the public through
• patient care
• basic and clinical research
• education of future physicians and other health
  professionals,
• provision of community service
• Based on the conviction that
• Patient Care is improved through better
  education of the next generation of physicians
• The Social Good must remain foremost in our
  sights as we face challenges and obstacles

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ACGMEs Values

• Honesty and Integrity
• Excellence and Innovation
• Accountability and Transparency
• Fairness and Equity
• Stewardship and Service
• Engagement of Stakeholders

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The two sides of the accreditation challenge
Car 54
Foster Innovation and Improvement in the Learning
Environment
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Getting the Balance Correct Between Trailing
Edge Accreditation and Leading Edge Innovation
Minimal Standards Accreditation
Active Fostering of Change/Innovation Through
Standards
Trailing Edge Phenomena
Leading Edge Phenomena
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ACGME 2009-2011

• Laying the groundwork for the
• next accreditation system
• To accomplish that goal,
• We need your help

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• Lets Frame the Discussion about
• Competencies, Outcomes, Portfolio,
• as essential tools in the
• Next Accreditation System

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The Continuum of Professional DevelopmentAuthorit
y and Decision Making versus Supervision
Graded or Progressive Responsibility
High
Supervision
Low
Authority and Decision Making
Low
High
Increase the Accreditation Emphasis on
Educational Outcomes
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The Continuum of Professional DevelopmentThe
Three Roles of the Physician1
Clinician
High
Teacher
Manager of Resources
Development
Low
Physical Diagnosis
Clerkship
Internship
Residency
Fellowship
Sub-Internship
Attending
1 As conceptualized and described by Gonnella,
J.S., Modified by Nasca, T.J.
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The Six (Seven) Competencies, and the Continuum
of Medical Education - Dreyfus Conceptual Model1

• Novice
• Advanced Beginner
• Competent
• Proficient
• Expert
• Master

• Medical Knowledge
• Patient Care
• Procedural and Technical Skills
• Interpersonal and Communication Skills
• Professionalism
• Practice Based Learning and Improvement
• Systems Based Practice

1 as presented by Leach, D., modified by Nasca,
T.J. American Board of Internal Medicine Summer
Retreat, August, 1999
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The Goal of the Continuum of Professional
Development
Master Expert Proficient Competent Advance
d Beginner Novice
Competencies
Undergraduate Graduate Medical
Clinical Medical Education
Education Practice
Increase the Accreditation Emphasis on
Educational Outcomes
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The Goal of the Continuum of Professional
Development in a 3 Year non-Surgical Specialty
Program
Master Expert Proficient Competent Advance
d Beginner Novice
PGY 1 PGY 2 PGY 3
MOC
Increase the Accreditation Emphasis on
Educational Outcomes
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The Goal of the Continuum of Professional
Development in a 5 Year Surgical Specialty Program
Master Expert Proficient Competent Advance
d Beginner Novice
PGY 1 PGY 2 PGY 3 PGY 4 PGY 5
MOC
Increase the Accreditation Emphasis on
Educational Outcomes
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Where are we in Operationalizing Outcomes?
Increase the Accreditation Emphasis on
Educational Outcomes
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Making Outcomes Based Accrediation a Reality
The Pieces of the Puzzle
Portfolio Essential Elements
Outcomes Based Evaluation Tool
Vetting and Development
Increase the Accreditation Emphasis on
Educational Outcomes
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Measurement of Outcomes in Accreditation
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Theoretical Competency Report Card Summary,
Program X, All Residents, All Levels
Professionalism
Systems Based Practice
Patient Care
Practice Based Learning And Improvement
Medical Knowledge
Communications
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Theoretical Competency Report Card Summary,
Program X, All Residents, All Levels
Professionalism
Systems Based Practice
Patient Care
Practice Based Learning And Improvement
Medical Knowledge
Communications
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Theoretical Competency Report Card Summary,
Program X, All Residents, All Levels
Professionalism
Systems Based Practice
Patient Care
Practice Based Learning And Improvement
Medical Knowledge
Communications
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(No Transcript)
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What Currently Drives the Curricula of our
Residency Programs?
Choose Educational Experiences within
Institution, Faculty
Curriculum Time Based
Educate Residents
Identify/Develop Evaluation Tools - Formative
and Summative - Experience Tracking
Circumstantial Practice
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What Will Drive the Curricula of our Residency
Programs in the Near Future?
Design Educational Experiences Rotations, Faculty
The Required Outcomes in Each Domain Of
Clinical Competency
Produce Proficient Physicians
Identify/Develop Evaluation Tools to Measure
Outcomes - Formative and Summative - Clinical
Outcomes Tracking (not just counting)
Intentional Practice
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Current versus The Next Accreditation System
Program Req. Revision
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Duty Hours and the Learning Environment

• Thomas J. Nasca, MD, MACP
• Chief Executive Officer

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History (in the USA)

• 1980s New York State enacts Bell Commission
  recommendations
• 1990s Anesthesiology, Emergency Medicine,
  Internal Medicine enact duty hour standards
• Late 1990s Learning Environment issues addressed
  in institutional requirements
• Heightening of union interest in unionization of
  residents

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History

• 2003 ACGME enacts Common Program Requirements for
  Resident Duty Hours
• Precipitated by threat of Federal intervention
• Met by some with Resistance, Anger, and
  Consternation
• Embraced in some programs/institutions, resisted
  in others
• Heterogeneous RRC approaches to enforcement
• Confusion/Ambivalence/Resistance to use of
  Resident Survey Data in case identification

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History 2003-2008

• Creation of a Hostile learning environment for
  medical education
• PATH Audits, Billing Regulations and Compliance
  Audits in teaching environment
• Medical Liability Crisis
• Increasing pressure on faculty clinical
  productivity
• Transfer of work from residents to others,
  including faculty
• Increasing sub-specialization pressures
  generalists disciplines
• Gains in support personnel eroding as margins
  pressured in many teaching hospitals more
  pressure on faculty
• Duty hour management transition from absolute
  maximums to scheduled to the limit

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Absolute Maximum versus Scheduled to the Limit
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History, 2003-2008, continued

• Emergence of
• the Patient Safety Movement
• evolving knowledge in sleep medicine related to
  fatigue and decision making
• receptivity to linkage of these two issues
• Increasing efforts to tie resident fatigue to
  patient safety in teaching hospitals
• ACGME makes slow progress towards uniform
  approach to enforcement at program level

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History, 2008 - Present

• 2008 ACGME Monitoring Committee Actions
• Institutional culpability for duty hour
  violations
• Mandates actions for repeat or chronic
  deficiencies
• 12/2008 Institute of Medicine Report released
• 2009 ACGME actions, thus far
• Administration analysis
• International Symposium
• On line study of Resident, Faculty, PD and DIO
  opinions
• Board of Directors Evaluation and Actions

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• Faced with the choice between
• changing one's mind and
• proving that there is no need to do so,

almost everybody gets busy on the proof.

• John Kenneth GalbraithAmerican Economist

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• One of the best lessons children learn through
  video games is
• that standing still will get them killed
• quicker than anything else.

• Jinx Milea and Pauline Little
• Why Jenny Cant Lead, 1986

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ACGMEs Duty in this setting

• Keep promise to profession to review resident
  duty hour standards at 5 years, and learn from
  our experience
• Use opportunity to set more appropriate standards
• Convene the Profession
• Incorporate IOM Report as one input into that
  process
• Maintain professional oversight of this and other
  aspects of the educational environment
• Minimize additional financial burden on
  institutions, programs, society
• Develop a consensus among the educational
  community in support of the next iteration of
  resident duty hour standards
• Publish scholarly justification for all actions
  taken

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Remember the Goal

• Enhancement in the quality of patient care (today
  and tomorrow1) through improvement in graduate
  medical education
• Development of the next generation of Virtuous
  Physicians2, who place the needs of their
  patients above their own

1 ACGME Mission Statement, parenthetical added by
Nasca 2 As described by Pellegrino and Thomasma
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Conceptualize the Challenge Differently
Not Rights and Wrongs, but Competing Goods

• Patient Safety in the teaching environment
• Patient Safety in the future practice of our
  trainees
• Impact of Fatigue on individuals
• Protective effect of teams and redundant systems
• Benefit of outstanding preparation by doing for
  independent practice
• Resident education during training
• Instillation of altruistic behaviors and
  effacement of self- interest for the benefit of
  others
• Attendance to resident personal needs and desires
• Cost of providing current level of care
• Benefit of additional caregivers in the clinical
  care environment

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While we must always strive to make it better,
remember

• the bulk of studies reviewed unquestionably
  show that quality of care is better in teaching
  hospitals.
• Process of care, the most sensitive and precise
  measure of quality, was better in teaching
  hospitals in all but one study, where the
  hospitals being compared were similar.

Quality of Care in Teaching Hospitals A
Literature Review Joel Kupersmith, MD Acad Med.
2005 80458466.
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• When you come to a fork in the road,
• take it!
• Yogi Berra

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I. Review/Revision of Resident Duty Hour
StandardsData Gathering Phase

• Web Based Survey of DIOs. Program Directors,
  Faculty, and Residents (Jan-April, 2009)
• Request for Organizational Positions (Feb-April
  2009)
• International Symposium March 4-5, 2009
• Annual ACGME Educational Meeting March 6-8, 2009
• Formal Review of the Literature (External- RFP
  released)
• Ethical Dimensions of Decisions to be made
  concerning Resident Duty Hour and the Learning
  Environment Standards
• National Congress on Duty Hour and the Learning
  Environment (June, 2009)

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II. Standards Evaluation and Modification Phase

• Task Force
• Council of Review Committees (RC Chairs) Chair
  Co-Chair Task Force
• 8 Members of the RC Chairs group
• Chair Co-Chair Task Force, Vice Chair, Public
  Member, AMA Resident Member from Board of
  Directors
• Two Resident Members from Council of Review
  Committee Residents
• CEO of ACGME Vice Chair Task Force
• Review accumulated information
• Draft Common Requirements and charge RRCs to
  modify Specialty Requirement as needed/desired
• Work with administration to develop rigorous
  published justification for standards
• Public Comment (Spring or Summer, 2010)
• Approval by CRC, Committee on Requirements,
  then Board of Directors

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Initial Time Course for Resident Duty Hour
Standards Review
Implementation ACGME
Action CRCC Action Public
Comment Preliminary Task Force Draft Task
Force Formation and Congress Resident Duty Hour
Data Gathering Phase
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III. Enforcement of Resident Duty Hour Standards

• Two tiered assessment of compliance
• Programmatic compliance
• As currently judged by each Review Committee,
  overseen by the Monitoring Committee
• Institutional environment, oversight, resources
• Yearly Site Visits, Unannounced Site Visits
• CEO of Sponsor and Participating Site Signatory
• Grading of Compliance (not binary)
• Publication of Results on ACGME website

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Factors considered in approach taken

• Logistics of annual site visit and review of
  8,700 programs daunting
• 9,200 site visits (1/year Unannounced
  Repeat)
• At approximately cost of 3000/site visit plus
  review costs of 300/visit, cost approaches 30
  million/year
• Current ACGME Budget 32 million
• Would require 94 increase in ACGME Accreditation
  Fees
• RRCs can not handle the volume
• IM RRC currently reviews 550-650 programs/year
• Would need to review nearly 2000 programs plus
  baseline reviews per year

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Enforcement Realities

• Costs for 720 Site Visits
• 670 Sponsor Site Visits and Reviews
• 50 Unannounced and Repeat Site Visits
• 2.4 million, or approximately 3600/Sponsor/year
• Requires 7.5 increase in accreditation fees
• Cultural change in isolated programs best
  accomplished through local peer pressure, rather
  than individual RRC action.
• Failure to enforce invites Federal action
• I-PRO for the nation
• Congress setting duty hour standards

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Accreditation by Review Committees and Compliance
by Institutional Oversight Committee

• Public Accountability
• CMS
• Department of Education
• Other?

Board of Directors
Institutional Compliance Oversight Function
Monitoring Committee
Accreditation Function
Monitoring Function to be determined
Firewall between Duty Hour Compliance Oversight
and Standard Setting/Accreditation Functions
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Evolution and Separation of Educational Program
Accreditation vs Duty Hours Adherence
Leading Edge
Regulatory Adherence
Trailing Edge
Trailing Edge
Substantial Compliance
Regulatory Adherence
Educational Accreditation Sweet Spot
Duty Hours Enforcement Sweet Spot
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The two sides of the accreditation challenge
Car 54
Foster Innovation and Improvement in the Learning
Environment
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• Strangely, this is the past
• that someone in the future

is longing to go back to.

• Ashliegh Brilliant

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• Somebody has to do something,

and its just incredibly pathetic that it has to
be us.

• Jerry Garcia
• The Grateful Dead

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Comments, Questions?