>>REGNIER: I’m Kate Regnier, I’m the Deputy Chief Executive at the Accreditation Council for Continuing Medical Education.
>>BRIGHAM: Hi, I’m Tim Brigham, the Senior Vice President for Education and Chief of Staff at the Accreditation Council for Graduate Medical Education.
>>REGNIER: Thank you Tim for joining me for a discussion. One of the things that’s so interesting is the perspective that you bring from your experiences that cross the continuum. So, can you talk a little bit about the CME experience that you had moving now into GME.
>>BRIGHAM: I became the Assistant Dean for CME and GME
>>BRIGHAM: At Jefferson Medical College. And was involved from the very beginning in a pilot project with the ACCME; where we developed a consortium with four schools, Temple Medical School, University Pittsburg School of Medicine, and Hershey Penn State School of Medicine, to try to move the accreditation needle in CME beyond where it was at that time. The field of CME and the discipline of CME has always been important to me. That continuum, I had a unique place at Jefferson, because I cross the continuum from undergraduate to graduate to practicing physicians. And the continuum and its’ connections has always been really important to me. And now, we have a chance to do something about it, I think. The two of us separated by six floors.
>>REGNIER: Correct. We have the opportunity, both in terms of the continuum, but also, just our location.
>>REGNIER: We, we have been able to meet and talk fairly regularly about things that ACGME is working on, things that ACCME is working on.
>>REGNIER: where there could be overlap. I think, would you agree it’s an exciting time where education, healthcare, patient care, quality are sort of all intersecting?
>>BRIGHAM: I think we’re in one of those rare moments in the space-time continuum where the right people are assembled with the right internal aspirations and external pressures to make fundamental transformational change, which will make the experience of the patients in the future better, will engage our learners on a whole better and exciting way, yeah, I think we’re at the right place, meaning in the time. And if we don’t take advantage of this window, shame on us.
>>REGNIER: I thought we could talk about some of the things that you’ve been working on, you and Tom Nasca and the others at ACGME. I thought we could try to talk about the Next Accreditation System, I thought we could talk about the milestones. I mean you and I have had good
>>REGNIER: chance to talk about the milestones and the potential overlap between GME and CME.
>>REGNIER: And then the CLER visits.
>>BRIGHAM: The next accreditation system at the ACGME moves away from a catch them being bad model to a quality improvement model. In other words we’re moving away from torturing the really good programs to find the toxic ones to one where we celebrate and reward the really good ones and everybody, the ACCGME, the ARCs within the ACCGME and the good programs work to help the, the programs that are struggling a little bit to move up a fundamental building blocks of that are the CLER visits, which CLER stands for Clinical Learning Environment Review, where we’re visiting every institution , every sponsoring institution in the country, every 18 months to ascertain how the residents are integrated into the safety and quality movements of the hospital. And that has all kinds of ramifications from duty hours to supervision to handovers to seeing how the residents are involved, all of the residents not just one or two who are on a committee of safety, are really integrated into learning about safety and quality and helping their institutions become a safer place. In most institutions we found there’s a bit of parallel play going on, where the , where the residents are doing one thing, taking care of most of the patients and there’s this sort of rigorous robust safety and quality movement that does not engage them at all. So, they’re not learning, they’re not contributing to it and the hospital’s struggling because the residents are doing a lot of the patient care if not most of it. The second piece of the next accreditation system if we move from the CLER as sort of the foundation, making sure that the institution has all those qualities that we want to see in an institution that will be educating our residents our future physicians out there in practice is a model of continuous improvement. So, the RRCs instead of episodically biopsying the program, we’ll be getting information on an annual basis that they can look at and say, this indicates that the program is going along in a fine way or there may be something going on in here and we’re going to have to take a look at it. Again, the taking a look at it is less to punish the group than to make sure that things are going in the way that we want them to go and that you would want then to go and that every patient would want them to go. And if not, how can we help that program adjust and move forward? And for the truly toxic programs they would still have to be dealt with in a different way.
>>REGNIER: So, the information that’s going to come more continuously.
>>REGNIER: Can you describe that a little bit
>>REGNIER: Is that where the milestones come in?
>>BRIGHAM: The milestones come in in that place. There are, we’re going to be looking at data that flows from the programs, that we’re already getting, for the most part,
>>REGNIER: Like the resident logs maybe is that?
>>BRIGHAM: We have, one is the annual update we get from the program, in terms of their faculty and resident scholarly activity, their any changes that might have happened in the residency program from the program directors leaving or coming, faculty leaving or coming, increase or decrease in resident complement. We’ll be looking at the resident survey that we have. We’re developing a new survey for faculty members. We’ll be looking at clinical experience that can come through case logs or other methodologies and then we’ll be looking at the milestones. The milestones are, the milestones are developmental trajectories that we expect every resident to sort of move through to a certain level before they graduate in each one of the six general competency areas.
>>REGNIER: So, this is where, normally, if we had a white board
>>BRIGHAM: Yes I’d be drawing
>>REGNIER: You’d be drawing pictures for me right?
>>BRIGHAM: Yes and we don’t have
>>REGNIER: We don’t have a white board, but the idea of the competencies can you describe the milestones maybe a little bit about the development and then what they are. The competencies and then these milestones.
>>BRIGHAM: Right. The, for those of your viewers at home who don’t know what
>>BRIGHAM: who don’t know what competencies are, six general competencies that the entire continuum of accreditation has sort of coalesced around and agreed upon. One is patient care, two is medical knowledge, three is professionalism, four is communication skills and interpersonal relationships, five is system-based practice, and six is practice based learning and improvement.
>>REGNIER: So, before you go on let me just pause there. I know you and I have had the chance to talk about the fact that when we revised our accreditation criteria you said accreditation systems have sort of rallied around these competencies
>>REGNIER: I would say that’s reflective in our criteria as well. When we revised our criteria back in 2004, 2005 we included a specific criteria that said the accredited providers will plan activities in the context of
>>REGNIER: the competencies.
>>REGNIER: They can be your competencies they could be, for example, the IOM competencies
>>REGNIER: The idea is these are desirable attributes that we want the education to revolve around or reflect.
>>BRIGHAM: Right. One of the things that we’ve worked really hard, it used to be that if a physician was good in one area, they were great in medical knowledge, or they were great in patient care, but had a deficiency in one of the other areas, we almost said something like, the abundance of the qualities in those one or two areas makes up for the deficiency in the other area. What we’ve said at the ACGME is no, we need a level of proficiency in each one of those competency areas. Our hope, by the way, I think, through some of the work we’ve been doing lately is that, is that the continuum in the United States, at any rate, we’ll sort of gravitate towards the six competencies that the ABMS and the ACGME came up with so that those are those six areas that we just talked about. Now, the milestones are, goes something like this, and I’ll come back to the six competencies in a second. What we did, is we convened specialty groups in each of the 27 core specialties to come up with milestones under each one of those six competencies areas, the six general competencies. Those groups were made up of entirely people from the specialty, they were put together by the board, invited by the board, had the relevant college residents program director members of the RRC and a couple of members of the ACGME, just to make sure that each one of the milestone groups was painting in the same frame.
>>BRIGHAM: In that frame what we were asking them to do was to come up with a number of sub-competencies under each competency. So, if we stuck with professions one of the sub-competencies might be could be honesty and integrity. And in honesty and integrity we asked them to, to paint a picture in some ways. To have five narrative streams that reflected what it was they expect of a novice in honesty and integrity all the way up to an expert.
>>REGNIER: So, sort of the development
>>BRIGHAM: Like a developmental scheme that you would have for child in pediatrics.
>>REGNIER: Right, OK.
>>BRIGHAM: So, what does it mean for a resident who comes in who’s just beginning to walk in that phase, to what does it look like when they’re running marathons as an expert, if that makes, I don’t know if that makes sense.
>>REGNIER: Sure. Sure.
>>BRIGHAM: Each one of those areas, we sort of conceptually used the Dreyfus model, novice, advanced beginner, competent, proficient, expert, but most of the groups have not used that nomenclature, but they do have sort of the developmental stream. So, they have created a narrative for each one of those developmental streams. So, what does it mean to be a novice in honesty and integrity? What does it mean to be competent? What does it mean to be proficient? They’ve done that for each one of the six competencies, have a number of sub-competencies under each of the competencies and then that narrative stream, those five narratives that we’re asking to construct are the milestones.
>>BRIGHAM: And the handoff, I think, one of the really, really neat things that these incredibly hard working people have done, I can’t take any of the credit for what they’ve done. The specialties have worked some of them over years to develop some of these milestones; they’ll be used in GME in a very special way to help us ascertain whether a program is on track. The boards will use them, if they so desire, for individual sort of verification that they’re worthy of certification or worthy of going into the next phase which is the unsupervised practice of medicine. But the link to the continuum, I think, is specially exciting to me. We will be able to reflect back if the, if the undergraduate, our undergraduate colleagues begin to take a look at the milestones and say how can we hook this back to what we’re doing?
>>REGNIER: to prepare these folks
>>BRIGHAM: for residency
>>BRIGHAM: That’s the front door, and in the back door, hopefully, what we’ll be able to give you and the boards is where these residents are, you’ll know pretty much from a wider perspective from a meta perspective, because all residents are expected to graduate at a certain level, but there’ll be individual variations on that.
>>BRIGHAM: We will be able to hand you and the boards conceptually residents, who will be in the next 40 years of their practice that you can help develop from, I said we had five steps, there’s really nine, because there’s a step in between each one of them that says they’ve completed this but they’re not here this
>>REGNIER: Right, right.
>>BRIGHAM: But if they hit the seventh step they’re, they are, that’s anchored to be theoretically right now, proficiency. Where we would expect somebody’s ready for the unsupervised practice of medicine. So, there’s two steps after that, at least. There’s expert and mastery.
This is a transcript of An Introduction to the ACGME’s Next Accreditation System (NAS) (Part 1 of 4).
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