Post on 26-Dec-2021
Acronym Update:
NAS, CLER, EPA and more
Surgery Grand Rounds November 6th, 2013 Katie McKinney Assistant Dean, GME Susan McDowell, DIO and Associate Dean, GME
Objectives Define NAS, CLER, EPA Compare ACGME accreditation
standards before and after the NAS Describe the meaning of milestones Demonstrate MedHub features pertinent
to NAS
Faculty Disclosure None
Why this topic? The Accreditation Council for Graduate
Medical Education (ACGME) published new accreditation standards (NAS) for Graduate Medical Education (GME) that were effective in a two year roll out beginning July 1, 2013.
Background to change Motivation
Medicare contributes billions of dollars annually to educate physicians
System for educating physicians must answer to the public for the graduates it produces.
Need for more explicit definitions of a ‘good physician’ Implement a more robust formula for developing/tracking
MD competence prior to allowing independent practice
Behind the scenes
July 1, 2013 Implementation
of NAS
2009 Initiation of
restructuring accreditation
1999 introduction
of core competencies
2000 IOM Report
Licensing Board CME standards
Healthcare Reform
Legislation
Why NAS now? Public stakeholders have heightened
expectations of physicians Patients, payers and the public demand
Access to proper care Information technology literacy Sensitivity to cost effectiveness Involvement of patients in their own care
Where are we now?
Phase 1 Radiology
Emergency Medicine Internal Medicine
Neurological Surgery Orthopedic Surgery
Pediatrics Plastics
Phase 2 Everybody else
General Surgery Thoracic Surgery
Urology Vascular
TBA Understanding
outcomes
July 2013 July 2014
NAS: what hasn’t changed? Pre-requisites for GME training:
Med school degree, pass USMLE exams 1-2CK/CS* GME training program content/length ACGME work hour rules:
PGY1 no more than 16 hours PGY2+ no more than 24 + 4 1 day off in 7 averaged over 4 weeks Minimum 8 hours off between shifts; rec 10 hours
Requirements for independent practice/licensure Completion of GME training Pass specialty board exam(s) Maintain CME
*or in select cases equivalent exams
NAS: what has changed? Before…
Rules Corresponding questions Correct/Incorrect answer Citation and Accreditation Decision
Wait 2 to 5 years and start all over
NAS: what has changed? Continuous Observations
Diagnose the Problem
Potential Problem
Ensure Program Fixes Problem Promote Innovation
NAS: what has changed? Continuous accreditation model No cycle lengths Data reviewed annually Accreditation status assigned annually
Commend a program Identify areas of concern requiring follow up Issue citations Continue or remove prior citations/concerns Increase or reduce resident complement
Self-Study visit every ten years…or so
NAS Data Annual program ACGME ADS Update
Program Characteristics-Structure/resources Program Changes-PD/Core Faculty/Residents Scholarly activity of faculty and residents Omission of data
Rolling Board pass rate Annual ACGME Resident/Faculty Survey Case/Procedure logs Semi-annual resident evaluation on Milestones
Milestones v Competencies Intent of milestones: operationalize ACGME
competencies: Patient Care Medical Knowledge Professionalism Systems based Practice Inter-professional and communication skills Practice Based Learning and Improvement
Milestones: knowledge, skills, attitudes for each competency organized into a developmental framework
Developmental framework?
MD degree
Finish GME
“The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty”
One size does NOT fit all ACGME developed concept Specialty boards developed milestones Result:
Formula for tracking milestones same across specialties: semi-annual report to ACGME
Milestones don’t translate outside of training specialty
Milestone examples Competency: patient care Goal of milestone: operationalize
knowledge, skills, attitudes that would demonstrate learner’s development in this domain
General Surgery: PC3-Performance of operations and procedures Orthopedics: PC1-Ankle fracture Urology: PC6-Performs open surgical procedures Internal Medicine: PC4-Skill in performing procedures
Milestone measurement Milestones are arranged into numbered
levels. These levels do not correspond with post-graduate year of education.
General Surgery: PC3-Performance of operations and procedures
Milestone Levels for General Surgery Critical
Deficiencies
Level 1
Level 2
Level 3 Level 4
learner behaviors are not within the spectrum of developing competence…they indicate significant deficiencies in a resident’s performance
demonstrating milestones expected of an incoming resident
advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level
continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency
advanced so that he/she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target
Compared to…NS, Ortho, Plastics, Thoracic, Uro Critical
Deficiencies
Level 1
Level 2
Level 3 Level 4 Level 5
learner behaviors are not within the spectrum of developing competence…they indicate significant deficiencies in a resident’s performance
demonstrating milestones expected of an incoming resident
advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level
continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency
advanced so that he/she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target
advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level
Milestone mayhem Difficulty with interpretation of meaning across
specialties Questions at training program level regarding
how to translate evaluation methods/assessment tools
Little (Phase 1) or no (Phase 2) longitudinal data to understand results
Take home for residents/faculty: understand whether and how NAS/milestones changes completing/interpreting evaluations
What about CLER? CLER=Clinical Learning Environment
Review ACGME process for understanding GME
and institutional ‘inter-connectedness’ related to clinical quality, patient safety, trainee quality of life
Underlying question: is everyone on the same page?
Why the CLER? • 2009-2010 ACGME “Duty Hours Task Force” and
“Task Force for Quality Care and Professionalism”
• Linked adherence to duty hours policies /integrity in reporting to professional responsibility for patient safety/quality
• Established importance of educating residents/fellows on institutional Patient Safety and Quality Improvement programs
• Assigned responsibility to institutions for engaging and monitoring residents/fellows across targeted areas
• Recommends assessment in the form of a sponsor visit program called the Clinical Learning Environment Review (CLER)
Nasca, T.J., Day, S.H., Amis, E.S., for the ACGME Duty Hour Task Force. Sounding Board: The New Recommendations on Duty Hours from the ACGME Task Force.
New England Journal of Medicine. 362 (25): e3(1-6). 2010. June 23, 2010.
CLER Program: 6 Focus Areas 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 Disparities in Health Care Delivery, and demonstration of impact
Establishment, implementation, and oversight of Supervision policies
Oversight of Transitions in Care Oversight of Duty Hours Policy, Fatigue Management
and Mitigation Education and monitoring of Professionalism
CLER Site Visit Little advance notice given or required prep Optional request to DIO to provide copies of
existing documents one week prior to visit: Relevant organizational charts, select
committee rosters Site’s organizational strategies for patient safety
and healthcare quality Institution/participating site’s policies on
supervision, transitions in care, duty hours
Proposed CLER Evaluation Process
CLER Buy In--“Why it matters to the individual training program”
CPR: VI.A.3. The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.
CPR: VI.A.5.g. the monitoring of their patient care performance improvement indicators; and,
Sponsoring Institution gets a public grade starting the second round of visits.
CLER-where are we? UK-UHC #12; Rising Star Award GME focus
Continuing standardization of processes/protocols for duty hours monitoring, supervision…
Enhance GME/programs awareness of enterprise quality/safety initiatives
Enhance resident/fellow meaningful involvement in enterprise patient safety/quality initiatives
MedHub Update Web-based platform for GME/training
program data management Replaces New Innovations as of
November 1 for: Evaluation completion Duty hours logging/tracking Procedures logging/tracking Trainee schedule management
Questions?