New Rules
Tex Med. 2012;108(8):51-54.
By Ken Ortolon
Texas medical educators say the Accreditation Council for Graduate Medical Education's (ACGME's) residency program accreditation process was extremely prescriptive and stifled innovation in graduate medical education (GME).
Surendra Varma, MD, associate dean of graduate medical education and resident affairs at the Texas Tech University Health Sciences Center in Lubbock, says the paperwork residency program directors had to fill out to prepare for an ACGME site visit was a hassle.
"We had about 100 pages of questions we had to complete every three years when they came for site visits," Dr. Varma said.
But in February, ACGME announced a new accreditation process that it says will ease that burden from the process it had developed over the past few decades. The trade-off, however, is the new system will make residency programs and their residents demonstrate that residents have the necessary skills to be outstanding physicians.
"There is now widespread consensus that moving to an outcomes-based accreditation system will prepare physicians to deliver quality patient care and be skilled in evidence-based medicine, team-based care, care coordination, and shared decision making – all critical to practicing in an increasingly complex health care system," said Thomas Nasca, MD, ACGME's chief executive officer.
Measuring Competencies
The new accreditation process has its roots in the Outcome Project ACGME began in 1998 to improve residents' ability to function effectively. Working with the American Board of Medical Specialties, ACGME developed a set of core competencies required of all physicians, turned those into accreditation program requirements, and mounted a multiyear program to implement them in all teaching institutions. ACGME approved its phased-in implementation last year.
ACGME will start the new system for emergency medicine, internal medicine, neurological surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urological surgery in 2013 and for all other specialties a year later.
ACGME says the new system follows closely recommendations made by the Institute of Medicine, the Medicare Payment Advisory Commission, and the Josiah Macy Jr. Foundation.
Under the system:
- Medical residents and fellows must demonstrate competency in six core areas – patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication.
- Teaching institutions must develop and publish the specific learning outcomes residents need to demonstrate as they progress through training.
- Institutions must give ACGME reports that document each resident's accomplishments in meeting benchmarks for physician competence every six months.
- ACGME will update the accreditation status of each residency program yearly based on trends in key performance parameters.
Lengthening the Cycle
ACGME officials say the new accreditation system will be more user friendly for the residency programs.
"One of the main missions in the next accreditation system is to decrease the burden of accreditation on the programs and on the institutions," said John Potts, MD, the ACGME senior vice president for surgical accreditation. He said accreditation "evolved into a very time-consuming process that requires a lot of resources on the part of the programs to receive their accreditation and, for that matter, a lot of time and effort on the part of the residency review committees that review each program."
Thomas Blackwell, MD, associate dean for GME at The University of Texas Medical Branch, says one of the biggest changes will be in the "cycle rate" of ACGME site visits.
Currently, a residency program might be subject to a site visit by a review committee anywhere from annually to once every five years, depending on how well the program does. Under the new system, site visits will occur only every 10 years and will be more along the lines of a self-study, says Dr. Potts, formerly a GME program director in surgery and assistant dean at the UT Health Science Center at Houston.
"In the self-study, we want to challenge the programs to review where they are, how they got there, what their aims are for the next several years, and, as best as they can, describe how they plan to get there," he said. "The visits will be less frequent and will take on an entirely different format, nature, and purpose than the visits we have today."
Achieving Milestones
The information residency programs must continuously give ACGME to replace site visits includes:
- Outcomes data, such as pass rates on medical specialty board certification exams;
- Results from resident and faculty surveys that measure things such as resident duty hours, residents' satisfaction with their education, faculty satisfaction with program administration, and whether residents get an adequate number of surgical cases or patient volumes.
Also, programs will have to report if each resident meets certain specialty-specific milestones that measure competence at regular intervals throughout his or her training.
"That data is going to be filled out on every resident and every six months sent to the ACGME to let them know how the residency program as a whole is progressing on its milestones," Dr. Blackwell said.
Some milestones will cut across all specialties, but others will be very specific to a particular specialty, he says.
For example, an orthopedic surgery milestone might measure a resident's skill level at total hip replacement, Dr. Blackwell says. An early milestone might measure whether a resident can do surgical planning and understand the anatomy of the hip.
As the resident moves toward completing his or her training, a later milestone might measure whether he or she could perform the procedure without assistance from start to finish.
"If they don't get there, the theory is we're not going to finish them," Dr. Blackwell added.
Dr. Potts says the milestones and outcomes measurement will help residency program directors meet one-on-one with residents, assess how they compare with their peers across the nation, identify areas where their skills need improvement, and devise a way to achieve that improvement.
Continuing Uncertainty
But he and others say there still is a great degree of uncertainty about exactly what the new accreditation process will look like and how it will be accepted.
"Right now it would be difficult to say whether this will be a positive change because I'm not really sure that they [ACGME] know themselves," Dr. Varma said. "Only time will tell whether the move is in the right direction. Let us give this our utmost cooperation."
Dr. Blackwell says most residency program directors he has talked to seem optimistic the changes will be positive, but there are still many details to be finalized, such as the milestones.
"We've been talking about changing how we do things, and I think most folks in my position may be cautiously optimistic that this is going to be a good thing," he said. "But we don't really know."
Still, ACGME is pressing forward. Dr. Blackwell says ACGME already notified several UTMB residency programs that they are moving into the new accreditation system. UTMB's internal medicine program, for example, received a letter stating that the next site visit had been pushed back and that it would have to start the new data reporting in June 2013.
Dr. Potts also says he received positive feedback from residency program directors. And he, for one, welcomes the new system.
"I was a program director for 21 years. What I said in my own mind, what I said privately, what I said publicly for years was that I wish this was a more collaborative process and less punitive process than that which we've been living under," he said. "This new system really provides the opportunity for a collaborative process."
The Texas Medical Association Council on Medical Education discussed the new accreditation system during its meeting at TexMed 2012 in May and was generally supportive. The council believes the system will be less burdensome and less prescriptive.
"The TMA Council on Medical Education is in full support of the new accreditation system. It is in alignment with the core competencies, and we are optimistic that the new accreditation system will be more efficient and allow innovation in graduate medical education," said council Chair Cynthia A. Jumper, MD, associate dean for health services management at Texas Tech University Health Sciences Center School of Medicine in Lubbock.
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