Hospice and Palliative Medicine Milestones - The Accreditation Council for Graduate Medical Education - acgme

 
Hospice and Palliative Medicine Milestones - The Accreditation Council for Graduate Medical Education - acgme
Hospice and Palliative Medicine Milestones
      The Accreditation Council for Graduate Medical Education

           Second Revision: March 2019
            First Revision: October 2014
Hospice and Palliative Medicine Milestones

The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME-
accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the
development of the fellow in key dimensions of the elements of physician competency in a specialty or
subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency,
nor are they designed to be relevant in any other context.

                                                                                                                ii
Hospice and Palliative Medicine Milestones

                                                    Co-Chairs
                               Jillian Gustin, MD and Lindy Landzaat, DO, FAAHPM
                                                   Work Group
     Michael Barnett, MD, MS, FACP, FAAP,                       Dale Lupu, MPH, PhD
     FAAHPM                                                     Laura J. Morrison, MD, FAAHPM
     Gary Buckholz, MD, HMDC, FAAHPM                            Tomasz Okon, MD
     April Christensen, MD, MS                                  Steven M. Radwany, MD, FACP, FAAHPM
     Laura Edgar, EdD, CAE                                      Holly Yang, MD, MSHPEd, HMDC, FACP,
     Jennifer Hwang, MD, MHS                                    FAAHPM
     Catherine Bree Johnston, MD, MPH

The ACGME would like to thank the following organizations for their continued support in the development of
the Milestones:

American Board of Internal Medicine

American Academy of Hospice and Palliative Medicine

                                                                                                              iii
Understanding Milestone Levels and Reporting

This document presents the Milestones, which programs use in a semi-annual review of fellow performance, and then report to
the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME Competencies organized in a
developmental framework. The narrative descriptions are targets for fellow performance throughout their educational program.

Milestones are arranged into levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert
resident/fellow in the specialty or subspecialty. For each reporting period, the Clinical Competency Committee will review the
completed evaluations to select the milestone levels that best describe each learner’s current performance, abilities, and attributes
for each subcompetency.

These levels do not correspond with post-graduate year of education. Depending on previous experience, a junior fellow may
achieve higher levels early in his/her educational program just as a senior fellow may be at a lower level later in his/her
educational program. There is no predetermined timing for a resident to attain any particular level. Fellows may also regress in
achievement of their milestones. This may happen for many reasons, such as over scoring in a previous review, a disjointed
experience in a particular procedure, or a significant act by the fellow.

Selection of a level implies the fellow substantially demonstrates the milestones in that level, as well as those in lower levels (see
the diagram on page vi).

                                                                                                                                         iv
Additional Notes

Level 4 is designed as a graduation goal but does not represent a graduation requirement. Making decisions about readiness for
graduation and unsupervised practice is the purview of the program director. Furthermore, Milestones 2.0 include revisions and
changes that preclude using Milestones as a sole assessment in high-stakes decisions (i.e., determination of eligibility for
certification or credentialing). Level 5 is designed to represent an expert fellow whose achievements in a subcompetency are
greater than the expectation. Milestones are primarily designed for formative, developmental purposes to support continuous
quality improvement for individual learners, education programs, and the specialty. The ACGME and its partners will continue to
evaluate and perform research on the Milestones to assess their impact and value.

Examples are provided for some milestones within this document. Please note: the examples are not the required element or
outcome; they are provided as a way to share the intent of the element.

Some milestone descriptions include statements about performing independently. These activities must occur in conformity to
ACGME supervision guidelines as described in the Program Requirements, as well as to institutional and program policies. For
example, a resident who performs a procedure independently must, at a minimum, be supervised through oversight.

A Supplemental Guide is also available to provide the intent of each subcompetency, examples for each level, assessment
methods or tools, and other available resources. The Supplemental Guide, like examples contained within the Milestones, is
designed only to assist the program director and Clinical Competency Committee, and is not meant to demonstrate any required
element or outcome.

Additional resources are available in the Milestones section of the ACGME website. Follow the links under “What We Do” at
www.acgme.org.

                                                                                                                                  v
The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME
Report Worksheet. For each reporting period, a fellow’s performance on the milestones for each sub-competency will be
indicated by selecting the level of milestones that best describes that fellow’s performance in relation to those milestones.

                 Selecting a response box in the                     Selecting a response box on the line in
                 middle of a level implies that                      between levels indicates that milestones
                 milestones in that level and in lower               in lower levels have been substantially
                 levels have been substantially                      demonstrated as well as some
                 demonstrated.                                       milestones in the higher level(s).

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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Patient Care 1: Comprehensive Whole Patient Assessment

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Performs a general                Performs a symptom-                 Performs a detailed                Performs a                        Promotes comprehensive
 history and physical              focused history and                 symptom assessment                 comprehensive                     symptom assessment
                                   physical                            using developmentally              symptom assessment                across care teams
                                                                       appropriate symptom                using developmentally
                                                                       assessment tools                   appropriate symptom
                                                                                                          assessment tools in
                                                                                                          collaboration with the
                                                                                                          interdisciplinary team

 Performs a general                Identifies potential                Performs a detailed                Performs a                        Promotes comprehensive
 psychosocial history              supports and stressors for          psychosocial and spiritual         comprehensive                     psychosocial and spiritual
                                   patients and their                  assessment using                   psychosocial and                  assessment across care
                                   families/caregivers                 developmentally                    spiritual assessment              teams
                                   including psychological,            appropriate assessment             using developmentally
                                   spiritual, social,                  tools                              appropriate assessment
                                   developmental stage,                                                   tools in collaboration
                                   financial, and cultural                                                with the interdisciplinary
                                   factors                                                                team

 Comments:
                                                                                                                               Not Yet Completed Level 1
                                                                                                                               Not Yet Assessable

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Patient Care 2: Addressing Suffering and Distress

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Manages common                    Manages common                      Manages complex                    Manages refractory                Manages physical
 physical symptoms with            physical symptoms with a            physical symptoms with a           symptoms across care              symptoms with innovative
 basic treatment options           range of treatment                  comprehensive range of             settings                          and advanced treatment
                                   options                             treatment options                                                    options

 Acknowledges                      Refers to interdisciplinary         Collaborates with the              Provides                          Maintains a therapeutic
 psychosocial and                  team to address                     interdisciplinary team to          comprehensive                     presence for a patient
 spiritual distress                psychosocial and spiritual          manage psychosocial and            management for                    with intractable suffering
                                   distress                            spiritual distress                 complex psychosocial              and assists families and
                                                                                                          and spiritual distress in         teams
                                                                                                          collaboration with
                                                                                                          community resources
                                                                                                          across care settings

 Identifies palliative             Initiates medical                   Mobilizes the                      Consistently manages              Participates in systems
 emergencies                       management for                      interdisciplinary team and         and provides                      improvement
                                   emergencies                         manages an emergency               anticipatory coaching             opportunities to address
                                                                       using comprehensive                across care settings              patient care emergencies
                                                                       treatments consistent with
                                                                       patient goals

 Comments:
                                                                                                                                Not Yet Completed Level 1
                                                                                                                                Not Yet Assessable

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Patient Care 3: Withholding and/or Withdrawal of Life-Sustaining Therapies (LST)

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Identifies distress               Identifies ethical, legal,          Develops a care plan               Facilitates shared                Promotes best practices
 associated with                   institutional, cultural, and        considering burdens and            decision making; plans            in withholding or
 withholding or                    religious perspectives to           benefits of withholding or         for withholding or                withdrawal of ANH or LST
 withdrawing artificial            withholding or                      withdrawing ANH in                 withdrawal of ANH;                at the system level
 nutrition or hydration            withdrawing ANH                     specific clinical scenarios        provides support to
 (ANH)                                                                                                    family/caregivers and
                                                                                                          teams

 Identifies distress               Identifies ethical, legal,          Manages withdrawal of              Facilitates shared
 associated with                   institutional, cultural, and        LST and manages                    decision making; plans
 withholding or                    religious perspectives to           symptoms before, during,           for withholding or
 withdrawing LST                   withholding or                      and after withdrawal or in         withdrawal of LST;
                                   withdrawing LST                     lieu of withholding LST            provides support to
                                                                                                          family/caregivers and
                                                                                                          teams

 Comments:
                                                                                                                               Not Yet Completed Level 1
                                                                                                                               Not Yet Assessable

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Patient Care 4: Care of the Imminently Dying

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Identifies signs and              Identifies risk of and              Manages evolving                   Manages distressing               Promotes best practices
 symptoms of imminent              manages common                      symptoms in the context            symptoms of imminent              in care of the imminently
 dying                             symptoms for the                    of declining organ                 death, including                  dying at the system level
                                   imminently dying                    function for the                   complex and refractory
                                                                       imminently dying                   symptoms, across care
                                                                                                          settings

 Identifies patients and           Assesses the etiology of            Provides anticipatory              Provides culturally
 families/caregivers in            psychosocial and spiritual          planning for patients,             sensitive and
 distress                          distress in patients and            families/caregivers and            developmentally
                                   families/caregivers and             teams                              appropriate
                                   uses the interdisciplinary                                             psychosocial and
                                   team to provide basic                                                  spiritual support to
                                   support                                                                distressed patients and
                                                                                                          families/caregivers, and
                                                                                                          identifies families at risk
                                                                                                          for complex
                                                                                                          bereavement

 Comments:
                                                                                                                               Not Yet Completed Level 1
                                                                                                                               Not Yet Assessable
Patient Care
The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training
program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that
includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
*Only required for Internal Medicine based programs

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Medical Knowledge 1: Disease Trajectories and Formulation of Prognosis in Serious Illness

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Recognizes common                 Identifies illness trajectory       Identifies potential impact        Integrates modifying              Advances knowledge of
 illness trajectories              of less common disease              of treatment on the illness        factors on the illness            application or
                                   and recognizes                      trajectory                         trajectory including              prognostication in serious
                                   prognostic uncertainty                                                 multi-morbidity,                  illness
                                                                                                          psychosocial factors,
                                                                                                          and functional status

 Identifies prognostic             Identifies and describes            Formulates a prognosis             Facilitates consensus
 formulation as a key              prognostic factors, tools,          by integrating prognostic          on prognosis in
 element for shared                and models                          factors, tools, and                collaboration with other
 decision making                                                       models, recognizing                care providers
                                                                       limitations

 Comments:
                                                                                                                               Not Yet Completed Level 1
                                                                                                                               Not Yet Assessable

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Medical Knowledge 2: Palliative Management of Pain Symptoms

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Lists commonly available          Describes indications and           Demonstrates knowledge             Demonstrates detailed             Advances knowledge
 opioid and non-opioid             use of opioid and non-              of mechanism of action,            knowledge of                      about pain management
 analgesics                        opioid analgesics                   metabolism, adverse                pharmacology of opioid            for palliative patients
                                                                       effects, interactions, and         and non-opioid
                                                                       conversions of opioid and          analgesics with risks
                                                                       non-opioid analgesics              and benefits related to
                                                                                                          specific patient
                                                                                                          characteristics

 Lists non-pharmacologic           Describes indications of            Describes locally                  Demonstrates
 interventions for pain            use of non-pharmacologic            available non-                     evidence-based
                                   interventions for pain              pharmacologic                      knowledge of non-
                                                                       interventions of pain              pharmacologic
                                                                                                          interventions

 Lists procedural                  Describes indications for           Describes referral criteria        Demonstrates detailed
 interventions for pain            some procedural and                 for locally available              knowledge of
                                   advanced interventions to           procedural and advanced            appropriate procedural
                                   address pain                        interventions to address           and advanced
                                                                       pain                               interventions to address
                                                                                                          pain in specific patients

 Comments:
                                                                                                                              Not Yet Completed Level 1
                                                                                                                              Not Yet Assessable

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Medical Knowledge 3: Palliative Management of Non-Pain Symptoms

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Lists commonly available          Descries indications and            Demonstrates knowledge             Demonstrates detailed             Advances knowledge
 medications for non-pain          use of medications for              of mechanism of action,            knowledge of                      about management for
 symptoms                          non-pain symptoms                   metabolism, adverse                pharmacology of                   non-pain symptoms for
                                                                       effects, interactions, and         medications for non-              palliative patients
                                                                       conversions (if applicable)        pain symptoms with
                                                                       of medications for non-            risks and benefits
                                                                       pain symptoms                      related to specific
                                                                                                          patient characteristics

 Lists non-pharmacologic           Describes indications and           Describes locally                  Demonstrates
 interventions for non-            use non-pharmacologic               available non-                     evidence-based
 pain symptoms                     interventions for non-pain          pharmacologic                      knowledge of non-
                                   symptoms                            interventions for non-pain         pharmacologic
                                                                       symptoms                           interventions for non-
                                                                                                          pain symptoms

 Lists procedural                  Describes indications for           Describes referral criteria        Demonstrates detailed
 interventions for non-            some procedural and                 for locally available              knowledge of
 pain symptoms                     advanced interventions to           procedural and advanced            appropriate procedural
                                   address non-pain                    interventions to address           and advanced
                                   symptoms                            non-pain symptoms                  interventions to address
                                                                                                          non-pain symptoms in
                                                                                                          specific patients

 Comments:
                                                                                                                               Not Yet Completed Level 1
                                                                                                                               Not Yet Assessable

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

Medical Knowledge
The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training
program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that
includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
*Only required for Internal Medicine based programs

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Systems-Based Practice 1: Patient Safety and Quality Improvement

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Demonstrates                      Identifies system factors           Participates in analysis of        Conducts analysis of              Actively engages teams
 knowledge of common               that lead to patient safety         patient safety events              patient safety events             and processes to modify
 patient safety events             events                              (simulated or actual)              and offers error                  systems to prevent
                                                                                                          prevention strategies             patient safety events
                                                                                                          (simulated or actual)

 Demonstrates                      Reports patient safety              Participates in disclosure         Discloses patient safety          Role models or mentors
 knowledge of how to               events through                      of patient safety events to        events to patients and            others in the disclosure of
 report patient safety             institutional reporting             patients and families              families (simulated or            patient safety events
 events                            systems (actual or                  (simulated or actual)              actual)
                                   simulated)

 Demonstrates                      Describes local quality             Participates in local              Demonstrates the skills           Creates, implements, and
 knowledge of basic                improvement initiatives             quality improvement                required to identify,             assesses quality
 quality improvement               (e.g., advance directives,          initiatives                        develop, implement,               improvement initiatives at
 methodologies and                 hospice length stay)                                                   and analyze a quality             the institutional or
 metrics                                                                                                  improvement project               community level

 Comments:
                                                                                                                              Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Systems-Based Practice 2: System Navigation for Patient-Centered Care

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Demonstrates                      Coordinates care of                 Coordinates care of                Role models effective             Analyses the process of
 knowledge of care                 patients in routine clinical        patients in complex                coordination of patient-          care coordination and
 coordination                      situations effectively using        clinical situations                centered care among               leads in the design and
                                   the roles of the                    effectively incorporating          different disciplines and         implementation of
                                   interprofessional teams             patient and family goals,          specialties                       improvements
                                                                       illness trajectory, and
                                                                       available resources

 Identifies key elements           Performs safe and                   Performs safe and                  Role models and                   Improves quality of
 for safe and effective            effective transitions of            effective transitions of           advocates for safe and            transitions of care within
 transitions of care and           care/hand-offs in routine           care/hand-offs in complex          effective transitions of          and across health care
 hand-offs                         clinical situations                 clinical situations                care/hand-offs within             delivery systems to
                                                                                                          and across health care            optimize patient outcomes
                                                                                                          delivery systems,
                                                                                                          including outpatient
                                                                                                          settings

 Demonstrates                      Identifies specific                 Uses local resources               Participates in changing          Leads innovations and
 knowledge of population           population and                      effectively to meet the            and adapting practice to          advocates for populations
 and community health              community health needs              needs of a patient                 provide for the needs of          and communities with
 needs and disparities             and inequities for the local        population and                     specific populations              health care inequities
                                   population                          community

 Comments:
                                                                                                                               Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Systems-Based Practice 3: Physician Role within Health Care Systems

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Identifies components of          Describes the physician’s           Analyzes how personal              Manages the                       Advocates for or leads
 the complex health care           role and how the                    practice affects the               interrelated components           change to enhance
 system                            interrelated components             system (e.g., length of            of the complex health             systems for patient- and
                                   of the complex health               stay, readmission rates,           care systems for                  family-centered, high
                                   care system impact                  prescribing patterns)              patient- and family-              value, efficient, and
                                   patient care                                                           centered, efficient, and          effective patient care
                                                                                                          effective patient care

 Describes basic health            Describes payment model             Uses shared decision               Advocates for patient             Participates in advocacy
 payment systems,                  for serious illness (e.g.,          making in patient care,            care, understanding the           activities for health policy
 including government,             hospice, palliative care,           taking into consideration          limitations of each               to better align payment
 private, public, and              rehab, concurrent care)             payment models                     patient’s payment                 systems with high-value
 uninsured care, as well                                                                                  model (e.g., community            care
 as different practice                                                                                    resources, patient
 models                                                                                                   assistance resources)

                                   Describes models of                 Identifies resources for           Describes resources for
                                   hospice and palliative              transition to independent          leadership and program
                                   care practice                       practice                           development and
                                                                                                          effectively plans for
                                                                                                          transition to
                                                                                                          independent practice

 Comments:
                                                                                                                            Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Systems-Based Practice 4: Hospice

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Identifies the hospice            Describes key domains of            Demonstrates clinical              Demonstrates clinical             Teaches and role models
 physician as having a             clinical competence for             competence in the role of          competence in the role            hospice care to non-
 specific clinical role in         hospice physicians                  hospice physician                  of hospice physician              hospice physicians across
 the hospice                       including interdisciplinary         including interdisciplinary        across all hospice                settings
 interdisciplinary team            teamwork, management                teamwork, management               settings
                                   of physical symptoms,               of physical symptoms,
                                   and use of the hospice              and use of the hospice
                                   formulary                           formulary, with
                                                                       supervision

 Identifies general                Describes major                     Demonstrates compliance            Demonstrates                      Advocates locally,
 eligibility guidelines for        regulatory requirements             with regulatory                    compliance with                   regionally, or nationally
 hospice care                      and guidelines for hospice          requirements and                   regulatory requirements           for the hospice model of
                                   care including eligibility,         guidelines for hospice             and guidelines in the             care
                                   levels of care, and scope           care, including                    role of hospice
                                   of mandated services                documentation, visits,             physician across all
                                                                       interdisciplinary team             hospice settings
                                                                       oversight, and institutional
                                                                       policy implementation,
                                                                       with supervision

 Comments:
                                                                                                                               Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

Systems-Based Practice
The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training
program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that
includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
*Only required for Internal Medicine based programs

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Practice-Based Learning and Improvement 1: Evidence-Based and Informed Practice

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Demonstrates how to               Articulates clinical                Locates and applies the            Critically appraises and          Coaches others to
 access and use available          questions and elicits               best available evidence,           applies evidence, even            critically appraise and
 evidence in routine               patient preferences and             integrated with patient            in the face of                    apply evidence and
 patient care                      values in order to guide            preferences and values to          uncertainty and                   patient preferences and
                                   evidence-based care                 guide patient care                 conflicting evidence, to          values into clinical care,
                                                                                                          guide care tailored to            and/or participates in the
                                                                                                          the individual patient            developing guidelines

 Comments:
                                                                                                                            Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Accepts responsibility for        Demonstrates openness               Seeks performance data             Intentionally seeks               Role models consistently
 personal and                      to performance data                 episodically, with                 performance data                  seeking performance
 professional                      (feedback and other                 adaptability and humility          consistently, with                data, with adaptability and
 development by                    input) in order to inform                                              adaptability and humility         humility
 establishing goals                goals

 Identifies gap(s) between         Analyzes and reflects on            Analyzes, reflects on, and         Independently analyzes,           Coaches others on
 expectations and actual           the factors that contribute         institutes behavioral              reflects on, and                  reflective practice
 performance                       to gap(s) between                   change(s) to narrow the            institutes behavioral
                                   expectations and actual             gap(s) between                     change(s) to narrow the
                                   performance                         expectations and actual            gap(s) between
                                                                       performance, with                  expectations and actual
                                                                       guidance                           performance

 Actively seeks                    Designs and implements              Independently creates              Uses performance data             Facilitates the design and
 opportunities to improve          a learning plan, with               and implements a                   to measure the                    implementation of
                                   prompting                           learning plan                      effectiveness of the              learning plans for others
                                                                                                          learning plan and, when
                                                                                                          necessary, improves it

 Comments:
                                                                                                                               Not Yet Completed Level 1

Practice-Based Learning and Improvement
The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training
program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that
includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
*Only required for Internal Medicine based programs

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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 Professionalism 1: Professional Behavior and Ethical Principles

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Identifies and describes          Takes responsibility for            Demonstrates                       Recognizes and                    Coaches others when
 potential triggers and            own professionalism                 professional behavior in           intervenes in situations          their behavior fails to
 reporting processes for           lapses                              complex stressful                  that may trigger                  meet professional
 professionalism lapses                                                situations                         professionalism lapses            expectations
                                                                                                          in self and others

 Demonstrates                      Demonstrates knowledge              Analyzes and seeks help            Collaborates with and             Identifies and seeks to
 knowledge of the ethical          of the ethical principles           in managing and                    uses appropriate                  address system-level
 principles underlying             underlying hospice and              resolving complex ethical          resources for managing            factors that induce or
 informed consent,                 palliative medicine issues          situations                         and resolving ethical             exacerbate ethical
 surrogate decision                                                                                       dilemmas as needed                problems or impede their
 making, advance                                                                                          (e.g., ethics                     resolution
 directives, confidentiality,                                                                             consultations, literature
 error disclosure,                                                                                        review, risk
 stewardship of limited                                                                                   management/legal
 resources, and related                                                                                   consultation)
 topics

 Comments:
                                                                                                                               Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
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Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Professionalism 2: Accountability/Conscientiousness

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Responds promptly to              Performs tasks and                  Performs tasks and                 Addresses situations              Proactively implements
 requests or reminders to          responsibilities in a timely        responsibilities in                that impacts the                  strategies to ensure that
 complete tasks and                manner with appropriate             collaboration with the             interdisciplinary team’s          the needs of patients,
 responsibilities                  attention to detail in              interdisciplinary team             ability to complete tasks         teams, and systems are
                                   routine situations                                                     and responsibilities in a         met
                                                                                                          timely manner

 Comments:
                                                                                                                               Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
                                                                                                                                                                        17
Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Professionalism 3: Self-Awareness and Help Seeking

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Recognizes status of              Independently recognizes            Proposes a plan to                 Independently develops            Coaches others when
 personal and                      status of personal and              optimize personal and              a plan to optimize                emotional responses or
 professional well-being,          professional well-being             professional well-being,           personal and                      limitations in
 with assistance                                                       with assistance                    professional well-being           knowledge/skills do not
                                                                                                                                            meet professional
                                                                                                                                            expectations

 Recognizes limits in the          Independently recognizes            Receives and integrates            Independently seeks,
 knowledge/skills of self          limits in the                       feedback into a plan to            receives, and integrates
 or team and values                knowledge/skills of self or         remediate or improve               feedback and develops
 feedback, with                    team and welcomes                   limits in the                      a plan to remediate or
 assistance                        feedback                            knowledge/skills of self or        improve limits in the
                                                                       team, with assistance              knowledge/skills of self
                                                                                                          or team

 Comments:
                                                                                                                                 Not Yet Completed Level 1

Professionalism
The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training
program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that
includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
*Only required for Internal Medicine based programs

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
                                                                                                                                                                        18
Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Uses language and non-            Establishes a therapeutic           Establishes a therapeutic          Easily establishes                Mentors others in
 verbal behavior to                relationship in                     relationship in challenging        therapeutic                       situational awareness and
 demonstrate respect and           straightforward                     patient/family encounters          relationships, with               critical self-reflection to
 establish rapport                 encounters using active                                                attention to                      consistently develop
                                   listening and clear                                                    patient/family concerns           positive therapeutic
                                   language                                                               and context, regardless           relationships
                                                                                                          of complexity

 Identifies common                 Identifies complex                  Reflects on personal               Consistently recognizes           Mentors self-awareness
 barriers to effective             barriers to effective               biases and modifies                personal biases while             practice and educates
 communication (e.g.,              communication (e.g.,                approach to minimize               attempting to                     others to use a contextual
 language, disability)             developmental stage,                communication barriers             proactively minimize              approach to minimize
 while accurately                  health literacy, cultural                                              communication barriers            communication barriers
 communicating own role            norms)
 within the health care
 system

 Comments:
                                                                                                                               Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
                                                                                                                                                                          19
Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Interpersonal and Communication Skills 2: Interprofessional and Team Communication

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Respectfully receives a           Clearly and concisely               Checks understanding of            Integrates                        Role models flexible
 consultation request              responds to a                       recommendations when               recommendations from              communication strategies
                                   consultation request                providing consultation             different members of              that value input from all
                                                                                                          the health care team to           health care team
                                                                                                          optimize patient care             members, resolving
                                                                                                                                            conflict when needed

 Understands and                   Solicits insights from and          Integrates contributions           Prevents and mediates             Fosters a culture of open
 respects the role and             uses language that values           from the interdisciplinary         conflict and distress             communication and
 function of                       all interdisciplinary team          team members into the              among the                         effective teamwork within
 interdisciplinary team            members                             care plan                          interdisciplinary team            the interdisciplinary team
 members                                                                                                  members

 Understands and                   Solicits insights from              Integrates contributions           Addresses conflict and            Attends to individual and
 respects the role and             other health care teams             from other health care             distress among other              team distress and
 function of other health          using language that                 team members into the              health care team                  promotes resilience
 care teams                        values all members                  care plan                          members in complex                among other health care
                                                                                                          patient situations                teams

 Comments:
                                                                                                                                Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
                                                                                                                                                                         20
Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Interpersonal and Communication Skills 3: Communication with Health Care Systems

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Accurately records                Demonstrates organized              Concisely reports                  Communicates clearly,             Advocates for a systems
 information in the patient        diagnostic and                      diagnostic and                     concisely, in a timely            approach for consistent
 record                            therapeutic reasoning               therapeutic reasoning and          manner, and in an                 documentation of
                                   through notes in the                physician-patient                  organized written form,           palliative care plan within
                                   patient record                      communications in the              including anticipatory            or across care settings
                                                                       patient record, including          guidance
                                                                       goals of care and
                                                                       advance care planning

 Safeguards patient                Demonstrates accurate,              Appropriately selects              Produces written or               Guides departmental or
 personal health                   timely, and appropriate             direct (e.g., telephone, in-       verbal communication              institutional
 information                       use of documentation                person) and indirect (e.g.,        (e.g., patient notes, e-          communication around
                                   shortcuts                           progress notes, text               mail, etc.) that serves           policies and procedures
                                                                       messages) forms of                 as an example for
                                                                       communication based on             others to follow
                                                                       context

 Communicates through              Documents required data             Uses appropriate                   Collaborates with the             Facilitates dialogue
 appropriate channels as           in formats specified by             channels to offer clear            interdisciplinary team to         regarding systems issues
 required by institution           institutional policy                and constructive                   initiate difficult                among larger community
 policy (e.g., patient                                                 suggestions to improve             conversations with                stakeholders (e.g.,
 safety reports, cell                                                  the system                         appropriate                       institution, health care
 phone/pager usage)                                                                                       stakeholders to improve           system, field)
                                                                                                          the system

 Comments:
                                                                                                                               Not Yet Completed Level 1

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
                                                                                                                                                                          21
Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

 Interpersonal and Communication Skills 4: Complex Communication Around Serious Illness

 Level 1                           Level 2                             Level 3                            Level 4                           Level 5
 Identifies prognostic             Assesses the patient’s              Delivers basic prognostic          Tailors communication             Coaches others in the
 communication as a key            families/caregivers’                information and attends to         of prognosis according            communication of
 element for shared                prognostic awareness                emotional responses of             to disease                        prognostic information
 decision making                   and identifies preferences          patient and                        characteristics and
                                   for receiving prognostic            families/caregivers                trajectory, patient
                                   information                                                            consent, family needs,
                                                                                                          and medical
                                                                                                          uncertainty, and is able
                                                                                                          to address intense
                                                                                                          emotional response

 Identifies the need to            Facilitates communication           Sensitively and                    Independently uses                Coaches shared decision
 assess patient/family             with patient/family by              compassionately delivers           shared decision making            making in patient/family
 expectations and                  introducing stakeholders,           medical information;               to align patient/family           communication
 understanding of their            setting the agenda,                 elicits patient/family             values, goals, and
 health status and                 clarifying expectations,            values, goals and                  preferences with
                                                                       preferences; and                   treatment options to
 treatment options                 and verifying an
                                                                       acknowledges uncertainty           make a personalized
                                   understanding of the                                                   care plan in situations
                                                                       and conflict, with
                                   clinical situation                  guidance                           with a high degree of
                                                                                                          uncertainty and conflict

 Comments:
                                                                                                                              Not Yet Completed Level 1

Interpersonal and Communication Skills
The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training
program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that
includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.
_____ Yes _____ No _____ Conditional on Improvement
*Only required for Internal Medicine based programs
©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
                                                                                                                                                                        22
Version 2                                           Hospice and Palliative Medicine, ACGME Report Worksheet

Overall Clinical Competence

This rating represents the assessment of the fellow's development of overall clinical competence during this year of training:

____ Superior: Far exceeds the expected level of development for this year of training

____ Satisfactory: Always meets and occasionally exceeds the expected level of development for this year of training

____ Conditional on Improvement: Meets some developmental milestones but occasionally falls short of the expected level of development for
      this year of training. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training.

____ Unsatisfactory: Consistently falls short of the expected level of development for this year of training.

*Only required for Internal Medicine based programs

©2019 Accreditation Council for Graduate Medical Education (ACGME)
All rights reserved except the copyright owners grant third parties the right to use the Hospice and Palliative Care Medicine Milestones on a non-exclusive basis for
educational purposes.
                                                                                                                                                                        23
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