The Next GME Accreditation System - Rationale and Benefits
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The n e w e ng l a n d j o u r na l of m e dic i n e
spe ci a l r e p or t
The Next GME Accreditation System — Rationale and Benefits
Thomas J. Nasca, M.D., M.A.C.P., Ingrid Philibert, Ph.D., M.B.A., Timothy Brigham, Ph.D., M.Div.,
and Timothy C. Flynn, M.D.
In 1999, the Accreditation Council for Graduate Limitations of the Current S ys tem
Medical Education (ACGME) introduced the six
domains of clinical competency to the profes- When the ACGME was established in 1981, the
sion,1 and in 2009, it began a multiyear process GME environment was facing two major stresses:
of restructuring its accreditation system to be variability in the quality of resident education8
based on educational outcomes in these compe- and the emerging formalization of subspecialty
tencies. The result of this effort is the Next Ac- education. In response, the ACGME’s approach
creditation System (NAS), scheduled for phased emphasized program structure, increased the
implementation beginning in July 2013. The aims amount and quality of formal teaching, fostered
of the NAS are threefold: to enhance the ability a balance between service and education, pro-
of the peer-review system to prepare physicians moted resident evaluation and feedback, and re-
for practice in the 21st century, to accelerate the quired financial and benefit support for trainees.
ACGME’s movement toward accreditation on These dimensions were incorporated into pro-
the basis of educational outcomes, and to reduce gram requirements that became increasingly
the burden associated with the current structure more specific during the next 30 years.
and process-based approach. The results have been largely salutary. Perfor-
Self-regulation is a fundamental professional mance on certifying examinations has improved,
responsibility, and the system for educating phy- residents are prepared to deal with the dramati-
sicians answers to the public for the graduates it cally increasing volume and complexity of infor-
produces.2 As the accreditor for graduate medi- mation in their specialty, and graduates and ac-
cal education (GME), the ACGME serves this ademic institutions have contributed to clinical
public trust by setting and enforcing standards advances and innovation that the public enjoys
that govern the specialty education of the next today.9,10 In addition, the role of the program
generation of physicians. In this article, we dis- director has been established as an educational
cuss the NAS, including elements and attributes career path, and the formal teaching and as-
of interest to stakeholders (program directors, sessment of residents and fellows have im-
leaders of sponsoring institutions, ACGME’s proved substantially.
partner organizations, residents, and the public). Yet success has come at a cost. Program re-
The ACGME’s public stakeholders have height- quirements have become prescriptive, and op-
ened expectations of physicians. No longer ac- portunities for innovation have progressively
cepting them as independent actors, they expect disappeared. As administrative burdens have
physicians to function as leaders and participants grown, program directors have been forced to
in team-oriented care. Patients, payers, and the manage programs rather than mentor residents,
public demand information-technology literacy, with a recent study reporting administrative
sensitivity to cost-effectiveness, the ability to in- tasks related to compliance as a factor in burn-
volve patients in their own care, and the use of out among directors of anesthesiology pro-
health information technology to improve care grams.11 Finally, educational standards often
for individuals and populations; they also expect lag behind delivery-system changes. The intro-
that GME will help to develop practitioners who duction of innovation through accreditation is
possess these skills along with the requisite limited and is often viewed as an unfunded
clinical and professional attributes.3-7 mandate.
10.1056/nejmsr1200117 nejm.org 1The n e w e ng l a n d j o u r na l of m e dic i n e
The Ne x t Accreditation S ys tem learning experiences (e.g., hours of lectures and
bedside teaching), leaving them free to innovate
In July 2013, the NAS will be implemented by in these areas while continuing to offer guidance
7 of the 26 ACGME-accredited core specialties to new programs and those that do not achieve
(emergency medicine, internal medicine, neuro- good educational outcomes.
logic surgery, orthopedic surgery, pediatrics, diag-
nostic radiology, and urology). In the remaining The Ed uc ational Mile s tone s
specialties and the transitional year (a year of
preparatory education for specialties such as A key element of the NAS is the measurement
ophthalmology and radiology that accept resi- and reporting of outcomes through the educa-
dents at the second postgraduate year), the NAS tional milestones, which is a natural progression
will be implemented in July 2014. Educational of the work on the six competencies. Starting
milestones (developmentally based, specialty- more than 10 years ago, the ACGME, in concert
specific achievements that residents are expected with the American Board of Medical Specialties
to demonstrate at established intervals as they (ABMS), established the conceptual framework
progress through training) have been completed and language of the six domains of clinical com-
or nearly completed for the seven specialties in petency and introduced them into the profes-
the first phase of implementation. The residency sion’s lexicon, mirroring the move toward out-
review committees in these specialties will be in comes and learner-centered approaches in other
an excellent position to begin to collect milestone domains of education.12
data during the 2012–2013 academic year to create In each specialty, the milestones result from
a baseline data set for the NAS. a close collaboration among the ABMS certify-
The NAS moves the ACGME from an episodic ing boards, the review committees, medical-
“biopsy” model (in which compliance is assessed specialty organizations, program-director as-
every 4 to 5 years for most programs) to annual sociations, and residents. The earliest efforts
data collection. Each review committee will per- involved internal medicine, pediatrics, and sur-
form an annual evaluation of trends in key per- gery,13-15 and by late 2011, milestones were be-
formance measurements and will extend the pe- ing developed in all specialties. The aim is to
riod between scheduled accreditation visits to create a logical trajectory of professional develop-
10 years. In addition to the milestones, other ment in essential elements of competency and
data elements for annual surveillance include meet criteria for effective assessment, including
the ACGME resident and faculty surveys and op- feasibility, demonstration of beneficial effect on
erative and case-log data. The NAS will elimi- learning, and acceptability in the community.16
nate the program information form, which is Programs in the NAS will submit composite
currently prepared before a site visit to describe milestone data on their residents every 6 months,
compliance with the requirements. Programs will synchronized with residents’ semiannual eval-
conduct a self-study before the 10-year site visit, uations. Although the internal collection of
similar to what is done by other educational ac- milestone data may be more comprehensive, the
creditors. It is envisioned that these self-studies data submitted to the ACGME will consist of 30
will go beyond a static description of a program to 36 dimensions that represent the consensus
by offering opportunities for meaningful discus- of the assessment committee on the educational
sion of what is important to stakeholders and achievements of residents, informed by evalua-
showcasing of achievements in key program ele- tions the program has performed. Table 1 shows
ments and learning outcomes. a sample of generic milestones for professional-
Ongoing data collection and trend analysis ism, interpersonal and communication skills,
will base accreditation in part on the educational practice-based learning and improvement, and
outcomes of programs while enhancing ongo- systems-based practice. The milestones are based
ing oversight to ensure that programs meet stan- on the published literature on these competen-
dards for high-quality education and a safe and cies17-22 and were developed by an expert panel
effective learning environment. Programs that with representation from the specialties in the
demonstrate high-quality outcomes will be freed early phase for use in milestone development.
to innovate by relaxing detailed process stan- At the completion of training, the final mile-
dards that specify elements of residents’ formal stones will provide meaningful data on the per-
2 10.1056/nejmsr1200117 nejm.orgTable 1. Four Selected General Milestones in the Next Accreditation System.*
Milestone Level 1 Level 2 Level 3 Level 4 Level 5
Professionalism Recognizes the importance Is consistently able to recognize Demonstrates awareness of Develops and applies a consistent Is knowledgeable about, consistently
and priority of patient and identify own beliefs and own values and beliefs and and appropriate approach to uses, and effectively manages ethi-
care, with an emphasis on values and their impact on how they affect perspective evaluating care, possible barri- cal principles of medicine in general
the care that the patient practice of medicine; recognizes on ethical issues; is able to ers, and strategies to intervene and as related to specialty care
wants and needs; demon- internal and external barriers effectively manage person- that consistently prioritizes the Demonstrates leadership and mentor-
strates a commitment to that interfere with patient care al beliefs to avoid any nega- patient’s best interest in all rela- ship on understanding and applying
this value Consistently recognizes ethical is- tive effect on patient care tionships and situations bioethical principles clinically, particu-
Is aware of basic bioethical sues in practice and is able to Is able to effectively analyze Consistently considers and man- larly responsiveness to patients above
principles and is able to discuss, analyze, and manage and manage ethical issues ages ethical issues in practice self-interest and self-monitoring
identify ethical issues in such issues in common and in complicated and chal- and develops and applies a Develops institutional and organiza-
clinical situations frequent clinical situations lenging clinical situations systematic and appropriate tional strategies to protect and
approach to analyzing and maintain these principles
managing ethical issues when
providing medical care
Interpersonal and Identifies team-based care as Actively participates in team- Facilitates or leads team-based NA Seeks leadership opportunities within
communication the optimal approach and based care; supports activities patient care activities professional organizations
skills is able to describe and ap- of other team members, com Actively participates in meet- Facilitates or leads meetings within the
preciate the expertise of municates their value to the ings not directly related to organization or system
each team member, includ- patient and family patient care
ing the patient and family
10.1056/nejmsr1200117
Practice-based Describes basic concepts in Ranks study designs according to Applies a set of critical apprais- Demonstrates a clinical practice Independently teaches and assesses
learning and clinical epidemiology, bio- their ability to minimize al criteria to different types that incorporates principles evidence-based medicine and infor-
special report
improvement statistics, and clinical rea- threats to validity and to gener- of research, including syn- and basic practices of evi- mation-mastery techniques
soning alize to larger populations opses of original research dence-based practice and Can cite evidence supporting several
nejm.org
Categorizes the study design Identifies critical threats to study findings, systematic reviews information mastery common practices
of a research study validity when reading a re- and meta-analyses, and
search paper or study synopsis clinical-practice guidelines
Distinguishes research outcomes Critically evaluates information
that directly affect patient care from others: colleagues,
from other outcomes experts, pharmaceutical
Formulates a searchable question representatives, and pa-
from a clinical question (e.g., tient-delivered information
using the PICO format)
Systems-based Can describe systems theory Reports problematic devices, Analyzes the causes of ad- Can compare and contrast failure Recommends and justifies characteris-
practice and the characteristics of architecture, and processes verse events through root- modes and effects analysis with tics of high-reliability organizations
high-reliability organizations (including errors and near cause analysis root-cause analysis as a patient- (e.g., reporting adverse events, root-
Understands the epidemiology misses) to supervisor, institu- Demonstrates basic usability safety tool in health care cause analysis, and failure modes
of medical errors and the tion, or program, as appropriate testing and critique design Develops content for and facilitates and effects analysis) to organizational
differences between medi- Illustrates with examples how of devices, architecture, a morbidity-and-mortality pre- leadership to promote patient safety
cal errors, near misses, and human-factors engineering and processes on the basis sentation or conference focus- Develops and works with multidiscipli-
sentinel events promotes patient safety (e.g., of principles of human- ing on systems-based errors in nary teams (e.g., human-factors en-
Can define human-factors Stroop effect, perceptual illu- factor engineering patient care gineers, reference librarians, and cog-
engineering sions, easily confused medi nitive and social scientists) to find
cations) solutions to patient-safety problems
* The four listed milestones, which were developed by an ACGME expert panel, reflect the following expected levels of performance: level 1, typical graduating medical student; levels 2 and 3, resident
during the program; level 4, graduating resident; and level 5, advanced, specialist resident or practicing physician. NA denotes not applicable, and PICO patient, population, or problem; interven-
tion; comparison (alternative to intervention); and outcome.
3The n e w e ng l a n d j o u r na l of m e dic i n e
formance that graduates must achieve before forming, efficient, and cost-effective health care
entering unsupervised practice. This process system and that have been recommended by ex-
moves the competencies “out of the realm of the perts and stakeholder groups.3-7
abstract and grounds them in a way that makes In the context of our aspirations for the NAS,
them meaningful to both learners and faculty.”13 it is important to note the limits of accreditation.
The final milestones also create the entry point Much has been written about the constrained
into the maintenance of certification and licen- environment for GME, including threatened re-
sure phase of lifelong learning. The initial mile- ductions in support for physician training and
stones for entering residents will add a perfor- increased productivity pressures on academic
mance-based vocabulary to conversations with institutions and their faculties. The development
medical schools about graduates’ preparedness of the NAS is sensitive to these factors, since
for supervised practice.23 Over time, the mile- they are characteristics of the environment in
stones will reach into undergraduate medical which GME programs, sponsoring institutions,
education to follow the adoption of the compe- and the ACGME operate. At the same time, ac-
tencies by many medical schools. This will con- creditation is not a panacea, and no accredita-
tribute to a more seamless transition across the tion model by itself can effectively compensate
medical-education continuum. for the overuse of resources, inefficiencies, and
Another key element of the NAS is emphasis disparities that characterize aspects of the na-
on the responsibility of the sponsoring institu- tion’s health care system. It would be presump-
tions for the quality and safety of the environ- tuous to expect accreditation to effectively resolve
ment for learning and patient care, a key dimen- these problems. Rather, its roles are to arm the
sion of the 2011 common program requirements.24 next generation of physicians with knowledge,
This will be accomplished through periodic site skills, and attributes that will enhance care in
visits to assess the learning environment. Insti- the future and to expand the traditional role of
tutions will see their results, and the first visit residents in the care of underserved populations
will establish a baseline for self-comparison over to an enhanced understanding of the problem of
time. The process will generate national data on health disparities and how to eradicate them.26
program and institutional attributes that have a Finally, although accreditation must be sensi-
salutary effect on quality and safety in settings tive to the burden it creates on programs, insti-
where residents learn and on the quality of care tutions, and individuals, it would be dangerous
rendered after graduation.25 to expect accreditation to reduce its expectations
to accommodate the host of other pressures on
Benefit s and Limitations the system of physician training. Any move to
create a reductionist model of accreditation to
The visits to sponsoring institutions will ensure avoid burdening the system may further erode
that residents are exposed to an appropriate public support for physician education and pub-
learning environment, and the milestones will lic trust in the physicians the system produces.
ensure that they demonstrate readiness for inde- Constrained finances and future threats of re-
pendent practice and possess the attributes that ductions make it even more important for ac-
the public deems to be important in physicians. creditation to ensure that learners are not un-
As future competencies emerge, the milestones duly burdened with service obligations that do
will enhance the ability of the ACGME to ensure not meaningfully contribute to their education27
their successful incorporation into the physician’s and that education and patient care proceed in
armamentarium. The NAS will enhance educa- an environment that complies with requirements
tion focused on physician competencies that are for duty hours, supervision, and other elements
deemed to be relevant to the health of individu- important to the safety of patients and resi-
als and populations. Through this, the NAS will dents.28 This makes the visits to sponsoring in-
benefit employers of new graduates and the pub- stitutions a critical component of the NAS in
lic by enhancing the competence of future physi- the untoward event of serious cuts in support
cians in areas that are relevant to a well-per- for GME.
4 10.1056/nejmsr1200117 nejm.orgspecial report
Conclusions system and enhances it with a more explicit fo-
cus on attributes of the learning environment
Key benefits of the NAS include the creation of a that carry over into a lifetime of practice in a
national framework for assessment that includes clinical specialty. By encouraging high-perform-
comparison data, reduction in the burden asso- ing programs to innovate, the system will open
ciated with the current process-based accredita- the quality ceiling and produce new learning.
tion system, the opportunity for residents to Simultaneously, an ongoing process-based ap-
learn in innovative programs, and enhanced res- proach for programs with less-than-optimal per-
ident education in quality, patient safety, and the formance will continue to raise the floor for all
new competencies. Over time, we envision that programs.
the NAS will allow the ACGME to create an ac- Disclosure forms provided by the authors are available with
creditation system that focuses less on the iden- the full text of this article at NEJM.org.
We thank the members of the ACGME expert milestone
tification of problems and more on the success panel: Susan Swing, Ph.D., ACGME, Arden Dingle, M.D., Emory
of programs and institutions in addressing them. Medical School, Catherine A. Marco, M.D., University of Toledo
Although the ACGME has not piloted the College of Medicine, Karen Brasel, M.D., M.P.H., Medical Col-
lege of Wisconsin, Rich Frankel, Ph.D., Indiana University,
NAS in its entirety, pivotal elements of the sys- Joanne Schwartzberg, M.D., American Medical Association,
tem have been tested successfully in the Educa- Tina Foster, M.D., M.P.H., Dartmouth–Hitchcock Medical Cen-
tional Innovation Project in internal medicine ter, Gary Loyd, M.D., M.M.M., University of Louisville School
of Medicine, Prathibha Varkey, M.B., B.S., M.H.P., M.H.E.P.,
and in a multiyear pilot in emergency medicine. Mayo Clinic; and Robin Hemphill, M.D., M.P.H., Douglas
Besides testing annual data collection, the Edu- Paull, M.D., and Linda Williams, R.N., M.S.I., VA National
cational Innovation Project provided the ACGME Center for Patient Safety.
with insight into standards that could be re- From the Accreditation Council for Graduate Medical Educa-
laxed for high-performing programs (i.e., a 40% tion, Chicago (T.J.N., I.P., T.B., T.C.F.); Jefferson Medical College
reduction in requirements for the internal medi- of Thomas Jefferson University, Philadelphia (T.J.N, T.B.); and the
University of Florida College of Medicine, Gainesville (T.C.F.).
cine program, which went into effect in July
200929). Knowledge about acquisition of data ele- This article (10.1056/NEJMsr1200117) was published on Febru-
ments around the milestones is being gained ary 22, 2012, at NEJM.org.
from the ACGME’s international accreditation 1. Swing SR, Clyman SG, Holmboe ES, Williams RG. Advanc-
effort in Singapore and will benefit the imple- ing resident assessment in graduate medical education. J Grad
mentation of the NAS. Finally, the learning Med Educ 2009;1:278-86.
2. McCullough LB. An ethical framework for the responsible
gained from the first phase of the NAS will bene- leadership of accountable care organizations. Am J Med Qual
fit the specialties that will implement the NAS 2011 November 23 (Epub ahead of print).
in the second phase. 3. Ensuring an effective physician workforce for the United
States: recommendations for reforming graduate medical edu-
Much work remains to be done. The next step cation to meet the needs of the public: conference summary.
in moving toward the NAS will involve inform- New York: Josiah Macy Jr. Foundation, September 2011 (http://
ing the GME community about the NAS, with a josiahmacyfoundation.org/docs/macy_pubs/JMF_GME_
Conference2_Monograph(2).pdf).
particular focus on the milestones. This work 4. Team-based competencies: building a shared foundation
will continue in close collaboration with program- for education and clinical practice: conference proceedings.
director organizations, the ABMS boards, the New York: Josiah Macy Jr. Foundation, September 2011 (http://
josiahmacyfoundation.org/docs/macy_pubs/Team-Based_
specialty colleges, and related academic organi- Competencies.pdf).
zations. The ACGME will continue its role in 5. Graduate medical education financing: focusing on educa-
educating program directors, faculty, and others tional priorities. Washington, DC: Medicare Payment Advisory
Commission (MedPAC), June 2011 (http://www.medpac.gov/
by building on its annual conference, with a chapters/Jun10_Ch04.pdf).
focus on faculty development that is sensitive to 6. Council on Graduate Medical Education. Eighteenth Report:
time and financial constraints for many faculty new paradigms for physician training for improving access to
health care. Rockville, MD: Department of Health and Human
members. Services, September 2007.
The NAS will support the education of physi- 7. America’s Affordable Health Choices Act of 2009. 111th
cians to provide care for Americans into the Cong., 2nd sess. HR 4872, Sec. 1505. Improving accountability
for approved medical residency training. Washington, DC: Gov-
middle of the century. This requires an endur- ernment Printing Office, 2010.
ing system that takes the best of the current 8. Federated Council for Internal Medicine. Enhancing stan-
10.1056/nejmsr1200117 nejm.org 5special report
dards for excellence in internal medicine training. Ann Intern 20. Moskowitz EJ, Nash DB. Accreditation Council for Graduate
Med 1987;107:775-8. Medical Education competencies: practice-based learning and
9. Zinner DE, Campbell EG. Life-science research within US systems-based practice. Am J Med Qual 2007;22:351-82.
academic medical centers. JAMA 2009;302:969-76. 21. Varkey P, Karlapudi S. Lessons learned from a 5-year expe-
10. Association of American Medical Colleges. Discoveries and rience with a 4-week experiential quality improvement curricu-
innovations in patient care and research, 2000 through 2010 lum in a preventive medicine fellowship. J Grad Med Educ 2009;
(http://services.aamc.org/innovations/index.cfm?fuseaction= 1:93-9.
home.search). 22. Ogrinc G, Headrick LA, Morrison LJ, Foster T. Teaching and
11. De Oliveira GS Jr, Almeida MD, Ahmad S, Fitzgerald PC, Mc- assessing resident competence in practice-based learning and
Carthy RJ. Anesthesiology residency program director burnout. improvement. J Gen Intern Med 2004;19:496-500.
J Clin Anesth 2011;23:176-82. 23. Lypson ML, Frohna JG, Gruppen LD, Woolliscroft JO. As-
12. Allan J. Learning outcomes in higher education. Studies High sessing residents’ competencies at baseline: identifying the gaps.
Educ 1996;21:93-108. Acad Med 2004;79:564-70.
13. Green ML, Aagaard EM, Caverzagie KJ, et al. Charting the 24. Nasca TJ, Day SH, Amis ES Jr. The new recommendations on
road to competence: developmental milestones for internal duty hours from the ACGME Task Force. N Engl J Med 2010.
medicine residency training. J Grad Med Educ 2009;1:5-20. DOI: 10.1056/NEJMsb1005800.
14. Hicks PJ, Schumacher DJ, Benson BJ, et al. The pediatrics 25. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Eval-
milestones: conceptual framework, guiding principles, and ap- uating obstetrical residency programs using patient outcomes.
proach to development. J Grad Med Educ 2010;2:410-8. JAMA 2009;302:1277-83.
15. Bell RH. National curricula, certification and credentialing. 26. Betancourt JR. Eliminating racial and ethnic disparities in
Surgeon 2011;9:Suppl 1:S10-S11. health care: what is the role of academic medicine? Acad Med
16. Norcini J, Anderson B, Bollela V, et al. Criteria for good as- 2006;81:788-92.
sessment: consensus statement and recommendations from the 27. Weinstein DF. Duty hours for resident physicians: tough
2010 Ottawa Conference. Med Teach 2011;33:206-14. choices for teaching hospitals. N Engl J Med 2002;347:1275-8.
17. Kahn MW. Etiquette-based medicine. N Engl J Med 2008;358: 28. AAMC policy guidance on graduate medical education: as-
1988-9. suring quality patient care and quality education. Acad Med 2003;
18. Kumagai AK, Lypson ML. Beyond cultural competence: crit- 78:112-6.
ical consciousness, social justice, and multicultural education. 29. Impact statement for revisions to the program requirements
Acad Med 2009;84:782-7. for graduate medical education in internal medicine, effective
19. Plochg T, Klazinga NS, Starfield B. Transforming medical July 1, 2009. Chicago: Accreditation Council for Graduate Medi-
professionalism to fit changing health needs. BMC Med 2009; cal Education, September 2008.
7:64. Copyright © 2012 Massachusetts Medical Society.
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