ACGME Competencies
Robert Wigton, MD
Associate Dean
Graduate Medical Education
Outline
1. Background: the ACGME requirements
2. What are the 6 Competencies and where
did they come from?
3. How do we teach them?
4. How do we evaluate them?
5. Where do we go from here?
6. How can this help your own professional
development?
ACGME (Accreditation Council for
Graduate Medical Education)
Predecessor = AMA Council on Medical
Education
Member Organizations
• American Board of Medical Specialties
(ABMS)
• American Hospital Association (AHA)
• American Medical Association (AMA)
• Association of American Medical Colleges
(AAMC)
• Council of Medical Specialty Societies
(CMSS)
Residency Review Committees (RRCs)
David Leach, MD
Executive Director
Recent Changes at the ACGME:
• Relationship of the ACGME to the Residency
Review Committees (RRCs)
• Common Program Requirements
• Work hours regulations
• The Outcomes Project
– 6 Resident Competencies
“General Competencies”
1. Patient Care
2. Medical Knowledge
3. Practice-Based Learning and
Improvement
4. Interpersonal and Communication Skills
5. Professionalism
6. Systems-Based Practice
Where Did the 6 Competencies
Come From?
Background:
Issues in Medical Practice
•
Government funding and regulation of health care with their complex
regulations and procedures
– Medicare
– DRGs and billing systems: require more sophisticated charting and billing
– Medicare payments to hospitals for residents (IME, DME)
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HMOs and the managed care movement:
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Systems of care affect productivity and workload
New emphasis on population medicine
Patient centered care
Concerns about HMOs’ negative effects on professionalism
Quality of care
– TQI: Deming, Don Berwick and IHI,
– NASA, Lucian Leape
– “To Err is Human”: IOM and medical error
•
Resident working conditions
– Libby Zion and the Bell Commission
Background: Managed Care
• Systems of care
• Emphasis on
population medicine
• Patient centered care
• Concerns about
professionalism
Background: Medical Errors
– NASA, Lucian Leape
– “To Err is Human”:
IOM and medical
error
Background: Quality of Care
– TQI: Deming,
– Don Berwick
– Institute for Healthcare
Improvement (IHI)
The “Meta-Curriculum”
Meta- = beside, about, beyond
Each is well established with national organizations, annual meetings,
and body of literature and many have dedicated journals
• TQI, QI, Continuous Improvement
• Medical Systems
• Medical Decision Making (MDM), Cost Effectiveness
• Evidence-Based Medicine (EBM)
• Medical Informatics
• Epidemiology, Medical Statistics
• Population Medicine
• Prevention
• Medical Interviewing
• Procedural Skills
• Teaching Residents to Teach
• Diversity
Minimum Requirements
(Inserted in All Special Requirements)
• The residency program must require its
residents to obtain competencies in the 6 areas
to the level expected of a new practitioner.
Programs must define the specific knowledge,
skills, and attitudes required and provide
educational experiences as needed
• The residency program must demonstrate that it
has an effective plan for assessing resident
performance throughout the program and for
utilizing assessment results to improve resident
performance.
General Competencies:
1. Patient Care
2. Medical Knowledge
3. Practice-Based Learning and
Improvement
4. Interpersonal and Communication Skills
5. Professionalism
6. Systems-Based Practice
6 Competencies
Mostly, these are bins or groupings of
related topics, not dimensions of behavior.
(Except for interpersonal skills)
• Bins
– Earth science, 18th century Europe,
cosmology, how to fix different brands of
refrigerators
• Dimensions
– Knowledge, friendliness, neatness, hand-eye
coordination, common sense, aggressiveness
Patient Care
The secret of the care of the patient is
caring for the patient...
Francis Wold Peabody 1927
Peabody FW. The care of the patient. JAMA. 1927;88:877-82
1. Patient Care
Residents must provide patient care that is
compassionate, appropriate, and effective -• Caring and respectful behaviors when interacting
with patients and their families
• Interviewing (Medical Interviewing)
• Informed decision making (MDM)
• Develop and carry out patient management plans
• Counsel and educate patients and their families
• Use information technology (Informatics)
• Perform competently all procedures (Procedural
Skills)
• Preventive health care services (Prevention)
• Work in a team
2. Medical Knowledge
Knowledge in field, including
• Investigatory and analytic thinking (MDM)
• Knowledge and application of the basic and
clinical sciences.
3. Practice-Based Learning
and Improvement
• Analyze own practice for needed improvements (TQI,
QI)
• Use evidence from scientific studies (EBM)
• Apply research and statistical methods (Statistics)
• Apply knowledge of study designs and statistical
methods to the appraisal of clinical studies and other
information on diagnostic and therapeutic effectiveness
(Epidemiology, Cost Effectiveness)
• Use information technology (Informatics)
• Facilitate the learning of others (Teaching Residents to
Teach)
4. Interpersonal and
Communication Skills
• Create therapeutic relationship with
patients
• Develop listening skills
• Work effectively as part of a health
care team.
5. Professionalism
• Respectful, altruistic
• Ethically sound practices
• Sensitive to culture, age, disability
(Diversity)
6. Systems-Based Practice
• Understand interaction of their practice
with larger system
• Know about practice and delivery systems
• Practice cost-effective health care
• Advocate for patients within the health
care system.
• Partner with health care managers and
health care providers to assess,
coordinate, and improve health care
Medical Outcomes Project
10 year timeline, RWJ development grant
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Teach the six competencies
Evaluate residents’ competencies
Demonstrate continuous improvement
Teaching Competencies:
COM Online Courses for Residents
330. House Officer Teaching Skills
331. Medical-Legal Issues
332. Quality of Care, EBM & Stats
333. Professionalism
333a. Strategies for Physician-Patient
Communication
334. Healthcare Economics (Systems)
334a. Personal Finance
334b. Billing & Documentation
335. Medical Ethics
Teaching Competencies:
Orientation Topics
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Malpractice
Medical Informatics
Fatigue and Working Conditions (SAFER)
Quality Improvement
Impaired Physicians
Licensure
Hospital Systems
Error and Safety
Patient Relations
Evaluation of Competencies
Evaluation Toolbox
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Record review
Chart stimulated recall
Checklist forms
Global ratings
Standardized patients
OSCEs
360˚ Assessment
Portfolios
Exams
Case logs
On the ACGME Website: www.ACGME.org . Go to Outcome Project
360 Degree Evaluation
• Surveys of people who work with the resident
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Nurses
Other residents
Students
Other health professionals
Staff
• Given as feedback to resident to help improve
(few studies of effectiveness and reliability in
resident education)
Chart-Stimulated Recall
• Oral exam of resident using recent patient
records
• Examiner probes reasoning, actions,
differentials etc.
• Exam procedure and scoring rules
standardized
(Well studied, psychometrics good)
Objective Structured Clinical
Examination (OSCE)
• Encounter stations lasting 10-15
minutes
• Each station designed to observe
and asses specific task
• Widely used
(Many studies of effectiveness and
generalizability)
Portfolios
• Collection of “products” of education
• Prepared by the resident
• May include
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Personal and professional goals
Learning objectives
Logs of procedures, cases
Case summaries
Documented achievements
Etc.
(Most studies are descriptive)
Tailoring Evaluation to the
Competency
Strategies for Creating Evaluations
• Import successful techniques, forms, protocols
from other programs
• Pool expertise with other program directors
• Enlist other faculty in your department
• Outcome research projects
• Visiting experts
• Grants
• RIME journal club
• Don’t reinvent the wheel if you don’t need to.
Issues for Designing Evaluation
• Evaluation should be useful and result in
measurable improvement
• Evaluation emphasis should be
proportional to importance of topic.
(Evaluation can drive the curriculum)
Professional Development
Strategies for Faculty
• Faculty Educational Portfolio
– Evaluation design
– Project leadership
– Creating online resources
• Papers
– Academic Med, Med. Educ., T&L in Med., others
– General Medical Journals, JAMA etc
– Journals in your specialty
• Presentations
– AAMC: RIME, GEA, Central GEA, GRA, ACGME
– International medical education meetings: AMEE etc
– Specialty meetings
References
• Lists of references at the ACGME web site: ACGME.org
for each of the competencies.
Also --• Berwick DM. Escape Fire : Designs for the Future of
Health Care
• Corrigan J, Kohn L, Donaldson, M.(eds) To Err Is
Human: Building a Safer Health System.
• Institute of Medicine (eds) Crossing the Quality Chasm:
A New Health System for the 21st Century
• Closing the Quality Gap. AHRQ publications at
http://www.ahrq.gov/downloads/pub/evidence/pdf/qualga
p1/contents.pdf