Acronym Update:

NAS, CLER, EPA and more

Surgery Grand Rounds November 6th, 2013 Katie McKinney Assistant Dean, GME Susan McDowell, DIO and Associate Dean, GME

Objectives Define NAS, CLER, EPA Compare ACGME accreditation

standards before and after the NAS Describe the meaning of milestones Demonstrate MedHub features pertinent

to NAS

Faculty Disclosure None

Why this topic? The Accreditation Council for Graduate

Medical Education (ACGME) published new accreditation standards (NAS) for Graduate Medical Education (GME) that were effective in a two year roll out beginning July 1, 2013.

Background to change Motivation

Medicare contributes billions of dollars annually to educate physicians

System for educating physicians must answer to the public for the graduates it produces.

Need for more explicit definitions of a ‘good physician’ Implement a more robust formula for developing/tracking

MD competence prior to allowing independent practice

Behind the scenes

July 1, 2013 Implementation

of NAS

2009 Initiation of

restructuring accreditation

1999 introduction

of core competencies

2000 IOM Report

Licensing Board CME standards

Healthcare Reform

Legislation

Why NAS now? Public stakeholders have heightened

expectations of physicians Patients, payers and the public demand

Access to proper care Information technology literacy Sensitivity to cost effectiveness Involvement of patients in their own care

Where are we now?

Phase 1 Radiology

Emergency Medicine Internal Medicine

Neurological Surgery Orthopedic Surgery

Pediatrics Plastics

Phase 2 Everybody else

General Surgery Thoracic Surgery

Urology Vascular

TBA Understanding

outcomes

July 2013 July 2014

NAS: what hasn’t changed? Pre-requisites for GME training:

Med school degree, pass USMLE exams 1-2CK/CS* GME training program content/length ACGME work hour rules:

PGY1 no more than 16 hours PGY2+ no more than 24 + 4 1 day off in 7 averaged over 4 weeks Minimum 8 hours off between shifts; rec 10 hours

Requirements for independent practice/licensure Completion of GME training Pass specialty board exam(s) Maintain CME

*or in select cases equivalent exams

NAS: what has changed? Before…

Rules Corresponding questions Correct/Incorrect answer Citation and Accreditation Decision

Wait 2 to 5 years and start all over

NAS: what has changed? Continuous Observations

Diagnose the Problem

Potential Problem

Ensure Program Fixes Problem Promote Innovation

NAS: what has changed? Continuous accreditation model No cycle lengths Data reviewed annually Accreditation status assigned annually

Commend a program Identify areas of concern requiring follow up Issue citations Continue or remove prior citations/concerns Increase or reduce resident complement

Self-Study visit every ten years…or so

NAS Data Annual program ACGME ADS Update

Program Characteristics-Structure/resources Program Changes-PD/Core Faculty/Residents Scholarly activity of faculty and residents Omission of data

Rolling Board pass rate Annual ACGME Resident/Faculty Survey Case/Procedure logs Semi-annual resident evaluation on Milestones

Milestones v Competencies Intent of milestones: operationalize ACGME

competencies: Patient Care Medical Knowledge Professionalism Systems based Practice Inter-professional and communication skills Practice Based Learning and Improvement

Milestones: knowledge, skills, attitudes for each competency organized into a developmental framework

Developmental framework?

MD degree

Finish GME

“The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty”

One size does NOT fit all ACGME developed concept Specialty boards developed milestones Result:

Formula for tracking milestones same across specialties: semi-annual report to ACGME

Milestones don’t translate outside of training specialty

Milestone examples Competency: patient care Goal of milestone: operationalize

knowledge, skills, attitudes that would demonstrate learner’s development in this domain

General Surgery: PC3-Performance of operations and procedures Orthopedics: PC1-Ankle fracture Urology: PC6-Performs open surgical procedures Internal Medicine: PC4-Skill in performing procedures

Milestone measurement Milestones are arranged into numbered

levels. These levels do not correspond with post-graduate year of education.

General Surgery: PC3-Performance of operations and procedures

Milestone Levels for General Surgery Critical

Deficiencies

Level 1

Level 2

Level 3 Level 4

learner behaviors are not within the spectrum of developing competence…they indicate significant deficiencies in a resident’s performance

demonstrating milestones expected of an incoming resident

advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level

continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency

advanced so that he/she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target

Compared to…NS, Ortho, Plastics, Thoracic, Uro Critical

Deficiencies

Level 1

Level 2

Level 3 Level 4 Level 5

learner behaviors are not within the spectrum of developing competence…they indicate significant deficiencies in a resident’s performance

demonstrating milestones expected of an incoming resident

advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level

continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency

advanced so that he/she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target

advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level

Milestone mayhem Difficulty with interpretation of meaning across

specialties Questions at training program level regarding

how to translate evaluation methods/assessment tools

Little (Phase 1) or no (Phase 2) longitudinal data to understand results

Take home for residents/faculty: understand whether and how NAS/milestones changes completing/interpreting evaluations

What about CLER? CLER=Clinical Learning Environment

Review ACGME process for understanding GME

and institutional ‘inter-connectedness’ related to clinical quality, patient safety, trainee quality of life

Underlying question: is everyone on the same page?

Why the CLER? • 2009-2010 ACGME “Duty Hours Task Force” and

“Task Force for Quality Care and Professionalism”

• Linked adherence to duty hours policies /integrity in reporting to professional responsibility for patient safety/quality

• Established importance of educating residents/fellows on institutional Patient Safety and Quality Improvement programs

• Assigned responsibility to institutions for engaging and monitoring residents/fellows across targeted areas

• Recommends assessment in the form of a sponsor visit program called the Clinical Learning Environment Review (CLER)

Nasca, T.J., Day, S.H., Amis, E.S., for the ACGME Duty Hour Task Force. Sounding Board: The New Recommendations on Duty Hours from the ACGME Task Force.

New England Journal of Medicine. 362 (25): e3(1-6). 2010. June 23, 2010.

CLER Program: 6 Focus Areas Integration of residents into institution’s Patient Safety

programs, and demonstration of impact Integration of residents into institution’s Quality

Improvement programs and efforts to reduce Disparities in Health Care Delivery, and demonstration of impact

Establishment, implementation, and oversight of Supervision policies

Oversight of Transitions in Care Oversight of Duty Hours Policy, Fatigue Management

and Mitigation Education and monitoring of Professionalism

CLER Site Visit Little advance notice given or required prep Optional request to DIO to provide copies of

existing documents one week prior to visit: Relevant organizational charts, select

committee rosters Site’s organizational strategies for patient safety

and healthcare quality Institution/participating site’s policies on

supervision, transitions in care, duty hours

Presenter

Presentation Notes

Pre-scheduled group interviews: Senior leadership of participating site (CEO, COO, CMO, CNO, DIO and Chair of GMEC)— beginning and end Leader(s) in patient safety and healthcare quality Peer-selected residents from each program area Core Faculty Program Directors Random interviews of staff and patients (e.g. nurses, pharmacist): “walk arounds” of patient floors, OR and clinics

Proposed CLER Evaluation Process

CLER Buy In--“Why it matters to the individual training program”

CPR: VI.A.3. The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

CPR: VI.A.5.g. the monitoring of their patient care performance improvement indicators; and,

Sponsoring Institution gets a public grade starting the second round of visits.

CLER-where are we? UK-UHC #12; Rising Star Award GME focus

Continuing standardization of processes/protocols for duty hours monitoring, supervision…

Enhance GME/programs awareness of enterprise quality/safety initiatives

Enhance resident/fellow meaningful involvement in enterprise patient safety/quality initiatives

MedHub Update Web-based platform for GME/training

program data management Replaces New Innovations as of

November 1 for: Evaluation completion Duty hours logging/tracking Procedures logging/tracking Trainee schedule management

Questions?