MILESTONES, EPAS, NAS…AND OTHER ACGME JARGON Committee on Graduate Medical Education
MILESTONES, EPAS, NAS…AND OTHER ACGME JARGON Committee on Graduate Medical Education September 24, 2012 Sara LP Ross, MD Objectives To discuss the Next Accreditation System and what is known about how that will look in 2019 To discuss the system of trainee evaluation – Milestones and EPAs NAS: Next Accreditation System Goals Complete realization of the Outcomes promise Free up “good programs” to innovate Assist poor programs in improving Reduce burden of accreditation Establish and implement milestones to better track program and institutional performance Provide accountability to the public July 2012: Seven initial core specialties/RRCs begin NAS training July 2013: NAS officially begins; seven specialties “go live”; remaining specialties begin training July 2014: All specialties/RRCs using NAS NAS: Next Accreditation System 10-year self-study visit model: next visit 2019 for all Peds department programs Residents will submit a confidential consensus list of five strengths and “opportunities for improvement” (OFIs) the residents wish to discuss Structure, Resources, Core processes, Detailed processes, Outcomes “What is your plan for the next 10 years to improve” Site visitor will share strengths, but will only share OFIs if residents give permission (makes residents feel more connected to the site visit) Annual program surveillance Performance indicators for each specialty developed by a “community of educators” within the specialty Annual Resident Survey Core elements of the competencies Levels of performance Core methods of assessment Annual Faculty Survey Case Log Data NAS: Next Accreditation System Institutional 18 month review Ongoing creation of Milestones Programs will get a letter annually stating that they meet all “performance indicator thresholds” May be placed on “accreditation with warning” at any point during the 10-year cycle May warrant an “immediate visit” If problems not fixed during a given window of time, program may be placed on probation Site Visits Structure of the visit: 2 site visitors Brief meeting with PD Resident and faculty interviews Meeting with DIO Meeting with PD PIF Elimination – YES (most likely) More focus on strengths of programs Competencies Competence: the ability to do something successfully (Oxford Dictionary of English) Competencies: broad, general attributes of a good doctor With attempt at evaluation they get widdled down to detailed skills/activities In the end don’t really reflect the original meaning of the general competency Competence = Attribute Activity= Element of professional work Entrustable Professional Activities (EPAs) Units of work that may be awarded a more or less formal qualification at the moment when supervisors confirm the trainee is ready to assume responsibility for such activities Entrustable Professional Activities (EPAs) Which critical professional activities cover the relevant competencies of the profession? How can supervisors learn when to entrust such activities to the trainee? “Trust reflects a dimension of competence that reaches further than observed ability. It includes the real outcome of training – the quality of care” Part of essential professional work Require specific knowledge, skill and attitude Lead to recognized output of professional labor Confined to qualified personnel Be independently executable within a timeframe Be observable and measurable in its process and outcome (well done or not well done) Reflect one or more competencies to be acquired EPAs Domains of Competency Competencies Milestones EPA/Competency Matrix Viewpoint: Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice? ten Cate, Olle; Scheele, Fedde Academic Medicine. 82(6):542-547, June 2007. DOI: 10.1097/ACM.0b013e31805559c7 EPAs May be acknowledged formally as a “statement of awarded responsibility” (STAR) Five levels of proficiency 1. 2. 3. 4. 5. Has knowledge May act under full supervision May act under moderate supervision May act independently May act as a supervisor and instructor Expected Levels of Confidence Time to achieve STAR in a specific EPA dependent on: The EPA The working environment The trainee The clinical teacher EPA Mapped to Competencies/ Subcompetencies Milestones Developmental roadmap for the competencies and subcompetencies Observable developmental steps moving residents from novices to experts/masters Means of restructuring competencies into a measurable rubric of six domains of clinical competency EPAs Domains of Competency Competencies Milestones EPA Serve as the primary admitting pediatrician for previously well children suffering from common acute problems Milestone Patient Care: Gather essential and accurate information about the patient Patient Care: Provide transfer of care that ensures seamless transitions Medical Knowledge: Demonstrate sufficient knowledge of the basic and clinically supportive sciences appropriate to pediatrics Level I Level II Level III Gathers too little info or exhaustively gathers info following a template regardless of patient's chief complaint. Recalls clinical info in the order elicited, with ability to gather, filter, prioritize, and connect pieces of info. Advanced development of pattern recognition leads to the creation of illness scripts which allow Clinical information to experience be gathered allows linkage while it is of signs and simultaneously symptoms of a filtered, current patient prioritized and to those synthesized encountered in into specific previous diagnostic patients. considerations. Robust illness scripts and instance scripts Well-developed lead to illness scripts unconscious allow essential gathering of and accurate info essential and to be gathered accurate info in and precise a targeted and diagnoses to be efficient reached with manner when ease and presented with efficiency when all but the most presented with complex or rare most pediatric clinical problems. problems. Demonstrates variability in transfer of info from one patient to the next. Frequent errors of both omission and commission. Uses a standard template for the info provided during the handoff. Unable to deviate from that template to adapt to more complex situations. May have errors of omission or commission. Neither anticipates nor attends to the needs of the receiver of info. Adapts and applies a standard template to increasingly complex situations in a broad variety of settings and disciplines. Ensures open communication, including but not limited to readbacks, repeatbacks and clarifying questions Does not know or remember the basic content knowledge of common pediatric problems and illnesses Learns from Able to analyze experience; and evaluate analyzes a Understands knowledge in a situation, the basic way that allows evaluates what Understands content the generation of worked well the basic knowledge of a meaningful and what did content pediatric differential not, and knowledge of practice, and is diagnosis and creates, adapts, pediatrics, but able to can develop or extrapolates is still learning synthesize and meaningful info to apply it to apply it in a clinical appropriately clinical clinical management to new clinical situations situation plans situations Adapts and applies a standardized template, relevant to individual contexts, reliably and reproducibly, with minimal errors of omission or commission. Allows ample opportunity for clarification and questions. Level IV Level V Adapts and applies the template w/o error and regardless of setting or complexity. Internalizes the professional responsibility aspect of handoff communication . What milestone levels equate to different levels of proficiency? Who determines you can practice the EPA independently going forward? Minimum standards for advancement/graduation? Where Are We in Pediatrics? January 2012 September 2012 The Pediatrics Milestone Project (51) Selection of 21 Pediatric Milestones to be reported on semi-annually - Requests for additional sites to study/ develop each of these milestones Fall/Winter 2012 Program development of evaluation tool July 2013 Implementation of Milestone reporting Where Are We in Pediatrics? January 2012 September 2012 The Pediatrics Milestone Project (51) Selection of 21 Pediatric Milestones to be reported on semi-annually - Requests for additional sites to study/ develop each of these milestones Fall/Winter 2012 Program development of evaluation tool July 2013 Implementation of Milestone reporting References Carraccio C, Burke A. Beyond competencies and milestones: Adding meaning through context. J of Grad Med Ed. 2010;2(3):419-422. ten Cate O. Trust, competence, and the supervisor’s role in postgraduate training. British Medical Journal. 2006;333:748-751. ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2001;82:542-547.