Michael T. Flannery, M.D., F.A.C.P.

Professor of Medicine

GME Internal Review Director

NEXT ACCREDITATION SYSTEM

THREE COMPONENTS

1.) Milestones

2.) Clinical Learning Environment Review

(CLER)

3.) Clinical Competency Committee (CCC)

NEXT ACCREDITATION SYSTEM

THREE COMPONENTS

1.) Milestones

2.) Clinical Learning Environment Review

(CLER)

3.) Clinical Competency Committee (CCC)

NEXT ACCREDITATION

SYSTEM GOALS

1.) Responsive to public

2.) Reduce accreditation burden

3.) Free good programs to innovate and

help poor programs to improve

MILESTONES

MILESTONES

1.) Assessment of individual residents

2.) Only one indicator to evaluate

performance

3.) Going from general competencies to

specific milestones

4.) Website for milestone: www.acgme-

nas.org/milestones-html

MILESTONES (con’t) 1.) Track resident’s linear training over six milestones

(more specific)

2.) Go from numbers to narratives

3.) Utilization of the institution

4.) Levels of training is observed behavior not PGY

status

MILESTONES (con’t)

MILESTONES (con’t) 1.) Some individual components may not be used in a

milestone

2.) Direct observation-observable skills, behavior and

attributes

3.) Subset of what residents do more or less

MILESTONES (con’t) 1.) PIF-less data

2.) Review with residents (survey) and faculty (survey)

3.) Focus on people and innovations rather than

numbers

MILESTONES (con’t) ADDITIONAL DATA

1.) Prior citations

2.) Changes since last site visit

3.) Resident/Faculty surveys

4.) Residency scholarly activity

MILESTONES (con’t) ADDITIONAL DATA CONTINUED

1.) Appropriate goals and objectives

2.) Resident quality improvement projects

3.) Faculty and resident evaluations of program

4.) Duty hour compliance

MILESTONES(con’t) ADDITIONAL DATA CONTINUED

1.) Board pass rates (three year rolling)

2.) Post graduate feedback

3.) Critical policies-supervision, fatigue mitigation and

transitions of care, etc.

PERFORMANCE INDICATORS 2013-2014

1.) ADS update

2.) Resident/faculty survey

3.) Milestone data

4.) Board performance

5.) Case log data

6.) Hospital accreditation status

7.) Resident/faculty scholarly activity

MILLER’S PYRIMID OF CLINICAL

COMPETENCE

MILESTONES (con’t) 1.) Who evaluates the milestones= Clinical Competency

Committee (CCC)

2.) Share educational milestones with faculty and form

CCC

3.) Phase I December 2013

4.) Phase II Summer 2014

5.) Anticipate multiple changes in milestone over the

next decade

CLINICAL COMPETENCE

COMMITTEE 1.) Group evaluation

2.) Roughly five faculty members involved in resident

teaching

3.) No residents and probably no program director

4.) First time milestone assessment trial (60 minutes)

5.) Problem resident-mentoring, skills evaluation,

rotational review

CLINICAL COMPETENCY

COMMITTEE (con’t) 1.) ACGME recommends quarterly meetings

2.) Not all CCC members must be M.D.s’

3.) Program director needs to choose members and

insure understanding of goals and process

CLINICAL COMPETENCY

COMMITTEE (con’t) 1.) The specific six competencies

2.) Members must review current ACGME milestones

3.) Again based observational behavior not PGY state

4.) Just one indicator amongst many key performance

indicators

CLINICAL COMPETENCY

COMMITTEE (con’t) 1.) Start by choosing members

2.) Review the milestones as they currently stand

3.) Consider one mock review of one resident per year

4.) Revise and start over

CLINICAL COMPETENCY

COMMITTEE (con’t) 1.) Track outcomes using existing tools and faculty

observation

2.) Program evaluation ABMS tracking will continue

3.) ACGME tracking will be withdrawn

4.) Goal is monitoring behavior over a continuum

student to resident to practice

5.) Narratives of competencies instead of numerical

evaluations

CLINICAL LEARNING

ENVIROMENT REVIEW (CLER) 1.) Focus on patient safety

2.) Health care quality

3.) Effective reporting systems

(feedback/communication)

CLER (con’t) WHY

1.) 1 out of 7 Medicare patients has a negative outcome due to error

2.) Errors are usually associated with system problems (80%) versus individual error (5%)

3.) Focus on systems look/sound alike, illegibility, abbreviations and multi-tasking

CLER (con’t) 1.) Improve morbidity/mortality conferences

2.) Encourage reporting of near misses

3.) Insure actions are within goals and objectives

4.) Consider GMEC QI officer/report

CLER (con’t) SIX FOCUS AREAS

1.) Patient safety

2.) Quality Improvement

3.) Supervision

4.) Transition in care

5.) Fatigue mitigation

6.) Professionalism

CLER (con’t) 5 KEY QUESTIONS

1.) Who at hospital advances the six focus areas?

2.) What is the GME relationship with their hospitals?

3.) How are residents and fellows engaged?

4.) How will GME and hospital integrate on the six

focus areas?

5.) Who at hospital determines areas of improvement?

CLER VISITS 1.) Short notice usually two weeks

2.) May occur every twelve to eighteen months

3.) Call the DIO whom selects site

4.) Length of the CLER visit is two to three days

5.) The CEO and CMOs’ are required to participate

6.) Others involved include the DIO, GMEC Chair and the resident on the GMEC

7.) Quality improvement officer (? hospital risk management)

CLER (con’t) 1.) Very little advanced notice

2.) Option to change date one occurrence

3.) DIO may offer documents including organizational

charts, organizational strategies for patient health

care safety and quality, sponsoring

institution/participating sites plans for supervision,

duty hours, etc.

CLER VISIT SCHEMATIC FLOW

1.) Three phases

2.) Initial meeting with DIO, GMEC Chair, CEO and CMO

A.) Resident meeting

B.) Core faculty meeting

C.) Program Director meeting

3.) Exit meeting with DIO, GMEC Chair, CEO, CMO

4.) Process will involve a walk around with a senior resident

+/- nursing staff

CLER (con’t) EVALUATION PROCESS

1.) Emphasis on expectations not requirements

2.) Initial expectations are based on expert data

3.) Object is to raise the floor for success

4.) Faculty development focus on a continuum from UME to GME to CME

THANK YOU

Web Site for NAS FAQ’s

http//www.acgme-nas.org/assets/pdf/NASFAQs.pdf