The General Competencies: An Update from the ACGME

1. The General Competencies: An Update from the ACGME Susan R. Swing, PhD Director of Research Patricia M. Surdyk, PhD Senior Project Manager Accreditation Council for Graduate Medical Education Association of Anesthesiology Program Directors Society of Academic Anesthesiology Chairs November 9, 2003

2. The ACGME Outcome Project • EMPHASIZE: • Competency- based learning and improved assessment of resident performance • Competencies and outcomes in accreditation • IMPROVE: • Preparation of physicians • Patient care

3. Improvement Main Entry: im·provePronunciation: im-'prüvFunction: verbInflected Form(s): im·proved; im·prov·ingEtymology: Anglo-French emprouer to invest profitably, from Old French en- + prou advantage, from Late Latin prode -- more at to enhance in value or quality : make better

4. Outcome Project Timeline • Phase 1 (July 2001-June 2002) • Taking stock • Getting started • Phase 2 (July 2002-June 2006) • Providing learning opportunities • Improving assessment • Using outcome data within the institution and program

5. Spread of the Competencies Organizations adopting the competencies or related domains: • American Board of Medical Specialties • Accreditation Council for Continuing Medical Education • Council of Medical Specialty Societies • American Osteopathic Association • National Center for Health Care Leadership • Institute of Medicine

6. Health Professions Education: A Bridge to Quality In its third report, the Institute of Medicine recommends that: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”

7. Project Principle • We tend to improve that which we measure. • Summative assessment • High-stakes decisions • Undertaken at end of training • Formative assessment • Ongoing • Developmental

9. Anesthesiology Profile • 55 programs reviewed by the RRC using the PIF Addendum (1485 programs reporting as of May 13, 2003) • Self-reports indicate: • 99% provide learning opportunities in all competencies • 85% engage in efforts to improve learning opportunities and/or assessment in all competencies • 84% use an additional assessment tool other than an “end-of-rotation ratings” to assess the competencies • 79% assess resident performance in every rotation

10. Anesthesiology Profile (cont’d) • Reports indicate (cont’d): • 67% use at least one other type of evaluator to assess Interpersonal and Communication Skills • 66% use at least one other type of evaluator to assess Professionalism • 91% report using scoring/rating criteria • 55% train faculty to use rating criteria • 90% use assessment data to provide oral or written feedback to residents for all competencies

11. Anesthesiology Profile (cont’d) • Patient Care(28 improvements reported) • A web-based evaluation system has been implemented to regularly evaluate resident competency in patient care. Every interaction from preoperative patient evaluation, planning the treatment plan, intraoperative management and postoperative care is evaluated by attending physician. The resident is able to view his performance as rated by the attending physician immediately…

12. Anesthesiology Profile (cont’d) • Patient Care(cont’d) • …This immediate feedback allows the residents to discuss and improve his performance, if necessary, with the attending physician. The program director by reviewing these evaluation reports on a regular basis is able to identify deficiencies early and implement remedial measures. Results are also discussed with clinical competence committee on a semi-annual basis or sooner if needed.

13. Anesthesiology Profile (cont’d) • Medical Knowledge (22 improvements reported) • Every year each first and second year resident is given a “mock” oral examination. The evaluation team consists of a faculty member and a third-year resident. A stem cell question is given, which outlines a patient, medical history, and proposed surgical procedure. The examinee is expected to perform a history, choose an anesthetic plan, and manage the patient preoperatively, intraoperatively and postoperatively…

14. Anesthesiology Profile (cont’d) • Medical Knowledge (cont’d) • …Selected topics dealing with any issue of anesthesiology or medicine, may be addressed. Since a third-year resident has the opportunity to function as an examiner, additional practice opportunity is achieved. At the end of the mock oral examination, the examinee is appraised of his/her performance, with areas of improvement/weakness identified and promulgated.

15. Anesthesiology Profile (cont’d) • Interpersonal and Communication Skills (13 improvements reported) • In an attempt to teach both Professionalism and Interpersonal/Communication Skills, we discuss occasional patient complaint letters and analyze what could have been done differently in the initial encounter, as well as how one should reply to the letter in order to assuage the patient’s disappointment or anger. Additionally, we present cases involving conflicts with colleagues and then formulate prevention and resolution strategies.

16. Anesthesiology Profile (cont’d) • Practice-based Learning and Improvement (16 improvements reported) • We have instituted monthly Problem-based Learning Discussions which are written to address many of the competencies, including knowledge, patient care, interpersonal and communication skills; but with each case, residents are supplied with current journal articles, are asked to prepare a management and treatment plan, and encouraged to investigate and evaluate their practice both individually and as a group.

17. Anesthesiology Profile (cont’d) • Professionalism (7 improvements reported) • Regularly during our Chairman’s Meeting sessions, we discuss essays, poems, short stories, and books that emphasize the special bond between the physician and patient. Our reference materials include the “Careers in Anesthesiology” series published by the Wood Library-Museum of Anesthesiology and co-edited by Drs. K. McGoldrick, D. Caton, and the late B. Raymond Fink, as well as “A Life in Medicine,” co-edited by Dr. Robert Coles and Randy Testa, and “A Piece of My Mind, edited by Roxanne K. Young.

18. Anesthesiology Profile (cont’d) • Systems-based Practice(7 improvements reported) • CA3 residents receive an in-depth introduction to the system of surgical services during the OR Management rotation and Practice Management lecture series. Through first-hand experience in the anesthesia scheduling and daily management of a very busy inpatient operating room,…

19. Anesthesiology Profile (cont’d) • Systems-based Practice(cont’d) • …residents gain an appreciation for resource and personnel allocation decisions and the implications of those decisions to quality of care, patient flow through the hospital and the practices of other health care providers. Residents must continually reevaluate the resources and personnel available to them and utilize those resources to efficiently address both planned and emergent situations.

20. Resources www.acgme.org

21. www.acgme.org/outcome/

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25. Still to Come… • Abstracts from ACGME/ABMS joint conference, Fostering Professionalism: Challenges and Opportunities • Instructional Methods Toolbox (mid 2004) • Presentations from ACGME/IHI joint conference, Professionalism and Practice-based Learning and Improvement(early 2004) • ACGME Annual Educational Conference, March 3-5, 2004