The Next GME Accreditation System — Rationale and Benefits

Thomas J. Nasca, M.D., M.A.C.P., Ingrid Philibert, Ph.D., M.B.A., Timothy Brigham, Ph.D., M.Div., and Timothy C. Flynn, M.D.

1999년 6개 영역 설정하고 2009년 인증시스템을 재구조화하는 다년도 과정이 시작됨. 그 결과가 NAS.

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced the six domains of clinical competency to the profession, 1 and in 2009, it began a multiyear process of restructuring its accreditation system to be based on educational outcomes in these competencies. The result of this effort is the Next Accreditation System (NAS), scheduled for phased implementation beginning in July 2013. 

NAS의 목적은 세 가지 : Peer-review시스템 능력 강화, 교육성과에 기반한 인증, 현재의 부담 경감

The aims of the NAS are threefold: 

• to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century, 
• to accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes, and 
• to reduce the burden associated with the current structure and process-based approach.

Self-regulation is a fundamental professional responsibility, and the system for educating physicians answers to the public for the graduates it produces.2 

As the accreditor for graduate medical education (GME), the ACGME serves this public trust by setting and enforcing standards that govern the specialty education of the next generation of physicians. In this article, we discuss the NAS, including elements and attributes of interest to stakeholders (program directors, leaders of sponsoring institutions, ACGME’s partner organizations, residents, and the public). 

ACGME의 공적 이해관계자(환자, Payer)가 기대하는 바도 있음. 또한 GME에서 그것을 충족시켜주기를 바람.

The ACGME’s public stakeholders have heightened expectations of physicians. No longer accepting them as independent actors, they expect physicians to function as leaders and participants in team-oriented care. Patients, payers, and the public demand information-technology literacy, sensitivity to cost-effectiveness, the ability to involve patients in their own care, and the use of health information technology to improve care for individuals and populations; they also expect that GME will help to develop practitioners who possess these skills along with the requisite clinical and professional attributes.3-7

현 시스템의 한계

Limitations of the Current System

ACGME가 1981년 처음 만들어졌을 때 두 가지 문제가 있었다. (1)레지던트 교육에 차이가 큰 것 (2)점차 늘어나고있는 세부전공 교육의 형식을 갖출 것. 그래서 ACGME는..

When the ACGME was established in 1981, the GME environment was facing two major stresses: variability in the quality of resident education8 and the emerging formalization of subspecialty education. In response, the ACGME’s approach..

• emphasized program structure, 
• increased the mount and quality of formal teaching, 
• fostered a balance between service and education, 
• promoted resident evaluation and feedback, and 
• required financial and benefit support for trainees. 

These dimensions were incorporated into program requirements that became increasingly more specific during the next 30 years.

효과는 좋았다. 

The results have been largely salutary. 

• Performance on certifying examinations has improved, 
• residents are prepared to deal with the dramatically increasing volume and complexity of information in their specialty, 
• and graduates and academic institutions have contributed to clinical advances and innovation that the public enjoys today.9,10 
• In addition, the role of the program director has been established as an educational career path, and 
• the formal teaching and assessment of residents and fellows have improved substantially.

그러나 치러야 할 비용도 있었다.

Yet success has come at a cost. 

• Program requirements have become prescriptive, and opportunities for innovation have progressively disappeared. 
• As administrative burdens have grown, program directors have been forced to manage programs rather than mentor residents, with a recent study reporting administrative tasks related to compliance as a factor in burnout among directors of anesthesiology programs. 11 
• Finally, educational standards often lag behind delivery-system changes. 
• The introduction of innovation through accreditation is limited and is often viewed as an unfunded mandate.

차기인증시스템

The Next Accreditation System

2013년 7월, NAS는 ACGME에서 인증받은 26개의 핵심 전공과목 중 7개에 도입될 것

In July 2013, the NAS will be implemented by 7 of the 26 ACGME-accredited core specialties (emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urology). In the remaining

specialties and the transitional year (a year of preparatory education for specialties such as ophthalmology and radiology that accept residents at the second postgraduate year), the NAS will be implemented in July 2014. 

7개 전공과목에 대해서 Educational milestone은 도입 첫 phase에 달성될 예정

Educational milestones (developmentally based, specialtyspecific achievements that residents are expected to demonstrate at established intervals as they progress through training) have been completed or nearly completed for the seven specialties in the first phase of implementation. The residency review committees in these specialties will be in an excellent position to begin to collect milestone data during the 2012–2013 academic year to create a baseline data set for the NAS.

NAS는 가끔씩 이뤄지는 "생검" 모델에서 연례 데이터 수집으로 바꿀 것. 

The NAS moves the ACGME from an episodic “biopsy” model (in which compliance is assessed every 4 to 5 years for most programs) to annual data collection. 

Each review committee will perform an annual evaluation of trends in key performance measurements and will extend the period between scheduled accreditation visits to 10 years. 

Milestone외에 설문조사와 operative data, case-log data가 있음.

In addition to the milestones, other data elements for annual surveillance include the ACGME resident and faculty surveys and operative and case-log data. The NAS will eliminate the program information form, which is currently prepared before a site visit to describe compliance with the requirements. 

프로그램은 자체적으로 Self-study를 할 것

Programs will conduct a self-study before the 10-year site visit, similar to what is done by other educational accreditors. 

It is envisioned that these self-studies will go beyond a static description of a program by offering opportunities for meaningful discussion of what is important to stakeholders and showcasing of achievements in key program elements and learning outcomes.

인증은 프로그램의 교육성과를 기반으로 이루어질 것이며 지속적 감독을 통해서 양질의 교육 기준을 달성하게 하고 안전하고 효과적인 학습환경을 만들어갈 것임.

Ongoing data collection and trend analysis will base accreditation in part on the educational outcomes of programs while enhancing ongoing oversight to ensure that programs meet standards for high-quality education and a safe and effective learning environment. 

높은 수준의 성과를 보여주는 프로그램은 세세한 기준을 달성하는 것에서는 자유로워지게 하여(freed) innovation을 유도하고자 함.

Programs that demonstrate high-quality outcomes will be freed to innovate by relaxing detailed process standards that specify elements of residents’ formal learning experiences (e.g., hours of lectures and bedside teaching), leaving them free to innovate in these areas while continuing to offer guidance to new programs and those that do not achieve good educational outcomes.

교육단계

The Educational Milestones

교육단계(Educational Milestones)는 NAS의 핵심 측정법

A key element of the NAS is the measurement and reporting of outcomes through the educational milestones, which is a natural progression of the work on the six competencies. 

Starting more than 10 years ago, the ACGME, in concert with the American Board of Medical Specialties (ABMS), established the conceptual framework and language of the six domains of clinical competency and introduced them into the profession’s lexicon, mirroring the move toward outcomes and learner-centered approaches in other domains of education.12

각 전공과목에 대해서 ABMS 위원회, 평가위원회, 프로그램관리자협회, 레지던트간의 협력작업을 통해 교육단계가 설정됨

In each specialty, the milestones result from a close collaboration among the ABMS certifying boards, the review committees, medicalspecialty organizations, program-director associations, and residents. 

The earliest efforts involved internal medicine, pediatrics, and surgery, 13-15 and by late 2011, milestones were being developed in all specialties. 

The aim is to create a logical trajectory of professional development in essential elements of competency and meet criteria for effective assessment, including feasibility, demonstration of beneficial effect on learning, and acceptability in the community.16

프로그램은 교육단계 데이터를 6개월 단위로 제출.

Programs in the NAS will submit composite milestone data on their residents every 6 months, synchronized with residents’ semiannual evaluations. 

Although the internal collection of milestone data may be more comprehensive, the data submitted to the ACGME will consist of 30 to 36 dimensions that represent the consensus of the assessment committee on the educational achievements of residents, informed by evaluations the program has performed. 

Table 1 shows a sample of generic milestones for professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice. The milestones are based on the published literature on these competencies17- 22 and were developed by an expert panel with representation from the specialties in the early phase for use in milestone development.

Final milestone의 활용

At the completion of training, the final milestones will provide...

meaningful data on the performance that graduates must achieve before entering unsupervised practice. This process moves the competencies “out of the realm of the abstract and grounds them in a way that makes them meaningful to both learners and faculty.”13 

The final milestones also create the entry point into the maintenance of certification and licensure phase of lifelong learning. 

Initial milestone은 의학교육 continuum의 부드러운(seamless) 연결에 기여할 것임

The initial milestones for entering residents will add a performance- based vocabulary to conversations with medical schools about graduates’ preparedness for supervised practice.23 Over time, the milestones will reach into undergraduate medical education to follow the adoption of the competencies by many medical schools. This will contribute to a more seamless transition across the medical-education continuum.

NAS의 또 다른 핵심요소는 해당기관이 학습과 환자진료 환경의 질(quality)와 안전(safety)에 대한 책임을 지는 것이다.

Another key element of the NAS is emphasis on the responsibility of the sponsoring institutions for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 common program requirements.24 This will be accomplished through periodic site visits to assess the learning environment. Institutions will see their results, and the  first visit will establish a baseline for self-comparison over time. The process will generate national data on program and institutional attributes that have a salutary effect on quality and safety in settings where residents learn and on the quality of care rendered after graduation.25

장점과 한계

Benefits and Limitations

방문평가(visits)의 장점, Milestone의 장점, Competency에 초점을 두는 것의 장점

The visits to sponsoring institutions will ensure that residents are exposed to an appropriate learning environment, and the milestones will ensure that they demonstrate readiness for independent practice and possess the attributes that the public deems to be important in physicians. As future competencies emerge, the milestones will enhance the ability of the ACGME to ensure their successful incorporation into the physician’s armamentarium. The NAS will enhance education focused on physician competencies that are deemed to be relevant to the health of individuals and populations. Through this, the NAS will benefit employers of new graduates and the public by enhancing the competence of future physicians in areas that are relevant to a well-performing, efficient, and cost-effective health care system and that have been recommended by experts and stakeholder groups.3-7

인증시스템의 한계

In the context of our aspirations for the NAS, it is important to note the limits of accreditation. 

• Much has been written about the constrained environment for GME, including threatened reductions in support for physician training and increased productivity pressures on academic institutions and their faculties. The development of the NAS is sensitive to these factors, since they are characteristics of the environment in which GME programs, sponsoring institutions, and the ACGME operate. 
• At the same time, accreditation is not a panacea, and no accreditation model by itself can effectively compensate for the overuse of resources, inefficiencies, and disparities that characterize aspects of the nation’s health care system. It would be presumptuous to expect accreditation to effectively resolve these problems. Rather, its roles are to arm the next generation of physicians with knowledge, skills, and attributes that will enhance care in the future and to expand the traditional role of residents in the care of underserved populations to an enhanced understanding of the problem of health disparities and how to eradicate them.26

인증시스템은 그것이 주는 부담에 대해서 민감할 필요가 있지만, 인증시스템이 인증대상에 대해서 가지는 기대치를 낮추는 것 역시 위험하다.

Finally, although accreditation must be sensitive to the burden it creates on programs, institutions, and individuals, it would be dangerous to expect accreditation to reduce its expectations to accommodate the host of other pressures on the system of physician training. Any move to create a reductionist model of accreditation to avoid burdening the system may further erode public support for physician education and public trust in the physicians the system produces. 

재정상황이 압박을 받고 있고, 삭감에 대한 위협이 있을수록 학습자들이 그들의 교육에 의미있는 기여를 하지 않는 과도한 부담을 져서는 안된다는 것이 오히려 더 강조되어야 한다. 

Constrained finances and future threats of reductions make it even more important for accreditation to ensure that learners are not unduly burdened with service obligations that do not meaningfully contribute to their education27 and that education and patient care proceed in an environment that complies with requirements for duty hours, supervision, and other elements important to the safety of patients and residents. 28 This makes the visits to sponsoring institutions a critical component of the NAS in the untoward event of serious cuts in support for GME.

The next GME accreditation system--rationale and benefits.