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ACGME looks to shift focus from residents' work hours


By Andis Robeznieks
Posted: June 17, 2013 - 12:00 pm ET
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If you don't like what's being said, the saying goes, change the conversation.

For the past several years, the agency that oversees the nation's residency programs—the Accreditation Council for Graduate Medical Education—has been mired in discussions dealing with resident work hours. The ACGME's Next Accreditation System, its new structure for evaluating physician training programs, is sure to shift talk to another topic.

“We did want to change the conversation,” said Timothy Brigham, ACGME's chief of staff and senior vice president of its department of education. “The conversation should never have really been about duty hours.”

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In 2003, the ACGME limited residents to an 80-hour week, averaged over four weeks, and then later refined these limits with new rules and supervision requirements that went in effect in July 2011.

Starting this July 1, the ACGME will require institutions to evaluate how well residents, at different points or milestones in their training, can demonstrate competency in patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication. The NAS will be rolled out for residency programs involving emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology and urology. It will be rolled out for the 19 other specialty programs ACGME oversees in July 2014.

“The idea is to plan a trajectory that will take residents from being novice to being an expert,” Brigham said. “Every resident will now know what journey they're expected to take.”

Andrew Roth, a healthcare attorney with the New York office of the firm Mintz Levin, has been advising residency programs for more than 30 years and thinks the new system makes sense.

“It's not enough to say a program is in compliance because it teaches A, B and C, now you have to prove residents have learned A, B and C and mastered the competencies associated with them,” Roth explained. “The NAS is truly a game changer.”

Under the old accreditation system, Roth said institutions had to create large paper documents known as Program Information Forms and spent inordinate amounts of time “making sure something on page 16 didn't contradict something on page 97.”

“I've spent thousands of hours working on PIFs, but even the best-written PIF is only as good as its underlying program,” he said. “Now, there will be no more PIFs and programs are on a continuous accreditation cycle.”

Program administrators are anticipating a heavier workload associated with the NAS, but note that they like the direction and goals of the new system.

“We're excited about it,” said Dr. Chad Vokoun, associate program director for internal medicine at the University of Nebraska Medical Center College of Medicine in Omaha. “This goes deeper into asking the question: Where is this person at in their individual training? You can never expect people to do X, Y and Z before they can do X—and then some get to Y and Z sooner than others.”

Dr. Susan Vanderberg-Dent, associate dean of the graduate medical program for Rush University Medical Center in Chicago, said that one particular aspect of the NAS that she liked was that it created a “common language” for the goals ACGME wanted residents and their programs to reach, but it wasn't prescriptive in requiring a universal path to these common goals.

Borrowing terminology from lean manufacturing efficiency-improvement processes, Dr. Brian Owens, graduate medical education director at Virginia Mason Medical Center in Seattle, explained that this integration requires putting institution's education “value stream map,” or analytical flow chart, on top of its operations value stream map. He added that Virginia Mason headed down this path more than a decade ago.

“We have a head start, no doubt about it,” Owens said.

ACGME's Brigham said the “philosophical base” of the NAS includes strategies to emphasize outcomes over processes, spark innovation, reduce administrative burdens and increase communication with external and internal stakeholders.

“I think it's a great time, in some ways, to be alive,” Brigham said. “We're in one of those times in history where aspirations and external pressures are in place to make changes and the people are there who can and want to make those changes.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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