Thursday, March 15, 2012 New accreditation system will shift focus of resident training

ACGME says it is moving from a blueprint that stifles originality to one that allows more flexibility in graduate medical education.

Carolyne Krupa, March 12, 2012

The Accreditation Council for Graduate Medical Education is revamping how it accredits graduate medical education programs in an effort to foster innovation and alleviate administrative burdens.

Starting in 2013, the Next Accreditation System will begin to shift away from a system described by many as too prescriptive and inflexible, said ACGME CEO Thomas Nasca, MD. The new system is designed to allow GME programs to better train physicians to meet the needs of today's changing health care system.

"If there is a criticism of our GME system, it is that it is slow to adapt to new needs," Dr. Nasca said. "We believe this new model is much better than our existing model in providing the impetus for the innovation to help [programs] improve and grow."

Details of the system have yet to be finalized, but it will include waivers from certain ACGME rules for high-performing programs. The system, announced online Feb. 22 in The New England Journal of Medicine, will be piloted in seven specialties starting in July 2013 and expand to the remaining 19 core specialties in 2014.

The current system has been in place since the ACGME was founded in 1981. At that time, there were disparate training programs for 28 specialties and subspecialties, and the ACGME's goal was to standardize the way all programs were evaluated. Uniform standards have since been established, but the system is criticized as being too rigid for today's more than 130 specialties and subspecialties, Dr. Nasca said.

"The price of those prescriptive standards has been to stifle innovation," he said.

Providing flexibility
Under the new system, programs with strong accreditation performance will be allowed to have a waiver from some of the ACGME standards that govern how residents are trained. For example, all programs are required to have residents go on teaching rounds, where they are introduced to patients and discuss their cases in groups with a faculty member at the bedside. In the new system, well-performing programs still would be required to do teaching rounds but could determine for themselves how those rounds are run.

"If I have a program that has excellent survey results, and if board scores continue to be excellent, why do I care how they do their teaching rounds?" Dr. Nasca asked.

More than 80% of ACGME-accredited programs are high performing and will be allowed some flexibility for innovation, he said.

The system will emphasize the six core competencies that the ACGME announced in 1999: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism; and systems-based practice. Program directors will be required to submit data to the ACGME from resident evaluations on those competencies that they already do every six months.

Committees for each specialty will review data annually to evaluate trends in key performance measurements. ACGME representatives will visit sponsoring GME programs every 18 months. But longer, more detailed accreditation visits will be done every 10years, as opposed to every four to five years, Dr. Nasca said.

Waiting for specifics
The Alliance for Academic Internal Medicine is optimistic about the changes, said AAIM President D. Craig Brater, MD, the Dean & Walter J. Daly Professor at Indiana University School of Medicine in Indianapolis. AAIM is a consortium of specialty organizations representing internal medicine departments at medical schools and teaching hospitals in the U.S. and Canada.

"The notion is now the time should be spent in having those kind of broader discussions looking at how individuals are really doing, rather than checking boxes about prescriptive stuff -- which is great," Dr. Brater said. "No one knows the residents better than the program leadership. They spend countless hours with these residents."

The new ACGME accreditation program keeps the same 6 core elements it has had since 1999. But change always comes with some difficulties. Dr. Brater said he anticipates some "bumps in the road," but AAIM is developing tools and guidance for program directors to help make the transition as smooth as possible.

Mark Friedell, MD, president of the Assn. of Program Directors in Surgery, said many program directors are unclear about how the new system will work and are awaiting more specifics.

"My biggest concern would be that this not cause more work for us to do, and hopefully make it easier to manage accreditation," said Dr. Friedell, chair of the University of Missouri-Kansas City Dept. of Surgery. "I have more questions now than I did before. I'm just waiting for all of the details to come out."

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