Special Feature

GME 2.0: The new accreditation system focuses on outcomes

It's all about the outcomes.

That's the focus of what is called the "next accreditation system" by the Accreditation Council for Graduate Medical Education (ACGME). Announced in the Feb. 22 New England Journal of Medicine, the concept has major ramifications for graduate medical education (GME) residency/fellowship programs, resident/fellow physicians, and patients alike:

• For programs, accreditation will be less about process and paperwork and more about outcomes, and the current episodic system of site visits will be replaced by a continuous process of quality improvement focused on supporting innovation and excellence
• For trainees, the "milestones" concept, which is part of the new accreditation system, builds upon the ACGME's six core competencies to specify benchmarks of skills and knowledge that residents must achieve at certain stages in their education, such as the third month, first year, and second year.
• For patients, the new system will offer further assurance that GME is changing to meet increased demands for patient safety and quality of care—and that new physicians will be well equipped for practice in tomorrow's health care environment.

Each of the ACGME's Review Committees in the various specialties, along with specialty medical organizations and specialty boards, are working to design and implement milestones by July 2014. Seven fields—emergency medicine, internal medicine, neurological surgery, orthopedic surgery, pediatrics, diagnostic radiology and urology—will pilot the milestones, with implementation by July 2013. For example, the Diagnostic Radiology Milestone Working Group is defining what it is that a diagnostic radiologist does (called "Entrustable Professional Activities" by the ACGME), and then developing applicable milestones.

One critical challenge for each working group is to develop something that not only can be measured but also can serve as a realistic marker of each individual physician's development from a recent medical school graduate to a doctor prepared for the independent practice of medicine. In addition, the need for meaningful milestones must be balanced against the concern of overwhelming program directors with an inordinate amount of data to be collected—which would, in fact, defeat one of the key goals of the next accreditation system.

For physicians, one of the attractive features of the milestones concept and the focus on outcomes is the possibility of more flexibility in residency length. If, say, a family medicine resident can meet all the milestones in two years rather than three, there's no reason the doctor could not complete the residency and enter into practice.

AMA policy supports such flexibility, which could have the added benefit of allowing young physicians the opportunity to begin to pay back medical school debt by entering into practice that much sooner. For example, the AMA's Principles of Graduate Medical Education state that "[t]he time required for an individual resident physician's education might be modified depending on the aptitude of the resident physician and the availability of required clinical experiences."

The author of a recent commentary in Academic Medicine notes, "Our present medical education system is primarily time defined, rather than competency based, in its milestones and metrics for advancement. Within the traditional calendar year framework, the hours available to attain proficiency in the practice of medicine have been progressively reduced in the name of eliminating fatigue-related error." The next accreditation system may hold promise in reframing our focus and moving the debate beyond what some call a "myopic" focus on duty hours towards flexibility, innovation and quality.