Milestones Ready or not.here they come! SIU SOM March 6, 2013
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1 Milestones Ready or not.here they come! SIU SOM March 6, 2013
2 A Word of Thanks Donald Brady Susan Guralnick Justin Held Eric Holmboe Tom Nasca John Mellinger Julie Rhodes Jennifer Rodgers Hilary Sanfey Debi Santini Andy Varney Eric Warm Every RRC member, program director, fellow DIO and GME leader who let us shamelessly borrow their great ideas
3 Objectives Participants will be able to Define Milestone, Entrustable Professional Activity and Competency Based Assessment Regurgitate current (today) and short-term (18 months) ACGME Milestone-related expectations Share collective Angst and Wisdom Determine next steps for faculty development
4 My Favorite Color is. 1. Blue 2. Red 3. Puce 4. I Can t Work This Thing 100% 0% 0% 0%
5 My program is well-prepared for ACGME Milestone Reporting 38% 1. What s a Milestone? 2. A Little (25%) 3. Half Way There (50%) 4. Pretty Much (75%) 5. Absolutely!! (100%) 5% 33% 19% 5%
6 Definitions and Background. Competence: An observable ability of a Health Professional, integrating multiple components, such as knowledge, skills, values. (International CBME Collaborators) The ability to do something successfully A quality An adjective Can have multiple domains
7 Entrustable Professional Activities An activity is something you can observe a noun A unit of work that should only be entrusted upon a competent enough professional (ten Cate, 2007) May be awarded qualification at the moment when supervisors confirm that the trainee is ready to assume responsibility for such activities. Entrustment can occur formally or informally. An event/outcome that marks a turning point or stage in training that is often manifest through a trainee being granted increased level of autonomy, responsibility or decision-making capacity. (Varney)
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9 EPA: Capable in the ICU Setting Run Code Use order sets Effective in Transitions of Care Lead an interdisciplinary team Run a family meeting
10 Milestones ACGME NAS FAQs December 2012 Observable developmental steps that describe a trajectory of progress on the competencies from novice (entering resident) to proficient (graduating resident) and, ultimately, to expert. They articulate shared understanding of expectations, set aspirational goals of excellence, provide a framework for discussions across the continuum and track educational outcomes
11 Eric Holmboe, 2013 ACGME Meeting
12 Milestones are a measure of Development Think Denver or Bailey Consistency, habits and skills are demonstrated in multiple contexts and settings over time
13 Can DO these well. The Good Resident EPAs Competencies Milestones 1. Titrate insulin 2. Manage We ventilator see these 3. Choose things antibiotics in the 4. Treat clinics painand on the 5. Diagnose wards VTE 6. Manage a team 7. Share decision making 8. Hand off properly 1. Patient Care 2. Medical Yet we Knowledge measure 3. Professionalism learners with these. 4. Communication Skills 5. Systems Based Practice 6. Practice Based Learning Courtesy of Eric Warm, MD University of Cincinnati
14 Can DO these well. The Good Resident EPAs Competencies Milestones 1. Titrate insulin 2. Manage ventilator This is what we 3. Choose antibiotics should be 4. Treat pain 5. Diagnose measuring VTE 6. Manage a team 7. Share decision making 8. Hand off properly 1. Patient Care 2. Medical Knowledge 3. Professionalism These are what we should be able to sort by 4. Communication Skills 5. Systems Based Practice 6. Practice Based Learning Courtesy of Eric Warm, MD University of Cincinnati
15 CANNOT DO these things well. The Struggling Resident EPAs Competencies Milestones 1. Titrate insulin 2. Manage This is ventilator what we see 3. Choose them antibiotics struggle with 4. Treat pain 5. Diagnose VTE 6. Manage a team 7. Share decision making 8. Hand off properly 1. Patient Care 2. Medical Knowledge These might point towards the reasons (and 3. Professionalism 4. Communication solutions) Skills for the struggles 5. Systems Based Practice 6. Practice Based Learning Courtesy of Eric Warm, MD University of Cincinnati
16 Held and Warm, 2013 ACGME Meeting
17 Held and Warm, 2013 ACGME Meeting
18 Ingredients Learning Activities Clinical Experiences Knowledge Tests Rotation Evals EPA Attainment Curricular Milestones Portfolio Products 360 degree evals Patient Satisfaction data Case logs Mini CEXs OSCEs Peer Evals Simulations Chart Stimulated Recalls Steps 1. Mix all assessment ingredients together 2. Add a generous amount of direct observations 3. Season with the shared wisdom and judgement of a Clinical Competence Committee 4. Transfer one half to promotions decisions and one half to an ungreased WebADs Milestones reporting form Milestones a la NAS
19 Better Ingredients Better Milestones!
20 ACGME Milestones
21 Eric Holmboe, 2013 ACGME Meeting
22 Eric Holmboe, 2013 ACGME Meeting
23 7 Early Adopter RRCs Diagnostic Radiology Emergency Medicine Internal Medicine Neurologic Surgery Orthopedic Surgery Pediatrics Urology
24 Timetable and Logistics. Phase 1 programs will submit initial milestone data in Dec 2013 and June 2014 All other core programs will begin submitting December 2014 Subspecialty milestone development will begin July 2013 Validity of milestones has yet to be established work in progress! Reportable milestones will be set by RRCs Programs may have additional curricular milestones Milestone data will be submitted via web ADs de-identified - RRC will see only aggregate data for program
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28 Exhibits integrity and ethical behavior in professional conduct Critical Deficiencies Ready for unsupervised practice Aspirational Dishonest in clinical interactions, documentation, research, or scholarly activity Refuses to be accountable for personal actions Does not adhere to basic ethical principles Blatantly disregards formal policies or procedures. Honest in clinical interactions, documentation, research, and scholarly activity. Requires oversight for professional actions Has a basic understanding of ethical principles, formal policies and procedures, and does not intentionally disregard them Honest and forthright in clinical interactions documentations, research, and scholarly activity Demonstrates accountability for the care of patients Adheres to ethical principles for documentation, follows formal policies and procedures, acknowledges and limits conflict of interest, and upholds ethical expectations of research and scholarly activity Demonstrates integrity, Honesty, and accountability to patients, society and the profession Actively manages challenging ethical dilemmas and conflicts of interest Identifies and responds appropriately to lapses of professional conduct among peer group Assists others in adhering to ethical principles and behaviors including integrity, honesty, and professional responsibility Role models integrity, honesty, accountability and professional conduct in all aspects of professional life Regularly reflects on personal professional Conduct Comments:
29 Wide Variability Among RRCs Radiology 12 Milestones Patient Care : 1. Consultant 2. Competence in procedures Internal Medicine - 22 Reporting Milestones 142 curricular Milestones Patient Care: 1. Gathers and synthesizes essential and accurate information to define each patient s clinical problem(s). 2. Develops and achieves comprehensive management plan for each patient. 3. Manages patients with progressive responsibility and independence. 4. Skill in performing procedures. 5. Requests and provides consultative care.
30 IPS and C 7 Early Adopter RRCs Donald Brady,Vanderbilt
31 Professionalism 7 Early Adoptor RRCs Donald Brady,Vanderbilt
32 Clinical Competence Committee Each program is expected to have a CCC by June 2013 CCC members should include core faculty who can observe and evaluate residents. May include other members Common model: 1 or 2 faculty review all evals for a resident before committee discussion
33 Eric Holmboe, 2013 ACGME Meeting
34 Eric Holmboe, 2013 ACGME Meeting
35 Random Important Points A Milestone must be an OBSERVABLE behavior or set of behaviors Milestone ratings DO NOT correspond to PGY level ACGME Milestones are not the same as Curricular Milestones
36 Please rate the extent to which the following statements describe your program
37 The evaluations of residents in my program are organized by the 6 ACGME competencies 71% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 0% 7% 4% 18%
38 The evaluations of residents in my program have a defined progression of competence or competencies. 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 42% 15% 8% 35% 0%
39 Teaching/learning opportunities, assessments and desired outcomes are aligned. 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 57% 29% 11% 0% 4%
40 . Learning experiences are deliberate (not circumstantial) 37% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 0% 4% 30% 30%
41 Desired outcomes drive teaching-learning and assessment decisions 58% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 0% 4% 12% 27%
42 Assessments are criterion referenced 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 0% 4% 15% 42% 38%
43 All faculty utilize a common frame of reference for resident assessment 43% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 21% 29% 7% 0%
44 Group assessments are employed in the rotation evaluation of residents 29% 29% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 8% 21% 13%
45 My program has a fully functional Clinical Competence Committee 43% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 18% 7% 21% 11%
46 My program s Clinical Competence Committee is prepared for the NAS 44% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 24% 4. Pretty Much (75%) 5. Absolutely (100%) 12% 12% 8%
47 All of my graduating residents are ready for independent practice 42% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 4. Pretty Much (75%) 5. Absolutely (100%) 12% 12% 35% 0%
48 I know what kind/areas of faculty development my program needs to be ready for Milestone assessment and reporting 42% 1. Not at all (0%) 2. A Little (25%) 3. About Half (50%) 23% 4. Pretty Much (75%) 5. Absolutely (100%) 8% 15% 12%
49 How do you translate competency- based info from rotational evals, 360 degree evals, CEXs, etc., into Milestone assessment?
50 Should specific Milestones be embedded into rotation evaluations?
51 Every milestone should be evaluated in multiple settings Need to determine which milestones best go in which settings Not everybody has to evaluate everything Rotation evals may end up with comb of EPAs, milestone items, milestone sub-items and non-milestone items. Guralnick, 2013 AGME Meeting
52 How can you ensure that all faculty have a common frame of reference for resident assessment?
53 Competency Based Assessment Effect of Construct Alignment RESULTS AND OUTCOMES CoBRA - Impact on grade inflation % of time an intern received an 8 ABIM 7/1/07 2/1/09 2/1/09 10/31/10 11/1/10 7/1/11 7/1/11 6/30/ % 35.0% 33.6% 30.0% 25.0% 20.0% 23.0% 19.0% 21.2% 25.0% 17.1% 23.1% 15.0% 10.0% 5.0% 9.7% 6.0% 4.0% 2.2% 11.1% 7.0% 3.9% 3.2% 12.0% 10.8% 10.0% 10.3% 8.2% 6.9% 6.9% 5.1% 4.9% 3.8% 3.0% 1.6% 9.9% 5.7% 3.8% 1.6% 10.5% 6.8% 5.1% 2.9% 0.0% Patient Care Medical Knowledge Practice Based Learning & Improvement Interpersonal & Communication Skills Professionalism Systems Based Practice OVERALL
54 Competency Based Assessment Effect of Construct Alignment Result and Outcomes CoBRA Impact on use of left side of scale % of time a PGY1 resident received a 3 ABIM 7/1/07 2/1/09 2/1/09 10/31/10 11/1/10 7/1/11 7/1/11 6/30/ % 10.8% 10.9% 10.0% 8.0% 6.5% 6.0% 5.4% 5.4% 4.3% 4.0% 2.0% 0.0% 0.6% 3.3% 2.3% 2.2% 1.1% 1.3% 0.0% 0.0% 0.0% 2.5% 3.5% 3.2% 3.3% Patient Care Medical Knowledge Practice Based Learning & Improvement 0.7% 1.5% 3.0% 1.3% Interpersonal & Communication Skills 1.9% 2.2% 1.7% 0.6% 0.0% Professionalism 3.0% 1.5% 3.0% Systems Based Practice 3.6% 2.6% 1.3% 0.2% OVERALL
55 Competency Based Assessment Effect of Construct Alignment DIFFERENCE BETWEEN PGY 1 AND 3 RESIDENT ACROSS ACGME Competencies Increased Assessor discrimination 6/1/04 6/30/07 (ABIM) 7/1/07 10/31/10 (CoBRA) 11/1/10 7/1/11 (CoBRA) 7/1/11 6/30/12 (CoBRA) Patient Care Medical Knowledge Practice Based Learning & Improvement Interpersonal & Communication Skills Professionalism Systems Based Practice
56 How do you know if your assessment strategies/tools really measure meaningful outcomes?
57 How do you know that your graduating residents are ready for independent practice?
58 There are a lot of Milestones and EPAs! How do you prioritize them for your program?
59 What should we (Community of SIU GME Leaders) do next?
60 WHEW!!!! THANK YOU
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