s u r v e y o f o p h t h a l m o l o g y 6 0 ( 2 0 1 5 ) 8 2 e8 5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/survophthal
Core competencies in ophthalmology
The Next Accreditation System in ophthalmology Andrew G. Lee, MDa,b,c,d,e,f,*, Anthony C. Arnold, MDg a
Baylor College of Medicine, Houston, Texas, USA Department of Ophthalmology, Houston Methodist Hospital, Houston, Texas, USA c Department of Ophthalmology, Weill Cornell Medical College, Houston, Texas, USA d Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA e Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA f The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA g The Jules Stein Eye Institute, University of California (UCLA), Los Angeles, California, USA b
article info
abstract
Article history:
The accreditation of graduate medical education through the evaluation of residency
Received 7 July 2014
programs and the teaching hospitals that offer them in the United States is the primary
Received in revised form 20 August
mission of the Accreditation Council for Graduate Medical Education (ACGME). In 1999, the
2014
ACGME formulated the six ACGME competencies and, ten years later, developed a multi-
Accepted 26 August 2014
year plan to restructure the accreditation process in order to assess educational out-
Available online 04 September 2014
comes. The result of these evolving efforts has been termed the Next Accreditation System
Edward Raab and Andrew G. Lee,
(NAS). The stated goals of the NAS are 1) to enhance the ability of the peer-review system to
Editors
prepare physicians for practice in the 21st century; 2) to accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes; and 3) to reduce the burden
Keywords:
associated with the current structure and process-based approach. The NAS is an inter-
Next Accreditation System
esting and novel approach to re-engineer the GME accreditation process to become more
ophthalmology
equitable, fair, and transparent and less costly and burdensome, and to improve resident education and ultimately patient care. The new process will rely upon measurable and meaningful outcomes rather than simply structure and process assessments. Instead of the episodic program biopsies with site visitor reports, detailed program information forms, and formal residency review committee evaluations that characterized the old accreditation system, the NAS will be based upon annual reports of specific quantitative, trended, performance benchmarks; the ACGME milestones; and an institutional clinical competency committee. In addition, a separate but related specialty-specific Clinical Environment Learning Review (CLER) will be a more detailed examination of the learning environment and infrastructure. The CLER, however, will not have a direct role in the accreditation decision-making process of the NAS. ª 2015 Elsevier Inc. All rights reserved.
Dr. Lee and Dr. Arnold served on the ACGME Residency Review Committee (RC) for Ophthalmology (Dr. Arnold as chair), but the views and opinions reflected in this article are those of the authors and do not necessarily reflect those of the ACGME or the RC. * Corresponding author: Andrew G. Lee, MD, Department of Ophthalmology, Houston Methodist Hospital, 6560 Fannin Street, Scurlock 450, Houston, Texas 77030, USA. E-mail address: [email protected] (A.G. Lee). 0039-6257/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.survophthal.2014.08.004
s u r v e y o f o p h t h a l m o l o g y 6 0 ( 2 0 1 5 ) 8 2 e8 5
1.
Introduction
The accreditation of graduate medical education (GME) programs in the United States is evolving. Over time it has become clear that there were significant limitations to the old accreditation system (OAS). This system emphasized structure and process assessments over outcomes and was sometimes perceived as including overly prescriptive requirements. The role of residency program directors became increasingly clerical and managerial and less about resident and faculty mentoring, educational career development, or fostering a safe and conducive learning environment. In the OAS, there was criticism from some program directors suggesting that programs entered in to the accreditation process with the goal of avoiding citations rather than creating new knowledge or supporting educational innovation and initiatives. The Next Accreditation System (NAS) represents a significant opportunity for change and improvement in the GME accreditation process. We compare and contrast the OAS with the NAS, discuss the background and current implementation for the NAS, and outline the future plans and the potential impact of the NAS on ophthalmology.1-5
2.
OAS versus NAS
The program director and program coordinators in the OAS were periodically (depending on review cycle and prior accreditation duration) required to produce detailed information on the operations of their program that included institutional infrastructure and inter-institutional agreements, teaching and learning activities, and details about the teaching and leadership of the faculty. In the OAS this voluminous document was called the program information form (PIF). Assembling the PIF was a daunting and time-consuming clerical, administrative, and managerial challenge. In addition to the departmental PIF, there was also mid-cycle internal GME committee institutional review. The PIF details were then verified and resident survey results were confirmed over a one- or two-day site visit (SV) by a site visitor who then prepared a detailed site visit report (SVR). The SVR then provided the basis for a focused expert peer review by two or more members of the Accreditation Council for Graduate Medical Education (ACGME) Review Committee (RC) for ophthalmology. These reviews by individual ophthalmology RC members often required hours poring over details in the PIF, the SVR, resident surveys, and resident case logs. The full committee review by the RC in the OAS was a high-stakes event that might produce one of the following decisions: initial or continued accreditation of variable duration with or without specific individual RC citations (based upon the specialty or common program requirements); requests for more information or progress reports; program probation; or in some extreme cases recommendation for loss of program accreditation. The OAS was time- and laborintensive for both programs and the RC and often was perceived as focused on the prescriptive structure and process assessments. The OAS was episodic (sometimes covering a
83
period of several years) and retrospective, and also lacked nationally benchmarked standardized quantitative, annual performance metrics. There was limited ability to promote improvements in programs doing well or to reward or provide incentives to develop programs for educational innovation. In response to the limitations of the OAS, the ACGME created the NAS. In the NAS, the PIF will no longer be necessary. Instead, programs will make annual reports on their progress and will be provided with recommendations for performance improvement and trend data. They would then be freed from the documentation burden of the PIF and a periodic site visit and could be encouraged to innovate and experiment. For those few programs flagged by the annual screening, additional RC evaluation may be required, and the program might be asked to undergo a focused or a full SVR, but in contrast to the OAS, the episodic, pre-planned SVR of all programs will no longer occur. Thus, the role of the RC for ophthalmology will change from a more focused regulatory and compliance verification role in the OAS to a broader oversight and educational role in the NAS. For ophthalmology (as well as other specialties), the NAS will have four key process changes from the OAS: 1. Clinical competency committees (CCCs).2 Within each specialty department or division a CCC shall meet and provide ongoing data analysis, resident and program feedback, and improvement measures across the six ACGME competencies (i.e., patient care, medical knowledge, professionalism, communication and interpersonal skills, practice based learning, and systems based competency). The CCCsdcomposed of core faculty, the program director, and other key stakeholdersdare charged with monitoring and tracking performance of residents and faculty. The ACGME has offered only limited guidelines for the structure, process, operations, and logistics for the CCC. French et al2 focus on the three key areas of CCC implementation: 1) the pre-review, 2) resident milestone review, and 3) post-review processes. They outline specific components related to shifting culture, committee membership, and terms, assessing available evidence, review dissemination, and provided example scenarios.2 2. ACGME Milestones. Evaluation of the ACGME milestones will become the major assessment of learning outcomes and progress over time. In a previous article in Survey of Ophthalmology, we described the ACGME Milestones Project as part of the NAS and the proposed ophthalmology milestones.3 More than 10 ophthalmology residency programs completed a pilot study of the milestones process, an important component of NAS. 3. The Milestone Project is embedded in the implementation matrix for the NAS with the general definition of a milestone being “skill and knowledge based developments that commonly occur by a specific time.” The definition includes “specific behaviors, attitudes, or outcomes in the general competency domains to be demonstrated by residents by a particular point in residency.” In many but not all of the milestone frameworks to date, including ophthalmology, the progression reflects movement across a Dreyfus model of expertise acquisition (e.g., novice, beginner, advanced
84
s u r v e y o f o p h t h a l m o l o g y 6 0 ( 2 0 1 5 ) 8 2 e8 5
for learning during the CLER will focus on institutional oversight and compliance with teaching and learning about patient safety and clinical quality.
Table 1 e Trended and weighted performance metrics in the Next Accreditation System Program data: Annual Accreditation Data System update (i.e., an update on structure and resources, attrition, and leadership changes) Resident and faculty scholarship Clinical experience (case logs) Resident survey Faculty survey Semiannual resident evaluation on milestones with a Clinical Competency Committee Rolling board certification examination pass rates Program self-study and site visit (every 10 years)
beginner, competent, proficient, and expert). Programs will be expected to submit the milestone data points every 6 months synchronized with the semiannual resident survey. The specific milestones and dimensions submitted to the ACGME for ophthalmology are described in more detail in the prior publication3 and are not repeated here. Individual departmental CCCs will be responsible for monitoring and verifying progress for individual residents with the milestone requirements. 4. Clinical Environment Learning Review (CLER). An additional change in the process, but not necessarily tied to the accreditation decision, is the shifting of the burden for ensuring a safe and high quality patient care and educational learning environment from individual departments of ophthalmology to the sponsoring and supervising institutions. Periodic site visits of the clinical environment
Table 1 lists the contents of the annual program review data in the Accreditation Data System. In contrast to the episodic PIF and SVR of the OAS, in the NAS, there are annual assessments. Programs with sufficient or superior educational outcomes would thus be freed from the burden of the traditional PIF and RRC review process and would instead be encouraged to experiment and to innovate. In contrast, programs failing to meet the predefined, weighted annual data requirements will receive feedback from the RC and make necessary corrections rather than waiting several years for an SV.
3.
Timeline
The NAS is being implemented in phases. In July 2013, the ACGME completed pilot programs with emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urology. The remaining specialties, including ophthalmology, are scheduled to implement the NAS in July 2014. Figure 1 shows a conceptual model of the NAS. The actual work flow for the ophthalmology RC will likely follow the example of the prior pilot specialties. It is anticipated that after reviewing the Accreditation Data System data prior to the RC meeting, the RC will have a
Fig. 1 e Conceptual model of the Next Accreditation System (NAS): Programs with the status of continued accreditation are subject to further review of only outcomes and core process measures. On the basis of that review, programs may retain a status of continued accreditation or could be given the status of accreditation with warning or probationary accreditation. Programs with either status are still subject to review of their compliance, with a review of outcomes, core process, and detail process. Programs applying for initial accreditation have no outcomes and so they are subject only to review of core and detail process. (Reproduced with the permission of the Accreditation Council for Graduate Medical Education [ACGME]. Copyright 2014 ACGME. Illustration and logo used with permission.)
s u r v e y o f o p h t h a l m o l o g y 6 0 ( 2 0 1 5 ) 8 2 e8 5
number of options similar to but not the same as in the OAS. Programs that meet all established performance thresholds will receive a letter of continued accreditation. If programs do not meet the established performance thresholds, however, a focused or full SV might be recommended. The goals of a focused SV include: 1) to assess selected aspects of a program or sponsoring institution identified by the RC as problematic or for follow up after initial review of annual accreditation information; 2) to evaluate the merits of any and all complaints against a program or institution; 3) to diagnose factors underlying deterioration in the trended performance of a program or institution as identified in review of annual accreditation information; and (4) to investigate an allegation of any egregious violations. A notice of only 30 days will be given before a focused SV because it is assumed that only minimal document preparation will be necessary, and the visit will likely be conducted by a team. In contrast, a full SV may be used to assess program or institutional compliance with all applicable requirements similar to the OAS. A full SV may also be necessary to review programs when annual accreditation information identifies specific issues or concerns across several key or critical areas as determined by the RRC. The full SV will also review new programs applying for initial accreditation as well as programs at the end of initial accreditation periods. A separate and special form of full SV (i.e., the “self-study visit”) will take place at once in a 10-year period for every program. The selfstudy visit will be based on a comprehensive self-study that is performed by the program or institution. The self-study describes how that individual program or institution creates an effective learning and working environment leading to desired educational outcomes and analyses the program’s or institution’s strengths, weaknesses, and plans for improvement.
4.
Conclusion
The disadvantages and limitations of the OAS led the ACGME to recognize the need for change. The NAS is an important step in developing an accreditation system and a residency review process that is fair, balanced, less prescriptive, and less burdensome to residents, program directors, and institutions. Ideally, in comparison to the OAS, the NAS will identify “programs in need” at the annual report stage rather than retrospectively, will free high performing programs from the
85
drudgery of the structure and process assessments of the PIF and SVR, and will promote educational innovation in programs that are doing well. This will ideally create better programs and better residents and ultimately improve patient care. A number of unanswered questions remain. These include the increase or decrease in time burden for program directors and the RC and the actual outcomes in terms of measurable improvements in resident education, patient safety, and quality of care. Will this foster the actual development and implementation of educational innovation? What is the sensitivity and specificity of the trended, annual performance indicators for identifying true outliers? How will the lack of a PIF or SVR affect the accreditation decision-making of the ophthalmology RC? The leadership of the ACGME has expressed interest in engaging the full educational community through a dedicated Web site (http://www.acgme-nas. org/) and through presentations and discussions at professional meetings, focus group sessions, and other venues. Only time will tell whether the aspirational goals of the NAS will be met and whether the NAS will truly be superior to the OAS.
Acknowledgment The authors wish to thank Mary Joyce Turner from the RC for Ophthalmology at the ACGME for her time and review of this manuscript.
references
1. Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation systemedrationale and benefits. N Engl J Med. 2012;366:1051e6 2. French JC, Dannefer EF, Colbert CY. A systematic approach toward building a fully operational clinical competency committee. J Surg Educ 2014; http://dx.doi.org/10.1016/j.jsurg. 2014.04.005. pii: S1931-7204(14)00107-X. [Epub ahead of print]. 3. Lee AG, Arnold AC. The ACGME Milestone Project in ophthalmology. Surv Ophthalmol. 2013;58:359e69 4. Marsh JL, Potts JR 3rd, Levine WN. Challenges in resident education: is the next accreditation system (NAS) the answer? AOA Critical Issues. J Bone Joint Surg Am. 2014;96:e75 5. Philbert I, Nasca TJ. The Next Accreditation System: stakeholder expectations and dialogue with the community. J Grad Med Educ. 2012;4:276e8
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/survophthal
Core competencies in ophthalmology
The Next Accreditation System in ophthalmology Andrew G. Lee, MDa,b,c,d,e,f,*, Anthony C. Arnold, MDg a
Baylor College of Medicine, Houston, Texas, USA Department of Ophthalmology, Houston Methodist Hospital, Houston, Texas, USA c Department of Ophthalmology, Weill Cornell Medical College, Houston, Texas, USA d Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA e Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA f The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA g The Jules Stein Eye Institute, University of California (UCLA), Los Angeles, California, USA b
article info
abstract
Article history:
The accreditation of graduate medical education through the evaluation of residency
Received 7 July 2014
programs and the teaching hospitals that offer them in the United States is the primary
Received in revised form 20 August
mission of the Accreditation Council for Graduate Medical Education (ACGME). In 1999, the
2014
ACGME formulated the six ACGME competencies and, ten years later, developed a multi-
Accepted 26 August 2014
year plan to restructure the accreditation process in order to assess educational out-
Available online 04 September 2014
comes. The result of these evolving efforts has been termed the Next Accreditation System
Edward Raab and Andrew G. Lee,
(NAS). The stated goals of the NAS are 1) to enhance the ability of the peer-review system to
Editors
prepare physicians for practice in the 21st century; 2) to accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes; and 3) to reduce the burden
Keywords:
associated with the current structure and process-based approach. The NAS is an inter-
Next Accreditation System
esting and novel approach to re-engineer the GME accreditation process to become more
ophthalmology
equitable, fair, and transparent and less costly and burdensome, and to improve resident education and ultimately patient care. The new process will rely upon measurable and meaningful outcomes rather than simply structure and process assessments. Instead of the episodic program biopsies with site visitor reports, detailed program information forms, and formal residency review committee evaluations that characterized the old accreditation system, the NAS will be based upon annual reports of specific quantitative, trended, performance benchmarks; the ACGME milestones; and an institutional clinical competency committee. In addition, a separate but related specialty-specific Clinical Environment Learning Review (CLER) will be a more detailed examination of the learning environment and infrastructure. The CLER, however, will not have a direct role in the accreditation decision-making process of the NAS. ª 2015 Elsevier Inc. All rights reserved.
Dr. Lee and Dr. Arnold served on the ACGME Residency Review Committee (RC) for Ophthalmology (Dr. Arnold as chair), but the views and opinions reflected in this article are those of the authors and do not necessarily reflect those of the ACGME or the RC. * Corresponding author: Andrew G. Lee, MD, Department of Ophthalmology, Houston Methodist Hospital, 6560 Fannin Street, Scurlock 450, Houston, Texas 77030, USA. E-mail address: [email protected] (A.G. Lee). 0039-6257/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.survophthal.2014.08.004
s u r v e y o f o p h t h a l m o l o g y 6 0 ( 2 0 1 5 ) 8 2 e8 5
1.
Introduction
The accreditation of graduate medical education (GME) programs in the United States is evolving. Over time it has become clear that there were significant limitations to the old accreditation system (OAS). This system emphasized structure and process assessments over outcomes and was sometimes perceived as including overly prescriptive requirements. The role of residency program directors became increasingly clerical and managerial and less about resident and faculty mentoring, educational career development, or fostering a safe and conducive learning environment. In the OAS, there was criticism from some program directors suggesting that programs entered in to the accreditation process with the goal of avoiding citations rather than creating new knowledge or supporting educational innovation and initiatives. The Next Accreditation System (NAS) represents a significant opportunity for change and improvement in the GME accreditation process. We compare and contrast the OAS with the NAS, discuss the background and current implementation for the NAS, and outline the future plans and the potential impact of the NAS on ophthalmology.1-5
2.
OAS versus NAS
The program director and program coordinators in the OAS were periodically (depending on review cycle and prior accreditation duration) required to produce detailed information on the operations of their program that included institutional infrastructure and inter-institutional agreements, teaching and learning activities, and details about the teaching and leadership of the faculty. In the OAS this voluminous document was called the program information form (PIF). Assembling the PIF was a daunting and time-consuming clerical, administrative, and managerial challenge. In addition to the departmental PIF, there was also mid-cycle internal GME committee institutional review. The PIF details were then verified and resident survey results were confirmed over a one- or two-day site visit (SV) by a site visitor who then prepared a detailed site visit report (SVR). The SVR then provided the basis for a focused expert peer review by two or more members of the Accreditation Council for Graduate Medical Education (ACGME) Review Committee (RC) for ophthalmology. These reviews by individual ophthalmology RC members often required hours poring over details in the PIF, the SVR, resident surveys, and resident case logs. The full committee review by the RC in the OAS was a high-stakes event that might produce one of the following decisions: initial or continued accreditation of variable duration with or without specific individual RC citations (based upon the specialty or common program requirements); requests for more information or progress reports; program probation; or in some extreme cases recommendation for loss of program accreditation. The OAS was time- and laborintensive for both programs and the RC and often was perceived as focused on the prescriptive structure and process assessments. The OAS was episodic (sometimes covering a
83
period of several years) and retrospective, and also lacked nationally benchmarked standardized quantitative, annual performance metrics. There was limited ability to promote improvements in programs doing well or to reward or provide incentives to develop programs for educational innovation. In response to the limitations of the OAS, the ACGME created the NAS. In the NAS, the PIF will no longer be necessary. Instead, programs will make annual reports on their progress and will be provided with recommendations for performance improvement and trend data. They would then be freed from the documentation burden of the PIF and a periodic site visit and could be encouraged to innovate and experiment. For those few programs flagged by the annual screening, additional RC evaluation may be required, and the program might be asked to undergo a focused or a full SVR, but in contrast to the OAS, the episodic, pre-planned SVR of all programs will no longer occur. Thus, the role of the RC for ophthalmology will change from a more focused regulatory and compliance verification role in the OAS to a broader oversight and educational role in the NAS. For ophthalmology (as well as other specialties), the NAS will have four key process changes from the OAS: 1. Clinical competency committees (CCCs).2 Within each specialty department or division a CCC shall meet and provide ongoing data analysis, resident and program feedback, and improvement measures across the six ACGME competencies (i.e., patient care, medical knowledge, professionalism, communication and interpersonal skills, practice based learning, and systems based competency). The CCCsdcomposed of core faculty, the program director, and other key stakeholdersdare charged with monitoring and tracking performance of residents and faculty. The ACGME has offered only limited guidelines for the structure, process, operations, and logistics for the CCC. French et al2 focus on the three key areas of CCC implementation: 1) the pre-review, 2) resident milestone review, and 3) post-review processes. They outline specific components related to shifting culture, committee membership, and terms, assessing available evidence, review dissemination, and provided example scenarios.2 2. ACGME Milestones. Evaluation of the ACGME milestones will become the major assessment of learning outcomes and progress over time. In a previous article in Survey of Ophthalmology, we described the ACGME Milestones Project as part of the NAS and the proposed ophthalmology milestones.3 More than 10 ophthalmology residency programs completed a pilot study of the milestones process, an important component of NAS. 3. The Milestone Project is embedded in the implementation matrix for the NAS with the general definition of a milestone being “skill and knowledge based developments that commonly occur by a specific time.” The definition includes “specific behaviors, attitudes, or outcomes in the general competency domains to be demonstrated by residents by a particular point in residency.” In many but not all of the milestone frameworks to date, including ophthalmology, the progression reflects movement across a Dreyfus model of expertise acquisition (e.g., novice, beginner, advanced
84
s u r v e y o f o p h t h a l m o l o g y 6 0 ( 2 0 1 5 ) 8 2 e8 5
for learning during the CLER will focus on institutional oversight and compliance with teaching and learning about patient safety and clinical quality.
Table 1 e Trended and weighted performance metrics in the Next Accreditation System Program data: Annual Accreditation Data System update (i.e., an update on structure and resources, attrition, and leadership changes) Resident and faculty scholarship Clinical experience (case logs) Resident survey Faculty survey Semiannual resident evaluation on milestones with a Clinical Competency Committee Rolling board certification examination pass rates Program self-study and site visit (every 10 years)
beginner, competent, proficient, and expert). Programs will be expected to submit the milestone data points every 6 months synchronized with the semiannual resident survey. The specific milestones and dimensions submitted to the ACGME for ophthalmology are described in more detail in the prior publication3 and are not repeated here. Individual departmental CCCs will be responsible for monitoring and verifying progress for individual residents with the milestone requirements. 4. Clinical Environment Learning Review (CLER). An additional change in the process, but not necessarily tied to the accreditation decision, is the shifting of the burden for ensuring a safe and high quality patient care and educational learning environment from individual departments of ophthalmology to the sponsoring and supervising institutions. Periodic site visits of the clinical environment
Table 1 lists the contents of the annual program review data in the Accreditation Data System. In contrast to the episodic PIF and SVR of the OAS, in the NAS, there are annual assessments. Programs with sufficient or superior educational outcomes would thus be freed from the burden of the traditional PIF and RRC review process and would instead be encouraged to experiment and to innovate. In contrast, programs failing to meet the predefined, weighted annual data requirements will receive feedback from the RC and make necessary corrections rather than waiting several years for an SV.
3.
Timeline
The NAS is being implemented in phases. In July 2013, the ACGME completed pilot programs with emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urology. The remaining specialties, including ophthalmology, are scheduled to implement the NAS in July 2014. Figure 1 shows a conceptual model of the NAS. The actual work flow for the ophthalmology RC will likely follow the example of the prior pilot specialties. It is anticipated that after reviewing the Accreditation Data System data prior to the RC meeting, the RC will have a
Fig. 1 e Conceptual model of the Next Accreditation System (NAS): Programs with the status of continued accreditation are subject to further review of only outcomes and core process measures. On the basis of that review, programs may retain a status of continued accreditation or could be given the status of accreditation with warning or probationary accreditation. Programs with either status are still subject to review of their compliance, with a review of outcomes, core process, and detail process. Programs applying for initial accreditation have no outcomes and so they are subject only to review of core and detail process. (Reproduced with the permission of the Accreditation Council for Graduate Medical Education [ACGME]. Copyright 2014 ACGME. Illustration and logo used with permission.)
s u r v e y o f o p h t h a l m o l o g y 6 0 ( 2 0 1 5 ) 8 2 e8 5
number of options similar to but not the same as in the OAS. Programs that meet all established performance thresholds will receive a letter of continued accreditation. If programs do not meet the established performance thresholds, however, a focused or full SV might be recommended. The goals of a focused SV include: 1) to assess selected aspects of a program or sponsoring institution identified by the RC as problematic or for follow up after initial review of annual accreditation information; 2) to evaluate the merits of any and all complaints against a program or institution; 3) to diagnose factors underlying deterioration in the trended performance of a program or institution as identified in review of annual accreditation information; and (4) to investigate an allegation of any egregious violations. A notice of only 30 days will be given before a focused SV because it is assumed that only minimal document preparation will be necessary, and the visit will likely be conducted by a team. In contrast, a full SV may be used to assess program or institutional compliance with all applicable requirements similar to the OAS. A full SV may also be necessary to review programs when annual accreditation information identifies specific issues or concerns across several key or critical areas as determined by the RRC. The full SV will also review new programs applying for initial accreditation as well as programs at the end of initial accreditation periods. A separate and special form of full SV (i.e., the “self-study visit”) will take place at once in a 10-year period for every program. The selfstudy visit will be based on a comprehensive self-study that is performed by the program or institution. The self-study describes how that individual program or institution creates an effective learning and working environment leading to desired educational outcomes and analyses the program’s or institution’s strengths, weaknesses, and plans for improvement.
4.
Conclusion
The disadvantages and limitations of the OAS led the ACGME to recognize the need for change. The NAS is an important step in developing an accreditation system and a residency review process that is fair, balanced, less prescriptive, and less burdensome to residents, program directors, and institutions. Ideally, in comparison to the OAS, the NAS will identify “programs in need” at the annual report stage rather than retrospectively, will free high performing programs from the
85
drudgery of the structure and process assessments of the PIF and SVR, and will promote educational innovation in programs that are doing well. This will ideally create better programs and better residents and ultimately improve patient care. A number of unanswered questions remain. These include the increase or decrease in time burden for program directors and the RC and the actual outcomes in terms of measurable improvements in resident education, patient safety, and quality of care. Will this foster the actual development and implementation of educational innovation? What is the sensitivity and specificity of the trended, annual performance indicators for identifying true outliers? How will the lack of a PIF or SVR affect the accreditation decision-making of the ophthalmology RC? The leadership of the ACGME has expressed interest in engaging the full educational community through a dedicated Web site (http://www.acgme-nas. org/) and through presentations and discussions at professional meetings, focus group sessions, and other venues. Only time will tell whether the aspirational goals of the NAS will be met and whether the NAS will truly be superior to the OAS.
Acknowledgment The authors wish to thank Mary Joyce Turner from the RC for Ophthalmology at the ACGME for her time and review of this manuscript.
references
1. Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation systemedrationale and benefits. N Engl J Med. 2012;366:1051e6 2. French JC, Dannefer EF, Colbert CY. A systematic approach toward building a fully operational clinical competency committee. J Surg Educ 2014; http://dx.doi.org/10.1016/j.jsurg. 2014.04.005. pii: S1931-7204(14)00107-X. [Epub ahead of print]. 3. Lee AG, Arnold AC. The ACGME Milestone Project in ophthalmology. Surv Ophthalmol. 2013;58:359e69 4. Marsh JL, Potts JR 3rd, Levine WN. Challenges in resident education: is the next accreditation system (NAS) the answer? AOA Critical Issues. J Bone Joint Surg Am. 2014;96:e75 5. Philbert I, Nasca TJ. The Next Accreditation System: stakeholder expectations and dialogue with the community. J Grad Med Educ. 2012;4:276e8
