Milestones - Council of Emergency Medicine Residency Directors

Report
Emergency Medicine Milestones
April 2, 2012
2012 CORD Academic Assembly
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Based on Core Competencies
Patient Care- 14
 Medical Knowledge-1
 Professionalism- 2
 Interpersonal Communication Skills- 2
 Practice-based Learning and Improvement- 2
 Systems-based Practice- 3
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A total of 24 Milestones
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Developed and completed Milestones in 5 months
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Based on Milestone progress, EM invited into NAS trial
rollout July, 2013
Milestones are truly along a continuum of end of
medical school to certification standards
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Approved by ABEM BOD 1/2012, and by RRC-EM 2/2012
Only specialty to take ABMS certification standards and apply
to Milestones
Milestones are based on extensive survey data related
to ABEM certification standards
Only specialty allowed to make revisions in program
requirements

Only specialty to integrate the Milestones into proposed
program requirement changes
Obtain outcome measures (i.e. milestones
of competency development) to use as
evidence of programs’ educational
effectiveness
6
Case Logs
Milestone
Reporting
(semiannually)
7
Resident
and Faculty
Opinions
Continuous
Oversight &
Improvement
Emphasis
Program &
Institutional
Information
ACGME
Residency Programs
• Accreditation – continuous monitoring of
programs; lengthening of site visit cycles
• Public Accountability – report at a national level
on competency outcomes
• Community of practice for evaluation and
research, with focus on continuous
improvement
• Guide curriculum development
• More explicit expectations of residents
• Support better assessment
• Enhanced opportunities for early
identification of under-performers
Milestones
Certification Boards
Residents
• Potential use – ascertain whether
individuals have demonstrated
qualifications needed to sit for Board exams
• Increased transparency of performance
requirements
• Encourage resident self-assessment and
self-directed learning
• Better feedback to residents
8
Feasibility
Quality
Reporting
• Balance costs
with benefits
• Manageable
number of
milestones
• Improvement
over current
approaches
• Meaningful &
substantive
• “Measurable”
• Specialtywide use of 5level
template for
milestones
reporting
• Central data
repository
9
Sponsorship
Who
When/How
• ACGME
• Certification
Boards
• Working
Group
• 3 – 4 meetings
• Interim work
and regular
communication
• Milestones
developed in 12
months (or less!)
• PDs, Residents,
Board, RRC,
Specialty
Organization,
ACGME
• Advisory
Group
10
Who
Who
• Expert Panel
• Assessment
Group
• Developing
milestones for ICS,
Prof, PBLI, SBP
• For adaption or
adoption
11
• Identifying
assessment tools
• Developing
implementation
guidelines
1999 - Outcome
Project Begins
2001- Quadrads
(Board, PD, RRC,
Res) Convened
2002-2008 –
Implementation
of 6 Competency
Domains
2009 – 2012
Milestone
Development
• All specialties to
be completed by
12/2012
• Pilot testing
ongoing
12
2013 & Beyond
• Large scale
implementation
of milestones for
testing
• New
accreditation
system launch ~
staggered
approach (e.g. 45 specialties at
first)

Development of Milestones

Almost as if there was a plan…
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Chair: Michael Beeson (Vice Chair, RRCEM)
Ted Christopher, M.D. (AACEM)
Kevin Rodgers, M.D. (AAEM)
Jamie Jones, M.D. (ABEM)
Mary Jo Wagner, M.D. (ACEP)
Philip Shayne, M.D. (CORD)
Jonathan Heidt, M.D. (EMRA)
Susan Promes, M.D. (SAEM)

The Model of the Clinical Practice of
Emergency Medicine
Most are familiar with the “Listing of Conditions
and Components”
 There is another aspect:

 Physician Task Definitions
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Prehospital Care
Emergency Stabilization
Performance of Focused History and Physical Exam
Modifying Factors
Professional and Legal Issues
Diagnostic Studies
Diagnosis
Therapeutic Interventions
Pharmacotherapy
Observation & Reassessment
Consultation and disposition
Prevention & Education
Documentation
Multi-tasking and Team Management

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Made up of ABEM Board members
Tasked with looking at entire initial
certification process
What are the standards?
 Have they changed?
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Evaluated changes in physician practice
Recommended changes to the content and
methods of administration of ABEM’s
examinations to assure relevancy to EM
practice
The result was additive and claritive to
physician task definitions
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Pre-hospital Care
Emergency Stabilization
Performance of Focused History and
Physical Exam
Modifying Factors
Professional and Legal Issues
Diagnostic Studies
Diagnosis
Therapeutic Interventions
Pharmacotherapy
Observation & Reassessment
Consultation
Disposition
Prevention & Education
Documentation
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Multi-tasking (Task-switching)
Team Management
General Approach to Procedures
Procedures
Contract Principles
Financial Issues
Operations
Clinical Informatics
Knowledge Translation
Performance Improvement
Systems-based Management
Disaster Management
Communication and Interpersonal
Skills
Teaching
Research
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With physician task definitions in place and the
REPP report’s addition, ABEM was ready to
write the Knowledge, Skills, and Abilities
(KSAs) that should make up an Initial
Certification Exam
An Advisory Panel was created in which KSAs
were written that defined expectations of an
individual pursuing initial certification in EM
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Based upon using Physician Task Definitions
as starting point
Each KSA was then developed into hierarchical
scales of performance competency
Accepted level of performance for the ABEM
Diplomate
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ABEM sent a survey to EM Diplomates and
had over 7000 responses
The survey queried importance and frequency
for each of the identified KSAs and Model
Content
The result is EM is a specialty in which our
practitioners have defined the frequency and
importance of expert panel defined KSAs
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A smooth transition?

Identified the Physician Task Definitions
essential to the defined needs for Milestones
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Pre-hospital Care
Emergency Stabilization
Performance of Focused History and
Physical Exam
Modifying Factors
Professional and Legal Issues
Diagnostic Studies
Diagnosis
Therapeutic Interventions
Pharmacotherapy
Observation & Reassessment
Consultation
Disposition
Prevention & Education
Documentation

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












Multi-tasking (Task-switching)
Team Management
General Approach to Procedures
Procedures
Contract Principles
Financial Issues
Operations
Clinical Informatics
Knowledge Translation
Performance Improvement
Systems-based Management
Disaster Management
Communication and Interpersonal
Skills
Teaching
Research

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Identified the Physician Task Definitions
essential to the defined needs for Milestones
Narrowed the list to 17 from 29
Then looked at ABEM’s additional work on
hierarchical scales of performance
Identified Milestones for each core competency
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Five levels
Level 1- entry level for a medical school
graduate
Level 4- The ABEM certification standard
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By definition where an individual should be at time
of graduation
Level 5- Attained after practice experience
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Based on Core Competencies
Patient Care- 14
 Medical Knowledge-1
 Professionalism- 2
 Interpersonal Communication Skills- 2
 Practice-based Learning and Improvement- 2
 Systems-based Practice- 3

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A total of 24 Milestones
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PC1- Emergency Stabilization
PC2- Performance of Focused History and
Physical Examination
PC3- Diagnostic Studies
PC4- Diagnosis
PC5- Pharmacotherapy
PC6- Observation and Reassessment
PC7- Disposition
PC8- Multi-tasking (Task-switching)
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PC9- General Approach to Procedures
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PC10- Airway Management
PC11- Anesthesia and Acute Pain Management
PC12- Other Diagnostic and Therapeutic Procedures:
Ultrasound (Diagnostic / Procedural)
PC13- Other Diagnostic and Therapeutic Procedures:
Wounds Management
PC14- Other Diagnostic and Therapeutic
Procedures: Vascular Access
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MK- Medical Knowledge
PROF1- Professional values
PROF2- Accountability
ICS1- Patient Centered Communication
ICS2- Team Management
PBLI1- Teaching
PBLI2- Practice Based Performance Improvement
SBP1- Patient Safety
SBP2- Systems-based Management
SBP3- Technology

Working Group Meeting March 10, 2012
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CORD, CDEM invited
Evaluated potential assessment methods
Made recommendations for assessment
 End of shift, direct observation, and simulation were
determined to likely be best assessment methods
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Validity studies
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ABEM undertaking at end of April, 2012
Avoid use as a simple subjective Likert scale
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Base marker scoring on objective measures
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EM will be used as pilot specialty in NAS
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Integration of Milestones into EM Program
Requirements
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Begins July, 2013
A first!
Development of assessment methodology
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Specialty-wide implementation of assessment
methods?
Partner with CORD
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Can CORD develop tools that are accepted by
most programs, that can be applied to end of shift,
direct observation, or simulation methods?
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Can CORD develop validity and reliability studies
for developed tools?
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Example is SDOT as a tool used with direct observation
as an assessment method
Inter-rater reliability
Can CORD develop faculty development
programs that teach use of developed tools to
ensure reliable application?

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