MILESTONES

Emergency Medicine MilestonesApril 2, 2012

2012 CORD Academic Assembly

Birmingham Hip Resurfacing

Emergency Medicine Milestones

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

A total of 24 Milestones

Emergency Medicine Firsts

Developed and completed Milestones in 5 months Approved by ABEM BOD 1/2012, and by RRC-EM 2/2012

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 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

How Did We Get to Milestones as a Specialty?

Overall Milestone Project Goal

Obtain outcome measures (i.e. milestones of competency

development) to use as evidence of programs’ educational effectiveness

6

Next Accreditation System

Continuous Oversight & Improvement

Emphasis

Milestone Reporting

(semi-annually)

Case LogsResident and

Faculty OpinionsProgram &

Institutional Information

7

Uses and Implications

8

Residency Programs Guide curriculum developmentMore explicit expectations of residentsSupport better assessmentEnhanced opportunities for early identification of under-performers

Residents Increased transparency of performance requirementsEncourage resident self-assessment and self-directed learningBetter feedback to residents

Milestones

Guiding Principles

9

Feasibility

•Balance costs with benefits•Manageable number of milestones

Quality•Improvement over current approaches•Meaningful & substantive•“Measurable”

Reporting

•Specialty-wide use of 5-level template for milestones reporting•Central data repository

Milestone Development

Sponsorship• ACGME• Certification

Boards

Who• Working

Group• PDs, Residents,

Board, RRC, Specialty Organization, ACGME

• Advisory Group

When/How• 3 – 4 meetings• Interim work

and regular communication

• Milestones developed in 12 months (or less!)

10

Milestone Development

Who• Expert Panel

• Developing milestones for ICS, Prof, PBLI, SBP

• For adaption or adoption

11

Who• Assessment

Group

• Identifying assessment tools

• Developing implementation guidelines

Outcome Project – Continued

12

1999 - Outcome

Project Begins

2001- Quadrads

(Board, PD, RRC, Res) Convened

2002-2008 – Implementatio

n of 6 Competency

Domains

2009 – 2012Milestone

Development

• All specialties to be completed by 12/2012

• Pilot testing ongoing

2013 & Beyond

• Large scale implementation of milestones for testing

• New accreditation system launch ~ staggered approach (e.g. 4-5 specialties at first)

Emergency Medicine

Development of Milestones Almost as if there was a plan…

Milestone Working Group

Chair: Michael Beeson (Vice Chair, RRC-EM)

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

ABEM’s Work

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

Physician Task Definitions from the Model

ABEM Initial Certification Task Force (ICTF)

Made up of ABEM Board members Tasked with looking at entire initial

certification process What are the standards? Have they changed?

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

Along Came the ABEM REPP Task Force (Relevance of Examinations to Physician

Practice)

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

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

Physician Task Definitions

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

ABEM Initial Certification Task Force

KSAs

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

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

KSAs

A smooth transition?

KSAs to Milestones to Markers

Milestone Working Group

Identified the Physician Task Definitions essential to the defined needs for Milestones

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

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

Physician Task Definitions

Milestone Working Group

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

Uniformity of Milestone Reporting

Five levels Level 1- entry level for a medical school

graduate Level 4- The ABEM certification standard

By definition where an individual should be at time of graduation

Level 5- Attained after practice experience

Emergency Medicine Milestones

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

A total of 24 Milestones

Milestones

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)

Milestones

PC9- General Approach to Procedures 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

Milestones

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

EM Milestones

Working Group Meeting March 10, 2012 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

Validity studies ABEM undertaking at end of April, 2012

Avoid use as a simple subjective Likert scale Base marker scoring on objective measures

Next Steps

EM will be used as pilot specialty in NAS Begins July, 2013

Integration of Milestones into EM Program Requirements A first!

Development of assessment methodology Specialty-wide implementation of assessment

methods? Partner with CORD

Challenges

Can CORD develop tools that are accepted by most programs, that can be applied to end of shift, direct observation, or simulation methods? Example is SDOT as a tool used with direct

observation as an assessment method Can CORD develop validity and reliability

studies for developed tools? Inter-rater reliability

Can CORD develop faculty development programs that teach use of developed tools to ensure reliable application?