The Next Accreditation System: Stakeholder Expectations and Dialogue with the Community

Abstract

In February 2012, in an article in the New England Journal of Medicine,¹ the Accreditation Council for Graduate Medical Education (ACGME) provided an initial description and the rationale for the Next Accreditation System (NAS). We follow up with this piece, which reflects on questions about the NAS, as a starting point for a dialogue with the community, and as the first in a series of articles that will describe key attributes of the NAS, offer practical guidance to programs and sponsoring institutions, and solicit stakeholder input. Dialogue with the community will be helpful in answering questions and in allowing the ACGME to clarify and refine certain elements of the NAS. This dialogue needs to be mindful that many details of the NAS are yet to be finalized. In communicating about the NAS, ACGME, thus, must balance a timely response to the community's desire to learn more and the need to have details well established to avoid a need to make changes after details have been released to stakeholders and the public.

We welcome questions and comments about the Next Accreditation System (NAS) in the form of “Letters to the Editor” and “News and Views Section” of the Journal of Graduate Medical Education. Please send submissions electronically to our editorial management system at http://www.editorialmanager.com/jgme/default.asp. The JGME plans to publish selected letters to encourage further dialogue with the stakeholder community.

Stakeholder Questions and Expectations

The immediate graduate medical education community—program directors, designated institutional officials (DIOs), and faculty and residents—are eager to learn more about the operational aspects of the NAS. Program directors in the 7 specialties that will implement the new system in July 2013 (emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urology, and their associated subspecialties), and DIOs have definitive questions about the NAS. Most of the questions posed to the ACGME to date relate to programs' and sponsoring institutions' interactions with the ACGME, such as “What will happen after July 2013?” and “Will my next site visit be converted into an NAS self-study, and when will it be scheduled?” Programs also are deeply curious about the nature and content of the regular data submissions to the ACGME, the administrative and data management aspects of the new system, and how the shift to outcomes-based accreditation will reduce process burdens.

The ACGME has started to provide answers to some of these questions, including information on the website, the recategorization of the Common Program Requirements to identify outcome requirements, and core and detailed requirements for structure, resources, and processes, with the note that detailed requirements may be waived to allow stable, high-performing programs to innovate.² All programs in the first 7 specialties that are transitioning into the NAS with their next site visit have received notice of their new site visit date, with an extension in the time to the next visit for programs with stable, high performance in the current accreditation system.

At the same time, a more far-reaching set of questions relates to how the NAS will change activities and practices within programs and teaching institutions, how it will change the daily work of program directors and faculty, or, in the case of residents, whether/how it might change their learning experience. Many relate to the educational Milestones, as a cornerstone of the NAS. The Milestones, which the educational community in each specialty began to develop in 2007, are specific dimensions of each of the 6 competencies essential to the development of clinical excellence in each specialty, and they describe the observable developmental steps in achieving clinical competence.³ Questions include “How do I prepare my faculty for assessing residents under the Milestones?” “Will we remediate a larger percentage of residents when assessments can measure dimensions important to performance in practice?” “How will the NAS change the work of my core faculty who will now meet as the members of the clinical competency committee?”

Stakeholders also are interested in how much and what type of work will be required in the NAS. They also want to learn about the new system's compatibility with current, well-established program and institutional practices for resident recruitment, faculty development, faculty promotion and recognition for teaching, and ongoing oversight of programs, including the internal review protocol. Experienced program directors well accustomed to and successful in the current system, wonder about the potential to innovate and customize elements of their well-functioning programs. Programs that have not done well in the current system may ask how NAS will offer them opportunities to improve or whether it may aggravate their problems.

For both groups, information on the ACGME's efforts to reduce burden, particularly administrative burden devoted to managing the accreditation process that does not contribute to an improved residency program or sponsoring institution, will be comforting. Program directors in the specialties that will implement the NAS in July 2014 have nearly 24 month to go in the current system and wonder what programs in the second phase will learn from the experience of the 7 specialties that will implement the NAS 1 year earlier.

Educators with an interest in learning outcomes, particularly those who have been frustrated by the stalled progress of the competencies, along with other stakeholders, are requesting more information about how the Milestones will realize the promise of outcomes-based accreditation the ACGME first made in 2002. Finally, policy makers and the public are beginning to understand that the Milestones provide a framework for measurement of meaningful outcomes in each specialty and want more detail to improve learning and ongoing maintenance of professional skills across the medical educational continuum.

Local Context

DIOs view the implementation of the NAS as a change in the local system, and many of their questions likely are focused at the local level, to explore how the NAS will fit within the typical patterns of assimilating new information and processes within their institution. Critical questions for DIOs that are also relevant to the ACGME's national rollout of the NAS are what are programs' and sponsoring institutions' absorptive capacities for new processes, how transferable are the skills for success in the NAS, and how institutions can identify the best practice in the NAS for adoption and adaptation. DIOs and program directors are also beginning to ask about local and national resources for professional development to prepare faculty for a renewed, prominent role in resident assessment in the NAS.

Work to benefit these emerging questions about the implementation of the NAS may include assessing structural, cultural, or other attributes that may assist in the adoption of the changes under the NAS. DIOs and their national organizations are also exploring how they can be proactive and influence adoption of the NAS with local information sessions and planned interventions, such as familiarization activities, professional development, and networking among programs. Ultimately, this may include bringing together early adopters and individuals with questions about the NAS, made possible by the 2-phase nature of the implementation process. However, the initial focus is on the programs in the first phase, which will need to create their own adoption strategies and role models.

An added attribute that may be highly relevant to the success of the local implementation of the NAS is considering, “What is the meaning of the NAS to the work and the professional identity of program directors and institutional leaders and to the professional identity of faculty?” A final philosophic question that seeks an answer from the wider community is how the NAS matches the goals and vision of the next generation of physicians and the needs, expectations, and values of the patients they will serve in the coming decades.

Communicating With Stakeholders

In the coming weeks and months, the ACGME will release additional information about the specific elements of the NAS, including data that will be used in the monitoring function, the nature of the Clinical Learning Environment Reviews for sponsoring institutions, and the format of the self-study and the other different types of site visits. Concurrently, the ACGME would like to extend to the educational community an invitation for an ongoing dialogue about the NAS to offer stakeholders an opportunity for questions and input. The leadership of the ACGME will continue to engage the educational community through presentations and discussions at professional meetings, focus sessions, other venues designed to seek input into elements of NAS, and through a dedicated website (http://www.acgme-nas.org/). These and other efforts will continue through the implementation of phase 2 of the fulfillment of the NAS in July 2014, with the aim of enhancing learning about the NAS at the local and national level, contributing to refinements in the ACGME's approach, and assuring effective communication with the community of educators.