The ACGME Council of Public Members

Creation of the Council of Public Members

The Accreditation Council for Graduate Medical Education (ACGME) Board of Directors established the Council of Public Members in February 2016 to serve as “an advisory body to the ACGME, increasing engagement on behalf of the Public.”¹ While other not-for-profit health care regulatory organizations have public member representatives and participation, the ACGME is unique among these organizations in sponsoring an official Council of Public Members.

The inaugural meeting of the Council of Public Members occurred in May 2016. The ACGME's bylaws were amended to include the Council, and its composition specified to include public members from each ACGME Review and Recognition Committee (Box 1), Public Directors on the ACGME Board of Directors, and at-large members chosen by the Board of Directors. In addition, the bylaws include the provision that the chair of the Council serves as a voting member of the ACGME Board of Directors.

Box 1 ACGME Review and Recognition Committees

• Allergy and Immunology

• Anesthesiology

• Colon and Rectal Surgery

• Dermatology

• Emergency Medicine

• Family Medicine

• Institutional

• Internal Medicine

• Medical Genetics and Genomics

• Neurological Surgery

• Neurology

• Nuclear Medicine

• Obstetrics and Gynecology

• Ophthalmology

• Orthopaedic Surgery

• Osteopathic Neuromusculoskeletal Medicine

• Osteopathic Principles (Osteopathic Recognition)

• Otolaryngology–Head and Neck Surgery

• Pathology

• Pediatrics

• Physical Medicine and Rehabilitation

• Plastic Surgery

• Preventive Medicine

• Psychiatry

• Radiation Oncology

• Radiology

• Surgery

• Thoracic Surgery

• Transitional Year

• Urology

At the May 2016 meeting, Council members discussed the definition of a public member and how the Council should be represented at the ACGME Board of Directors, and also established a work group to create a charter for the Council. At the November 2017 meeting, the Council of Public Members adopted a purpose statement as part of its charter (Box 2).

Box 2 ACGME Council of Public Members Purpose Statement

With the goal of increasing public trust in physician residency and fellowship training to promote high-quality medical care for all, the purposes of the Council are to:

• Advise the Board of Directors from the public perspective, including on strategic and accreditation issues;

• Bring the voice of the public and patients to the ACGME;

• Engage with the public and patient population, as recommended by the ACGME; and

• Enhance the effectiveness of the public members in their roles as members of the Review Committees, the Board of Directors, and other committees and task forces.

In 7 subsequent meetings, held semiannually in the spring and fall, along with periodic conference calls, the Council formed work groups on various topics: reviewing and commenting on the Common Program Requirements, onboarding and orientation, public member development, and evaluating the effectiveness of the Council. Agenda items have included knowledge sharing and skill development (eg, conflict management styles, patient values research) as well as interactive sessions to learn about ACGME activities and provide feedback on topics including strategic planning, physician well-being, the Back to Bedside grants program, the Sponsoring Institution 2025 initiative, Milestones 2.0, population health, public policy, field activities/site visits, and diversity and inclusion.

As of November 2019, the Council is comprised of 30 public members on Review and Recognition Committees, 3 Public Directors on the ACGME Board, and 1 at-large member.

Research on Public Members

Between November 2018 and November 2019, a self-reflection exercise was conducted to capture the perceptions of public members' contributions by the Council of Public Members and the ACGME Council of Review Committee Chairs. In addition, a review of the literature was conducted on the role of public members in the not-for-profit health care regulatory arena.

Literature Review

After identifying search terms and reviewing the literature, 3 out of 10 articles were identified as describing individual public member's roles within their respective organizations in the health care regulatory arena.^2–4 While the published literature did not directly address the concept of a “council” of public members, it did address the struggles public members and their organizations grapple with concerning the definition of a public member, the value that members gain from their role, and the influence these members have on their organizations.

The literature supports the fact that other organizations with public members do not have a formal council that is exclusively dedicated to public members. This council gives ACGME public members and directors the opportunity to meet each other, form bonds, and belong to a group in which their independent “outsider” perspective is what forms the group identity.

Public Member Definition: 

The lack of agreement on a singular definition of a public member was a common thread in the articles reviewed, with a diversity of opinion around who is an “optimal public member.” The research that the ACGME collected from the self-reflection exercise directly parallels the findings from the published literature, addressing connections that individual members may have to the health care industry and the importance, or lack thereof, of that connection.

According to Johnson et al, “Organizations differed on whether any professional connection to the health care industry threatens the public member's role in representing the ‘patient's' or ‘general public's' perspective.”² This school of thought was echoed throughout the literature, and no clear conclusion was reached regarding whether a connection to health care affected public members' ability to accomplish their jobs. The Council has discussed this at length and considered that a strictly public perspective may not be as important as an orientation experience that helps them achieve the goals of their role.

Value of Public Members: 

The influence of public members is well documented in the literature, with “the vast majority of [state medical] licensing boards in the United States”⁴ having public members represented on their boards. The unique perspectives that public members bring often relate to asking clarifying questions regarding the organization's processes and insisting on transparency by asking the simple question, “Why?”²

The public member's role is also important because the presence of people outside the profession challenges an organization to consider eliminating jargon, clarifying its operations, and simplifying the organizational terms it uses that might seem confusing or too technical. This can be anything, including organizational policies and procedures, terminology, and general organizational structure. Public members bring questions to the organization from a perspective that would normally not be considered.²

Value to Public Members: 

When asked, public members greatly valued the relationships they gained from fellow members and organizational staff.² They also appreciated being able to make recommendations and participate on a board. Public members noted the most important ways an organization demonstrates appreciation is by providing support from senior leadership and staff, appropriate term lengths, and networking, participation, and engagement opportunities.²

Assessment of ACGME Public Member Contributions

By late 2019, many ACGME Review Committee public members were at the midpoint of their 6-year term. A work group of the Council had formed that focused on evaluating their effectiveness. Working with the Council of Review Committee Chairs, this work group conducted a qualitative assessment to explore how public members themselves and Review Committee chairs viewed the role of public members in committee work.

Public members and Review Committee chairs completed a self-reflection exercise that used a qualitative, grounded theory approach. Questionnaires tailored to each group were completed during the course of the ACGME's winter Review Committee meetings (December 2018 to February 2019), and the responses were analyzed and presented to the Council of Public Members in May 2019.

Through this self-reflection exercise, ACGME public members indicated they have been accepted by the Review Committee chairs and members and integrated into the work of the committees. Chairs and public members agree that public members contribute by disrupting “groupthink” and asking questions, are involved in the accreditation evaluation, decisions, and policy issues, and often address issues of well-being, safety, and patient experience of physicians in training.

Additionally, ACGME chairs said they see value in public members bringing outside knowledge to the Committees' work, reinforcing consistency and objectivity during reviews. Chairs also noted they would like to see public members be more vocal in committee deliberations and bring a stronger public viewpoint to the table.

The results of this exercise mirror the findings in the literature. A common role for a public member is to question why and how things are being done, and provide greater transparency and a broader perspective to the work of the organization. They also highlight that, in their role on the Review Committees, the public members, chairs, and ACGME as a whole are grappling with the same questions and concerns as other regulatory bodies. These issues include the qualifications of a public member for a health-related organization (ie, should the individual have health care or medical education experience or not?), and how these individuals, as they are integrated into the Committees, maintain their judicial, editorial, and thought independence during their 6-year tenure. The project also highlighted the need to provide public members with a robust onboarding process so they can feel both comfortable in their roles and able to optimally contribute to the committees on which they serve.

Conclusions

The unique role that the Council of Public Members has brought to the ACGME is to help public members address issues inherent to their role and empower them to focus on the unique role they play bringing additional points of view related to patients, families, and societal needs to the Review Committees and the ACGME Board of Directors. Public members also have a role in questioning the assumptions and groupthink that might exist when physicians, many of whom already know each other, are the only ones making decisions. A set of themes influencing the success of the Council and the individual members surfaced in the literature review and in Council discussions, and is shown in Box 3.

Box 3 Factors Impacting the Effectiveness of ACGME Public Members

The following items have been identified from the self-reflection exercise and reinforced by a review of the literature:

1. Creation of the Council of Public Members provides support and opportunities to reflect on the unique role of the public member.

2. The Chair of the Board and the CEO/President showed support to the Council by attending every meeting during the first 3 years.

3. A direct connection was made to the ACGME Board of Directors by having the Council written into the bylaws and the Council Chair included as a voting member of the Board, in addition to the 3 Public Directors already on the ACGME Board.

4. The value of Council meetings included the importance of developing relationships and networking among the public members, with the majority of the members attending at least one Council meeting annually.

5. Strong administrative support to develop agendas, presentations, and working sessions with regular attendance of a variety of ACGME staff representing different aspects of the organizations work (eg, site visits, distance learning, CLER, Milestones, etc).

6. Term lengths that allow for members to learn about the organization and develop proficiency in the work of the Board, Review Committees, task forces, etc.

7. Council elects chair and vice chair who run the meetings, set the agendas, and participate in the other Councils' meetings (eg, Council of Review Committee Chairs and Council of Review Committee Residents). Collaboration between the chair of the Council of Public Members and the chair of the Council of Review Committee Chairs was instrumental in conducting the self-reflection exercise and underlines the importance of ongoing collaboration among all 3 Councils.

The ACGME culture has been enhanced by including public members. The Council of Public Members and the Council of Review Committee Chairs both reviewed the findings of the self-reflection exercise and concluded the presence of public members has changed the dialogue within the Review Committees along with other task forces and work groups that have included public members.

As the roles of public members and of the Council of Public Members mature beyond the first cohort of volunteers, the organization and the Council will continue to explore, examine, and reflect on how public members can help advance the ACGME's mission to improve the health care of the nation through the accreditation of residency and fellowship programs and institutions that sponsor these programs.