Creating a High-Quality Faculty Orientation and Ongoing Member Development Curriculum for the Clinical Competency Committee

As part of the Next Accreditation System set forth by the Accreditation Council for Graduate Medical Education (ACGME), all ACGME-accredited programs are to have a policy to “determine the criteria for promotion and/or renewal of a resident's/fellow's appointment,” which is monitored through clinical competency committees (CCCs).^1,2 The purpose and structure of the CCC has developed over the years^1,3,4; however, there is still room for improvement. Committees are expected to have a degree of turnover of faculty to ideally have a committee consisting of both new and returning members. New CCC members should be acclimated to the ACGME, each institution's graduate medical education (GME) department, and departmental guidelines and policies. Additionally, assessment tools, guidelines, and policies that affect the CCC are constantly being updated and improved. To keep up with fluid changes around the CCC, an annual orientation is needed. Assessment tool training, review of committee structure, and bias training are some of the components that should be included in orientation for new members. Furthermore, existing members should review updated guidelines and policies. Members should also review and incorporate best practices and participate in self-assessments of the committee itself. For these reasons, returning members should also undergo an annual reorientation. A shared mental model exists when all members are unified about the goals and objectives for the residents, how to assess residents, the infrastructure of the program, and the infrastructure of the committee.³ Currently, there are no written standards on how to orient new members or to reorient current members. CCC orientation for new members and returning members not only will cultivate a shared mental model on resident evaluation, but also will provide ongoing professional development by fulfilling faculty commitment to “engage in professional development applicable to their responsibilities as educational leaders” as recommended by the ACGME.²

Orientation for New CCC Members

For the CCC to function at its optimum level of productivity, each member must be aware of the structure, policies, assessment tools, guidelines, and other information germane to the committee. Lack of understanding or awareness of any of these areas decreases the efficiency and productivity of the CCC. Therefore, it is imperative that new members complete an orientation that addresses each of the essential working components of the committee.

Components of New Member Orientation

New member orientation should include a review of (1) the function and responsibility of the CCC; (2) the ACGME Common Program Requirements (CPRs); (3) specific departmental CCC policies and confidentiality agreements; (4) the program's educational goals and objectives; (5) the program's assessment tools; and (6) bias training (Table 1).^5,6

Table 1.

New Member Orientation^a

Component of the Orientation	Explanation
Review the function and responsibility of the CCC	The function and responsibility of the CCC is outlined by the ACGME. A brief description is as follows: a committee that determines, or participates in determining, criteria for appointment, contract renewal, promotion to the next postgraduate year, and graduation. The ultimate purpose is to demonstrate to the public that training programs graduate safe trainees who are well prepared for practice.1
Review of the ACGME Common Program Requirements	“A basic set of standard (requirements) in training and preparing resident and fellow physicians.”7
Review of the CCC policies and confidentiality agreement	A policy set forth by each individual CCC that may include: CCC membership, leadership positions, meeting details, voting regulations, contingency plans, and succession plans.1
Review the program goals and objectives	Set of learning standards and requirements that each learner should obtain as set forth by the training program.8
Review the programs assessment tools and developmental markers	Items used toward the aggregate data to assess a learner. Examples include: Milestones; evaluations (from faculty, peer, administrators, and ancillary staff); entrustable professional activities; testing scores (quizzes, in-service examinations, semiannual examinations, practicums); and simulation and module performance.4,8,10,12,13
Conduct bias training	Training on either innate or conscious inclinations leading to unfair outcomes. Training should bring awareness examples of types of bias such as but not limited to anchoring, bandwagoning, framing effect, and groupthink.6

Abbreviations: CCC, clinical competency committee; ACGME, Accreditation Council for Graduate Medical Education.

^aBased on Promes et al.⁵

New members must know the infrastructure of both the committee and the program. The infrastructure, function, and responsibility of the CCC is thoroughly outlined by Andolsek and colleagues.¹ The ACGME further outlines the infrastructure of the program through the CPRs, which are frequently updated; committee members must stay abreast of the changes to the CPRs.⁸ The structure of the CCC and its respective committee positions (eg, chair, program director, member) should be clearly outlined in the program's CCC policy to provide structure to the processes and minimize subjectivity.¹ This policy, which should be reviewed by the new members, should further contain details about CCC membership, meeting details, voting regulations, contingency meeting plans, and succession planning.⁹ Confidentiality must be addressed in the committee policy and/or through a separate confidentiality statement.

New members must also become familiar to the unique goals and objectives that outline the competencies of each specialty, institution, and department, creating the standard for resident performance. Importantly, analyzing and applying assessment tools is the crux of the CCC's purpose. Milestone and assessment tools, such as evaluations and entrustable professional activity (EPA) levels, are employed to ensure that residents are meeting the standards of the department, institution, and specialty.^4,10–13 While anyone evaluating a trainee must know how to use these tools, each member of the CCC must have expert knowledge of these tools and how possible results of the aggregate data from these tools can be addressed.

Recommendations

It is our recommendation to provide new members with documentation of the ACGME CPRs,⁸ the department's CCC policy, the program's goals and objectives, and a summary of the assessment tools and Milestones¹¹ prior to the orientation for review. New members should be given ample time to review these materials to allow for a more effective and efficient review during orientation. Additionally, new members should be familiar with all the program's assessment tools and developmental markers. For example, Milestones are a standard tool used in all ACGME-accredited residency and fellowship programs and fundamental to fulfilling the essential purpose of the CCC.¹¹ There are various exercises to help the new member become familiarized with this tool. One exercise is to have the new member complete a Milestones evaluation for a fictitious resident or fellow during orientation. Committee members can then hold a feedback session to assess how the new member applied the Milestones evaluation. We encourage new members to observe a couple meetings to reinforce what was learned during orientation before becoming a voting or active member of the CCC. New members should understand all components of the CCC and complete all parts of the orientation prior to becoming a voting or active member of the CCC.

Orientation for Returning CCC Members

Returning members should participate in an annual review of their role within the CCC as part of their professional faculty development.² These members should stay up-to-date with all changes that relate to the CCC. Ultimately, providing a routine annual orientation for returning members of the CCC will help to ensure the effective and efficient operation of the committee.

Content of Return Member Orientation

Similar to the new member orientation, the returning member orientation should include a review of (1) the function and responsibility of the CCC, (2) recent updates in the CPRs, (3) recent updates to the departmental CCC policies, (4) any updates to the program's goals and objectives, and (5) recent updates to assessment tools, as well as latest changes in the Milestones. This annual review will allow returning members to stay abreast of the continuous updates and changes to the various tools, policies, and guidelines. Furthermore, returning committee members will have the opportunity to assess the committee's functionality and performance. This assessment is achieved by (1) reviewing the academic due process and legal considerations, (2) completing committee self-assessment activities, and (3) discussing recommendations for revisions to the department committee's policies and confidentiality agreements (Table 2).

Table 2.

Returning Member Orientation

Component of the Orientation	Explanation
Review the function and responsibility of the CCC	The function and responsibility of the CCC is outlined by the ACGME. A brief description is as follows: a committee that determines, or participates in determining, criteria for appointment, contract renewal, promotion to the next postgraduate year, and graduation. The ultimate purpose is to demonstrate to the public that training programs graduate safe trainees who are well-prepared for practice.1
Review updates of the ACGME Common Program Requirements	“A basic set of standard (requirements) in training and preparing resident and fellow physicians.”7
Review updates of the CCC policies and confidentiality agreement	A policy set forth by each individual CCC that may include: CCC membership, leadership positions, meeting details, voting regulations, contingency plans, and succession plans.1
Review updates the program's goals and objectives	Set of learning standards and requirements that each learner should obtain as set forth by the training program.8
Review updates of the program's assessment tools and developmental markers	Items used toward the aggregate data to assess a learner. Examples include: Milestones, evaluations (from faculty, peer, administrators, and ancillary staff); entrustable professional activities; testing scores (quizzes, in-service examinations, semiannual examinations, practicums); and simulation and module performance.4,8,10,12,13
Review the academic due process and legal considerations for the past year	Academic due process is the procedure of providing fair judgement for learners who are subjected adverse disciplinary actions (such as remediation or dismissal) as a result of failing to meet academic or professional requirements. Failure to provide due process can provoke legal action by the learner.1,14
Conduct self-assessments of the committee	Self-assessments allow for the CCC to get feedback on its performance review of how members critically review a trainee as well as collective committee logistics and performance metrics. Self-assessments can be in the form of group discussions, audits, and evaluations.1
Discuss recommendations for revisions to the committee's policies and agreements	The committee can utilize the feedback received from the review of academic due processes, review of legal considerations, and self-assessments to guide recommendations for changes in the committee policies and agreements.

Abbreviations: CCC, clinical competency committee; ACGME, Accreditation Council for Graduate Medical Education.

The last 3 components of the returning member orientation allow for quality improvement of the CCC.¹ Designated time to review challenging cases and complete self-assessments during a yearly orientation can help the CCC establish new processes that will better mitigate challenges as well as reinforce strengths within the committee. The ultimate goal of a yearly review during orientation is to edify the committee's best practices and to further improve committee outcomes.

Recommendations

As with the new member orientation, returning member orientation should also provide a yearly review and updates to the policies, guidelines, tools, and materials related to the CCC. Unlike the new member orientation, returning member orientation provides the opportunity for members to improve the systems of the CCC through review of the management of adverse circumstances as well as successes. Much of the latter part of the orientation for returning members will require group discussion and feedback. Therefore, larger CCCs should consider breaking into smaller groups for more meaningful discussions and feedback. The latter half of the orientation can be centered around actual challenging and controversial cases the committee encountered during the year. Learning points from these cases should be highlighted by probing questions and group discussion. Such questions should be up for discussion: Was there academic due process? Were there legal considerations? How does the CCC's function interact with or overlap the legal team? What are the attendant legal ramifications?¹⁴ Should non-traditional members (eg, public members, researchers, physician aides) serve on the CCC to better address the needs of the department?¹ Are protocols in place to guide the committee in handling situations such as emergencies with the trainees or lead members? This exercise poses analytical questions that can ultimately be used to further improve systems processes within the CCC.

Additionally, an internal audit of the CCC may help streamline the committee's self-assessment process.¹ Members should participate in a review of how they have evaluated trainees. Members can also complete an evaluation of the committee as a whole, committee members, and committee leadership. The results of these reviews and evaluations should be used to identify and improve areas of opportunity and reinforce areas that worked well. Review of the committee's past performance can lead to changes in policies that ultimately improve the committee's function and outcomes.

Conclusions

Providing an annual orientation for both new and returning members helps to ensure that all processes concerning the CCC are aligned and that challenges to its effective functioning are addressed. It also ensures that committee policies and structure (such as meeting logistics, review of data, and voting regulations) are clearly outlined and communicated to its members. Orientation is an opportune time to review and improve on past performances while promoting faculty development. With proper planning, learning tools, and education of CCC structure, feedback, and communication among members initiated through orientation, the CCC can function at peak performance throughout the year.