1. The Clinical Competency Committee
Dean Seehusen, MD, MPH
Associate Dean for Graduate Medical Education
Professor of Family Medicine

2. Learning Objectives
Upon completion of this session, participants should be able to:
Define the minimal membership of the Clinical Competency Committee and who else may be included
Describe preparation for a CCC meeting
Describe at least two best practices for running a CCC meeting
Name at least three factors that significantly contribute to positive or negative functioning of the CCC

3. Agenda Background on resident evaluation The benefits of the CCC
Structure of the CCC
CCC meetings
Additional CCC tips and thoughts

4. Resident Evaluation

5. Competency: Who Decides and How
Traditionally, competency was assumed at the end of a defined period of training
This ignores individual variation among trainees
The PD essentially bore the full weight of deciding
Disagreements were difficult to resolve
The ACGME started a movement toward competency- based evaluation in the 1990
6 core competencies
Milestones
Entrusted Professional Activities (EPA) in the future?

6. Origins of the CCC
Some programs have always had a CCC, although it may have been called many different things
The move to competency based assessment led the advent of many new evaluation tools
Milestones and EPAs have only increased the amount of evaluation done
The volume of data became overwhelming for the PD to sift through alone
The ACGME now mandates that a committee play a key role in competency assessment

7. ACGME. Clinical Competency Committees 2nd Edition
ACGME. Clinical Competency Committees 2nd Edition. Available at:

8. Benefits of the CCC

9. From the PD Perspective
Spreads the workload and responsibility
Greater “buy-in” from faculty
Increases credibility and reproducibility of evaluations comes with a larger number of voices at the table
Higher quality and quantity of feedback
ACGME. Clinical Competency Committees 2nd Edition. Available at:

10. From the Program Perspective
Develops a shared mental model of expectations
Insures competency is adequately evaluated and reported
Standardizes evaluation between residents
Ensures each resident is progressing along a proper trajectory
Identifies residents in difficulty
Identifies program weaknesses
Acts as a form of faculty development
ACGME. Clinical Competency Committees 2nd Edition. Available at:

11. From the Resident Perspective
Higher quality and quantity of feedback
Performance is measured against a national set of standards (milestones)
Increases transparency of evaluations
More perspectives lessens the likelihood of a skewed evaluation
ACGME. Clinical Competency Committees 2nd Edition. Available at:

12. CCC Structure

13. Minimal Requirements The PD must appoint the CCC Three faculty members
Written description of responsibilities
Advise the PD on resident progress, promotion, graduation, dismissal
Review of residents and prepare milestone evaluations semi-annually
ACGME. Common Program Requirements. Available online at:

14. Size and Constitution
The minimum is set (3) but the maximum is not set
A program may have more than 1 CCC; for instance based on PGY level or competencies
The literature suggests 5-7 members is ideal and more than 10 members becomes counterproductive
Diverse groups make better decisions

15. CCC Structural Options
Some specialties have additional rules (in anesthesia, for example, the PD cannot Chair the CCC)
Additional physician faculty can come from other programs
Other health professionals can be assigned if they have extensive contact with the residents
Chief residents that have graduated the core program can be assigned to the CCC
Program Coordinators may administratively attend the CCC; any input should only be provided through standard evaluation channels such as 360o evaluations
A “public member” is allowable
ACGME. Clinical Competency Committees 2nd Edition. Available at:

16. CCC Meetings

17. Preparing for CCC Meetings
The PD and CCC Chair, if different, should determine how the CCC will generally function
The Chair, should develop a shared mental model with the CCC members covering:
The milestones
The role of the CCC
The CCC process for that program
Create a map, or matrix, showing where each milestone is taught and evaluated in the program’s curriculum
Make note of “gaps” discovered in the map
Note tools that do not seem to add much to the evaluation process

18. Two Mapping Examples ICU rotation evaluation by faculty
Clinic rotation evaluation by faculty
IM Milestone PC1: Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s).
IM Milestone ICS1: Communicates effectively with patients and caregivers.
ICU rotation evaluation by faculty
OSCE
Mini-CEX
Ward rotation evaluation by faculty

19. Assessing Milestones
Assigning one or more members to review certain residents, or certain data, before the meeting will save time
The ACGME discourages simple use of statistical data or use of a single data point to assign make determinations
If during a given period, not enough data on a milestone has been gathered, hold the prior milestone rating
The goal is consensus; the ACGME discourages voting
The CCC only advises; the PD has final authority for assessment, promotion and graduation
ACGME. Clinical Competency Committees 2nd Edition. Available at:

20. Additional CCC Duties
Determine baseline milestones for fellows accepted into to a program that do not meet the standard eligibility requirements within 6 weeks of matriculation
May help create and monitor remediation plans for residents in difficulty
Identify potential improvements in the program’s evaluation process
ACGME. Clinical Competency Committees 2nd Edition. Available at:

21. Running the Meeting Have enough time
Use the same approach for every resident
Have a method to ensure all voices are heard
Consider starting with the junior person
The Chair should speak last
The PD should speak the least or not at all
Consider designating a “Devil’s Advocate”
Have a solid documentation plan
Have a solid communication plan
ACGME. Clinical Competency Committees 2nd Edition. Available at:

22. Two Broad CCC Approaches
Problem Identification Model (by far the most common)
Looking for red flags
Most time spent on low performing residents
Focus on global performance
Provides less effective feedback to learners
Developmental Model
Data synthesis is very time consuming
Focus on comparing performance to milestones
Assessment more balanced and nuanced
Feedback framed in developmental language
Hauer KE, Chesluk B, Iobst W, Holmboe E, Baron RB, Boscardin CK, Cate OT, O'Sullivan PS. Reviewing residents' competence: a qualitative study of the role of clinical competency committees in performance assessment. Acad Med. 2015;90(8): PMID:

23. CCC Food for Thought

24. Common Pitfalls
Spending a disproportionate time on residents in difficulty
Relying too heavily on the least reliable evaluation tools, such as end of rotation evaluations
Too little, or too much, data
Lack of confidentiality
Lack of a solid communication strategy to the resident
Groupthink

25. Groupthink
Groupthink is a term first used in 1972 by social psychologist Irving L. Janis
A psychological phenomenon in which people strive for consensus within a group.
In many cases, people will set aside their own personal beliefs or adopt the opinion of the rest of the group.
People who are opposed to the decisions or overriding opinion of the group as a whole frequently remain quiet, preferring to keep the peace rather than disrupt the uniformity of the crowd.
Janis, I. L. "Groupthink". Psychology Today. 1971;5 (6): 43–46, 74–76.

26. Features of Groupthink
Illusions of invulnerability lead members of the group to be overly optimistic and engage in risk-taking.
Unquestioned beliefs lead members to ignore possible moral problems and ignore consequences of individual and group actions.
Rationalizing prevents members from reconsidering their beliefs and causes them to ignore warning signs.
Stereotyping leads members of the in-group to ignore or even demonize out-group members who may oppose or challenge the group's ideas.
Self-censorship causes people who might have doubts to hide their fears or misgivings.
"Mindguards" act as self-appointed censors to hide problematic information from the group.
Illusions of unanimity lead members to believe that everyone is in agreement and feels the same way.
Direct pressure to conform is often placed on members who pose questions, and those who question the group are often seen as disloyal or traitorous.
Janis, I. L. "Groupthink". Psychology Today. 1971;5 (6): 43–46, 74–76.

27. Influences on Group Process
Member characteristics
Member homogeneity
Size
Understanding of the work
Group leader
Information sharing procedures
Time pressures
Hauer KE, Cate OT, Boscardin CK, Iobst W, Holmboe ES, Chesluk B, Baron RB, O'Sullivan PS. Ensuring Resident Competence: A Narrative Review of the Literature on Group Decision Making to Inform the Work of Clinical Competency Committees. J Grad Med Educ. 2016;8(2): PMID:

28. Competency Champions
Department of Surgery, University of New Mexico, Albuquerque
Six faculty designated “Competency Champions” – one of each of the ACGME Core Competencies
Functions of experts on those milestones
Help write remediation plans for residents not functioning at the expected level in their competency
Ketteler ER, Auyang ED, Beard KE, McBride EL, McKee R, Russell JC, Szoka NL, Nelson MT. Competency champions in the clinical competency committee: a successful strategy to implement milestone evaluations and competency coaching. J Surg Educ. 2014;71(1):36-8. PMID:

29. Some Last Thoughts Assess how well the CCC is functioning periodically
Improving the CCC can be selected as an annual enhancement project for the PEC
There are no “term limits” defined by the ACGME but you may consider them useful in your program
“Fresh blood” brings new perspectives
Serving on the CCC is a form of faculty development that would benefit all of your faculty
Turnover means loss of expertise
There is a cost to educating new members

30. The CCC Guidebook
CCC Guidebook from the ACGME available at: etencyCommitteeGuidebook.pdf
A CCC knowledge quiz
A step-by-step CCC creation guide
An annotated bibliography
Case studies
ACGME. Clinical Competency Committees 2nd Edition. Available at:

31. Learning Objectives
Upon completion of this session, participants should be able to:
Define the minimal membership of the Clinical Competency Committee and who else may be included
Describe preparation for a CCC meeting
Describe at least two best practices for running a CCC meeting
Name at least three factors that significantly contribute to positive or negative functioning of the CCC

32. Bibliography

33. Bibliography
ACGME. Clinical Competency Committees 2nd Edition. Available at: itteeGuidebook.pdf
ACGME. Common Program Requirements. Available online at: PRs_ pdf
French JC, Dannefer EF, Colbert CY. A systematic approach toward building a fully operational clinical competency committee. J Surg Educ. 2014;71(6):e22-7. PMID:
Hauer KE, Cate OT, Boscardin CK, Iobst W, Holmboe ES, Chesluk B, Baron RB, O'Sullivan PS. Ensuring Resident Competence: A Narrative Review of the Literature on Group Decision Making to Inform the Work of Clinical Competency Committees. J Grad Med Educ. 2016;8(2): PMID:

34. Bibliography
Hauer KE, Chesluk B, Iobst W, Holmboe E, Baron RB, Boscardin CK, Cate OT, O'Sullivan PS. Reviewing residents' competence: a qualitative study of the role of clinical competency committees in performance assessment. Acad Med. 2015;90(8): PMID:
Ketteler ER, Auyang ED, Beard KE, McBride EL, McKee R, Russell JC, Szoka NL, Nelson MT. Competency champions in the clinical competency committee: a successful strategy to implement milestone evaluations and competency coaching. J Surg Educ. 2014;71(1):36-8. PMID:
Chahine S, Cristancho S, Padgett J, Lingard L. How do small groups make decisions? : A theoretical framework to inform the implementation and study of clinical competency committees. Perspect Med Educ. 2017;6(3): PMID: