1. Emergency Medicine Milestones April 2, 2012 2012 CORD Academic Assembly

3.  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

4.  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

6. Obtain outcome measures (i.e. milestones of competency development) to use as evidence of programs’ educational effectiveness 6

7. Continuous Oversight & Improvement Emphasis Milestone Reporting (semi- annually) Case Logs Resident and Faculty Opinions Program & Institutional Information 7

8. 8 ACGME Accreditation – continuous monitoring of programs; lengthening of site visit cycles Public Accountability – report at a national level on competency outcomes Community of practice for evaluation and research, with focus on continuous improvement Residency Programs Guide curriculum development More explicit expectations of residents Support better assessment Enhanced opportunities for early identification of under-performers Certification Boards Potential use – ascertain whether individuals have demonstrated qualifications needed to sit for Board exams Residents Increased transparency of performance requirements Encourage resident self-assessment and self-directed learning Better feedback to residents Milestones

9. 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

10. 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

11. Who Expert Panel Developing milestones for ICS, Prof, PBLI, SBP For adaption or adoption 11 Who Assessment Group Identifying assessment tools Developing implementation guidelines

12. 12 1999 - Outcome Project Begins 2001- Quadrads (Board, PD, RRC, Res) Convened 2002-2008 – Implementation of 6 Competency Domains 2009 – 2012 Milestone 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)

13.  Development of Milestones  Almost as if there was a plan…

14.  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)

15.  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

16.  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

17.  Made up of ABEM Board members  Tasked with looking at entire initial certification process  What are the standards?  Have they changed?

18.  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

19.  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

20.  With physician task definitions in place and the REPP report’s addition, ABEM was ready to write the K nowledge, S kills, and A bilities (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

21.  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

22.  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

23.  A smooth transition?

24.  Identified the Physician Task Definitions essential to the defined needs for Milestones

25.  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

26.  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

27.  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

28.  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

29.  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)

30.  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

31.  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

33.  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

34.  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

35.  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?