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AAOS Now

Published 4/1/2014
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John L. Marsh, MD; Pamela Derstine, PhD, MHPE; John Potts, MD

Changes in Orthopaedic Residency and Fellowship Accreditation

John L. Marsh, MD; Pamela Derstine, PhD, MHPE; and John Potts, MD

Graduate Medical Education (GME) training programs are accredited through an oversight process that ensures that residencies and fellowships meet approved standards. This accrediting process is one of the most important recurring events in the eyes of orthopaedic program directors. But last July, the whole process changed.

These changes—along with the advent of the six competencies and the 80-hour work week—will rank as a major event in GME.

The accreditation process and the program requirements that guide residency training are developed by the Accreditation Council for Graduate Medical Education (ACGME) and its review committees. Orthopaedic residency and fellowship programs are accredited by the Orthopaedic Residency Review Committee (RRC). With the introduction of the Next Accreditation System (NAS), the ACGME is dramatically changing the accreditation process.

This article will review the changes in program accreditation in the following four important areas and describe how they will affect orthopaedic programs and fellowships:

  • the NAS review process
  • milestones
  • single program sponsors for fellowships
  • fellowship eligibility

NAS
Traditionally, program review included an extensive program information form (PIF) prepared by the program director and a scheduled site visit and report by a member of the ACGME field staff. That process has now significantly changed.

On Jan. 10–11, 2014, the orthopaedic RRC became the first RRC to review programs using NAS. NAS’ focus is on data that reflect important educational outcomes for programs. NAS puts less emphasis on lengthy paragraphs written by program directors and opinions of site visitors and more emphasis on data elements such as a resident survey, faculty survey, case–log-based procedural experiences, attrition, part 1 and 2 board pass rates, faculty, resident scholarships, and data omissions.

With NAS, all programs will be assigned an accreditation decision every year. New applications and requests for additional residency slots will also be reviewed. Although this first meeting in the new format was very busy, the RRC thought that the NAS review process was fair and that they had enough data to guide decisions. The absence of the PIF or site visitor report was not a major concern in program review. Further work to better define and identify the important data elements will improve the process, and the RRC is optimistic that NAS will be a better system of program accreditation than previous systems.

According to the NAS plan for yearly data review, data for all core residencies and fellowship programs will be reviewed by the RRC’s executive director. This process and subsequent more detailed review by the RRC is guided by a dashboard of indicators based on the NAS data elements.

Milestones
Milestones will become a new data element in NAS and are designed to assess whether programs are moving residents through appropriate educational landmarks. Although originally designed for program accreditation, milestones will also become a major tool in individual resident assessment and feedback.

The orthopaedic milestones were developed by a work group charged by the ACGME and the American Board of Orthopaedic Surgery. They assess program outcomes by assigning each resident standardized levels of progress, based on a 5-point scale from novice (level 1) through to expert (level 5). PGY-1 residents are expected to be at level 1 and PGY-5 residents should be at level 4. Level 5 represents expertise that most residents will not achieve.

The core orthopaedic residency milestones include 16 clinical areas, each with a medical knowledge and a patient care (which includes procedural or surgical skills) component (32 total milestones). The other four competencies (professionalism, practice-based learning and improvement, systems-based practice, and interpersonal and communication skills) are evaluated with nine additional milestones.

Each of these 41 milestone evaluations will be assessed and reported to the ACGME for each resident semiannually. Each program must have a consistent group (the Clinical Competency Committee) that performs the milestone evaluations. The first reporting period for milestones was December 2013.

Milestones were not used in the January 2014 RRC NAS review process, and it is estimated that at least 2 years of data will be required to be useful in program accreditation. Most program directors will probably incorporate milestones into their electronic assessment system and use them as part of their rotation evaluation process. Although the sheer number of assessments may be intimidating, it is exciting that orthopaedic residents across the country will now be assessed on a uniform scale. Milestones for fellowships have also been developed and will be required near the end of 2014, one year behind the core residency milestones.

Single program sponsors
This new rule is part of NAS and is in part designed to ensure institutional oversight of programs. It will mostly affect fellowships in sports and hand. As of July 2013, no new independent subspecialty programs may be established; all newly accredited fellowships must be sponsored by an institution that also sponsors a core program, and the fellowship must have a defined relationship with the core.

Single program sponsors (“stand-alone programs”) are currently accredited as both a program and sponsoring institution under the authority of the RRC. As of July 1, 2015, the sponsoring institution will be accredited under the authority of the Institutional Review Committee (IRC), not the RRC, although the program will continue to be accredited under the authority of the RRC. In addition, the sponsoring institution will undergo CLER (Clinical Learning Environment Review) visits.

Stand-alone programs may choose to pursue a second option by July 1, 2015, by seeking a “geographically proximate” institution that already is accredited under the authority of the IRC. The definition of geographically proximate is yet to be determined. Until further notice, the determination of whether a program and its sponsoring institution are geographically proximate will be made by the RRC.

The advantage of this choice for a stand-alone program is that the new sponsoring institution will be subject to the CLER visits, thus relieving the program of this responsibility. At this time, the new institution is not required to also sponsor a core program. However, if it does sponsor a core program, the fellowship program will operate as a dependent subspecialty program.

Further communication from the IRC will be forthcoming. No action on the part of programs or their sponsoring institutions is needed, unless a program wishes to change sponsorship to an institution that is already accredited under the authority of the IRC.

Eligibility for fellowships
The ACGME has more tightly defined eligibility for entry into its programs, which will affect orthopaedic fellowships. Previously, the RRC permitted fellowships to occasionally enroll international graduates or graduates of osteopathic programs without citation. The new rules require that all ACGME-accredited programs accept only graduates from ACGME- or Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited programs. Because these rules go into effect on July 1, 2016, they need to be considered for next year’s recruitment and match.

The RRC will accept exceptions to this rule, but exceptions are now tightly defined. A prospective fellow who has graduated from an international or osteopathic program will have to be “exceptionally qualified,” which means that the candidate must have demonstrated clinical excellence, in comparison to peers, throughout training. In addition, the candidate would have to demonstrate exceptional qualification in at least one of the following ways:

  • clinical or research training in the specialty or subspecialty
  • scholarship in the specialty or subspecialty
  • leadership during or after residency
  • completion of an ACGME International-accredited residency program

The program director, the fellowship selection committee, and the institutional Graduate Medical Educational Committee or a subcommittee thereof would all have to agree that the candidate was “exceptionally qualified.” These applicants would also have to have satisfactorily completed all three steps of the U.S. Medical Licensing Exam and have received certification from the Educational Committee for Foreign Medical Graduates (if an international graduate).

The match process (through both the San Francisco Match and the National Resident Matching Program) constitutes a binding agreement between the program and the matched candidate. It would be inappropriate (and a match violation) for a program to match a candidate who did not fulfill the eligibility criteria. Accordingly, program directors must ensure that every candidate on the program’s submitted match list is, in fact, eligible for entry into the program. A plan of action should be developed during the fellowship interview process.

Summary
The ACGME has instituted substantial changes to accreditation of GME. Under the NAS program, which went into effect in July 2013, accreditation decisions will be based on data reviewed by the RRC on a yearly basis. Milestones will become an important part of this process after a minimum of 2 years of data have been collected.

In NAS, institutional oversight is stressed, so all programs will have to have a sponsoring institution that meets all institutional requirements. In orthopaedics, this will mostly affect sports and hand fellowships. Eligibility of trainees for ACGME-accredited programs that require prior training will need to be in ACGME- or RCPSC-accredited programs or meet strict eligibility exception standards.

John L. Marsh, MD, chairs the Orthopaedic RRC; Pamela Derstine, PhD, MHPE, is the executive director of the Orthopaedic RRC; and John Potts, MD, is senior vice president of surgical accreditation at the ACGME.