Lisa Maxwell

Accountable care organizations: an opportunity for synergy.

With the reelection of President Obama, full enactment of the Patient Protection and Affordable Care Act is all but certain. Part of that legislation is the establishment of Accountable Care Organizations (ACOs). These large networks require a minimum of 5,000 Medicare patients, and will assume the total costs for their care in many cases. Over 140 ACOs are already established with over 130,000 physicians and 2.2 million beneficiaries.1 Much of the broad legislation governing ACOs has yet to be converted to specific regulations, which will vary between states. Because so much of this change has yet to be decided, and large systems will have to rapidly adapt, ACOs may become a sudden order of business for family medicine program directors. ACOs are a model of shared risk for costs and savings of a defined population. The more patients a network has, the more easily they can spread the costs of expensive care of the relatively few. In the ACO model, hospitals will shift from revenue centers to cost centers. ACOs have the potential to shift systems to embrace wellness rather than reactive illness care. In the future, we may get reports on how much our patients cost the system, rather than how much revenue we generated with our level-4 visits, inpatient billing, and procedures. Many systems will need to increase their primary care workforce as more patients have health coverage, and systems shift their emphasis to outpatient and preventive care. Insurance and payment reforms are the first 2 steps in health care reform. The third phase is delivery system reform.1 A need to educate those making ACO formation decisions will exist, regarding the value of family medicine residency programs to ACO networks. One of the fundamental objectives of the National Institute of Program Director Development (NIPDD) training is to understand the worth of your program; in the world of ACOs, our 2 principal strengths to promote will be cost-effective care and workforce generation. To truly provide population health care (rather than just those who come to see us) will require a fundamental shift in perspective for our systems, and most of us as well. Many of us will need to learn new skills; we will need to strongly advocate for resources such as case managers, chronic disease registries, and searchable electronic health records to provide high quality, cost-effective health care to a population. We also need to advocate for payment reforms that truly reflect our value to our systems. If we are not involved in the early formation and leadership of ACOs, we risk maintaining the status quo of huge payment disparities between procedure-based specialists and diverse primary care practices. These disparities discourage future medical students from entering primary care, which eventually will hurt all of our patients. Residency education about cost-effective care is optimized if the system can provide each resident with clinical quality and cost data on their own panel of patients, rather than having them subsumed under the faculty patient panel. We need to advocate for not just teaching about quality improvement, but doing it in our residency practices. Family medicine has a long and celebrated history of advocating for our patients. With the formation of ACOs, there is a moral imperative that we advocate for systems that reflect our values as a specialty. In the next few months, many decisions will be made that will affect both process values (the rules that govern decision-making processes such as transparency, accountability, and participation) and content values (clinical effectiveness, cost-effectiveness, justice/equality, and autonomy).2 We all need to ensure that family medicine has a voice at the table, and that we are proud of the end result. After all, the ACOs created in the next few months will be the ones our graduates will be practicing in for the foreseeable future.

FROM FAMILY MEDICINE MILESTONES TO ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPAS)

Since publication of the 2 Institute of Medicine reports, To Err is Human1 and Crossing the Quality Chasm,2 the public and government expect and demand higher quality and safer patient care. To accomplish its mission of improving health care by assessing and advancing the quality of resident physicians’ education,3 the Accreditation Council for Graduate Medical Education (ACGME) encouraged competency-based education with the creation of 6 core competencies. Recently, the ACGME created the milestones, which emphasize competency-based developmental outcomes. The family medicine milestones, to become effective July 1, 2014, consist of 22 outcomes based on the 6 core competencies. A mandate for family medicine residency programs is to ensure their graduates are able to provide safe health care to their patients. As programs begin to implement the milestones, an emerging complimentary theme is the entrustable professional activity (EPA), which is a way to translate competencies into clinical practice.4 Collectively, a set of EPAs for family medicine constitute the core clinical activities of a family physician,5 ie, what does a family physician do in practice and how do we know a graduate is competent to independently and safely practice those activities? Going beyond a checklist of behaviors, EPAs define the “knowledge, skills, and attitudes” integrated across the competency domains and the work that a family physician does.4 As family medicine is such a rigorous and diverse specialty, constructing a comprehensive list of EPAs is indeed a daunting task. One educator recommends a graduate medical education program have no more than 20 to 30 EPAs that are clear but not too detailed.6 An initial attempt at defining EPAs in family medicine included a list of 76 items that mostly focused on the ambulatory setting.6 Ideally, EPAs should be independently executable within a given time frame as well as observable and measurable.4 Ultimately, the EPAs should be a list of what the public can expect from their family physicians. Currently, a committee of family medicine leaders is drafting a list of EPAs for our specialty. They are expected to release the list this fall–intentionally coinciding with the anticipated Family Medicine for America’s Health report. The emergence of EPAs in family medicine is intended to support the milestones, and it is important to note their differences. Milestones follow each competency along a developmental continuum. While milestones detail individual competencies, real care delivery requires integration of these abilities in a more complex manner.5 For example, an EPA on care for the underserved/vulnerable patient would require a resident (on multiple occasions) to demonstrate knowledge of population health, advocacy, and cost awareness, and to employ team-based care, utilize IT resources, etc. Proficiency in an EPA requires mastery of several competencies, and goes well beyond ACGME program requirements, time spent on rotations, or patient numbers. The EPA assessments are based on specific observable activities throughout residency and not just a general impression. EPAs can also be used to drive curriculum development at the residency level. Program directors should use EPAs as they are intended to strengthen professional standards, improve patient safety, and enhance outcomes. The implementation of EPAs is not meant to be burdensome; rather, they should help programs bridge the gap between initial competency-based assessments and real-world practice. EPAs will be particularly helpful for family medicine faculty who struggle with Likert scale numerical ratings. We are in an exciting time in family medicine education as we look to incorporating milestones and EPAs into our residency programs. Implementation should produce higher quality graduates who will provide safe, quality care to their patients and communities.

THE NATIONAL GRADUATE SURVEY FOR FAMILY MEDICINE.

The Association of Family Medicine Residency Directors (AFMRD) is excited to announce the rollout of a standardized national graduate survey. Beginning in 2016, the survey will be conducted through the American Board of Family Medicine (ABFM) Maintenance of Certification process. Understanding the scope of practice and success of family medicine residency graduates post-residency is a crucial step in improving residency education. The Accreditation Council of Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Family Medicine state that “Program graduates should be surveyed at least every 5 years, and the results should be used in the annual program evaluation” (V.C.6, Detail Requirement). Although some residencies collaborated on standardized surveys and data collection previously, no standardized national initiative was in place. Recognizing an opportunity to both standardize the survey process and increase the response rate, the AFMRD approached the ABFM to explore opportunities to use ABFM-collected data to fulfill the graduate survey requirement. In turn, the ABFM offered to sponsor the development of a graduate survey to be administered through the Maintenance of Certification process, thus assuring a high response rate. In cooperation with the ABFM, the AFMRD led a steering committee of representatives from AFMRD, ABFM, family medicine research organizations, the ACGME, and a new graduate. The steering committee identified the major stakeholders of a national graduate survey to be, in order of priority: (1) residencies for use in program evaluation and improvement and for milestone validation; (2) family medicine organizations regarding family medicine practice scope and characteristics, as well as the quality of and trends in medical education; and (3) the “public” for use in educational research and policy analysis. The steering committee recommended and then conducted a competitive request for proposal (RFP) process to select a survey development team, ultimately choosing a team from the University of Washington, headed by Dr Freddy Chen. The survey development team completed a needs assessment and a literature search, reviewed previously developed graduate surveys, and conducted phone interviews of key stakeholders and recent graduates and roundtable discussions with program directors. In order to achieve a high survey completion rate, the goal was to limit the survey to questions that can be completed in fewer than 12 minutes. Two rounds of pilot testing have included input from stakeholders, including significant AFMRD input, to identify the most important questions to be included in the survey. The survey is now being rolled out by the ABFM to all ABFM Diplomates 3 years after graduation. The ABFM will incorporate the survey into its Maintenance of Certification process, providing information to residency programs each year on the survey cohort. This meets the ACGME program requirement and provides valuable information to each program for continuous quality improvement of residency education. The ABFM will provide each program with its own confidential survey results, with individual responses de-identified. Individual program data will not be available to the ACGME for individual program accreditation. Broader graduate survey data will be available in aggregate form only, to assure the anonymity of information that may be sensitive for individual programs. A data set for research purposes will be available in de-identified form through the ABFM upon request. The ABFM and AFMRD are committed to the protection of individual data, while providing only aggregate data for national analysis. The steering committee recommended using a 3-year post-graduation timeframe. Graduate scope of practice and success information is likely most useful to programs at that time, being neither too soon nor too long from the time of graduation. While the initial survey will include only residents 3 years after graduation, the ABFM intends to expand the survey so that each ABFM Diplomate completes a survey every 5 years, providing more robust information to programs. Starting in 2016, the AFMRD plans to create an advisory group to work with the ABFM to annually monitor the performance of the survey, the usefulness of the data for residencies, and to determine if any changes are needed in the questions. The AFMRD urges all program directors to inform their residents and graduates of the importance of the national graduate survey and to encourage their participation; additionally the AFMRD encourages program directors to incorporate the results into their annual program evaluation.

A FAMILY MEDICINE RESIDENCY PROGRAM CURRICULUM RESOURCE

Family medicine has been thrust into the national spotlight by the Affordable Care Act of 2010 bringing the concept of the medical home to the forefront and placing family physicians at the hub of the medical care delivery model of the future. These events also task training programs across this

EDUCATION GAPS BETWEEN FAMILY PHYSICIANS AND LICENSED NURSE PRACTITIONERS

As millions of Americans gain coverage for medical care in the coming years and as the need for primary care in patient-centered medical home (PCMH) models increases, our medical homes will need to provide more access to care. One such method is through advanced physician extenders which include

IMPLICATIONS OF THE 2011 ACGME DUTY HOUR RULES

In May 2010, Dr Thomas Nasca, Accreditation Council for Graduate Medical Education (ACGME) CEO, outlined the process of revising the 2003 duty hour requirements. He stated the overriding principles of patient safety and excellent patient care in teaching settings, delivering outstanding education

AFMRD STRATEGIC PLAN 2014 – 2016

Dale Carnegie once said, “The person who starts out going nowhere, eventually gets there.” With that in mind, the AFMRD Board embarked on a yearlong endeavor to develop our 3-year strategic plan. We wanted a roadmap that would guide our decision making for the foreseeable future. We also wanted

Quality assessment and improvement of post graduate family medicine training in the USA

Abstract Background: In 2013, the World Organisation of Family Doctors published training standards for post-graduate medical education (GME) in Family Medicine/General Practice (FP/GP). GME quality has not been well-defined, other than meeting accreditation standards. In 2009, the Association of Family Medicine Residency Directors (AFMRD) developed a tool that would aid in raising the quality of family medicine residency training in the USA. Objective: We describe the development of this quality improvement tool, which we called the residency performance index (RPI), and its first three years of use by US family medicine residency (FMR) programmes. The RPI uses metrics specific to family medicine training in the USA to help programmes identify strengths and areas for improvement in their educational activities. Our review of three years of experience with the RPI revealed difficulties with collecting data, and lack of information on graduates’ scope of practice. It also showed the potential usefulness of the tool as a programme improvement mechanism. Conclusions: The RPI is a nationwide, standardised, programme quality improvement tool for family medicine residency programmes in the USA, which was successfully launched as part of AFMRD’s strategic plan. Although some initial challenges need to be addressed, it has the promise to aid family medicine residencies in their internal improvement efforts. This model could be adapted in other post-graduate training settings in FM/GP around the world.

A prescription to advocate for graduate medical education reform.

Training the next generation of physicians in a system wrought with funding disparities has left many residency program directors wondering if there is hope for change—and what role they might play in bringing about change. The current state of graduate medical education (GME) financing is based on outdated statutory formulas that are focused on cost-based reimbursements in the hospital setting. The consequences of this imbalanced funding are significant: the formula impacts access to care, contributes to physician workforce shortages, and ultimately fails to meet the health care needs in the United States. Between 1998 and 2008, there was an increase in the number of residency slots in specialties known for competitive incomes and appealing lifestyles (radiology, ophthalmology, anesthesia, and dermatology) and a decrease in primary care slots (family medicine, pediatrics, and internal medicine). Despite the increasing need for primary care physicians across the country, research indicates that hospitals largely favor higher revenue-generating specialty training, as there is a direct correlation between specialty income and GME slots offered.1 In response to the failures of the Centers for Medicare and Medicaid Services (CMS) to meet the health care needs of the public, the Institute of Medicine (IOM) issued a report calling for dramatic changes in GME funding and governance.2 Specifically, the report recommends providing funding directly to sponsoring institutions, thereby promoting more training at community-based sites. In addition, the report supports the creation of an oversight council to track performance outcomes and lead policy development. Shortly after the IOM report was released, the American Academy of Family Physicians (AAFP) also took a stand emphasizing the need to expand primary care GME by instilling accountability in a budget-neutral manner. The AAFP proposed that CMS limit direct graduate medical education and indirect medical education payments to the training of first-certificate residency programs. They also proposed that CMS require all sponsoring institutions and teaching hospitals seeking new Medicare and/or Medicaid-financed GME positions meet minimum primary care training thresholds as a condition of their expansion. This change could fund an additional 7,000 new residency training spots with a minimum of 50% going to primary care specialties. In addition, AAFP’s proposal would require hospitals and sponsoring institutions to demonstrate a commitment to primary care through the establishment of thresholds and maintenance of effort requirements applicable to all institutions currently receiving GME financing. This is to ensure that institutions truly support training the primary care physicians this country needs. These collective GME refinancing recommendations would result in positive changes for the future of family medicine training. We anticipate a more robust workforce in a variety of geographic and practice settings. The larger impact would be shifting the focus of health care away from acute illness and toward population health and preventative care. The medical organizations that represent teaching hospitals are opposed to these changes, however. As family physicians, we must start educating our colleagues in other specialties on why the current system is unsustainable and harmful to patients and physicians alike, emphasizing that better health outcomes occur when primary care is available and affordable. Second, we must collaborate with other primary care specialties in order to speak to the value of primary care with a unified voice. Program directors carry a strong influence in their communities. Our call to action: contact your representatives and ask them to sponsor or support a bill that includes the AAFP’s proposal for GME reform. Use the AAFP’s resources (http://www.aafp.org/advocacy/informed/workforce/gme.html) to educate your legislators on this very important topic. Encourage your residents, faculty, and patients to do the same. Change comes when we speak with one voice on an issue that affects every American. It’s time to fix this broken system.

THE RESIDENCY PERFORMANCE INDEX (RPI): AN AFMRD TOOL FOR FAMILY MEDICINE RESIDENCY PROGRAM ASSESSMENT

The Residency Performance Index (RPI) was developed by the Association of Family Medicine Programs (AFMRD) in 2012 to spur residency program quality improvement, using program metrics and benchmark criteria specific to family medicine training. RPI provides a “dashboard” for program directors, using criteria believed to be critical to program quality and yet measureable and/or published. Using concepts borrowed from AAFP Residency Program Solutions’ Criteria for Excellence and TransforMED MHIQ, the dashboard uses the convention of red, yellow, and green to indicate achievement of targets representing the floor, status quo, and excellence. Like the dashboard of your car, the intent of the RPI is to monitor the important functions of the program and alert the driver (program director/program evaluation committee) if maintenance is required. The development of RPI was well timed, considering the ACGME’s emphasis on conducting meaningful quality self-assessment and improvement. The RPI can summarize much of the data used internally by a program’s program evaluation committee to conduct its annual program evaluation. Consecutive annual RPI reports tracking progression from deficiency (red) to excellence (green) can be useful trending information for the 10-year self-study process. RPI is a powerful tool that can easily organize and communicate meaningful data. It can provide faculty and leadership with an at-a-glance view of current status and future needs, and convey the complicated nature of residency training and accreditation. The visual presentation and comparison to aggregate data is appealing to data-minded individuals (DIOs, CMOs, etc) and is consistent with current business practices within and outside health care. Programs could, for example, use “red” items to advocate for corrective resources from their departments and systems, similar to the silver lining of RC citations, but with no accreditation repercussions. The RPI is available at no cost to AFMRD program directors. Those who use the RPI tool, including AFMRD itself, have a professional obligation to use it for self-improvement purposes only. Publication or comparison of individual RPI data to that of other programs or data sets is strictly prohibited. The tool must never be used as an advertising/promotional tool. It is also not an accrediting tool (no accrediting bodies, including the RC-FM have access to the data). In a world obsessed with rankings, it should be noted that RPI does not produce or promote a ranking system of any kind. The AFMRD owns all RPI data and survey results and uses data only in an anonymous, aggregate form for the purpose of advancing the mission of the AFMRD. Aggregate data can be used as a self-improvement tool for the discipline itself by identifying gaps and potential trends in family medicine training. Once such improvement areas are identified, national organizations such as the AFMRD can: Tailor national education offerings to meet identified training and faculty development needs Focus advocacy efforts with accrediting bodies, such as the RC-FM and ABFM Focus on areas nationally that fall into yellow or red zones of metrics Use data to bring context to discussions of training guidelines and best practices To our knowledge, this is the first US specialty-based comprehensive quality improvement tool for residency programs. The larger GME community has taken notice. The RPI is featured in the December 2014 issue of the Journal of Graduate Medical Education.1 The article outlines the development, implementation, benefits and current challenges of the tool. The future direction of RPI will address its recognized limitations, which include: Single specialty study, which reduces generalizability Volunteer participants that introduce the potential for selection bias Concerns about data collection, terminology of data, and keeping pace with ACGME Redundant data entry and timing of data collection Metrics and red/yellow/green levels set by consensus, expert opinion (lack of evidence for metrics) RPI has been well accepted and shows promise as a self-improvement tool for both individual residency programs as well as the discipline of family medicine itself. It has already been utilized by 122 out of 480 residency programs. In order to realize the full benefits of the tool and rectify its limitations, the family medicine residency training community must embrace the tool and commit to accurate data entry and a higher participation rate.