The internal medicine reporting milestones and the next accreditation system.

The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcomes Project in 1999, which requires resident training programs to assess trainee accomplishment of learning objectives across 6 general domains of competence: patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills (1). To facilitate this initiative, the ACGME launched the Milestones Project in 2009, charging each specialty to identify “the milestones of competency development” (2). Milestones are observable developmental steps that describe progression from a beginning learner to the expected level of proficiency at the completion of training. Accordingly, predefined milestones can be used to assess and document a trainee’s developmental progression toward competence. Starting in July 2013, ACGME’s Next Accreditation System (NAS) will require the demonstration of educational outcomes through assessment and semiannual reporting of these milestones (3). In anticipation of the launch of the Milestones Project, the internal medicine education community developed and published a set of 142 observable, developmental milestones that describe the progression of specific knowledge, skills, and attitudes culminating at the proficient trainee (4). The Table lists 3 milestones for systems-based practice as an example. Since their publication in 2009, these milestones have served as a valuable resource for developing curricula and assessment tools and providing feedback to trainees. However, they did not provide an optimal format for reporting trainee outcomes because they were too numerous and specific. Recognizing this weakness, as well as the emerging need for a specialty-driven, milestones-based outcome reporting structure for the NAS, the internal medicine education community, along with the ACGME and the American Board of Internal Medicine (ABIM), sought to generate more synthetic and narrative-based milestones for reporting educational outcomes. We describe the development and use of what will be called “reporting milestones.” (The ACGME will not refer to the term reporting milestones in its communications, instead choosing to title the outcomes-reporting structure of the NAS simply as “milestones.”) To facilitate dialogue in the internal medicine community, we use the label “reporting milestones” to differentiate them from the prior 142 milestones, now called “curricular milestones.” HOW WERE THE REPORTING MILESTONES DEVELOPED? A task force of experts in milestones and competencybased education was brought together by the ABIM and ACGME with the charge of articulating synthetic, competency-based developmental milestones for use in residency training and outcomes reporting. Borrowing from prior descriptions of narrative development and using the curricular milestones and ACGME common program requirements as a starting point, the task force began assembling narratives that describe key stages of emerging competence for each ACGME competency domain (5, 6). Using individual literature-based review, several conference calls, and multiple in-person meetings, the task force refined this work iteratively to include both concrete experience (such as assessable learner performance) and abstract concepts (such as ideal definitions of competence). Midway through the process, focus groups of residency program leaders were convened to assess the face validity and perceived value of the draft. Near the completion of the work, 37 internal medicine residency programs participated in a feasibility study testing the process for incorporating the reporting milestones into a programmatic evaluation of trainee competence and reporting outcomes in the NAS. Feedback from the focus groups and feasibility study included the need for consistent wording throughout the milestones and avoidance of medical jargon. This feedback was incorporated into the final reporting milestones document.