The Diagnostic Radiology Milestone Project

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The Diagnostic Radiology Milestone ProjectA Joint Initiative ofThe Accreditation Council for Graduate Medical EducationandThe American Board of Radiology

The Diagnostic Radiology Milestone ProjectThe Milestones are designed only for use in evaluation of resident physicians in the context of their participation in ACGMEaccredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development ofthe resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neitherrepresent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant inany other context.i

Diagnostic Radiology MilestonesWorking GroupChair: Kay Vydareny, MDAdvisorTimothy Brigham, MDiv, PhDE. Stephen Amis Jr., MDGary Becker, MDJames Borgstede, MDDorothy Bulas, MDJannette Collins, MDLawrence Davis, MDJennifer Gould, MDJason Itri, MDJeanne LaBerge, MDLynne Meyer, PhD, MPHDuane Mezwa, MDRichard Morin, PhDSteven Nestler, PhDRobert D. Zimmerman, MDii

Milestone ReportingThis document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME.Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental frameworkfrom less to more advanced. They are descriptors and targets for resident performance as a resident moves from entry into diagnostic radiologyresidency through graduation. In the initial years of implementation, the Review Committee will examine milestone performance data for eachprogram’s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing.For each reporting period, review and reporting will involve selecting the level of milestones that best describes each resident’s currentperformance level in relation to milestones. Milestones are arranged into numbered levels. Selection of a level implies that the residentsubstantially demonstrates the milestones in that level, as well as those in lower levels (see the figure on page v). A general interpretation of levelsfor diagnostic radiology is below:Level 1: The resident demonstrates milestones expected of one who has had some education in diagnostic radiology.Level 2: The resident is advancing and demonstrating additional milestones.Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates the majority ofmilestones targeted for residency.Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level isdesigned as the graduation target.Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which mightdescribe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residentswill reach this level.iii

Additional NotesLevel 4 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation isthe purview of the residency program director (see the following NAS FAQ for educational milestones on the ACGME’s NAS microsite for furtherdiscussion of this issue: “Can a resident graduate if he or she does not reach every milestone?”). Study of milestone performance data will berequired before the ACGME and its partners will be able to determine whether Level 4 milestones and milestones in lower levels are in theappropriate level within the developmental framework, and whether milestone data are of sufficient quality to be used for high stakes decisions.Some milestone descriptions include statements about performing independently. These activities must follow the ACGME supervision guidelines.For example, a resident who performs a procedure or takes independent call must, at a minimum, be supervised through oversight.Answers to Frequently Asked Questions about the NAS and milestones are available on the ACGME’s NAS microsite: http://www.acgmenas.org/assets/pdf/NASFAQs.pdf.iv

The figure below presents an example set of milestones for one sub-competency in the same format as the milestone report worksheet. Foreach reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by: selecting the level of milestones that best describes that resident’s performance in relation to the milestonesor selecting the “Has not Achieved Level 1” response optionSelecting a response box in the middle of alevel implies that milestones in that level andin lower levels have been substantiallydemonstrated.Selecting a response box on the line in between levelsindicates that milestones in lower levels have beensubstantially demonstrated as well as some milestonesin the higher level(s).v

Version 12/2012DIAGNOSTIC RADIOLOGY MILESTONESACGME REPORT WORKSHEETPatient Care and Technical Skills (Residents must be able to meet previous year milestones when evaluated at a specific level)PCTS1: ConsultantHas notAchievedLevel 1Level 1Uses established evidencebased imaging guidelines suchas American College ofRadiology (ACR)Appropriateness Criteria Appropriately uses theElectronic Health Record toobtain relevant clinicalinformationLevel 2Level 3Recommends appropriateimaging of common*conditions independentlyRecommends appropriateimaging of uncommon*conditions independently*As defined by theresidency program*As defined by theresidency programLevel 4Integrates current researchand literature withguidelines, taking intoconsideration costeffectiveness and riskbenefit analysis, torecommend imagingLevel 5Participates in research,development, andimplementation of imagingguidelinesComments:Possible Methods of Assessment/Examples: 360 Evaluation/Multi-rater/PeerDirect observation and feedbackEnd-of-Rotation Global AssessmentSelf-Assessment and Reflections/PortfolioEnd-of-Year ExaminationSimulation/OSCECopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.1

Version 12/2012Patient Care and Technical SkillsPCTS2: Competence in proceduresHas notAchievedLevel 1Level 1Competently performs basicprocedures* under indirectsupervisionRecognizes and managescomplications of basicprocedures*Basic procedures, as definedby each residency program,include those needed to takeindependent callLevel 2Level 3Competently performsintermediate procedures,as defined by the residencyprogramCompetently performsadvanced procedures, asdefined by the residencyprogramRecognizes and managescomplications ofintermediate proceduresRecognizes and managescomplications of advancedproceduresLevel 4Able to competently andindependently perform thefollowing procedures: adult and pediatricfluoro studies lumbar puncture image-guided venousand arterial access hands-on adult andpediatric ultrasoundstudies drainage of effusionsand abscesses image-guided biopsy nuclear medicine I131 treatments ( 33and 33 mCi)Level 5Able to teach proceduresto junior-level residentsCompetently performscomplex procedures,modifies procedures asneeded, and anticipatesand managescomplications of complexproceduresComments:Possible Methods of Assessment/Examples: 360 Evaluation/Multi-rater/Peer End-of-Rotation Global Assessment Case/Procedure Logs, including complications Direct observation and feedback Procedural competency checklists Self-Assessment and Reflections/Portfolio Simulation/OSCECopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.2

Version 12/2012Medical KnowledgeMK1: Protocol selection and optimization of imagesHas notAchievedLevel 1Level 1Selects appropriate protocoland contrast agent/dose forbasic imaging, includingprotocols encountered duringindependent call as defined bythe residency programRecognizes sub-optimalimagingLevel 2Selects appropriateprotocols and contrastagent/dose forintermediate imaging asdefined by the residencyprogramLevel 3Selects appropriateprotocols and contrastagent/dose for advancedimaging as defined by theresidency programLevel 4Independently modifiesprotocols as determined byclinical circumstancesLevel 5Teaches and/or writesimaging protocolsApplies physical principlesto optimize image qualityDemonstrates knowledgeof physical principles tooptimize image qualityComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment Direct observation and feedback Self-Assessment and Reflections/Portfolio Core exam OSCE/simulationCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.3

Version 12/2012Medical KnowledgeMK2: Interpretation of examinationsHas notAchievedLevel 1Level 1Makes core observations,formulates differentialdiagnoses, and recognizescritical findingsDifferentiates normal fromabnormalLevel 2Makes secondaryobservations, narrows thedifferential diagnosis, anddescribes managementoptionsLevel 3Provides accurate, focused,and efficientinterpretationsPrioritizes differentialdiagnoses andrecommends managementLevel 4Makes subtle observationsSuggests a single diagnosiswhen appropriateIntegrates current researchand literature withguidelines to recommendmanagementLevel 5Demonstrates expertiseand efficiency at a levelexpected of a subspecialistAdvances the art andscience of imageinterpretationComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment Direct observation and feedback Reading out with resident ER preparedness test Review of reports Rate of major discrepancies Core examCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.4

Version 12/2012Systems-based PracticeSBP1: Quality Improvement (QI)Has notAchievedLevel 1Level 1Level 2Describes departmental QIinitiativesIncorporates QI intoclinical practiceDescribes the departmentalincident/occurrence reportingsystemParticipates in thedepartmentalincident/occurrencereporting systemLevel 3Identifies and begins asystems-based practiceproject incorporating QImethodologyLevel 4Completes a systemsbased practice project asrequired by the ACGMEReview CommitteeDescribes nationalradiology quality programs(e.g., National RadiologyData Registry,accreditation, peer-review)Level 5Leads a team in the designand implementation of aQI projectRoutinely participates inroot cause analysisComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment 360 Evaluation/Multi-rater/Peer Direct observation and feedback Self-Assessment and Reflections/Portfolio Semi-annual evaluation with program director Written feedback on project (with mentor) Project presentation feedback (faculty, peers, others in system) Critical incidents reporting and feedbackCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.5

Version 12/2012Systems-based PracticeSBP2: Health care economicsHas notAchievedLevel 1Level 1Describes the mechanisms forreimbursement, includingtypes of payorsLevel 2States relative cost ofcommon proceduresLevel 3Describes the technical andprofessional componentsof imaging costsLevel 4Describes measurementsof productivity (e.g., RVUs)Level 5Describes the radiologyrevenue cycleComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment Project presentation feedback (faculty, peers, others in system) Completion of knowledge-based modulesSuggested educational strategies: Annual QA session with head of billing Institute for Health Care International modules Agency for Healthcare Research and Quality modulesCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.6

Version 12/2012Practice-based Learning and ImprovementPBLI1: Patient safety: contrast agents; radiation safety; MR safety; sedationHas notAchievedLevel 1Level 1Contrast Agents:Recognizes and managescontrast reactionsRadiation Safety:Describes the mechanisms ofradiation injury and the ALARA(“as low as reasonablyachievable”) conceptMR Safety:Describes risks of MRILevel 2Level 3Level 4Contrast Agents:Re-demonstratesrecognition andmanagement of contrastreactionsContrast Agents:Re-demonstratesrecognition andmanagement of contrastreactionsContrast Agents:Re-demonstratesrecognition andmanagement of contrastreactionsRadiation Safety:Accesses resources todetermine exam-specificaverage radiation doseinformationRadiation Safety:Communicates the relativerisk of exam-specificradiation exposure topatients and practitionersRadiation Safety:Applies principles of ImageGently and Image Wisely MR Safety:Accesses resources todetermine the safety ofimplanted devices andretained metalMR Safety:Communicates MR safetyof common implants andretained foreign bodies topatients and practitionersMR Safety:Applies principles of MRsafety including safetyzones and pre-MRscreeningSedation:Describes the principles ofconscious sedationLevel 5Contrast Agents:Teaches appropriatetreatment of contrastreactionsRadiation Safety:Promotes radiation safetyMR Safety:Participates in establishingor directing a safe MRprogramSedation:Selects appropriatesedation agent and dosefor conscious sedationComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment 360 Evaluation/Multi-rater/Peer Simulation/OSCE Direct observation and feedback Self-Assessment and Reflections/Portfolio Completion of institutional safety modules, BCLS/ACLSCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.7

Version 12/2012Practice-based Learning and ImprovementPBLI2: Self-Directed LearningHas notAchievedLevel 1Level 1Develops an annual learningplan based on self-reflectionand program feedbackLevel 2Evaluates and modifieslearning planLevel 3Evaluates and modifieslearning planLevel 4Evaluates and modifieslearning planLevel 5Advocates for lifelonglearning at local andnational levelsComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment Semi-annual evaluation meeting with program director Self-Assessment and Reflections/Portfolio Resident teaching and feedback Core examCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.8

Version 12/2012Practice-based Learning and ImprovementPBLI3: Scholarly activityHas notAchievedLevel 1Level 1Documents training in criticalthinking skills and researchdesignLevel 2Works with facultymentors to identifypotential scholarly projectsLevel 3Begins scholarly projectLevel 4Completes and presents ascholarly projectLevel 5Independently conductsresearch and contributesto the scientific literatureand/or completes morethan one scholarly projectCompletes an IRBsubmissionComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment Self-Assessment and Reflections/Portfolio Core exam Journal club discussions Written feedback on project (with mentor) Project presentation feedback (faculty, peers, others in system) Completion of AJR Self-Assessment Modules or CITI modulesCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.9

Version 12/2012ProfessionalismPROF1: Professional Values and EthicsHas notAchievedLevel 1Level 1Level 2Level 3Level 4Level 5Demonstrates the followingIs an effective health careIs an effective health careServes as a role model forParticipates in local andprofessional behaviors:team memberteam leader, promotingprofessional behaviornational organizations toprimacy of patient welfare,advance professionalism recognizes theDemonstrates professional in radiologyimportance and priority of Demonstrates professional patient autonomy, andbehaviors listed in thesocial justicebehaviors listed in thepatient care andsecond columnsecond columnMentors others regardingadvocates for patientDemonstrates professionalprofessionalism and ethicsinterestsbehaviorslistedinthe fulfills work-relatedsecond columnresponsibilities is truthful recognizes personallimitations and seeks helpwhen appropriate recognizes personalimpairment and seekshelp when needed responds appropriately toconstructive criticism places needs of patientsbefore self maintains appropriateboundaries with patients,colleagues, and others exhibits tolerance andacceptance of diverseindividuals and groups maintains patientconfidentiality fulfills institutional andprogram requirementsrelated to professionalismand ethics attends requiredCopyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.10

Version 12/2012conferencesComments:Possible Methods of Assessment/Examples: End-of-Rotation Global Assessment 360 Evaluation/Multi-rater/Peer Simulation/OSCE Direct observation and feedback Conference attendance logs Timeliness in completing institutional and program requirementsSuggested Educational Tools:1. Teaching and Assessing Professionalism: A Program Director’s Guide by the ABP and APPD – see Chapter 8: Measuring Professionalism Critical incidents Peer assessments Multi-source assessments Professionalism Mini-Evaluation Exercise (P-MEX)2.The Professionalism Mini-Evaluation Exercise:A Preliminary Investigation Richard Cruess, Jodi Herold McIlroy, Sylvia Cruess, Shiphra Ginsburg, and Yvonne Steinert Acad Med. 2006 Oct;81(10 Suppl):S74-83.ABRF Online Modules on Ethics and 4.“Medical Professionalism in the New Millennium: A Physician Charter.” Ann Intern Med. 5 February 2002;136(3):243-246. "Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Radiology. All rights reserved.The copyright owners grant third parties the right to use the Diagnostic Radiology Milestones on a non-exclusive basis for educational purposes.11

Version 12/2012Interpersonal and Communication SkillsICS1: Effective communication with patients, families, and caregiversHas notAchievedLevel 1Level 1Communicates informationabout imaging and examina

The American Board of Radiology . i The Diagnostic Radiology Milestone Project The Milestones are designed only for use in evaluation of resident physicians in the context of their participation in ACGME accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician .

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