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Medical Education  |   April 2015
The Single Graduate Medical Education Accreditation System
Author Notes
  • From the University of Pikeville-Kentucky College of Osteopathic Medicine (Dr Buser) and the Department of Education at the American Osteopathic Association (AOA) in Chicago, Illinois (Mr Swartwout, Ms Gross, and Ms Biszewski). Dr Buser is a member of the AOA Board of Trustees and was a member of the AOA-ACGME (Accreditation Council for Graduate Medical Education) Joint Task Force. 
  •  *Address correspondence to the AOA Department of Education, 142 E Ontario St, Chicago, IL 60611-2864. E-mail: singleGME@osteopathic.org
     
Article Information
Medical Education / Graduate Medical Education
Medical Education   |   April 2015
The Single Graduate Medical Education Accreditation System
The Journal of the American Osteopathic Association, April 2015, Vol. 115, 251-255. doi:10.7556/jaoa.2015.049
The Journal of the American Osteopathic Association, April 2015, Vol. 115, 251-255. doi:10.7556/jaoa.2015.049
Abstract

In 2014, the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and the Accreditation Council for Graduate Medical Education signed a historic Memorandum of Understanding, which creates a single accreditation system for graduate medical education. The present article outlines the history of the agreement and the 5-year transition process, which begins July 1, 2015, and ends June 30, 2020.

Currently, 2 graduate medical education (GME) accreditation authorities are recognized in the United States: the American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Education (ACGME). For more than 30 years, osteopathic physicians (ie, DOs) have had the choice of graduate training under either authority. Graduates could enter into ACGME training programs via 1 of 3 pathways: (1) directly after graduating from an osteopathic medical college, (2) after completing a 1-year osteopathic traditional rotating internship, or (3) for sub-specialty training after completing AOA-accredited training in a specialty field (eg, training in an AOA-accredited orthopedic surgery program and then an ACGME hand surgery subspecialty program). 
In 2009, the ACGME began to restructure its accreditation system to be based on educational outcomes related to 6 core competencies and concluded that it could not ensure the competence of the physician unless that individual had progressed through its new accreditation system from the beginning. Thus, in the fall of 2011, the ACGME proposed new Common Program Requirements that would have restricted access of physicians moving from non-ACGME (and Canadian-accredited) training programs to ACGME programs beginning July 1, 2016. To address this situation and to discuss potential remedies, a joint task force of representatives from the AOA, the American Association of Colleges of Osteopathic Medicine (AACOM), and the ACGME first met in early 2012. After many months, the task force concluded that the best solution for trainees, the public, and others was the creation of a single accreditation system for GME. 
The framework of and transition to a single accreditation system are described in a Memorandum of Understanding (MOU), which was signed by the AOA, AACOM, and the ACGME in early 2014.1 The present article describes key features of the MOU (including the 5-year transition and the organizational structure of the new system), the benefits of a single accreditation system, the AOA's monitoring of the implementation process, and next steps. 
Memorandum of Understanding
The MOU outlines the 5-year timeline to establish the single GME accreditation system and key provisions of the new system; the AOA will continue to approve osteopathic GME programs through June 30, 2020. Institutions accredited by the AOA may apply for ACGME accreditation beginning April 1, 2015.2 Those institutions that submit a completed application are granted preaccreditation status. Likewise, AOA-accredited training programs that have a preaccredited sponsoring institution may apply for ACGME accreditation beginning July 1, 2015.2 The institutions and training programs have a 5-year window to achieve ACGME accreditation. The institutions and training programs in the preaccreditation status are not ACGME accredited and therefore must maintain their accreditation status under the aegis of the AOA. 
Osteopathic postdoctoral training institutions are an innovation of the osteopathic medical education system. These institutions provide a link between undergraduate and graduate medical education and allow for an efficient flow of resources and services, such as curriculum delivery, faculty development, and research. The MOU specifically allows osteopathic postdoctoral training institutions that meet the requirements to apply for institutional sponsorship. 
Preaccreditation status is a key provision of the MOU and is a specific term that confers specific benefits. One benefit is that AOA-accredited GME training that has occurred in an AOA residency program with preaccreditation status is deemed to meet the ACGME initial year and fellowship eligibility requirements as long as that clinical training meets the ACGME eligibility requirements in effect on June 30, 2013, or July 1, 2016.3 This rule allows AOA residents to enter advanced ACGME training through the less restrictive eligibility requirements, be they the requirements as of June 30, 2013, or those as of July 1, 2016.3 
For training programs, a benefit of preaccreditation status is that it modifies the faculty credentials requirement so that AOA-certified physicians are acceptable as ACGME faculty. It also allows for a program codirector certified by the American Board of Medical Specialties if one is needed. 
The MOU provides for changes to the governance of ACGME as well. In February 2015, the AOA and AACOM became member organizations of the ACGME,4 joining the 5 existing member organizations—the American Medical Association, the American Hospital Association, the American Board of Medical Specialties, the Council on Medical Specialty Societies, and the Association of American Medical Colleges. By 2020, the AOA and AACOM will each be entitled to nominate a total of 4 directors to the ACGME Board of Directors. This process is phased in through the transition period, with the ACGME electing 2 new directors from each organization: 2 from the AOA (Karen J. Nichols, DO, and David A. Forstein, DO) and 2 from AACOM (Clinton E. Adams, DO, and Gary L. Slick, DO). In addition, the AOA will nominate 1 or more members to review committees for which there are currently AOA-accredited training programs. 
The MOU also provides for the creation of 2 new committees. One is a recognition committee (the Osteopathic Principles Committee) responsible for reviewing and evaluating the osteopathic principles dimension of the program that seeks osteopathic recognition. This committee will also determine the prerequisite knowledge and skills required for an MD to enter a residency program with osteopathic recognition. The osteopathic recognition requirements developed by the Osteopathic Principles Committee were approved by the ACGME Board of Directors and are available at http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/Osteopathic_Recogniton_Reqs_07012015.pdf. 
Osteopathic recognition is an important concept. Under the single accreditation system, some training programs will have the designation of osteopathic recognition to indicate that they are meeting standards relevant to osteopathic principles, including osteopathic manipulative treatment (OMT). Allopathic graduates (ie, MDs) seeking to train in those programs would need prerequisite education in osteopathic principles and practice. The Osteopathic Principles Committee has proposed that a training program does not have to require all training positions to be osteopathic. Instead, training programs will be able to designate a subset of training positions and reserve them to train residents osteopathically. 
The other newly formed committee is the Osteopathic Neuromusculoskeletal Medicine (ONMM) Review Committee, which has the authority to accredit programs delegated to it from the ACGME Board of Directors. Like the Osteopathic Principles Committee, the ONMM Review Committee has drafted standards for ONMM, which were approved by the ACGME Board of Directors in February 2015 and are available at http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/ONMM_Reqs_07012015.pdf. Going forward, the ONMM Review Committee will… 

…set accreditation standards, provide peer evaluation of programs or institutions to assess the degree to which the program or institution complies with the published set of educational standards, and confer an accreditation status for programs and institutions meeting those standards.5

 
Although not specifically identified in the MOU, the methodology for accreditation is an important component of the single accreditation system. While the AOA has used a specific grading rubric to accredit its training programs, the ACGME uses a "substantial compliance" framework. A training program that is substantially in compliance with the training standards will be accredited by the ACGME. There are no singular standards for which a training program would lose its accreditation. 
Benefits of a Single Accreditation System
There are many benefits of a single accreditation system. One is the preservation of access to ACGME training programs, upon which the osteopathic medical profession is dependent. In 2014, the AOA had approximately 10,500 funded residency training positions, which would support at most 3500 graduates. In contrast, in the 2013-2014 academic year, osteopathic medical schools graduated more than 5000 DOs,6 of whom about 45% entered into an ACGME-accredited training program and 48% entered into an AOA-accredited training program. In short, the osteopathic medical profession is reliant on ACGME-accredited programs for training positions. 
Another benefit is that it will eliminate unnecessary duplication. Each authority establishes minimum standards against which programs are evaluated. The ACGME and the AOA requirements for training programs are fairly similar, which means that there are duplicate organizational structures between the 2 accreditation systems. Review teams composed of AOA and ACGME specialty experts found the specialty standards to be similar in the specialties reviewed (internal medicine, family medicine, general surgery, orthopedic surgery, emergency medicine, and obstetrics and gynecology). 
Other benefits of the single accreditation system include the following: 
  • Demonstration of consistent quality of GME training. The training programs in a specialty will be consistently evaluated, whether they are ACGME accredited only or they are ACGME accredited with osteopathic recognition.
  • Alignment of competency standards. This alignment will demonstrate that all physicians—DOs and MDs—are trained to the same competency standards.
  • Alignment with policymakers' expectations. The federal government has increasingly questioned the value of the current system of governance and financing of GME. A single accreditation system demonstrates to Congress that duplication is being eliminated and high-quality graduates are being produced. The new accreditation system will be able to quantitatively demonstrate the quality of the product.
  • ■ Unification of voice on GME access and funding issues. Over the past 20 years, Congress has enacted laws to limit GME reimbursement by Medicare. A single accreditation system, comprising both DOs and MDs, will create a stronger united front in responding to congressional proposals.
  • Visibility of osteopathic medicine. The single accreditation system will open the possibility of osteopathic recognition for training programs that have been formerly only ACGME accredited (ie, allopathic) and provide new training opportunities for both DOs and MDs in osteopathic principles and practice.
AOA Monitoring of the Single Accreditation System Implementation
At its July 2014 annual meeting, the AOA House of Delegates voted to support the decision to pursue a single accreditation system,7 endorsing the 3 organizations' plans to begin implementation of the MOU. The House of Delegates asked that the implementation be monitored with respect to the following 7 issues: 
  1. ability of AOA-trained and –board certified physicians to serve as program directors in the single GME accreditation system
  2. maintenance of smaller rural and community-based training programs
  3. number of solely AOA–board certified physicians serving as program directors in each specialty
  4. number of osteopathic-identified GME programs and number of osteopathic-identified GME positions gained and lost
  5. number of osteopathic residents taking osteopathic board certification examinations
  6. status of osteopathic board certification being deemed equivalent by the ACGME
  7. importance of osteopathic board certification as a valid outcome measure of the quality of osteopathic residency programs
The House of Delegates also asked that the AOA seek to allow consideration of special exceptions for training programs with unusual and extenuating circumstances. 
The AOA Board of Trustees has access to considerable data on AOA residency training programs and will monitor their progress as they enter the single accreditation system. The Table provides a snapshot of osteopathic training programs as of May 31, 2014. 
Table.
Osteopathic Graduate Medical Education Programs and Positions Approved by the American Osteopathic Associationa
Positions
Description Programs Funded Filled
    Type of Training
        Residencies 773 (69) 8999 (86) 7206 (88)
        Fellowships 225 (20) 599 (6) 376 (5)
        Internships 121 (11) 899 (9) 628 (8)
        Total, No. 1119 10,497 8210
    Region
        Mid-Atlantic 327 (29) 3389 (32) 2539 (31)
        New England 21 (2) 177 (2) 130 (2)
        North Central 423 (38) 3636 (35) 3107 (38)
        Northwest 26 (2) 274 (3) 163 (2)
        South Central 70 (6) 569 (5) 458 (6)
        Southeast 180 (16) 1788 (17) 1360 (17)
        Southwest 72 (6) 664 (6) 453 (6)
        Total, No. 1119 10,497 8210
a Data current as of May 31, 2014. Data presented as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.Source: American Osteopathic Association Masterfile.
Table.
Osteopathic Graduate Medical Education Programs and Positions Approved by the American Osteopathic Associationa
Positions
Description Programs Funded Filled
    Type of Training
        Residencies 773 (69) 8999 (86) 7206 (88)
        Fellowships 225 (20) 599 (6) 376 (5)
        Internships 121 (11) 899 (9) 628 (8)
        Total, No. 1119 10,497 8210
    Region
        Mid-Atlantic 327 (29) 3389 (32) 2539 (31)
        New England 21 (2) 177 (2) 130 (2)
        North Central 423 (38) 3636 (35) 3107 (38)
        Northwest 26 (2) 274 (3) 163 (2)
        South Central 70 (6) 569 (5) 458 (6)
        Southeast 180 (16) 1788 (17) 1360 (17)
        Southwest 72 (6) 664 (6) 453 (6)
        Total, No. 1119 10,497 8210
a Data current as of May 31, 2014. Data presented as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.Source: American Osteopathic Association Masterfile.
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Next Steps
The single accreditation system focuses on GME. It does not address undergraduate medical education accreditation, continuing medical education, board certification, or licensing examinations. The AOA emphasized these points throughout the 2 years of discussion that led to the creation of the single GME accreditation system, and it will continue to do so into the future. The AOA will continuously monitor the transition of osteopathic training programs into the ACGME system, especially smaller rural and community-based programs, which are important in addressing the health care needs of the nation. 
The AOA will continue to provide communications on the progress of the single accreditation system. For more information on this topic, visit http://www.osteopathic.org/acgme, which is updated as new information becomes available. 
References
Allopathic and Osteopathic Medical Communities Commit to a Single Graduate Medical Education Accreditation System [news release]. American Osteopathic Association website. http://www.osteopathic.org/inside-aoa/news-and-publications/media-center/2014-news-releases/Pages/2-26-allopathic-and-osteopathic-medical-communities-commit-to-single-graduate-medical-education-accreditation-system.aspx. Posted February 26, 2014. Accessed February 24, 2015.
Timeline for AOA-approved programs to apply for ACGME accreditation. Accreditation Council for Graduate Medical Education website. http://acgme.org/acgmeweb/Portals/0/PDFs/Nasca-Community/Timeline.pdf. Accessed February 26, 2015.
Pathways to ACGME accreditation for osteopathic programs. Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/PDFs/Nasca-Community/PathwaystoACGMEAccreditationforAOA-ApprovedPrograms.pdf. Accessed March 10, 2015.
American Osteopathic Association and American Association of Colleges of Osteopathic Medicine join the Accreditation Council for Graduate Medical Education [news release]. American Osteopathic Association website. http://www.osteopathic.org/inside-aoa/news-and-publications/media-center/2015-news-releases/Pages/1-14-aoa-and-aacom-join-the-accreditation-council-for-graduate-medical-education.aspx. Posted January 14, 2015. Accessed February 26, 2015.
Appointment process for ACGME review committee members including resident members. Accreditation Council for Graduate Medical Education website. https://www.acgme.org/acgmeweb/Portals/0/AppointmentProcess_ACGMERCMembers.pdf. Accessed February 24, 2015.
Biszewski M, Martinez B. Appendix 1: osteopathic graduate medical education, 2015. J Am Osteopath Assoc. 2015;115(4):268-274. doi:10.7556/jaoa.2015.052.
The single GME accreditation system. American Osteopathic Association website. http://www.osteopathic.org/inside-aoa/single-gme-accreditation-system/Pages/default.aspx. Accessed February 24, 2015.
Table.
Osteopathic Graduate Medical Education Programs and Positions Approved by the American Osteopathic Associationa
Positions
Description Programs Funded Filled
    Type of Training
        Residencies 773 (69) 8999 (86) 7206 (88)
        Fellowships 225 (20) 599 (6) 376 (5)
        Internships 121 (11) 899 (9) 628 (8)
        Total, No. 1119 10,497 8210
    Region
        Mid-Atlantic 327 (29) 3389 (32) 2539 (31)
        New England 21 (2) 177 (2) 130 (2)
        North Central 423 (38) 3636 (35) 3107 (38)
        Northwest 26 (2) 274 (3) 163 (2)
        South Central 70 (6) 569 (5) 458 (6)
        Southeast 180 (16) 1788 (17) 1360 (17)
        Southwest 72 (6) 664 (6) 453 (6)
        Total, No. 1119 10,497 8210
a Data current as of May 31, 2014. Data presented as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.Source: American Osteopathic Association Masterfile.
Table.
Osteopathic Graduate Medical Education Programs and Positions Approved by the American Osteopathic Associationa
Positions
Description Programs Funded Filled
    Type of Training
        Residencies 773 (69) 8999 (86) 7206 (88)
        Fellowships 225 (20) 599 (6) 376 (5)
        Internships 121 (11) 899 (9) 628 (8)
        Total, No. 1119 10,497 8210
    Region
        Mid-Atlantic 327 (29) 3389 (32) 2539 (31)
        New England 21 (2) 177 (2) 130 (2)
        North Central 423 (38) 3636 (35) 3107 (38)
        Northwest 26 (2) 274 (3) 163 (2)
        South Central 70 (6) 569 (5) 458 (6)
        Southeast 180 (16) 1788 (17) 1360 (17)
        Southwest 72 (6) 664 (6) 453 (6)
        Total, No. 1119 10,497 8210
a Data current as of May 31, 2014. Data presented as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.Source: American Osteopathic Association Masterfile.
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