Abstract
Beginning in 2020, all residency programs will be accredited by the Accreditation Council for Graduate Medical Education (ACGME). Programs accredited by the American Osteopathic Association (AOA) that do not achieve ACGME pre-accreditation status by 2020 will be forced to close, resulting in loss of graduate medical education slots and affecting the physician workforce locally and nationally. Current ACGME programs are in a position to help consult, support, and learn from local AOA-only programs as they work toward meeting ACGME accreditation requirements, but to date there have been only limited collaborations. A regional network of ACGME- and dually accredited family medicine residency programs (“the Network”) and family medicine programs solely accredited by the AOA recognized the imperative to support the AOA-only programs with their accreditation transitions to preserve their primary care residency positions. This article describes the inputs, activities, outputs, and outcomes of these collaborative efforts to establish communications and strategies using a logic model program “road map” format. Initial efforts included a collaborative conference and ongoing consultations and workshops. This model can be replicated for program collaborations in other locations.
In early 2014, the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine announced their agreement to transition to a single accreditation system (SAS) for graduate medical education (GME).
1,2 Beginning July 1, 2015, AOA programs could apply for ACGME accreditation; these programs must achieve ACGME pre-accreditation by June 30, 2020, when the AOA will cease to accredit GME programs.
1-3 Programs that do not meet ACGME standards will no longer be accredited and will therefore be forced to close.
Current workforce analyses by multiple national organizations project the need for more primary care physicians nationally to meet the demand for primary care created by the Affordable Care Act and other health care reform initiatives.
4-6 This demand, in turn, creates a particular need for developing new primary care residency positions.
7 Residency programs accredited by the AOA are an important component of current physician workforce training, particularly for primary care; as of 2016, the 1200 AOA-accredited residency training programs had more than 9000 osteopathic physicians enrolled, almost half of whom were in primary care programs.
8 Ensuring that as many AOA programs as possible successfully achieve ACGME accreditation is an essential element of a primary care workforce strategy.
Although discussions are occurring within the ACGME and the AOA to facilitate the transition to the SAS, many individual osteopathic sponsoring institutions and programs are struggling to determine how to meet ACGME accreditation standards. Conversely, many ACGME-accredited programs are trying to evaluate the benefits of incorporating osteopathic principles and specifically whether achieving Osteopathic Recognition
9 should be an important educational focus in their programs.
The ACGME-accredited family medicine residency programs in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) have comprised a collaborative network (“the Network”) for more than 40 years. These programs include dually accredited programs (ie, programs with both ACGME and AOA accreditation). With the SAS, the 5 AOA-only family medicine programs in WWAMI (all in Washington State) will join the Network. Both the Network and the AOA-only family medicine programs recognized the imperative to support the AOA-only programs with their accreditation transitions so that none of the primary care residency slots (and, therefore, potential primary care physician workforce members) are lost. Also, for ACGME-accredited programs, knowledge about the requirements for Osteopathic Recognition was needed. In this article, we describe the approach we took in the WWAMI region to work toward these outcomes using a logic model structure.
What Is a Logic Model and Why Use One?
Logic models are a tool used in program planning and evaluation as a way to conceptualize change in a concrete way and to work toward ongoing process improvement. They provide a visual framework for a project; a typical simple logic model includes specifying and showing the “flow” between resources/inputs, activities, outputs, outcomes, and impact. Developing this tool forces the planning team to consider the desired end results of a program and the resources required to meet the intended outcomes.
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Logic models, which can be simple or complex, have several inherent limitations, particularly with a simple logic model structure. Namely, any unanticipated program change or additional relationships that develop outside of your planned activities will affect other parts of your programming and therefore alter the content within the logic model. For example, if resources required to complete an activity suddenly become unavailable—such as if a funding source disappears—the program's ability to meet short- and long-term outcomes would be affected.
We chose to use a logic model to describe our processes in the WWAMI region because it provides a good structure for sharing collaborative input and activities and tracking the multiple stages of outcomes toward meeting our long-term end goal. In our approach, presenting content in the framework of a logic model provides detail in a transparent way about required resources and gives a realistic picture of the “stepwise” way in which goals are met (in the short, intermediate, and long term). Our logic model provides a sample “road map” (
Figure) showing the sequence of events we undertook to help all programs in our region toward the desired end results of ACGME accreditation and Osteopathic Recognition.
Development and Application of the Model: Collaborative Work on Inputs, Activities, and Outputs
Inputs
Network leadership approached the program directors of regional AOA-only family medicine residency programs and the leadership at Pacific Northwest University of Health Sciences College of Osteopathic Medicine (PNWU-COM), the largest osteopathic medical school in the region, to begin a conversation about collaborating to help all AOA-only family medicine programs in the region achieve ACGME accreditation and, if desired, Osteopathic Recognition. Buy-in and a desire to act from all involved was key.
After some of the initial collaborative work had taken place, the Network secured additional funding from Washington State to assist the AOA-only programs with their accreditation transition. This funding has provided tangible support for our collaborative activities—including ongoing staff and faculty efforts for consultation, facilitation, and logistical planning. Without this funding and time commitment, our activities would not have been so extensive.
Activities and Outputs
Collaborative Conference: Initial Activity
Before any funding, a team comprising the Network director and 2 administrative staff as well as the PNWU-COM director of continuing medical education and GME was formed to develop a 1-day conference to bring together program directors from both the Network and the AOA-only programs. The conference incorporated established components of successful organization integration models: an independent integration consultant that understands the primary organization (in this case the ACGME); structure with good communication; relationship building; socialization; increased speed of integration; and short-term results.
10-12 The content specifically addressed ACGME accreditation at both the sponsoring institution and program levels and Osteopathic Recognition through presentations and workshops.
To assess the impact of the conference on knowledge, skills, and attitudes related to understanding of the SAS and preparedness for transition, we used an unvalidated pre- and postconference survey. The pre- and postsurveys were identical and included questions regarding rating current knowledge on aspects of the transition and requirements, attitudes toward transition processes, and evaluation of resources and skills needed to meet the required transition changes.
This protocol was determined to be exempt from institutional review board review by the University of Washington Human Subjects Division.
Outputs for Collaborative Conference
Twenty-three people participated in the conference. For both pre- and postsurveys, 9 of the 13 people who responded were from AOA-only programs, and the other 4 were from programs in the Network, either ACGME or dually accredited.
Workshops and Other Efforts: Ongoing Activities
Following the success of the Collaborative Conference and the interest from everyone to continue to work together, plans were set forth for (1) supporting the AOA-only programs in their accreditation transition work, including bringing these programs into the Network, and (2) providing basic osteopathic training for ACGME programs seeking Osteopathic Recognition.
Accreditation Transition Workshops are held quarterly with AOA-only program directors, focusing on challenges and accreditation details of the transition. Consultations on the accreditation process by program are also held. Network resources are shared, including access to Network data, participation on the program director and program coordinator listservs, and access to quarterly director development sessions and business meetings, during which many tips and best practices are shared.
For programs across the Network pursuing Osteopathic Recognition, PNWU-COM, in collaboration with the Network, is leading Osteopathic Principles and Practice Workshops and advising on applications submitted to obtain recognition.
Outputs for Workshops and Other Efforts
The quarterly Accreditation Transition Workshops provide time for discussing specifics of ACGME accreditation that are different from AOA accreditation and sharing challenges and successes. From these workshops and consultations, as well as the other Network meetings and resources, the AOA-only program directors get practical solutions on how to maximize their available resources to meet these new standards, as well as actual resources, such as example Milestone evaluation form templates, that reduce the need to “reinvent the wheel.”
The Osteopathic Principles and Practice Workshop helps those less familiar with osteopathic medicine get an understanding of its foundations and learn basic manipulation techniques.
Outcomes and Their Implications
Short-Term Outcomes
Collaborative Conference
Before the conference, participants from Network programs rated themselves higher on all knowledge, attitudes, and skills/resources questions than the AOA-only program participants. Network program participants also felt more strongly that for the transition to the SAS, they had enough faculty resources and that their faculty were prepared.
The postsurvey showed improvement across all questions and categories for the AOA-only programs; it also showed improvement for the Network programs in most areas, though the improvements were less marked or consistent.
Workshops and Other Efforts
The quarterly Accreditation Transition Workshops and other ongoing efforts provide AOA-only programs a “deep dive” into the world of ACGME accreditation. Ongoing evaluations of these efforts demonstrate continued increases in knowledge of these processes and comfort with the requirements of ACGME accreditation.
Likewise, the Osteopathic Principles and Practice Workshops increase the knowledge of faculty in Network programs around precepting for and practice of osteopathic manipulation. Twelve of these workshops have been held around the region to date, with another 3 scheduled before the end of the year.
Intermediate Outcomes
Leaders in both ACGME and AOA institutions and organizations are working to develop support for current AOA-only programs to achieve ACGME accreditation by 2020.
On a local scale, the collaborative work among the Network, PNWU-COM, and all of the residency programs has put in motion the components that the literature states facilitate successful integration: developing structure with good communication and integration teams; building relationships that acknowledge value and aid in socialization; increasing the speed of integration; and achieving short-term results.
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Our work to date has demonstrated that making this connection between the regional programs, sharing knowledge about the ACGME accreditation process with AOA-only programs, and continuing to offer opportunities for consultation and support has increased preparedness for the transition. So far, all 5 AOA-only programs in the region have applied for or achieved Sponsoring Institutional Accreditation and are actively in the process of applying for ACGME accreditation.
The Osteopathic Principles and Practice Workshops have increased the ability of ACGME-accredited programs to offer osteopathic residents and others interested in osteopathic medicine more opportunities to practice osteopathic medicine. As of September 2017, 6 Network programs have received Osteopathic Recognition, another has an application pending, and several more are putting applications together.
Impact/Long-Term Outcomes
The ultimate goal of this collaboration is successful ACGME accreditation for all AOA-only family medicine programs in the WWAMI region, as well as Osteopathic Recognition for all regional programs that are interested in achieving that distinction. Our desire is to preserve as many residency education slots for the region as possible and keep more primary care physicians in the rural and underserved settings where they are most needed.
As the regional osteopathic programs work toward ACGME accreditation—and after the window for ACGME accreditation has passed—the Network will continue to collaborate with all regional programs to lend ongoing support for faculty and staff development; faculty recruitment; facilitation of program-to-program sharing of best practices, resources, and faculty expertise; peer consultations and site visits for training; access to shared regional data; and a variety of other services.
Limitations and Applicability for Other Programs
As noted in the explanation of the limitations of a logic model, any changes to resources or relationships can affect program activities and outcomes. Our overall work to date has been limited by the realities of scheduling and by leadership transitions within programs, meaning that the group with whom we have collaborated is not always the same each time. We have attempted to overcome this limitation by making our resources and services as accessible to all involved as possible.
The Network has a unique set of resources because it has historically connected regional programs, which may be a limitation of applying our work to date elsewhere. However, stand-alone programs are likewise in positions that can aid in the support of AOA-only programs as they make the accreditation transition. Every ACGME-accredited program fits the basic requirements of having knowledge of the ACGME accreditation standards and being independent of the transition process. Although the Network consists only of family medicine programs, conversations in the WWAMI region have indicated parallel needs and interests for other primary care specialties, particularly general internal medicine.
ACGME programs can help preserve local GME slots with 2 simple actions: communication and collaboration with local AOA-only programs. These actions include reaching out to begin building relationships, sharing knowledge of ACGME processes to help bring AOA-only programs up to speed more quickly, and passing along tips and insights. A recent tool published by the American Academy of Family Physicians, the “Family Medicine Residency Explorer” (
http://www.aafp.org/medical-school-residency/program-directors/explorer.html), may be useful for some programs looking for other programs in their community to connect with.
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In return, ACGME programs can receive help from the osteopathic medical community in understanding osteopathic principles and what is involved in achieving Osteopathic Recognition. Given the complexity of navigating the ACGME requirements at all levels, starting this process as soon as possible is essential for preservation of existing AOA primary care GME positions.
Future collaborative efforts are planned to include faculty and director development, financial viability of programs, models for resident training in patient-centered medical homes, evaluation and feedback systems, engagement in the ACGME Clinical Learning Environment Reviews, and other approaches to GME training.
Conclusion
Programs accredited by the ACGME are positioned to help consult, support, and learn from local AOA-only programs as they work toward meeting ACGME accreditation requirements. It is imperative that ACGME-accredited programs take on this role to help preserve current osteopathic GME slots—and therefore physician pipeline and workforce—both locally and nationally as soon as possible.
Acknowledgments
We thank Nancy Stevens, MD, MPH, for her vision, insight, and oversight of the Network's collaboration with regional AOA programs and institutions as well as leading the conference work; Celia Freeman, MBA, former Director of CME/GME, Regional Executive Director, OPTI-West Educational Consortium, for her collaboration with Dr Stevens in creating the conference; and Tiffany Hou, MSIS, for her assistance with data collection and cleaning.
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