#58 Board Member & RRC
Are you aware of the new mission, vision and values recently developed by ACGME?
Yes. I like them.
What impact, if any, does their new mission, vision, values have on you and your associates?
Tremendous impact as I’m both on the board and I see on an RRC committee.
In general, what can the ACGME do to make your life easier?
The major burden is the changing flow. The flow is at a tempo that is such that as soon as you get one thing handled another bump comes along. The faculty who are not as invested in the educational process from the standpoint of accreditation have initial resistance to new changes. There is such a tendency for status quo in the age range from 50-60 because when they were residents it wasn’t done that way.
The ACGME could be sensitive to the timing of rollouts of new projects. It needs to be solid in its communication. Most people are multi-tasking and having multiple mailings of the same thought is a good thing. Most people receive emails and pay more attention to them than paper mail.
Do we have the right appointing organizations? (To the board? To the RRCs?) Should others be appointing? Who?
I think the ones we have are reasonable.
Should the Board be composed of competencies rather than representation?
I would have a lot of fear around the repercussions from how the current appointing organizations. If we were to eliminate them, I’m sure we would have a stronger board because they bring so much politics. I suppose we could ask the organizations to provide the expertise we’re looking for. But GME needs the integration with organizations such as the AMA and the ABMS. I favor having some continued authority by organizations to which GME is beholden which are the current appointing organizations.
Do you feel similarly about the executive committee?
I’m a newcomer on that and everyone is there for very pure reasons. It is too small to fraction it up into appointing organizations. Right now people have great authority and they need to be appointed regardless of their organization. My sense is that the chair is rotated from the organizations.
What’s the optimal size for the board?
Most of them are between 12 and 20.
What if the executive committee was 12-15 people as a governing board and the larger board was an advisory one?
I don’t know. What’s the relationship between the executive committee and the full board? Right now the full board seems more like a rubber stamp. The executive committee is the working section of the board and has true input based on a sound and complete knowledge base. Another way to change things would be to get more involvement of the full board. My sense is that the full board lacks the input into decision-making that I’ve seen in other boards of this size.
Is there something that could change about the board that would more align with the mission, vision and values?
I like the idea of a competency-based board.
Who should appoint members to the RRC’s?
You need one from the ABMS and from a membership society. Right now the AMA is the weakest link to these committees. The AMA goes fishing for RRC members who have never had anything to do with the AMA before. There needs to be a fiduciary responsibility to the RRC and not to the AMA. We need to consider who needs to be at the table. The ABMS and the membership societies are slam dunks. If the AMA were a more unified voice for medicine, that would be a logical choice. We don’t want politics; we want education.
Would the RRCs benefit from an open nomination?
It depends on how it would be done. Right now, the ACGME board has next to zero knowledge about what happens in an RRC. The best knowers of who should be on the RRC are the people on the RRCs. Maybe those members should be surveyed and not the ACGME board members.
Is there anything to do to improve transparency?
I would suggest that there would be a monthly communication to all board members about what’s happening in the ACGME. This doesn’t have to be a polished document. It doesn’t work to get the agenda right before the board meeting.
What’s the right relationship between ACGME and the RRCs?
It must be one of good communication, mutual trust, cross-fertilization. ACGME board members need to go to RRC meetings.
How should the ACGME deal with consistency?
The monitoring committee is trying to address inconsistencies. This is a long term issue. Some reviews only happen at 3-5 year intervals. It’s a process that is impacted by the inevitable differences in specialties. Some specialties take the cream of the crop and others don’t and still don’t fill the number of slots. Almost by definition, there will be differences. This is a fascinating issue. There needs to be a minimum bar and then a stretch of a laudable bar with best practices. The ACGME needs to understand that there will be difference.
Should the RRCs do more collaborating between them?
The monitoring committee is the first step. It has limited time because it only meets 3 times a year. It would be good to have staff as well as other RRC members. It’s really only at the ACGME level that any differences become apparent.
We need to be very aware of the differences. Some RRCs are very political, where the ABMS director has a heavy hand at the meetings. Others RRCs are overburdened. The workload is very different. Maybe there could be a clustering of RRCs that would make sense.
How can we make sure that there is adequate representation from the RRCs in the halls of the ACGME?
The RRC council has come a long way. This has been very good and needs to be supported. Its presence should be made more evident to the board.
One thing that is regrettable is that there are some ACGME board members who fly in for the activities but don’t get a good snapshot of what’s happening in the RRC council. I don’t know if there is a logistical issue or a lack of content.
What would you say is the greatest strength of the ACGME?
They assure where doctors are trained with specialties receive a good education. The care of the public would degrade without them.
What’s the blind spot of the ACGME?
Lack of awareness of financial and political burdens on training programs today.
If you were going to send a message to the Board of ACGME, what would that be?
My institution has to beg for every penny that supports an educational program. GME Cap is a federal edict dating back decades that limit the number of training slots of every institution. If there is a desire to build up cardiology because it’s lucrative, they can take away other slots because they’ll make money. If I’m an ophthalmologist and I want 3 slots, I have to fight for this. The doctors who run this are driven by monetary factors and that doesn’t dovetail with education. Education is not a money winner for institutions at any level. When you have institutions struggling to keep the doors open, education is not going to win. Some of the ACGME mandates have been very helpful in supporting educational missions. Most look at house staff as cheap labor. I wish the ACGME would pay more attention to the financial and political burdens that educators face in a medical environment.
What would you advise to the search committee?
David has been wonderful. He gets reality. He is a superb human being. The next person is going to have huge issues to face. The AAMC has decided they want to have an increase med school class size by 20%. These people are going to need training but they’re faced with the GME cap and we have to deal with what’s going to happen to these people. Some institutions are getting creative about other funding sources, such as industries as pharmaceuticals. I’m worried that if we start going to industry-sponsored education, we’ll have a sentinel shift in the type of doctors that are turned out. This is a tremendous diminishment of professionalism that the ACGME has to pay attention to.
#59 ACGME Employee
Are you aware of the new mission, vision and values recently developed by ACGME?
Yes
What impact, if any, does their new mission, vision, values have on you and your associates?
I’m the implementer. I set fees and fee structures, so any projects that come out of the mission and vision need to be approved for that. I also handle resources in the data field. It has a great impact on what I do and what I plan for so we can accomplish what the executive committee and board approves.
In general, what can the ACGME do to make your life easier?
It would be nice if they had a better understanding of the commitment to long-term projects. Board members are on 6 year terms. The executive committee is usually less than that, usually 2 or 3, sometimes 4 years. Projects can take longer than that to evolve. GME can take years to make changes and see the impact. Sometimes they get derailed and change course in midstream, especially when different people with different agendas and allegiances to organizations come on board. It would be easier for us at the staff level to plan and budget if there was more awareness of the consequences of these changes.
Are you familiar with the governance structure and the board?Do you presently know how new members of the board of the ACGME are appointed?
Yes
Do we have the right appointing organizations? (To the board? To the RRCs?) Should others be appointing? Who?
There are opportunities missed by not being able to nominate others who are not part of the nominating organizations. I think the number of the board is too large. Boeing has 12, Abbott Labs has 10. We only need as many as we have because of the work of accreditation. I would have the council deal with that and have the 5 member organizations nominate one, other similar to what we have now, but we should have 9 at large positions. I would have a business structure, more than an academic one,
The board of directors would look at strategic, political, and financial issues, while the council decides the governing aspects. The chair could be on standing committees but doesn’t vote. They would influence one another but not be beholden to one another.
Should the Board be composed of competencies rather than representation?
Yes, but only once you’ve been on the council for several years and then get voted by your peers to the board. Right now the parents have too much influence.
I would call the executive director be the CEO and be a full voting member. One of the volunteers would be the chair. The members of the board be the chairs of the standing committees. The public members would be voting members of both the council and the board. This is to get away from being an AMA or such appointee.
I think yes, to add more diversity, maybe geographic and academic diversity as well. We right now are at the mercy of who is given to us and at times we’re top heavy on various specialties. Right now it’s pathologies. The outside world can see us being underserved. It’s easy to throw stones because our process is not very good right now. The ACGME could avoid that.
Who could decide on the RRC members?
The council members should decide if someone is not acceptable. They would be more neutral than the existing RRC.
Is there anything to do to improve transparency?
Most of the people on the staff and the board are type A personalities. The subcommittee comes to the board and asks for approval. If the board member hasn’t seen the information, then they won’t approve. They need some orientation in being a member, so they feel more comfortable in asking questions and comfortable endorsing what their peers are recommending. In this type of work, you can’t be in all things at all times.
What’s the right relationship between ACGME and the RRCs?
The RRCs are committees of the ACGME which has global standards that the RRCs must meet. The RRCs are responsible for their specialty-specific standards. There is some sense of threat that the RRC is losing their independence, but I think that is fading out with new blood.
How should the ACGME deal with consistency?
We have an old model in which the RRC created the standard and the metrics and got those approved. Now we’re starting a program to have a central group that informs the RRC of the standards. This group will decide the data that will need to be collected. If there are similar standards across many RRCs we will have the same questions. An example is that there’s a standard that they must have access to a library and we ask it in 26 different ways. We have inconsistencies in how we’re asking, not necessarily in what we’re asking. We need to make this a top priority.
Should the RRCs do more collaborating between them?
I don’t know if there’s a great need for it. We’re trying to build up the chair council. We need to make that more informative and share best practices. Let the staff help guide that.
How can we make sure that there is adequate representation from the RRCs in the halls of the ACGME?
I think they are heard, but you probably get a different opinion from them. The chair of the chairs is now on the ACGME board and I would make sure he is a voting member.
What would you say is the greatest strength of the ACGME?
We do a lot fairly inexpensively, consistently and accurately. We have a well-defined appeals process. Adverse actions are not taken lightly and are not easily accomplished. Programs have a full voice to represent themselves and give their side. We don’t arbitrarily establish standards. It gets vetted through the entire community.
What’s the blind spot of the ACGME?
The council itself doesn’t know how to handle the politics when an outside organization tries to bring its agenda through the members of the ACGME that they’ve appointed. Collegiality and politeness towards one another have caused unnecessary initiatives and discussions to occur. The full committee doesn’t know how to handle that, to quash it before it happens. The blind spot is knowing it’s there and not addressing it because of collegiality.
If you were going to send a message to the Board of ACGME, what would that be?
Reduce the size of the board to nine.
Identify the functions of the board, the accreditation council and the RRC so it’s absolutely clear what’s expected of those volunteers and members.
Create a more robust orientation and development process to ensure that as members leave and new ones come on the concepts are reinforced, all gathered around the mission, vision and values of the ACGME.
We should make it more merit based instead of a right to be on the council. We need a better understanding of the expertise of the staff. Board members are there at most 6 years. We have staff who have been there for 15 years or more. There is valuable knowledge on the part of the staff. Many board members appreciate that but some do not. There are lost ideas and potential because of that. The orientation needs to show the expertise of the staff.
Any comments for the search committee?
David’s a visionary. In trying to achieve that vision, we underneath him have identified specific projects that we’ve talked about or started to get us there, such as the outcomes project and the portfolio. They won’t be ready for prime time for at least 3 – 5 years. His leadership on the national scene has allowed for an opening for acceptance. Without him, the ideas are immediately quashed. The medical field doesn’t see education as part of the scene of medical care. David has opened the doors for people to be more amenable to potential change, even made them want to change. I will be curious if whoever replaces him will have the same abilities. I wonder if his replacement will cause people to retrench.
The staff under us might not be affected until the specific projects change. At the management level, lots will change.
I hope they find someone who is committed to the same concepts he is, such as competency-based education, outcomes analysis, data driven, learning portfolio and someone who has the same philosophy.
#60 Member Organization
Are you aware of the new mission, vision and values recently developed by ACGME?
Yes.
What impact, if any, does their new mission, vision, values have on you and your associates?
In the sense that ACGME does not rattle the chains, then there’s not too much impact.
In general, what can the ACGME do to make your life easier?