Physician Competencies for a 21st Century Health Care System

Ongoing changes in demographics and health care financing will require reforms in health care delivery. An aging population and increasing rates of chronic disease, advances in medical science, health information technology's ability to make care safer and more efficient, skyrocketing costs, and the impact of the Patient Protection and Affordable Care Act (ACA) will require a rethinking of how care is delivered. As the Institute for Healthcare Improvement put forth in 2007, improving health care delivery in the United States requires a focus on 3 areas:All care providers will need new skills and knowledge to reach this triple aim. As health care financing moves from volume-based to value-based payments, clinicians will be required to work in inter-professional teams, coordinate care across settings, utilize evidence-based practices to improve quality and patient safety, and promote greater efficiency in care delivery. The health care system will need to adapt to support these changes, and hospitals and health systems will need to acquire new competencies.In the fall of 2011, the American Hospital Association (AHA) asked its regional policy boards, governing councils, and committees to review the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties' (ABMS) competencies. Participants indicated how evident the 6 competencies were in physicians entering practice, and how important these competencies were in their organizations. They also discussed the skills physicians needed to practice and lead in a reformed health care environment and whether the ACGME/ABMS competencies appropriately represented these skills. The effort incorporated input from the AHA Board of Trustees, the Physician Leadership Forum advisory committee, an AHA Task Force, and the regional policy boards, governing councils and committees. The AHA also collected comments from numerous organizations involved in graduate and continuing medical education, accreditation and certification, including the ACGME, the ABMS, the Accreditation Council for Continuing Medical Education, the Association of American Medical Colleges, the American Medical Association, the American Osteopathic Association, and others.The survey and discussions highlighted gaps in the importance AHA members assigned to several competencies and their perceptions of the extent to which physicians entering practice evidenced these competencies (Table). Due to its importance to health care delivery and its inclusion by the Institute of Medicine in its list of competencies, AHA added informatics to the list of competencies.2Participants identified attributes important to practice in the 21st century not addressed in the ACGME/ABMS competencies. Besides informatics, these included conflict management, palliative and end-of-life care, systems theory and analysis, customer service and improving the patient experience. To work in a reformed health care environment, physicians need to develop skills to lead and facilitate care teams, understand and use systems theory and information technology to improve quality and patient safety, and understand organizational behavior. AHA governance members noted that that increased inter-professional training and practice are necessary to allow physicians and other clinicians to work more collaboratively and understand the roles each could fulfill in providing patient care. Finally, they saw the need for additional education on population health management, options for palliative care, resource management, medical economics, organizational governance, and health policy.Additional physician competencies needed for effective practice in a reformed health care system are shown in Box 1.Participants discussed initiatives in their own organizations to address some of the perceived gaps in physician education. Examples included leadership programs for physicians and administrators, multidisciplinary team training and team-based rounds, dedicated time for residents to learn administrative skills, and use of simulation labs. Additional specific examples are provided in an online supplement to this article. Other institutions have initiated changes in management including physician employment models, service line management, and use of nonphysician practitioners. Some organizations have focused on cultural changes including drafting a code of conduct for all employees reflecting some of the competencies and fostering a culture of continuous learning.The AHA policy groups provided suggestions for how to improve the impact of the competencies through environmental and process changes. They felt that the entire health care sector needed to foster a continuous learning environment. Participants recommended added professional development for faculty on how to teach and evaluate the competencies, to provide a more uniform base and ensure that residents receive similar training regardless of training site. They felt it was important to place greater weight on the nonclinical competencies. Several institutions reported success with using 360-degree feedback for residents, and with postresidency orientation to new settings of care to help close the gaps between training and real world needs. They also suggested adding requirements for medical staff appointments and reappointments linked to the competencies. Finally, members emphasized that accreditation and evaluation of residency programs should include the integration of residents into the quality and patient safety programs of the hospital.In October 2011, the AHA assembled a Task Force of physicians and other clinicians to review the results of the AHA policy discussion and recommend approaches to improve the focus and impact of the competencies. The Task Force felt that the competencies should be embraced by all providing care, but focused its work on the existing physician competencies and their broader adoption and use. It noted that, while the 6 competencies were essential to good patient care, they were not equally emphasized in physician training and practice. Task force members strongly believed that fully ingraining the competencies into the fabric of health care delivery would improve quality and the patient experience, reduce costs, and assist in coordinating care for individuals with chronic conditions.The Task Force felt that hospitals, as sites of a significant amount of physician training and practice, could be leveraged to encourage full adoption of the competencies. Members also emphasized the need for additional feedback from patients, clinical staff, hospitals, and others to shape efforts to teach and assess the competencies, and influence the educational system to ensure all viewpoints are included. Finally, the group felt that focus on the competencies should begin with admission to medical school, be emphasized in resident training, and remain a required part of continuing medical education.The task force proposed a two-pronged approach:The Task Force made several specific recommendations (Box 2). These are aggregated into undergraduate, graduate and continuing medical education, to collectively ensure the best possible groundwork is set for the development on each competency during training and practice.ACGME is working with its review committees, specialty medical organizations, and specialty boards to develop the educational milestones, specific benchmarks of skills and knowledge residents in every specialty must achieve at certain stages in their education. The milestones will offer documentation of residents' progress on the 6 competencies. While the competencies should be part of the educational system, certain skills should be emphasized earlier in training and others later. Systems-based practice and practice-based learning lend themselves to emphasis during and following residency training. As with all medical education, mastery of the core competencies is a continuous process. Completion of residency training should be considered a beginning rather than an end of education.To communicate the recommendations to the educational community, AHA members suggested that case examples from successful hospital efforts to incorporate the competencies into residency programs and continuing education should be collected, shared, and highlighted in publications for broader awareness. An appendix with specific examples is provided as a web-based addendum to this article. AHA members also suggested broad sharing within the hospital community through the national organization and state and metropolitan hospital associations. This effort is intended to stimulate thinking about how hospitals can begin to ingrain the competencies into their organizations and help support efforts to move towards greater adoption of the competencies beyond medical schools, residency programs, and practicing physicians' maintenance of competency efforts.Health care delivery in a reformed health care system will need to utilize the full professional capabilities of all members of the clinical team, practicing within their recognized disciplines, and a clear respect and understanding of the skills of the different allied health professionals. This will enhance the ability for health care delivery teams to function effectively and could be facilitated through joint education and training programs.The medical education community, accreditation and certification organizations, along with the AHA and others play a key role in improving education. Using the competencies as a common framework, this document helps stimulate dialogue on the ways the community can collaborate to advance the competencies in the health care delivery system.