2007; 29: 648–654

The ACGME outcome project: retrospective

and prospective
SUSAN R. SWING
Accreditation Council for Graduate Medical Education, Chicago, IL, USA

Abstract
Background: The Accreditation Council for Graduate Medical Education began an initiative in 1998 to improve resident
physicians’ ability to provide quality patient care and to work effectively in current and evolving healthcare delivery systems.
Aims: This initiative, called the Outcome Project, seeks changes in residency programs that focus education on the competency
domains, enhance assessment of resident performance and increase utilization of educational outcomes for improving residents’
education. Increased emphasis on educational outcome measures in accreditation is another important goal.
Results: A considerable amount of development, dissemination and educational activity has been carried out to support project
implementation. Thus far, observed effects include changes to accreditation requirements and information collection and
enhancements of the educational environments and curriculum of residency education programs.
Conclusion: Prospects for meaningful change are good. Further development of assessment methods is needed to advance
in-training evaluation of residents and the ACGME goals for utilizing performance data in accreditation and linking education and
patient care quality.

Introduction Practice points

The Accreditation Council for Graduate Medical Education . The ACGME Outcome Project has stimulated wide-
(ACGME) began its general competency and outcome spread, fundamental change in physician education.
initiative in 1998. This initiative, called the Outcome Project, . Voluntary activities of numerous medical organizations
requires that US’ graduate medical education programs foster have contributed substantially to the spread of change.
resident physicians’ development of competencies in six . Components of the general competency domains are
domains and collect performance data that reliably and closely aligned with health care quality aims.
accurately depicts residents’ ability to care for patients and . Further enhancement of performance assessment meth-
to work effectively in healthcare delivery systems. This odologies is required to attain Outcome Project goals
approach assumes that quality patient care results when and to measure effects.
residents acquire and apply competencies effectively.
Changing accreditation is another important goal of
this project. Eventually, the ACGME wants its accreditation Initial steps: the general
committees, the Residency Review Committees, to take into
competencies and accreditation
account residency programs’ educational outcomes when
making accreditation decisions instead of relying solely on
requirements
programs’ descriptions of their resources and educational The ACGME and American Board of Medical Specialties
policies and processes. Aggregate resident performance data (ABMS) jointly identified six domains of general competencies;
that illustrates progressive improvement in teamwork, for they are patient care, medical knowledge, practice-based
example, is one way that educational outcome data might be learning and improvement, interpersonal and communication
used. skills, professionalism and systems-based practice.
Many graduate medical educators responded immediately The General Competencies are the cornerstone of the
to the Outcome Project with enhancements to their Outcome Project. Table 1 displays the six general competency
educational programs. Achievement of widespread substantive domains and their current and proposed components
change continues as a challenge still to be accomplished. (Accreditation Council for Graduate Medical Education 1999).
Activities undertaken to support accomplishment of Outcome The competencies were the product of a multi-step
Project goals and advances observed thus far are described systematic development process. First, a list of competencies
in this paper. was compiled from the literature and organized into

Correspondence: Susan R. Swing, PhD, ACGME, 515 N. State Street, Ste 2000, Chicago, IL 60610, USA. Tel: 312-755-7447; fax: 312 755-7498;
email: srs@acgme.org

648 ISSN 0142–159X print/ISSN 1466–187X online/07/070648–7 ß 2007 Informa UK Ltd.

DOI: 10.1080/01421590701392903
 The ACGME outcome project: retrospective and prospective

Table 1. ACGME General Competency domains and constituent components.a

Patient care
. communicate effectively; demonstrate caring and respectful behavior,
. gather essential and accurate information,
. make informed decisions about diagnostic and therapeutic interventions,
. develop and carry out patient managment plans,
. perform competently medical and invasive procedures,
. provide patient counseling and education,
. use technology,
. provide preventive and health maintenance services, and
. working with other care providers to provide patient-focused care.
Medical knowledgea
. obtain biomedical, clinical, social-behavioral and epidemiological knowledge, and
. demonstrate investigatory and analytic thinking.
Practice-based learning and improvement
. identify strengths, deficiencies and limits in one’s knowledge and experience,d
. set learning and improvement goals,d
. identify and perform appropriate learning activities,d
. incorporate formative evaluative feedback into daily practice,d
. systematically analyse practice and implement changes to improve practice,
. appraise and use scientific evidence,
. use technology to optimize learning, and
. participate in the education of patients, famililes and other health professionals.
Inter-personal and communication skills
. create and sustain a therapeutic, ethical relationships with patients,b
. communicate effectively using listening, verbal, non-verbal, questioning, explanatory and writing skills,b
. communicate effectively with patients, families and the public,c
. communicate effectively with physicians, other health professionals and health-related agencies,d
. work with other care providers as a team leader or member,
. act in a consultative role to other physicians, health-related agencies and policy-makers,c and
. maintain medical records.d
Professionalism
. demonstrate respect, compassion and integrity,
. demonstrate responsiveness to patient needs that supercedes self-interest,
. demonstrate accountability to patients, society and the profession,
. demonstrate excellence and on-going professional development,d
. demonstrate adherence to ethical principles,
. demonstrate sensitivity and responsiveness to diverse patient population, and
. demonstrate respect for patient privacy and automony.c
Systems-based practice
. understand how one’s actions affect and are affected by the larger system,b
. work in various healthcare delivery or public health settings,b
. coordinate patient care,d
. incorporate cost awareness and risk-benefit analysis,c
. advocate for quality patient care and optimal health care or public health systems,c
. work in inter-professional teams to enhance quality and safety,d and
. participate in identifying system errors.d

a
Table includes competency components from the 1999 approved language and 2007 proposed General Competency
language in the ACGME Common Program Requirements. bThis component is not included in the proposed 2007
language. cThis component is included in the proposed 2007 language and is a modification of the 1999 language.
d
This component is new and in the proposed 2007 language.

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S. R. Swing

13 domains. Domain experts provided feedback. A focus domains, their methods for assessing residents’ learning and
group of program directors provided feedback on the revised performance and changes they recently implemented to
competency list. Then residents, RRC members and members improve teaching and assessment. Early on a process was
of the ACGME’s Institutional Review Committee rated and put in place so ACGME field staff could verify that the
ranked the proposed competency domains and components implementation processes the programs reported were being
on: (a) how important it is as an element of future physicians’ carried out. Data collection and verification began in mid-2002.
competence; and (b) how important it is for resident All these processes will be revised in 2007.
physicians to engage in learning activities in the area. During 2000 and 2001, Residency Review Committee Chairs
External stakeholders appraised the competencies during or selected members of the committees participated in small
structured interviews. The ACGME’s Outcome Project group activities organized by the ACGME and ABMS to further
Advisory Group synthesized and discussed the information develop and adapt competency definitions to their individual
that had been collected. The product of their deliberations was specialties and to identify assessment approaches. A repre-
a set of six competency domains. Follow-up work entailed sentative from each specialty’s certification board and program
reconfiguring the components of the retained domains into the director organization and a resident from the specialty also
six categories. Further changes were made as the ACGME and participated in the initial two meetings and follow-up activities.
ABMS reconciled their organization’s competency domains In 2005, similarly constituted groups were convened to discuss
and constituent components. assessment approaches that could apply to both resident
Next, the Advisory Group drafted a version of the general and practicing physicians and be used for in-training
competencies for inclusion in accreditation program require- assessment, certification and maintenance of certification.
ments. This version provided a general description of each A workgroup of RRC members contributed by identifying
competency domain. Later on, residency RRCs, specialty a starter set of assessment methods for three of the
organizations, program directors and others would be invited competency domains. (Accreditation Council for Graduate
to shape competency language to fit their specialties and local Medical Education 2002). Their suggestions were based on
contexts. The ACGME adopted the competency domains and literature reviews conducted by ACGME staff. More recently,
their components and the program requirement version of the RRC members participated in a development course to
general competencies in September 1999. Accreditation facilitate their evaluations of the adequacy of program
requirements that instructed programs to develop specific implementation of general competency and outcome assess-
learning objectives for the competencies, offer education in the ment requirements. Periodically, through-out the development
competencies and assess residents’ learning and performance process, educational sessions and updates on implementation
also were adopted at this time. The ACGME’s approval of the progress have been provided to ACGME staff, including field
requirements effectively lauched the Outcome Project. A flurry staff, and RRC Chairs.
of activity immediately ensued as graduate medical educators The roll-out of the general competencies and accreditation
endeavored to understand the implications of the require- requirements stimulated interest, confusion and many requests
ments and to put into place requisite instructional and from resident educators. They asked for further explanation
assessment methods. of the practical meaning of the competencies, the Outcome
The ACGME developed a four-phase timeline that provided Project rationale, criteria for successful implementation
for gradual implementation of learning opportunites, assess- and concrete illustrations of ways to foster learning and
ment and use of data for improvement across 15 years. assess resident capabilities in the six domains. The requests
(Accreditation Council for Graduate Medical Education 2001) made clear that GME educators needed assistance in:
Current and future implementation expectations for residency writing goals and objectives, identifying and developing
programs are: (1) full integration of the competencies into the appropriate learning activities, identifying and developing
curriculum as evidenced by robust learning opportunities and good assessment approaches, identifying performance
assessment (Phase 2); (2) use of aggregate performance data standards and aligning learning activities and assessment.
to assess residency program effectiveness and to identify The ACGME and its collaborative partners undertook
improvements needed (Phase 2); and (3) linkage of education a multi-faceted educational approach to enhance understand-
and patient care quality using external measures such as ing of and engagement in the initiative. ACGME staff delivered
patient care process and outcome indicators and patient over 200 Outcome Project updates and presentations to
questionnaires (Phase 3). program director groups, national medical organizations and
others in response to requests. Staff facilitated workshops at
On-going development and multi-institutional gatherings of graduate medical education
faculty to build practical knowledge for application to
implementation curriculum development. Annually from 2001–2006, the
Integration of the Outcome Project into the accreditation ACGME and Institute of Healthcare Improvement sponsored
process began with development of accreditation require- an invitational workshop on Practice-Based Learning and
ments. Another implementation step entailed development of Improvement and one other competency domain. The aim
an information reporting form for residency programs. This was to develop a well informed cohort of committed educators
form, which has enabled electronic data collection, asks and advocates.
programs to report the instructional activities they offer to The Outcome Project has provided enhanced opportunities
facilitate residents’ development of capabilities in the six for GME educators to participate in the education of their
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 The ACGME outcome project: retrospective and prospective

colleagues. Presentations of ‘examples from the field’ as well . The Council of Residency Directors in Emergency Medicine
as poster presentations have become regular events at the and the American Board of Psychiatry and Neurology
ACGME’s expanded annual educational conference. GME identified learning objectives, instructional activities and
educators also have been invited to present posters at annuals assessment techniques for the six competency domains and
meetings on the competencies co-sponsored by the ACGME published their work (Academic Emergency Medicine 2002;
and ABMS. Special Outcome Project issues of the ACGME Scheiber et al. 2003);
Bulletin have featured articles by GME educators. The ACGME . The American Board of Internal Medicine (2004) and
website, introduced in 2002, invites and displays examples Council of Resident Education in Obstetrics and
from the field in which GME educators and institutional Gynecology (2003) developed assessment tools for use by
officials describe practices implemented as learning residency programs;
opportunities for residents, assessments of residents or faculty . The American Board of Family Medicine (2006) developed
development. It also houses a variety of implementation an electronic portfolio that stores and maintains
and educational resources, including assessment tools, resident performance information including evaluations
educational resource booklets, references to scholarly articles and competencies met; and
and presentations with facilitator guides. . The American College of Surgeons (2003) has a task force to
lead development and implementation efforts for four of the
six competency domains.
Implementation progress and
accomplishments
At this stage in the implementation process, residency Changes in resident learning opportunities and
programs are expected to have in place competency-related assessment
learning objectives, learning opportunities for residents in each As part of their reporting requirements for their accreditation
of the six domains and methods for assessing residents’ review, residency programs describe how they are teaching
capabilities in the six domains. An evaluation is underway to and assessing the competencies and report changes they have
determine the extent to which these expectations have been made to improve residents’ learning opportunities. Information
met. Accomplishments of the Outcome Project, however, are collected between 2002 and 2006 curently are being analysed.
best viewed through a wider lens that captures the range of Trends observed thus far are presented below.
multi-faceted effects of this national level educational change Residency programs are:
initiative. A sample of effects observed thus far is described
below. This information is derived from tacit knowledge, . revising and expanding learning objectives to reflect the
informal surveys, literature searches and inspection of the competencies;
ACGME database of educational practices. . adding learning opportunities for the competencies, most
often in the form of new department lectures or confer-
ences; individual or group projects; or lecture, discussion or
Adoption of the General Competencies framework conference series offered by the institution;
. enhancing performance feedback, in particular by including
The General Competencies have become the common multi-source feedback and direct observation; and
language for defining physician competence and the organizing . engaging faculty in development sessions in order to
principles for education of physicians in training. The graduate enhance their understanding of the competencies and to
and continuing medical accrediting, certifying and licensure increase their skill in evaluating resident performance and
bodies in the US have all adopted the General Competency providing substantive feedback.
domains. These organizations oversee the quality of education
and performance of resident and practicing physicians. Numerous programs reported the addition of lectures or
conferences to augment residents’ knowledge of specialty-
specific issues. Enhancements in learning opportunities in
Widespread engagement of the medical education other competency areas are more likely to be provided
community through core curriculum lecture series or computer modules
developed by the institution and offered to residency
Numerous program director organizations, specialty colleges,
programs in all specialties. These activities are focused on
societies or academies and specialty certification boards
inter-personal and communication skills, professionalism and
have engaged in activities to support teaching and assessment
systems-based practice.
of the General Competencies. Thus, the Outcome Project can
Resident engagement in quality improvement projects and
be credited with increasing and focusing the educational
evidence-based medicine activities are frequently reported
development activities of a large number of professional
new additions to the curriculum. The programs report quality
medical organizations. A sample of the activities and products
improvement projects that entail some or all of the following:
are cited below:
resident examination of their own patient care using process
. The American Academy of Allergy and Immunology (2002) and outcome data; literature searches to locate strategies for
has a website of resources for teaching and assessing the improving care; and implementation of the strategies.
competencies; Residents also search the literature for answers to clinical
651
S. R. Swing

questions about their patients and facilitate the learning of their Looking forward: linking patient
patient care team by reporting on their findings. care quality and education in the
A large and increasing number of programs are augmenting
general competencies
their assessment of residents by engaging nurses, resident
peers, patients, office staff, therapists, technicians or others in From the beginning, resident educators have challenged the
performance evaluation of residents. In many of the programs, ACGME to provide evidence that teaching and assessing the
these multi-source evaluations focus on residents’ inter- competencies (a) will result in better prepared new physicians
personal and communication skills and professionalism. and better patient care or (b) has resulted in better new
More programs are beginning to directly observe residents’ physicians and better patient care. Evidence for the potential
clinical performance, concurrently assess it and provide feed- of the Outcome Project to have positive effects currently exists.
back. The American Board of Internal Medicine’s Mini-CEX or Some of this evidence, which shows that competency
derivations of this method are commonly reported approaches. components in communication and practice-based learning
Increases in the frequency of resident evaluation are also being (i.e. evidence-based medicine, critical appraisal and quality
reported. improvement) can be improved through education, has been
reviewed elsewhere (Swing 2004). There is also support
for the current relevance of numerous competency compo-
nents. As shown in Table 2, many of the General Competency
Changes to the learning environment
components are the same as those associated with attainment
Enhancements to instructional methods and assessment are of the healthcare quality aims the Institute of Medicine (2001)
one type of change to the learning environment. Other presented in its report ‘Crossing the Quality Chasm’ as
changes have been reported in response to informal polling healthcare improvement priorities.
that asks participants to report effects of the Outcome Project. Furthermore, there is evidence that links constituent
Among the reported effects are: components or sets of components of the aims to desired
outcomes and patient perceptions of care quality. For instance,
. greater involvement in GME by institutional officials and
use of technology, such as physician order entry systems that
institutional Graduate Medical Education Committees;
include medication dosing and selection guidelines improved
. increased engagement of faculty in education and more
paitent safety, in particular prescribing and reducing falls
faculty development in education;
among the elderly (Agency for Healthcare Research & Quality
. increased resources for GME (simulation centers,
2005). Patient-centered communication creates trust, which
professional educators and support personnel, electronic
in turn is related to patients’ disclosure of information
evaluation systems);
(Berrios-Rivera et al. 2006); adherence to medication
. increased discussion and thinking about educational issues
(Schneider et al. 2004; Piette et al. 2005); and willingness to
and the educational process;
seek care (Owlsley et al. 2006). Effective communication
. broader perspective on what constitutes a ‘competent
and teamwork are associated with safe care (Shapiro 2004;
physician’; increased focus on professionalism, systems
Sutcliffe 2004) and efficient care (Overdyk et al. 1998;
issues, safety and communication; and
Friedman & Berger 2004). Thus, by extension, there is
. more substantive performance feedback to residents.
reason to believe that residents’ acquisition of knowledge
and skills associated with the General Competencies prepares
them to address important healthcare aims and to improve
patient care quality.
Changes to accreditation Obtaining evidence that links competency-related educa-
tional activities, improvements in resident performance and
Changes to the accreditation process were described better patient care will be challenging. Among the development
previously under development and implementation. These and implementation steps needed to gather requisite evidence
changes include program requirements that describe the are: (1) identification or development of assessment tools that
competencies residents are expected to demonstrate prior to are accurate, reliable and sensitive to change; (2) assessment
graduation and processes for evaluating residents’ learning of resident performance before competency-based education
and performance; data collection forms for programs to use and again afterwards; (3) centralized compilation of the
for reporting their teaching/learning and assessment performance data, along with information on competency-
activities; and a site visit review process for verification of based education or decentralized compilation of data from
information programs provide about their implementation numerous large sub-sets of programs; and (4) analyses
activities. that examine the relationship of education and resident
At the current time, accreditation reviews of program performance.
implementation largely are calibrated to ensure that programs Linking patient care quality and education in the compe-
are attending to the competencies and exhibiting implementa- tencies is the goal of Phase 3 of the Outcome Project.
tion progress. Consistent with the implementation timeline, the Assessment and analyses, in addition to that described above,
focus of accreditation is still on the processes of teaching and will be required to establish that patient care is better in
assessing the competencies and does not yet include residency programs that have effective education in the
consideration of programs’ educational outcomes. competencies. These additional measurement activities
652
 The ACGME outcome project: retrospective and prospective

Table 2. Currrent healthcare priorities and related general competency components.

Priority General Competency component

Safe care . Monitoring of care/practice analysis,

. Use of evidence-based guidelines,

. Coordination of care,

. Use of technology, and

. Communication and team work (Gaba 2000; Shapiro 2004; Sutcliffe 2004;
Agency for Healthcare Research and Quality 2005; Kralewski et al. 2005).

Equitable care . Monitoring of care; practice analysis by patients’ race, ethnicity, age, etc.,

. Use of evidence-based guidelines,

. Knowledge of sociocultural influences on patients’ health beliefs and behaviors,

. Awareness of the impact of race, ethnicity and culture on clinical decision-making,

. Ability to understand and communicate with patients’ from diverse backgrounds, and

. Provision of care via multi-disciplinary treatment and preventive care teams (Betancourt 2006).
. Evidence-based decision-making (Stewart et al. 1999;
Effective care Institute of Medicine 2001; Schneider et al. 2004).

Efficient care . Performance monitoring analysis; use of benchmarks, and

. Communication and teamwork (Overdyk et al. 1998; Friedman & Berger 2004).

Patient-centered care . Respect patients’ values, preferences and expressed needs,

. Ensure physical comfort and provide emotional support,

. Provide the information, communication and education that people need and want,
. Encourage and legitimize patient’s participation in care decisions;
involve the patients’ family and friends in their care, and
. Coordinate and integrate care across boundaries of the system
(Gerteis et al. 1993; Schneider et al. 2004; Haidet et al. 2005; Piette et al. 2005;
Berrios-Rivera et al. 2006; Owlsley et al. 2006).

Coordination of care;
chronic care/disease management . Use of proper diagnostic and treatment methods,

. Application of clinical protocols and agreed on standards of care,

. Work within a multi-disciplinary team structure that also
includes patients, families and community resources,

. Teamwork skills; team building and leadership skills,

. Use of technology,

. On-going monitoring of patient status, and

. Timely communication (Wagner et al. 1996; Sidorov et al. 2002;
Corbett et al. 2005; Kralewski et al. 2005; Dorr et al. 2006; Wise et al. 2006).

present a new set of challenges. Measurement of patient care and a framework for thinking about and organizing graduate
quality, in particular using clinical process and outcome medical education. The competencies have expanded beliefs
measures, is still in its infancy. Assessing care quality using about what it means to be a competent physician. Many
patient care process measures associated with desired out- residency programs have made changes in their curriculum to
comes has some advantages, but, to-date, a relatively small better foster residents’ development in the competencies and
number of validated process measures exist. Collecting, to better assess their learning and performance. Much
cleaning and compiling the process data that do exist is time additional educational development and implementation will
intensive and expensive. Furthermore, special models and be needed, however, in order to achieve widespread change
measurement approaches will be needed that isolate resident and improvement. Elements of the accreditation process have
contributions to care quality from those of other providers and changed to increase emphasis on the competencies and
from system effects (Swing et al. in press). assessment of residents. However, increased emphasis on the
use of outcome data in accreditation has not occurred yet.
Further development and implementation of assessment tools
Summary and conclusions and electronic data collection systems will be needed before
The Outcome Project has effected medical education in the this change can occur and before effects of competency-based
US. The General Competencies serve as a common language education on resident performance can be evaluated.
653
S. R. Swing

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Emergency Department: Improving outcomes for older patients. Aust
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