From Chrysalis to Taking Flight, the Metamorphosis of the ACGME During Dr Thomas Nasca’s Tenure as CEO

Thomas J. Nasca, MD, MACP, concludes his 17-year tenure as the President and CEO of the Accreditation Council for Graduate Medical Education (ACGME) at the end of 2024. He led and supported substantial changes in accreditation and medical education, and no single article can give justice to all of them. This article will review some of the key changes and themes that occurred during 3 important phases: the development years leading to the Next Accreditation System (NAS), implementation of the NAS, and the impact of the COVID-19 pandemic. The objectives of this article are to: (1) Review some of the key changes that occurred during each phase; (2) Describe some of the essential themes and philosophy undergirding these phases; and (3) Reflect on critical issues currently facing accreditation and medical education.

The ACGME Outcome Project, formally launched in 2001, was a groundbreaking initiative that sought to shift the focus of GME from an overreliance on structure and process-based educational design, which relies heavily on proxy measures to judge competence (eg, examinations), to outcome-based education, in which the competencies (ie, abilities) of graduating residents and fellows are the primary goal of GME.^1,2  The ACGME, in collaboration with the American Board of Medical Specialties (ABMS), introduced the 6 general competency framework: patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.¹  The ACGME worked to support this initiative through several activities designed to promote innovation, such as the Educational Innovation Project in internal medicine, which ultimately served as the pilot for the NAS, and the Quadrad meeting, which brought key regulators and membership organizations together to support implementation of the 6 competencies.^3-5 

Despite the promising vision of the Outcome Project and some early successes, several challenges emerged. First, efforts to streamline program requirements proved difficult given that a review committee’s traditional and primary focus was on assurance policies and measures to enforce accreditation standards. Second, training programs and stakeholders struggled to balance retooling educational programs with regulatory demands. Third, GME programs encountered practical difficulties in integrating the 6 Core Competencies into their curricula and assessment methods, especially the newer competencies of Systems-Based Practice and Practice-Based Learning and Improvement.^6,7  Finally, the controversy surrounding resident duty hours culminated in an Institute of Medicine (now the National Academy of Medicine [NAM]) 2008 study that was highly critical of duty hour rules and that highlighted concerns about resident fatigue, patient safety, and educational outcomes.⁸  Furthermore, the inclusion of physician competencies in the US House of Representatives version of the Healthcare Reform Act reflected a lack of confidence in the ACGME’s ability to regulate duty hours effectively. Although these provisions did not make the final version of the act, they underscored the ongoing debate about the role of duty hours in medical education. These developments formed the context of the early years of Dr Nasca’s tenure.

Dr Nasca assumed the helm against this background of both early progress and continued challenges. This period was marked by significant changes in the ACGME’s approach to accreditation, which focused on enhancing the quality of GME through evidence-based policies and innovative frameworks. The duty hours issue required urgent attention and led to the Duty Hours Congress that brought together key stakeholders to address this contentious issue. This collaborative effort generated a reasonable compromise between maintaining the quality of resident education, safeguarding resident well-being, and working to ensure that patients receive high-quality and safe care through appropriate supervision.⁹  The duty hours efforts would subsequently catalyze 2 major national randomized controlled trials of approaches to the standard 80 duty hours per week in general surgery and internal medicine. While models of less than 80 hours per week were not studied, this body of research marked an important philosophical shift in how essential accreditation polices can and should be informed by research and evidence, and not just the consensus opinion of experts.^10,11 

The development of the NAS was a pivotal moment in the evolution of accreditation in medical education. Laying out the rationale in a landmark article in 2012, the NAS represented a major shift toward continuous accreditation based on outcomes, longitudinal performance metrics, and continuous improvement.^12,13  The NAS, for the first time, added 2 components focused on continuous improvement instead of just minimal assurance standards: Competency Milestones and the Clinical Learning Environment Review (CLER) program.^14,15 

In 2007 the Milestones initiative was catalyzed by an exploratory internal medicine educational community meeting, which culminated in a first set of Milestones published in 2009, along with pilots and efforts in other specialties.^15-17  The CLER program, catalyzed by a seminal article highlighting the critical role of the learning environment in shaping educational outcomes and graduate abilities, was also planned and introduced as a second critical improvement component.^18-20  The NAS recognized the importance of nested and interdependent relationships that impact both educational and health care outcomes. The Figure displays how the NAS has evolved to combine assurance and improvement components and their interactions across the nested relationships of learners in programs embedded within institutions. This new accreditation model next evolved over 2 critical periods: the initial implementation phase from 2012 to 2020, and the COVID-19 pandemic period from 2020 to 2023.

The period from 2012 to 2020 saw the implementation of multiple key initiatives that transformed the landscape of GME. During this time, the NAS was fully implemented and rebalanced the focus of accreditation from mostly structure and process requirements to a combined focus with continuous quality improvement and educational outcomes. The NAS allowed for continuous monitoring (assurance) and improvement of residency programs based on increasing access to data and performance metrics (Figure).²¹  During this time, review committees sought to reduce the number of program requirements, spur innovation through the Advancing Innovation in Residency Education (AIRE) program, and begin the journey to incorporate more competency-based medical education (CBME) principles.^12,21,22  One of the more important events during this time was the implementation of the Single Accreditation System (SAS).^23,24 

Until 2014, the allopathic and osteopathic GME communities had operated under separate accrediting organizations and processes. As Nasca and colleagues noted in a recent article, there were 2 main drivers to pursue a single, unified system of accreditation.²⁵  First, there was a growing imbalance between the output of undergraduate osteopathic medical education and the capacity of American Osteopathic Association (AOA)–approved GME programs. Second, the ACGME was working to establish the first systematic national system of CBME through the implementation of the Milestone Project. The latter driver also connected to both the ACGME’s and AOA’s desire to best serve the public and create harmonized standards for GME training. One cannot overstate the importance of shared standards to improve the training for all residents and fellows. The SAS was fully realized in 2020. It is noteworthy that Karen Nichols, DO, a leader within the osteopathic community, served recently as chair of the ACGME Board of Directors. The SAS can be seen through the lens of the proverb, “If you want to go fast, go alone; if you want to go far, go together.” The collaboration and collectivism represented by the SAS initiative, driven by shared values, represents an important inflection point for medical education in the United States.

Early in Dr Nasca’s tenure, countries approached the ACGME about obtaining accreditation as a mechanism to improve the quality of their medical education systems. In 2009, Singapore became one of the first countries to seek accreditation. Singapore became a pilot program and the catalyst to create ACGME International (ACGME-I).²⁶  Multiple countries have now sought and achieved ACGME-I accreditation, which integrates key NAS principles and components (eg, Milestones) into ACGME-I requirements and policies.²⁷  The primary philosophy of ACGME-I is to help countries and international institutions use the levers and tools of accreditation to improve the quality of education within the local context, while always remaining cognizant of local cultural perspectives and needs. ACGME-I has its own set of requirements and board of directors.

The CLER program was launched to provide rich data and formative feedback to institutions to improve their learning environments.¹⁴  This initiative aimed to enhance the quality of resident education by encouraging institutional leaders to enhance areas such as patient safety, professionalism, and interprofessional teamwork through the interdependent relationships of training programs embedded within the institution (Figure).²⁸  The initial design of the CLER program involved in-person site visits by an evaluation team. The team used a multipronged approach to explore different key areas (called Pathways in the CLER guidance document)¹⁴  at the institutional level. The ensuing CLER report was primarily designed to help C-suite leadership use the findings to improve institutional level activities of the CLER Pathways to Excellence, support their GME programs, and improve patient care.^29-32 

The CLER initiative also launched several targeted projects to further catalyze improvement. One such project was the Pursuing Excellence in Clinical Learning Environments Initiative where the ACGME provided institutional seed grants that supported teams of institutional executives and their GME leaders to address critical quality and safety issues.³³  The results of Pursuing Excellence were published in 2020.³⁴  Faculty development for the Program Directors Patient Safety and Quality (PDPQ) Educators Network uses the innovative Project Echo model to deliver longitudinal faculty training in quality improvement and patient safety.³⁵  This ongoing effort involves specialty program director organizations to up-skill faculty in implementing, teaching, and assessing quality improvement and patient safety.

Milestones are designed to be primarily formative, to assist in judgments and graduation decisions for each resident and fellow. Seven specialties implemented Milestones in July 2013, with almost all specialties using Milestones by 2020.^15,36  For the first time, Milestones provided a narrative-based, developmental rubric for curriculum and assessment in support of CBME.³⁷  The Milestones were also essential to support the new NAS requirement that Clinical Competency Committees (CCCs) judge the developmental progress of residents and fellows at least every 6 months. CCCs use the Milestones to assess the progress of residents and fellows and provide individualized learning plans for trainees.³⁸  Milestones also created a national data set, grounded mostly in work-based assessments, that provides useful data for local and national improvement efforts and outcomes-based medical education research.

Thanks to the efforts of all residency and fellowship programs manually entering data every 6 months, the ACGME receives Milestone data on every resident and fellow in GME. This data has enabled the rapid development of validity and outcomes-based research that is beginning to provide increasingly robust data that can be used by training programs for their improvement efforts. Multiple studies have found initial validity evidence for the Milestones process.^39-43  Perhaps more important, studies examining the relationship between Milestone judgements and early clinical practice are providing early insights into the effectiveness of Milestones and what sources of data (eg, registries versus claims data) show the most promise for outcomes-based studies.^44-47 

Along with others, Dr Nasca recognized that simply promulgating changes in requirements, along with new educational approaches and frameworks as an accreditation body, was insufficient to realize true improvement in outcomes. During this period the ACGME took on the role of convener to bring key leaders and organizations together to confront and address crucial issues facing medicine and medical education. One notable initiative, catalyzed by the ACGME, was fostering a national dialogue on physician suicide and the larger, thorny topic of clinician and resident well-being. The ACGME partnered with the Association of American Medical Colleges (AAMC) and the NAM to launch the Action Collaborative on Clinician Well-Being and Resilience.^48,49  The ACGME also created a toolkit, including guidance on what to do after a tragic suicide, and the Aware wellness app to support training programs in their wellness efforts.⁵⁰  In addition, the ACGME expanded and evolved important educational and wellness resources.⁵⁰  The Box provides more examples of critical meetings hosted by the ACGME.

In 2009, under the tenure and leadership of Dr Nasca, the original ACGME Bulletin was converted by Ingrid Philibert, PhD, MA, MBA, to the Journal of Graduate Medical Education (JGME) to promote a culture of scholarly inquiry and innovation in GME and create a venue for evidence-based GME research. JGME, now open access, became the first peer-reviewed journal focused solely on GME. JGME has grown substantially in reach and impact and has provided a platform for disseminating GME research and best practices.^51,52  The journal has also produced important supplements, such as on Milestones 2.0 with articles on assessment, key concepts, and challenging competencies; international GME; and climate change and GME.^53-55 

In 1996 I attended my first ACGME Annual Educational Conference as the Training Officer for a naval internal medicine training program, in preparation for an upcoming site visit. I spent a day with my colleague Richard Hawkins, MD, (now president of ABMS), learning what and what not to do for accreditation. Fast forward almost 30 years to where the conference now welcomes over 4000 participants each year and offers plenaries on key topics (eg, wellness, artificial intelligence, quality improvement and patient safety), professional development, networking, and collaboration opportunities among GME stakeholders. The conference also includes pre-courses for program coordinators, osteopathic training programs, and outcomes research.⁵⁶ 

Recognizing the ongoing persistent, pernicious problems of bias and racism, Dr Nasca and the ACGME Board of Directors launched a task force to explore the issues of bias and racism. The task force led to the establishment of the ACGME Department of Diversity, Equity, and Inclusion (DEI).⁵⁷  This department underscores the ACGME’s commitment to fostering a diverse and inclusive learning environment across all sponsoring institutions and training programs. One of the educational products developed under the guidance of Bonnie Mason, MD, is the Equity Matters Toolkit.⁵⁸  The multicomponent toolkit is a wonderful resource that can be used across the entire medical education continuum. Over this period the ACGME Board of Directors also became more diverse, to reflect the organization’s commitment to DEI at the highest governance levels. Finally, the ACGME is partnering with others on the development of a DEI textbook.

With the launch of the Milestones, there was a clear need to provide resources to support implementation. The ACGME created multiple guidebooks, which are routinely updated, for Milestones, CCCs, and an Assessment Toolkit.^38,39,59  All Milestones 2.0 come with a specialty-specific supplemental guide, produced by the Milestones writing groups, which provides examples for every subcompetency at each Milestone level. More recently the ACGME has produced a toolkit for faculty development on direct observation and working with struggling learners.^60,61 

The COVID-19 pandemic was a horrific event that resulted in the estimated deaths of over 20 million people worldwide between January 2020 and August 2022. Over one million died in the United States alone.⁶²  This period was marked by the incredible professionalism of the health care workforce, including medical students, residents, and fellows. The ACGME navigated its dual role as both a facilitator and a regulator during the pandemic, through balancing the need for flexibility with the imperative to maintain educational standards.^63-65 

Building on its convener role, the CLER department began holding regular national calls for designated institutional officials ([DIOs], individuals responsible for GME within a sponsoring institution) to provide updates and answer questions. This effort resulted in a new National Organization of DIOs.⁶⁶  ACGME staff also held virtual focus group sessions with residents from specialties most directly affected (eg, emergency medicine). The ACGME partnered with the AAMC, AOA, and Intealth to create transition toolkits for medical students starting residency, residents starting fellowship, and residents and fellows starting clinical practice.⁶⁷  The ACGME’s assessment course became completely virtual, with different models offered and tried. The ABMS and ACGME coproduced guidance for programs regarding assessment to determine readiness for graduation, as the usual proxies of competence, such as specific rotations or procedures completed, were not available during the COVID-19 pandemic.^68,69  All of these reactive yet necessary activities highlight the urgent need to accelerate the adoption and implementation of CBME. Regrettably, progress on CBME adoption within medical education regulation remains slow.

The Table summarizes some of the key leadership themes of Dr Nasca’s tenure, marked by major and meaningful changes. Looking ahead, the ACGME is poised to continue its evolution in an increasingly digitized and uncertain world. Despite the highly effective changes led by Dr Nasca and the ACGME, the next President and CEO of the ACGME will inherit ongoing and new challenges in medical education and professional self-regulation. First, regulatory bodies like the ACGME and others must more quickly adapt to advances in information technology, accelerating digital capabilities, and artificial intelligence. Most regulatory organizations are behind in needed digital transformation. The ACGME is currently on this journey and will need to leverage digital technologies to enhance the efficiency and effectiveness of GME accreditation, and substantially reduce the burden on training programs.

Second, the ACGME will need to remain responsive to the evolving health care landscape, to ensure that accreditation standards and educational practices continue to meet the needs of patients, trainees, and the broader health care system. The gap between the pace of change in health care practice and delivery and its educational counterparts is widening.

Third, the ACGME’s use of scenario planning as part of its strategic thinking and planning has served the ACGME well to this point. However, the results of the recent elections, recent state legislative actions, and Supreme Court decisions will likely require all regulatory organizations to be continually flexible, nimble, and responsive.

Finally, the ACGME should build on its initial efforts in innovation by working with its regulatory partners to accelerate the adoption of outcomes-based education and innovative models of medical education. By nature, professional regulation tends to be conservative and cautious, which may create inertia and contribute to the worrisome gaps between changes occurring in health care practice and delivery, and medical education design and practices. The COVID-19 pandemic exposed this problem and should be a wake-up call, even 4 years since 2020, to transform medical education across the continuum. The ACGME’s embrace of a continuous quality improvement component for accreditation can serve as a model for other regulatory organizations involved in medicine and medical education.

In conclusion, the period from 2007 to 2024 has been marked by significant thematic changes in the ACGME’s approach to regulating GME. Through a focus on evidence-based policies, a balanced approach to assurance and improvement in accreditation, appropriate facilitation, collaboration, and a commitment to DEI, the ACGME has positioned itself as an innovative leader in promoting the quality and effectiveness of GME.

The author would like to thank Dr Susan Day and Mr John Duval for their insights and wisdom.

Disclaimer: Eric S. Holmboe, MD, was employed by the Accreditation Council for Graduate Medical Education from 2014 to 2023. He also receives royalties for a textbook on assessment from Elsevier publishing.

ChatGPT4.0 was used to assist in the analysis of key themes discussed in this article.