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Expert Consensus On The ACGME Competencies That Align With Vascular Quality Initiative Surgical Outcomes
Brigitte K. Smith, MD, MHPE¹, Kenji Yamazaki, PhD², Ara Tekian, PhD, MHPE³, Benjamin S. Brooke, MD, PhD¹, Eric Holmboe, MD², Stanley J. Hamstra, PhD⁴, Erica L. Mitchell, MD, MEd⁵, Yoon Soo Park, PhD⁶.
¹University of Utah, Salt Lake City, UT, USA, ²Accreditation Council for Graduate Medical Education, Chicago, IL, USA, ³University of Illinois at Chicago, Chicago, IL, USA, ⁴University of Toronto, Toronto, ON, Canada, ⁵University of Tennessee, Memphis, TN, USA, ⁶Massachusetts General Hospital, Boston, MA, USA.

ObjectiveThe policy and practice of vascular surgical education has evolved significantly since the advent of the Accreditation Council for Graduate Medical Education (ACGME) Milestones. Concomitantly, greater emphasis has been placed nationally on vascular surgery (VS) quality and outcomes as measured by the Vascular Quality Initiative (VQI) procedure registries. As such, no data support the association between VS ACGME Milestones performance with patient outcomes. In order to investigate associations between training and surgical outcomes, a critical first step is to determine which ACGME competencies contribute to patient outcomes. We sought to investigate the VS Milestones considered essential for quality patient care outcomes vis-a-vis 8 VQI registries.
MethodsExperts in both VS clinical care and education were recruited to participate in a modified Delphi consensus building process. A master list of items for competency rating was created using the 31 ACGME VS sub-competencies and 8 VQI procedure registries. These items were entered into a 2-round Delphi process. Positive consensus was reached when > 75% of participants ranked a competency as mandatory to quality outcomes. (Table)
Results13 VS experts and contributors to the VS Milestones participated; 12 experts (92%) participated in all rounds of the Delphi process. Expert consensus deemed only 9 to 15 of the 31 subcompetencies as mandatory to quality patient outcomes vis-a-vis the 8 VQI clinical modules. Practice-based learning and improvement (PBLI), and professionalism were deemed not essential to quality patient outcomes. Radiation safety was the only systems-based practice (SBP) sub-competency uniformly defined as supportive to patient outcomes.
ConclusionsEstablishing a translational link between training and clinical outcomes is essential to enhancing the quality of educational practice and policy. This study advances this effort through national expert consensus, demonstrating high degree of agreement among VS experts regarding the relevance of ACGME sub-competencies to quality patient outcomes as captured by the 8 VQI clinical registries. SBP, PBLI, and Professionalism competencies were identified as unlikely to be associated with clinical outcomes. Future research should investigate the relevance of these core competencies to other measures of surgeon performance not captured in the VQI, such as patient reported outcomes and practice management.

Vascular Surgery ACGME Subcompetencies		Vascular Quality Initiative (VQI) Outcomes
		CEA		CAS		Open AAA		EVAR		TEVAR		Supra Bypass		Infra Bypass		PVI
		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
PC-1	Patient Data	2.58	.90	2.58	.90	2.67	.89	2.67	.89	2.67	.89	2.58	.90	2.58	.90	2.58	.90
PC-2	Vascular Medicine	2.25	.97	2.33	.89							2.08	1.00	2.25	.97	2.25	.97
PC-3	Perioperative Care	2.83	.39	2.83	.39	2.83	.39	2.67	.49	2.75	.45	2.75	.45	2.83	.39	2.58	.51
PC-4	Longitudinal Care	2.08	.90	2.17	.94	1.92	.79	2.42	1.00	2.33	.98	2.17	.94	2.42	1.00	2.42	1.00
PC-5	Technical Skills – Procedural Preparation	2.58	.51	2.75	.45	2.67	.49	2.75	.45	2.75	.45	2.67	.49	2.75	.45	2.67	.49
PC-6	Technical Skills – Open Surgical Skills	3.00	.00			3.00	.00					3.00	.00	3.00	.00
PC-7	Technical Skills – Endovascular			3.00	.00			2.75	.45	2.67	.49					2.92	.29
PC-8	Vascular Imaging	2.42	.67	2.83	.58	2.33	.65	3.00	.00	3.00	.00	2.17	.58	2.58	.67	2.83	.39
MK-1	Procedural Rationale – Basic Procedures
MK-2	Procedural Anatomy – Basic Procedures
MK-3	Procedural Understanding – Basic Procedures
MK-4	Crisis Management – Basoc Procedures
MK-5	Procedural Rationale – Intermediate Procedures	2.75	.62					2.58	.67					2.83	.58
MK-6	Procedural Anatomy – Intermediate Procedures	2.83	.39					2.83	.39					2.92	.29	2.67	.49
MK-7	Procedural Understanding – Intermediate Procedures	2.92	.29					2.92	.29					2.92	.29	2.75	.45
MK-8	Crisis Management – Intermediate Procedures	2.92	.29					2.92	.29					2.92	.29	2.83	.39
MK-9	Procedural Rationale – Advanced Procedures	2.17	1.19	2.75	.62	2.75	.62	2.42	1.00	2.67	.65	2.67	.65	2.42	1.00	2.42	1.00
MK-10	Procedural Anatomy – Advanced Procedures	2.25	1.14	2.92	.29	2.92	.29	2.58	.90	2.83	.39	2.75	.45	2.58	.90	2.50	.90
MK-11	Procedural Understanding – Advanced Procedures	2.42	1.16	3.00	.00	3.00	.00	2.67	.89	2.92	.29	2.92	.29	2.67	.89	2.67	.89
MK-12	Crisis Management – Advanced Procedures	2.33	1.15	2.92	.29	2.92	.29	2.58	.90	2.92	.29	2.92	.29	2.58	.90	2.58	.90
SBP-1	Radiation Safety			2.33	.78			2.50	.80	2.50	.80					2.42	.79
SBP-2	Coordination of Care	1.92	.51	2.17	.58	2.25	.62	2.25	.62	2.33	.65	2.17	.58	2.17	.58	2.08	.67
SBP-3	Improvement of Care
PBLI-1	Teaching
PBLI-2	Self-directed Learning	2.08	.90	2.08	.90	2.00	.85	2.17	.94	2.25	.97	2.00	.85	1.92	.79	2.17	.94
PBLI-3	Quality Improvement	2.08	.79	2.17	.83	2.25	.87	2.25	.87	2.25	.87	2.17	.83	2.17	.83	2.17	.83
PROF-1	Integrity	2.33	1.07	2.33	1.07	2.33	1.07	2.33	1.07	2.33	1.07	2.33	1.07	2.33	1.07	2.33	1.07
PROF-2	Personal Wellbeing
PROF-3	Administrative Tasks
ICS-1	Communication with Patients and Families	2.33	.65	2.50	.67	2.50	.67	2.33	.65	2.50	.67	2.50	.67	2.33	.65	2.50	.67
ICS-2	Communications with Healthcare Team	2.50	.52	2.67	.49	2.50	.52	2.67	.49	2.67	.49	2.50	.52	2.67	.49	2.67	.49

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