The Blood Banking and Transfusion Medicine Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

The American Board of Pathology

July 2015

The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME- accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development of the fellow in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context.

Blood Banking and Transfusion Medicine Milestones

Chair: Mark Brissette, MD Working Group Advisory Group Ronald E. Domen, MD C. Bruce Alexander, MD Laura Edgar, EdD, CAE Julia C. Iezzoni, MD James R. Stubbs, MD Rebecca Johnson, MD

Wesley Y. Naritoku, MD, PhD

Milestone Reporting

This document presents Milestones designed for programs to use in semi-annual review of fellow performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves from entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine Milestone performance data for each program’s fellows as one element in the Next Accreditation System (NAS) to determine whether fellows overall are progressing.

For each period, review and reporting will involve selecting milestone levels that best describe each fellow’s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert in the subspecialty. These levels do not correspond with post-graduate year of education.

Selection of a level implies that the fellow substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page v).

Level 1: The fellow demonstrates milestones expected of an incoming fellow.

Level 2: The fellow is advancing and demonstrates additional milestones, but is not yet performing at a mid-fellowship level.

Level 3: The fellow continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for fellowship.

Level 4: The fellow has advanced so that he or she now substantially demonstrates the milestones targeted for fellowship. This level is designed as the graduation target.

Level 5: The fellow has advanced beyond performance targets set for fellowship and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional fellows will reach this level.

Additional Notes

Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the fellowship program director. Study of Milestone performance data will be required before the ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the developmental framework, and whether Milestone data are of sufficient quality to be used for high-stakes decisions.

Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are provided as a way to share the intent of the element.

Some milestone descriptions include statements about performing independently. These activities must occur in conformity to the ACGME supervision guidelines, as well as to institutional and program policies. For example, a fellow who performs a procedure independently must, at a minimum, be supervised through oversight.

Answers to Frequently Asked Questions about Milestones are available on the Milestones web page: http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.

The diagram below presents an example set of milestones for one sub-competency in the same format as the ACGME Report Worksheet. For each reporting period, a fellow’s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones that best describes that fellow’s performance in relation to those milestones.

Selecting a response box in the middle of Selecting a response box on the line in a level implies that milestones in that between levels indicates that milestones in level and in lower levels have been lower levels have been substantially substantially demonstrated. demonstrated as well as some milestones in the higher level(s).

v Version 5/2014 Blood Banking and Transfusion Medicine Milestones: ACGME Report Worksheet

PC1 — Consultation

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the role of the Performs timely, clinically Effectively communicates Competently and Demonstrates proficiency at consultant in blood useful consultation for consultative independently performs BB/TM consultation banking/transfusion requests for blood products, recommendations and action consultation during night medicine (BB/TM) (including apheresis, transfusion plans and weekend emergent therapeutic apheresis) reactions, and other situations, as well as during Develops a portfolio of immunohematology work- normal hours Observes and assists in the consultations ups and evaluations consultation Effectively teaches rotating Independently prepares full residents and fellows in Able to use the electronic and complete consultative performing consultations medical record (EMR) and reports other electronic resources to obtain clinical and disease information

Comments: Not yet achieved Level 1

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Blood banking and Transfusion Medicine Milestones on a non-exclusive bases for educational purposes. 1 Version 5/2014 Blood Banking and Transfusion Medicine Milestones: ACGME Report Worksheet

PC2 — Interpretation, Reporting, and Diagnosis

Level 1 Level 2 Level 3 Level 4 Level 5 Observes and assists in the Accurately interprets and Prepares a differential Interacts with other health Demonstrates proficiency in interpretation of reports results diagnosis for abnormal test care teams to discuss test interpretation, reporting, immunohematology tests results or findings results and make and diagnosis in BB/TM Understands basic test recommendations Understands basic platforms and methodology Demonstrates knowledge of indications for tests the current literature related Understands justifications to test results and testing for additional testing algorithms Effectively teaches rotating Critically evaluates and applies residents and fellows in the current literature performing consultations

PC3 — Procedures

Level 1 Level 2 Level 3 Level 4 Level 5 Understands basic concepts Understands indications, Able to discuss with attending Documents, and discusses, Demonstrates proficiency at underlying common contraindications, and staff member(s) the role of with the clinical care team, BB/TM procedures procedures performed in potential complications for the BB/TM physician in indications, Proficient in the oversight BB/TM and apheresis procedures procedures contraindications, and and management of (therapeutic and donor) complications of the Applies concepts and Actively participates in procedure apheresis in all settings Obtains an appropriate knowledge of therapeutic apheresis procedures history and performs an apheresis in clinical including therapeutic, Demonstrates competence appropriate physical situations hematopoietic stem cell (HSC) in the independent examination on the collection, and donor oversight and management Performs a “time-out” and apheresis patient collections of the procedure in all obtains informed consent settings (as appropriate) Manages therapeutic apheresis procedures with Can independently act in the minimal oversight role of an apheresis consultant Demonstrates ability to manage complications and to support ancillary staff

MK1 — Fundamental and Diagnostic Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies the key resources Demonstrates basic Applies evidence-based Demonstrates competence Demonstrates proficiency of for learning in BB/TM textbook-level knowledge in medicine principles to patient of knowledge in all aspects knowledge in all aspects of BB/TM care of BB/TM BB/TM

Uses multiple learning Teaches rotating residents and Teaches across departments Serves as an educational sources to acquire fellows resource for the community knowledge at-large

Performs self-directed learning

MK2 — Apheresis

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates knowledge Demonstrates knowledge Demonstrates expertise in Demonstrates competence Proficient in knowledge of of the general principles and appropriate use of the knowledge of diseases in knowledge of common apheresis across all settings and risks of apheresis basic clinical tests for commonly treated with risk factors in therapeutic assessment and apheresis apheresis related to management of apheresis medications, including ACE patients Demonstrate the ability to inhibitor use, anti- manage the unique diabetic medications, problems associated with antibiotics, and apheresis of donors giving anticoagulants blood component, stem cells, or cellular therapy products

SBP1 — Regulatory

Level 1 Level 2 Level 3 Level 4 Level 5 Understands that With substantial guidance With minimal guidance, Participates as a team Actively participates in, or laboratories are regulated implements state, federal, implements state, federal, and member in a mock or actual performs, inspections of a by state, federal, and and professional professional organization inspection of a laboratory or laboratory or blood center professional organizations organization standards or standards or elements of blood center, or equivalent at an outside facility elements of checklists in the checklists in the laboratory (e.g., tracers, self- Understands the use of Able to lead an inspection of laboratory inspection) proficiency testing Able to implement corrective a laboratory Reviews proficiency testing action based on proficiency Understands the basics of results testing results quality assurance

Demonstrates compliance with national regulations for patient privacy and confidentiality (e.g., HIPAA, state laws, institutional policies)

SBP2 — Health Care Teams

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance With substantial guidance, With minimal guidance, plays Independently plays a role Effectively plays a lead role of the transfusion medicine plays a role in the health a role in the health care team in the health care team in the health care team physician’s role in the health care team (e.g., case (e.g., case presentation, (e.g., case presentation, (e.g., case presentation, care team presentation, consultation, consultation, test selection consultation, test selection consultation, test selection test selection guidance) guidance) guidance) guidance)

SBP3 — Lab Management: Resource Utilization (personnel and finance)

Level 1 Level 2 Level 3 Level 4 Level 5 Aware of the roles of a Knows the personnel and Describes the process of Participates in employee Manages personnel transfusion medicine lines of reporting in the personnel management and interviews/performance effectively physician in managing laboratory employment laws (e.g., evaluation (real or personnel; interprets an interview questions, Family simulated experiences) Develops a budget organizational chart Describes the elements of a and Medical Leave Act, budget (e.g., personnel, termination policies) Participates in a budget Recognizes different budget capital equipment) cycle exercise (draft, defend, types (e.g., capital vs. Understands the basics of and propose logical cuts operating budget) transfusion medicine practice and/or additions) finance (e.g., Part A and Part B, Centers for Medicare & Medicaid Services [CMS])

PBLI1 — Evidence-based Utilization

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance With substantial guidance, With minimal guidance, Independently performs a Implements institutional of evidence-based utilization critically reviews the critically reviews the literature critical review of the utilization guidelines for of laboratory tests, results, literature addressing addressing evidence-based literature addressing laboratory tests and results, blood utilization and evidence-based utilization of utilization of laboratory tests, evidence-based utilization of blood utilization and management, and apheresis laboratory tests, results, results, blood utilization and laboratory tests and results, management, and apheresis blood utilization and management, and apheresis blood utilization and management, and apheresis management, or apheresis; and designs utilization guidelines

PBLI2 — Process Improvement and Patient Safety

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates awareness of Consistently demonstrates Contributes to practice change Participates in and Routinely uses identified common sources of error in work habits that minimize based on an identified error or completes a laboratory errors and discrepancies to laboratory and donor error; consistently and systematic problem (e.g., quality improvement project improve practice and processes and transitions in promptly communicates post-analytic, pre-analytic, laboratory processes care discrepancies to health care laboratory, or interpretative) Trouble-shoots patient providers (as appropriate) safety issues (including pre- Models patient safety Understands the importance Trouble-shoots pre-analytic analytic, analytic, and post- practices; able to write and of identity and integrity of Consistently checks identity problems, including deviations analytic) implement policies on the specimen and and integrity of specimen; from policies (waivers), with patient safety; completes requisition form and verifies independently obtains minimal supervision maintenance of certification the identity clinical information when (MOC) patient safety needed; incorporates other module resources, such as EMR and radiology; handles deviations from policies (waivers) with supervision

PBLI3 — Research and Scholarly Activity

Level 1 Level 2 Level 3 Level 4 Level 5 Has knowledge of the basic Applies evidence-based Educates others through Applies evidence-based Prepares for and presents at principles of research medicine in presentations, BB/TM journal clubs medicine in presentations at national or international (demographics, IRB, human such as at journal club, and, local or regional meetings meetings subjects), including how as appropriate, identifies research is conducted, research project early in Prepares and submits Completes research project, articles for peer-reviewed evaluated, explained to fellowship patients, and applied to if undertaken publication patient care

PROF1 — Receiving and Providing Feedback

Level 1 Level 2 Level 3 Level 4 Level 5 Receives feedback Modifies practice in Consistently receives feedback Modifies and maintains Encourages and actively constructively response to feedback and modifies practice changes in practice based seeks and provides feedback on feedback to improve performance

Provides constructive feedback

PROF2 — Accountability, Honesty, and Integrity

Level 1 Level 2 Level 3 Level 4 Level 5 Completes assigned tasks on Reliably completes assigned Anticipates team needs and Anticipates team needs and Exemplifies effective time tasks in a timely manner; steps in to assist as needed takes leadership role to management of multiple assists team members when independently implement competing tasks, with Is honest and understands Identifies personal limitations requested; respects solutions reliable follow-up; is a the concepts of ethical and takes responsibility for assigned schedules source of support/guidance behavior; seeks counsel errors Institutes corrective to other members of the when ethical questions arise Acknowledges personal measures for errors health care team limitations, near misses and Is viewed by members of errors, and putting the needs of patients first; the health care team as accepting personal engages in ethical behavior responsibility, and always putting the needs of the patient above his/her own interests

Serves as a role model for ethical and professional behavior

PROF 3 — Cultural Competency

Level 1 Level 2 Level 3 Level 4 Level 5 Respects diversity and Embraces diversity and Demonstrates cultural Exemplifies cultural Models cultural autonomy; recognizes respects vulnerable competency; recognizes competency; recognizes competency, and vulnerable populations populations; aware of cultural differences that may cultural differences, and recognition of cultural potential for bias or cultural affect care and the workplace, identifies and avoids biases differences that may affect differences to affect care and identifies and avoids that may affect care and the care and the workplace; and the workplace biases workplace works with peers to avoid biases Understands and complies with institutional policies affecting cultural competency

ICS1 — Communication with Health Care Providers, Families, Patients, and Donors (as applicable)

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance With substantial guidance, With minimal guidance, Effectively communicates Serves as a role model for of timely and effective provides timely and provides timely and effective complex, difficult, or effective and professional communication with health effective communication communication with health challenging information communication to health care providers, families, with health care providers, care providers, families, (e.g., errors, complications, care providers, families, patients, and donors (as families, patients, and patients, and donors (as adverse events, and bad patients, and donors (as applicable) donors (as applicable) applicable) news) applicable)

Understands that the With substantial guidance, With minimal guidance, Independently and written report is a form of produces a clear and produces a clear and consistently produces a communication that must understandable written understandable written report clear and understandable be clear and understandable report written report

Effectively utilizes the electronic health record

ICS2 — Personnel Management and Conflict Resolution

Level 1 Level 2 Level 3 Level 4 Level 5 Understands the importance With substantial guidance With minimal guidance Independently manages Anticipates, mitigates, and of conflict and complaint manages conflicts and manages conflicts and conflicts and complaints manages potential conflicts resolution complaints complaints and complaints

Copyright (c) Pending. The Accreditation Council for Graduate Medical Education and the American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Blood banking and Transfusion Medicine Milestones on a non-exclusive bases for educational purposes. 16