Sleep Medicine Milestones

The Accreditation Council for Graduate Medical Education

Second Revision: December 2019 First Revision: October 2014

©2019 Accreditation Council for Graduate Medical Education (ACGME) All rights reserved except the copyright owners grant third parties the right to use the Sleep Medicine Milestones on a non-exclusive basis for educational purposes.

Sleep Medicine Milestones

The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME- accredited 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.

Sleep Medicine Milestones

Working Group Kanika Bagai, MD, MSCI Ricky Mohon, MD Kathleen Doo, MD, MHPE Hala Samman, MD Brynn Dredla, MD Anita Shelgikar, MD, MHPE Laura Edgar, EdD, CAE Ian Weir, DO Vishesh Kapur, MD, MPH Michelle Zeidler, MD, MS Roneil Malkani, MD, MSCI

The ACGME would like to thank the following organizations for their continued support in the development of the Milestones: American Board of Internal Medicine ACGME Review Committee for Internal Medicine

Understanding Milestone Levels and Reporting

This document presents the Milestones, which programs use in a semi-annual review of fellow performance, and then report to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME Competencies organized in a developmental framework. The narrative descriptions are targets for fellow performance throughout their educational program.

Milestones are arranged into levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert fellow in the specialty or subspecialty. For each reporting period, the Clinical Competency Committee will review the completed evaluations to select the milestone levels that best describe each learner’s current performance, abilities, and attributes for each subcompetency.

These levels do not correspond with post-graduate year of education. Depending on previous experience, a junior fellow may achieve higher levels early in his/her educational program just as a senior fellow may be at a lower level later in his/her educational program. There is no predetermined timing for a fellow to attain any particular level. Fellows may also regress in achievement of their milestones. This may happen for many reasons, such as over scoring in a previous review, a disjointed experience in a particular procedure, or a significant act by the fellow.

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

Additional Notes

Level 4 is designed as a graduation goal but does not represent a graduation requirement. Making decisions about readiness for graduation and unsupervised practice is the purview of the program director. Furthermore, Milestones 2.0 include revisions and changes that preclude using Milestones as a sole assessment in high-stakes decisions (i.e., determination of eligibility for certification or credentialing). Level 5 is designed to represent an expert fellow whose achievements in a subcompetency are greater than the expectation. Milestones are primarily designed for formative, developmental purposes to support continuous quality improvement for individual learners, education programs, and the specialty. The ACGME and its partners will continue to evaluate and perform research on the Milestones to assess their impact and value.

Some milestone descriptions include statements about performing independently. These activities must occur in conformity to ACGME supervision guidelines as described in the Program Requirements, 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.

A Supplemental Guide is also available to provide the intent of each subcompetency, examples for each level, assessment methods or tools, and other available resources. The Supplemental Guide, is designed only to assist the program director and Clinical Competency Committee, and is not meant to demonstrate any required element or outcome.

Additional resources are available in the Milestones section of the ACGME website. Follow the links under “What We Do” at www.acgme.org.

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

Patient Care 1: Gather and Synthesize Information from Sleep Medicine Patients Across the Lifespan

Level 1 Level 2 Level 3 Level 4 Level 5 Elicits and concisely Elicits and concisely Efficiently elicits and Obtains relevant Role models integration of reports a hypothesis- reports a hypothesis- concisely reports a historical subtleties, history and physical driven patient history for driven patient history for hypothesis-driven patient including sensitive examination and collateral common patient uncommon patient history for complex information that informs data presentations presentations patient presentations, the differential diagnosis incorporating pertinent psychosocial and other determinants of health

Seeks and obtains data Independently seeks and Reconciles current data Reconciles current data from collateral sources, obtains data from with collateral sources for with collateral sources with guidance collateral sources common cases for uncommon and complex cases

Performs a hypothesis- Performs a hypothesis Performs a hypothesis- Elicits subtle findings on driven physical exam for driven physical exam for driven physical exam for a physical exam a common patient an uncommon patient complex patient presentation and presentation presentation attends to patient comfort and safety

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 2: Use of Diagnostic Tools in Sleep Medicine Across the Lifespan

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies diagnostic tools Selects diagnostic tools Selects diagnostic tools Integrates clinical Integrates current and used to evaluate patients for patients with common for patients with findings and test new diagnostic tools in with sleep disorders sleep disorders uncommon and complex performance novel ways to further sleep disorders characteristics to obtain evaluate sleep disorders the diagnosis

Identifies available Explains common uses of Identifies limitations of Incorporates consumer Incorporates consumer consumer sleep consumer sleep consumer sleep sleep technologies for sleep technologies in technologies technologies technologies individual use novel ways or for population use

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 3: Interpretation of Physiologic Testing in Sleep Medicine Across the Lifespan

Level 1 Level 2 Level 3 Level 4 Level 5 Describes the basic Identifies common Identifies uncommon Identifies the technical Demonstrates expertise in principles of signal abnormalities and abnormalities and basis and limitations of advanced principles of acquisition and artifacts variants the testing modalities; signal acquisition and processing troubleshoots signal processing processing

Identifies characteristics Interprets routine testing Interprets routine testing Interprets advanced Applies current of normal sleep-wake to identify common sleep- to identify uncommon testing; interprets technologies for novel physiology wake disorders sleep-wake disorders testing of complex use; incorporates sleep-wake disorders emerging technologies to diagnose and treat sleep- wake disorders

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 4: Management Plan for Sleep Medicine Patients Across the Lifespan

Level 1 Level 2 Level 3 Level 4 Level 5 Implements Implements management Develops and implements Adjusts comprehensive Develops and implements management plans for plans for uncommon management plan for management plans by a personalized common sleep disorders sleep disorders and to complex sleep disorders incorporating management plan for and recommends maintain and promote and to maintain and psychosocial and other patients with subtle strategies to maintain sleep health promote sleep health determinants of health presentations, rare or and promote sleep and response to therapy ambiguous sleep health disorders

Advocates to maintain and promote sleep health for patients and populations

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement *Only required for Internal Medicine based programs

Medical Knowledge 1: Sleep Medicine Clinical Science

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates knowledge Integrates scientific Synthesizes scientific Demonstrates expertise knowledge of physiology of physiology and knowledge to address knowledge to address in sleep science and its and pathophysiology of pathophysiology of complex sleep disorders complex or atypical application to clinical common sleep disorders uncommon sleep sleep disorders in the medicine disorders context of a patient with comorbid conditions that impact management of the patient’s sleep disorder

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 2: Therapeutic Knowledge for Sleep Disorders

Level 1 Level 2 Level 3 Level 4 Level 5 Describes the indications Analyzes the indications, Demonstrates knowledge Synthesizes knowledge Demonstrates an and scientific basis for contraindications, and of multimodal therapeutic of therapeutic options understanding of common therapies for complications of common approaches to sleep within the clinical emerging, atypical, or sleep disorders therapies for sleep disorders in the context of context (patient, complex therapeutic disorders a patient’s comorbid system, society) to options conditions to formulate optimize treatment plan treatment options and adherence

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement *Only required for Internal Medicine based programs

Systems-Based Practice 1: Patient Safety and Quality Improvement

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Identifies system factors Participates in analysis of Conducts analysis of Actively engages teams knowledge of common that lead to patient safety patient safety events patient safety events and processes to modify patient safety events events and offers error systems to prevent prevention strategies patient safety events

Demonstrates Reports patient safety Participates in disclosure Discloses patient safety Role models or mentors knowledge of how to events through of patient safety events to events to patients and others in the disclosure of report patient safety institutional reporting patients and families families patient safety events events systems

Demonstrates Describes local quality Participates in local Demonstrates the skills Creates, implements, and knowledge of basic improvement initiatives quality improvement required to identify, assesses quality quality improvement initiatives develop, implement, improvement initiatives at methodologies and and analyze a quality the institutional or metrics improvement project community level

Comments: Not Yet Completed Level 1

Systems-Based Practice 2: System Navigation for Patient-Centered Care

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Coordinates care of Coordinates care of Role models effective Analyses the process of knowledge of care patients in routine clinical patients in complex coordination of patient- care coordination and coordination situations, performs clinical situations, centered care among leads in the design and transitions of care, and performs transitions of different disciplines and implementation of effectively uses care, and effectively uses specialties improvements interprofessional teams interprofessional teams

Demonstrates Identifies specific Uses local resources Participates in changing Leads innovations and knowledge of population population and effectively to meet the and adapting practice to advocates for populations and community health community health needs needs of a patient provide for the needs of and communities with needs and disparities and inequities for their population and specific populations health care inequities local population community

Comments: Not Yet Completed Level 1

Systems-Based Practice 3: Physician Role in Health Care Systems

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies key Describes how Discusses how individual Manages various Advocates for or leads components of the components of a health practice affects the components of the systems change that health care system care system are broader system health care system to enhances high-value, interrelated, and how this provide efficient and efficient, and effective impacts patient care effective patient care patient care

Describes basic health Delivers care with Engages with patients in Advocates for patient Participates in health payment systems and consideration of each shared decision making, care needs with policy advocacy activities practice models patient’s payment model informed by each consideration of the patient’s payment models limitations of each patient’s payment model

Identifies basic Demonstrates use of Describes core Analyzes individual Educates others to knowledge domains for information technology administrative knowledge practice patterns and prepare them for effective transition to required for medical needed for transition to professional transition to practice practice practice practice requirements in preparation for practice

Comments: Not Yet Completed Level 1

Systems-Based Practice The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement *Only required for Internal Medicine based programs

Practice-Based Learning and Improvement 1: Evidence-Based and Informed Practice

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates how to Articulates clinical Locates and applies the Critically appraises and Coaches others to access and use available questions and elicits best available evidence, applies evidence even critically appraise and evidence, and patient preferences and integrated with patient in the face of apply evidence for incorporate patient values in order to guide preference, to the care of uncertainty and complex patients; and/or preferences and values evidence-based care complex patients conflicting evidence to participates in the in order to take care of a guide care, tailored to development of guidelines routine patient the individual patient

Comments: Not Yet Completed Level 1

Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth

Level 1 Level 2 Level 3 Level 4 Level 5 Accepts responsibility for Demonstrates openness Solicits performance Intentionally seeks Role models consistently personal and to performance feedback feedback and data performance feedback seeking performance professional and other data in order to episodically, with data consistently, with data, with adaptability for development by inform goals adaptability for personal adaptability for personal personal growth establishing goals growth growth

Identifies the factors Analyzes and reflects on Institutes behavioral Challenges Coaches others on which contribute to gaps the factors which changes to narrow gaps assumptions and reflective practice between expectations contribute to gaps between expectations and considers alternatives in and actual performance between expectations and actual performance narrowing gaps actual performance between expectations and actual performance

Identifies gaps in Designs and implements Independently creates Uses performance data Facilitates the design and knowledge a learning plan, with and implements a to measure the implementation of prompting learning plan effectiveness of the learning plans for others learning plan and when necessary, improves it

Comments: Not Yet Completed Level 1

Practice-Based Learning and Improvement The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement *Only required for Internal Medicine based programs

Professionalism 1: Professional Behavior and Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies and describes Describes when and how Takes responsibility for Recognizes situations Coaches others when potential triggers for to appropriately report own professionalism that may trigger their behavior fails to professionalism lapses professionalism lapses, lapses professionalism lapses meet professional including strategies for and intervenes to expectations addressing common prevent lapses in self barriers and others

Demonstrates Recognizes and manages Identifies need to seek Uses appropriate Identifies and seeks to knowledge of the ethical straightforward ethical help in managing complex resources for managing address system-level principles commonly situations ethical situations and resolving ethical factors that induce or identified in sleep dilemmas exacerbate ethical medicine problems or impede their resolution

Comments: Not Yet Completed Level 1

Professionalism 2: Accountability/Conscientiousness

Level 1 Level 2 Level 3 Level 4 Level 5 Responds promptly to Completes tasks and Recognizes barriers that Proactively implements Takes ownership of requests or reminders to responsibilities in a timely may impact self or others’ strategies for timely task system outcomes complete tasks and manner ability to complete tasks completion to ensure responsibilities; takes and responsibilities in a that the needs of responsibility for timely manner patients, teams, and incomplete tasks systems are met

Comments: Not Yet Completed Level 1

Professionalism 3: Self-Awareness and Help-Seeking

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes the status of Demonstrates appropriate With assistance, Independently Coaches others when personal and help-seeking behaviors proposes a plan to develops, reassesses emotional responses or professional well-being optimize personal and and modifies plans to limitations in professional well-being optimize personal and knowledge/skills do not professional well-being meet professional expectations

Comments: Not Yet Completed Level 1

Professionalism The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement *Only required for Internal Medicine based programs

Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication

Level 1 Level 2 Level 3 Level 4 Level 5 Uses language and Establishes a therapeutic Establishes a therapeutic Easily establishes Mentors others in nonverbal behavior to relationship in relationship therapeutic situational awareness and demonstrate respect and straightforward in challenging patient relationships, with critical self-reflection to establish rapport encounters using active encounters attention to consistently develop listening and clear patient/family concerns positive therapeutic language and context, regardless relationships of complexity

Identifies the need to Communicates Communicates medical Uses shared decision Role models shared individualize compassionately with information in the context making to align decision making in the communication patient/family to clarify of patient/family values, patient/family values, context of patient/family strategies based on expectations and verify uncertainty, and conflict goals, and preferences values, uncertainty, and patient/family understanding of the with treatment options conflict expectations and clinical situation understanding

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills 2: Barrier and Bias Mitigation

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies common Identifies complex barriers Recognizes personal Recognizes personal Mentors others on barriers to effective to effective patient care biases and mitigates biases and proactively recognition of bias and patient care barriers to optimize mitigates barriers to mitigation of barriers to patient care, when optimize patient care optimize patient care prompted

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills 3: Interprofessional and Team Communication

Level 1 Level 2 Level 3 Level 4 Level 5 Respectfully receives Clearly and concisely Assesses understanding and requests responds to and requests of recommendations consultations consultations when providing and receiving consultations Coordinates Role models flexible recommendations from communication strategies different members of that value input from all Uses language that Communicates Uses active listening to the health care team health care team values all members of information effectively adapt communication and consultants to members and the health care team with all health care team style to fit health care optimize patient care consultants, resolving members team needs conflict when needed

Receptive to feedback Solicits feedback on Communicates concerns Communicates on performance as a performance as a and provides feedback to feedback and member of the health member of the health peers and learners constructive criticism to care team care team supervisors and faculty members

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills 4: Communication within Health Care Systems

Level 1 Level 2 Level 3 Level 4 Level 5 Accurately records Demonstrates organized Concisely and clearly Communicates Role models exemplary information in the patient diagnostic and reports diagnostic and anticipatory guidance in communication and record in a timely therapeutic reasoning therapeutic reasoning in the patient record facilitates secure manner through notes in the the patient record in a information sharing within patient record manner that reflects level the broader health care of service system

Safeguards patient Documents required data Appropriately selects Is effective in direct and Facilitates dialogue personal health in formats specified by direct and indirect forms indirect forms of regarding systems information and institutional policy of communication based communication communication issues communicates through on context among larger community appropriate channels as stakeholders required by institutional policy

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills The fellow is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in the training program. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care.

_____ Yes _____ No _____ Conditional on Improvement *Only required for Internal Medicine based programs

Overall Clinical Competence

This rating represents the assessment of the fellow's development of overall clinical competence during this year of training:

____Superior: Far exceeds the expected level of development for this year of training

____Satisfactory: Always meets and occasionally exceeds the expected level of development for this year of training

____Conditional on Improvement: Meets some developmental milestones but occasionally falls short of the expected level of development for this year of training. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training.

____Unsatisfactory: Consistently falls short of the expected level of development for this year of training.

*Only required for Internal Medicine based programs