Anesthesiology Milestones

The Accreditation Council for Graduate Medical Education

Implementation Date: July 1, 2021 Second Revision: November 2020 First Revision: December 2013

©2020 Accreditation Council for Graduate Medical Education (ACGME) All rights reserved except the copyright owners grant third parties the right to use the Anesthesiology Milestones on a non-exclusive basis for educational purposes.

Anesthesiology Milestones

The Milestones are designed only for use in evaluation of residents in the context of their participation in ACGME-accredited residency programs. The Milestones provide a framework for the assessment of the development of the resident in key dimensions of the elements of physician competence 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.

Anesthesiology Milestones

Work Group Aditee Ambardekar, MD, MSEd Timothy Long, MD Kaitlyn Brennan, DO, MPH Anne Marie McKenzie-Brown, MD Rupa Dainer, MD John Mitchell, MD Crys Draconi Carlos Trombetta, MD, MEd Laura Edgar, EdD, CAE Chelsia Varner Jackson, MD Herodotos Ellinas, MD, MHPE Kathryn Walker, MD, MEd Martin Laskey, DO Bradley Wargo, DO

The ACGME would like to thank the following organizations for their continued support in the development of the Milestones: American Board of Anesthesiology American Osteopathic Association American Osteopathic College of Anesthesiologists Review Committee for Anesthesiology Society for Education in Anesthesia

Understanding Milestone Levels and Reporting

This document presents the Milestones, which programs use in a semi-annual review of resident 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 resident 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 resident 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 resident may achieve higher levels early in his/her educational program just as a senior resident may be at a lower level later in his/her educational program. There is no predetermined timing for a resident to attain any particular level. Residents 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 resident.

Selection of a level implies the resident 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 resident 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.

Examples are provided for some milestones within this document. Please note: 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 ACGME supervision guidelines as described in the Program Requirements, as well as to institutional and program policies. For example, a resident 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, like examples contained within the Milestones, 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 resident’s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones that best describes that resident’s performance in relation to those milestones.

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

Patient Care 1: Pre-Anesthetic Evaluation

Level 1 Level 2 Level 3 Level 4 Level 5 Performs basic chart Performs focused chart Interprets chart review Evaluates diagnostic review review, with indirect information to assess data and provides risk supervision need for further work-up stratification based on comorbidities and anesthetic implications

Conducts patient Interviews the patient and Interprets information Independently identifies interview, with direct gathers pertinent collected during patient the need for additional supervision information, with indirect interview, with assistance evaluation and suggests supervision therapeutic interventions

Conducts and interprets Conducts a focused Identifies comorbidities on Independently identifies Independently identifies a a physical examination, physical examination, with physical examination that concerning physical previously undiagnosed with direct supervision indirect supervision may require further exam findings that condition evaluation, with indirect require further supervision evaluation

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 2: Peri-Operative Care and Management

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies the Develops an anesthetic Develops an anesthetic Develops an anesthetic components of an plan for a healthy patient plan for patients with well- plan for patients with anesthetic plan undergoing controlled comorbidities multiple, uncontrolled uncomplicated or undergoing comorbidities, and procedures complicated procedures undergoing complicated procedures

Identifies the Implements simple peri- Identifies patients with a Implements the In collaboration with other components of a pain operative pain history of chronic pain anesthetic plan for specialists, develops management plan management plan who require a modified patients with complex protocols for multimodal peri-operative pain pain history and analgesia plan for management plan polypharmacy patients with a complex pain history and substance use disorder

Identifies potential Identifies patient specific Develops the anesthetic Implements the Develops departmental or impact of anesthesia risks factors for long-term plan based on risk factors anesthetic plan to institutional protocols for beyond intra-operative anesthetic effects to mitigate the long-term mitigate the long-term reduction of the long-term period impact of anesthesia impact of anesthesia impact of anesthesia

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 3: Application and Interpretation of Monitors

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies standard Independently selects Selects advanced Independently selects monitors central and arterial monitors based on patient advanced monitors catheters based on comorbidities and based on patient patient comorbidities and procedure, with comorbidities and procedure supervision procedure

Applies standard Inserts central and arterial Inserts or applies Independently inserts or Functions as a consultant monitors to patients catheters, with advanced monitors, with applies advanced for difficult advanced supervision supervision invasive monitors monitor placement

Interprets standard Addresses malfunctions Recognizes and Independently interprets Participates in the monitoring data in standard monitors and addresses malfunctions in data, recognizes, and research and/or interprets data from advanced monitors and addresses malfunctions development of protocols central and arterial lines, interprets data, with in monitors and other for monitoring technology with supervision supervision anesthesia equipment

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 4: Intra-Operative Care

Level 1 Level 2 Level 3 Level 4 Level 5 Assists in the initiation of Plans and initiates the Plans and initiates the Independently plans the anesthetic anesthetic for healthy anesthetic in a patient and initiates the patients undergoing with well-controlled anesthetic in a patient uncomplicated comorbidities, or with multiple, procedures undergoing complicated uncontrolled procedures comorbidities undergoing complicated procedures

Assists in maintenance Manages expected Independently manages Independently manages Manages rare events of anesthetic care events during anesthetic expected events during unexpected events during anesthetic care care, with supervision anesthetic care during anesthetic care

Assists with emergence Anticipates and manages Anticipates and manages Independently Manages rare events from anesthesia expected events during unexpected events during anticipates and during emergence emergence, with emergence, with manages unexpected supervision supervision events during emergence

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 5: Airway Management

Level 1 Level 2 Level 3 Level 4 Level 5 Performs basic airway Uses the airway exam Devises airway Independently devises assessment and identifiable risk management plans that airway management factors to formulate a address contingencies, plans that address patient-specific plan with supervision contingencies

Performs bag-mask Prepares basic equipment Prepares and Independently prepares Functions as an expert in ventilation in and manages an incorporates advanced and incorporates an airway crisis for uncomplicated airway uncomplicated airway equipment in the advanced equipment in complicated airways management of a the management of a complicated airway, with complicated airway supervision

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 6: Point-of-Care Ultrasound

Level 1 Level 2 Level 3 Level 4 Level 5 Lists and explains the Selects ultrasound Selects ultrasound Independently selects Participates in research basic science and equipment for equipment for a patient proper ultrasound of emerging ultrasound terminology of procedures, with with difficult anatomy, with equipment and settings procedures ultrasound supervision supervision for indicated scenarios

Identifies relevant Conducts point-of-care Interprets point-of-care Independently conducts Participates in the anatomy using ultrasound, with ultrasound, with and interprets point-of- development of ultrasound supervision supervision care ultrasound institutional protocols for point-of-care ultrasound

Uses ultrasound for Uses ultrasound for Uses ultrasound for Independently uses vascular access in vascular access in routine vascular access in ultrasound for vascular routine situations, with situations complex situations, with access in complex supervision supervision situations

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 7: Situational Awareness and Crisis Management

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates vigilance Demonstrates awareness Demonstrates awareness Independently during clinical care of case flow and of case flow and demonstrates developments throughout developments throughout awareness of case flow a procedure a procedure, including and developments those outside of one’s throughout a procedure, own immediate control, including those outside with supervision of one’s own immediate control

Articulates causes of Recognizes crisis Anticipates impending Independently common peri-operative situations; calls for help crisis and identifies anticipates impending crisis situations possible etiologies with crisis and identifies supervision possible etiologies

Responds to crisis Participates in Initiates management and Independently initiates Leads the health care situations as a reliable management during crisis resolves crisis situations, management and team in the management team member situations with supervision resolves crisis situations of crisis situations

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 8: Post-Operative Care

Level 1 Level 2 Level 3 Level 4 Level 5 Outlines post-operative Plans disposition for Identifies unexpected Independently identifies Develops protocols for disposition options for uncomplicated changes in patient status unexpected changes in disposition based on patients procedures meriting change in patient status meriting procedure and patient disposition, with change in disposition comorbidities supervision

Lists complications Diagnoses, manages, and Diagnoses, manages, and Independently commonly encountered documents commonly documents uncommon diagnoses, manages, post-operatively encountered complications arising from and documents complications arising from anesthetic care, with uncommon anesthetic care, with supervision complications arising supervision from anesthetic care

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 9: Critical Care

Level 1 Level 2 Level 3 Level 4 Level 5 Acquires data for the Interprets routine Interprets advanced Independently interprets care of the critically-ill diagnostic data in the diagnostic data in the advanced diagnostic patient care of critically-ill care of critically-ill data in the care of patients patients, with supervision critically-ill patients

Recognizes when a Prioritizes the care of the Prioritizes the care of Independently Leads and deploys patient is critically ill critically-ill patient multiple critically-ill prioritizes the care of resources in the care of patients, with supervision multiple critically-ill the critically-ill patient patients

Implements the care Develops and implements Develops and Functions in a supervisory team’s plan for a critically- a comprehensive plan of implements a role managing all patients ill patient care for the critically-ill comprehensive plan of in a unit and the unit’s patient, with supervision care for the critically-ill resources patient

Comments: Not Yet Completed Level 1 Not Yet Assessable

Patient Care 10: Regional (Peripheral and Neuraxial) Anesthesia

Level 1 Level 2 Level 3 Level 4 Level 5 Describes anatomy Describes indications and Develops a patient- and Independently develops relevant to regional contraindications for procedure-specific a patient- and anesthesia regional anesthesia regional anesthesia plan, procedure-specific with supervision regional anesthesia plan

Prepares the patient and Performs regional Performs regional Independently performs Serves as a consultant on the equipment for anesthesia techniques, anesthesia techniques, regional anesthesia advanced or difficult common regional with direct supervision with indirect supervision techniques regional techniques anesthesia techniques

Describes potential Recognizes and manages Recognizes and manages Independently Develops institutional complications of regional complications of regional complications of regional recognizes and protocol for using regional anesthesia anesthesia, with direct anesthesia, with indirect manages complications anesthesia and managing supervision supervision of regional anesthesia complications

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 1: Foundational Knowledge

Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates Demonstrates knowledge Demonstrates knowledge Demonstrates Demonstrates scientific knowledge of of common medical and of complex medical and comprehensive knowledge of uncommon, pathophysiology and surgical disease, surgical disease, knowledge of medical atypical, or complex treatment of medical and treatments, and treatments, and and surgical disease as conditions as it relates to surgical conditions populations as it relates to populations as it relates to it relates to the full the full spectrum of the anesthetic care anesthetic care spectrum of the patient’s peri-operative patient’s peri-operative care care

Identifies medications Demonstrates knowledge Demonstrates knowledge Demonstrates Participates in research used to treat common of pharmacology of of medications used in comprehensive related to pharmacology comorbidities medications routinely subspecialty areas (e.g., knowledge of used in anesthetic care cardiac, obstetrics) pharmacology in the setting of complex comorbidities

Comments: Not Yet Completed Level 1 Not Yet Assessable

Medical Knowledge 2: Clinical Reasoning

Level 1 Level 2 Level 3 Level 4 Level 5 Organizes and Integrates information Develops a thorough and Develops prioritized Coaches others to accurately summarizes from all sources to prioritized differential differential diagnoses in develop prioritized information obtained develop a basic diagnosis for common complex patient differential diagnoses in from the patient differential diagnosis for patient presentations presentations and complex patient evaluation to develop a common patient incorporates subtle, presentations clinical impression presentations unusual, or conflicting findings

Lists types of clinical Identifies clinical Retrospectively applies Continually re-appraises Models how to recognize reasoning errors reasoning errors within clinical reasoning one’s clinical reasoning errors and reflect upon patient care, with principles to identify to improve patient care one’s own clinical guidance errors in real time reasoning

Comments: Not Yet Completed Level 1 Not Yet Assessable

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 events that impact events (simulated or actual) and offers error systems to prevent patient safety prevention strategies patient safety events (simulated or actual)

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 (simulated or patient safety events events systems (simulated or (simulated or actual) actual) actual)

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

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 Analyzes the process of knowledge of care patients in routine clinical patients in complex coordination of patient- care coordination and coordination situations effectively using clinical situations centered care among participates in the design the roles of the effectively using the roles different disciplines and and implementation of interprofessional team of the interprofessional specialties improvements members team members

Identifies key elements Performs safe and Performs safe and Role models and Improves quality of for safe and effective effective transitions of effective transitions of advocates for safe and transitions of care within transitions of care and care/hand-offs in routine care/hand-offs in complex effective transitions of and across health care hand-offs clinical situations clinical situations care/hand-offs within delivery systems to and across health care optimize patient outcomes delivery systems

Demonstrates Identifies specific Uses institutional Participates in changing Advocates for populations knowledge of population population and resources effectively to and adapting practice to and communities with and community health community health needs meet the needs of a provide for the needs of health care inequities in needs and disparities and inequities for their patient population and specific populations the peri-operative setting 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 complex practice affects the components of the systems change that complex health care health care system are broader system (e.g., complex health care enhances high-value, system (e.g., hospital, interrelated, and how this length of stay, system to provide efficient, and effective skilled nursing facility, impacts patient care readmission rates, clinical efficient and effective patient care finance, personnel, efficiency) patient care and technology) transition of care

States factors impacting Documents anesthetic Explains the impact of Practices and Engages in external the costs of anesthetic detail to facilitate accurate documentation on billing advocates for cost- activities related to care billing and reimbursement and reimbursement effective patient care advocacy for cost- effective care

Comments: Not Yet Completed Level 1

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

Level 1 Level 2 Level 3 Level 4 Level 5 Accesses and uses Articulates clinical Locates and applies the Appraises and applies Coaches others to evidence in routine questions and elicits best available evidence, evidence, even in the appraise and apply patient care patient preferences and integrated with patient face of uncertainty and evidence for complex values to guide evidence- preference, to the care of conflicting evidence, to patients and/or based care complex patients guide individualized participates in the care development of guidelines

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 Seeks performance data Intentionally seeks Role models consistently personal and to performance data episodically, with performance data seeking performance professional (feedback and other adaptability and humility consistently, with data, with adaptability and development by input) to form goals adaptability and humility humility establishing goals

Identifies the factors that Analyzes and Institutes behavioral Considers alternatives Models reflective practice contribute to acknowledges the factors change(s) to improve to improve performance performance deficits that contribute to performance performance deficits

Actively seeks Designs and implements Independently creates Integrates performance Facilitates the design and opportunities to improve a learning plan, with and implements a data to adapt the implementation of prompting learning plan learning plan learning plans for others

Comments: Not Yet Completed Level 1

Professionalism 1: Professional Behavior and Ethical Principles

Level 1 Level 2 Level 3 Level 4 Level 5 Identifies potential Demonstrates insight into Demonstrates Recognizes situations Coaches others when triggers for professional behavior in professional behavior in that may trigger their behavior fails to professionalism lapses routine situations complex or stressful professionalism lapses meet professional situations and intervenes to expectations prevent lapses in oneself

Describes when and how Takes responsibility for Recognizes need to seek Actively solicits help to report lapses in one’s own help in managing and and acts on professionalism professionalism lapses resolving complex recommendations to interpersonal situations resolve complex interpersonal situations

Demonstrates Analyzes straightforward Analyzes complex Recognizes and utilizes Identifies and seeks to knowledge of the ethical situations using ethical situations using ethical resources for managing address system-level principles underlying principles principles and resolving ethical factors that induce or patient care dilemmas exacerbate ethical 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 Performs tasks and Performs tasks and Prioritizes tasks and requests or reminders to responsibilities in a timely responsibilities in a timely responsibilities in a complete tasks manner manner with appropriate timely manner with attention to detail in appropriate attention to routine situations detail in complex or stressful situations

Takes responsibility for Recognizes situations Takes responsibility for Proactively implements Designs and implements failure to complete tasks that may impact one’s tasks not completed in a strategies to ensure that an institutional systems own ability to complete timely manner and the needs of patients, approach to ensure timely tasks and responsibilities identifies strategies to teams, and systems are task completion and in a timely manner prevent recurrence met shared responsibility

Comments: Not Yet Completed Level 1

Professionalism 3: Well-Being

Level 1 Level 2 Level 3 Level 4 Level 5 Recognizes the Lists available resources With assistance, Independently develops Creates institutional-level importance of for personal and proposes a plan to a plan to promote interventions that promote addressing personal and professional well-being promote personal and personal and colleagues’ well-being professional well-being professional well-being professional well-being

Describes institutional Recognizes which Describes institutional Describes institutional resources that are meant institutional factors affect factors that positively programs designed to to promote well-being well-being and/or negatively affect examine systemic well-being contributors to burnout

Comments: Not Yet Completed Level 1

This subcompetency is not intended to evaluate a resident’s well-being. Rather, the intent is to ensure that each resident has the fundamental knowledge of factors that affect well-being, the mechanisms by which those factors affect well-being, and available resources and tools to improve well-being.

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

Level 1 Level 2 Level 3 Level 4 Level 5 Communicates with Customizes Explains complex and Facilitates difficult Mentors others in the patients and their communication in the difficult information to discussions with facilitation of crucial families in an setting of personal biases patients and patients’ patients and patients’ conversations understandable and and barriers with patients families families respectful manner and patients’ families

Provides timely updates Actively listens to patients Uses shared decision Effectively negotiates Mentors others in conflict to patients and patients’ and patients’ families to making to make a and manages conflict resolution families elicit patient preferences personalized care plan among patients, and expectations patients’ families, and the health care team

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills 2: Interprofessional and Team Communication

Level 1 Level 2 Level 3 Level 4 Level 5 Respectfully requests or Clearly, concisely and Uses closed-loop Coordinates Role models flexible receives consultations promptly requests or communication to verify recommendations from communication strategies responds to a understanding different members of that value input from all consultation the health care team to health care team optimize patient care members, resolving conflict when needed

Uses language that Communicates Adapts communication Maintains effective Leads an after-event values all members of information effectively style to fit team needs communication in crisis debrief of the health care the health care team with all health care team situations team members

Respectfully receives Solicits feedback on Communicates concerns Communicates Facilitates regular health feedback from the health performance as a and provides feedback to constructive feedback to care team-based care team member of the health peers and learners superiors feedback in complex care team situations

Comments: Not Yet Completed Level 1

Interpersonal and Communication Skills 3: Communication within Health Care Systems

Level 1 Level 2 Level 3 Level 4 Level 5 Accurately records Accurately records Accurately records Uses medical record Explores innovative uses information in the patient information in the information in the functionality to highlight of the medical record to record; demonstrates anesthetic record for anesthetic record and challenges in anesthetic facilitate peri-operative judicious use of basic cases communicates complex care to facilitate future management documentation shortcuts care decisions for peri-operative complex cases management

Safeguards patient Documents required data Appropriately selects Models exemplary Guides departmental or personal health in formats specified by direct and indirect forms written or verbal institutional policies and information institutional policy of communication based communication procedures around on context communication

Communicates through Respectfully Respectfully Uses appropriate Initiates difficult appropriate channels as communicates concerns communicates concerns channels to offer clear conversations with required by institutional about the system about the system and and constructive appropriate stakeholders policy contributes to solutions suggestions to improve to improve the system the system

Comments: Not Yet Completed Level 1