With an eye to creating medical educational and training programs that are relevant to a physician’s daily practice, in order to continuously improve medical training and health care, the Accreditation Council for Graduate Medical Education (ACGME) developed and recommended a set of skills that define a solid foundation of competence for the practicing physician. Adopted in 1999, these six ACGME Core Competencies are the skills and attributes that residents must achieve through medical training; more than that, these core competencies can be extremely helpful in refining the training programs themselves.

How Do the ACGME Core Competencies Help in Assessing Residents?

ACGME Core Competencies measure a resident’s ability to administer a high level of care to diagnose and treat illness, offer and implement strategies to continuously improve patient health and wellness, offer advice and resources to prevent disease in patients, and provide not only physical treatment, but also emotional support in caring for for patients and interacting  with patients’ families and support systems.

What Are the ACGME Core Competencies?

The six ACGME Core Competencies are as follows:

  • Practice-Based Learning and Improvement
  • Patient Care and Procedural Skills
  • Systems-Based Practice
  • Medical Knowledge
  • Interpersonal and Communication Skills
  • Professionalism

In Part 1 of this series, we listed the ACGME Core Competencies with a focus on EPAs (Entrustable Professional Activities) and Milestones. We went on to delve into Practice-Based Learning and Improvement, then Patient Care and Procedural Skills. In this post, we will discuss the ACGME Core Competency of Systems-Based Practice.

ACGME Core Competency: Systems-Based Practice

Systems-Based Practice is often seen as a relatively abstract concept for residents to master. Whereas most of the ACGME Core Competencies reflect what happens as a physician is interacting with patients on a day-to-day basis, this core competency focuses on the underpinnings of health care in a good medical practice: safety and quality in health care, physician advocacy, health insurance, health care economics, transitions of care, different health care systems, pay for performance, patient centered medical home, and chronic care. What do all of these diverse facets of medical practice have in common? They all operate by systems. In fact, it is safe to say that if good systems can make a medical practice, then bad systems can certainly break one.

Health care does not exist in a vacuum; as soon as residents graduate, they will be participating in the health care system as a whole: working in the health care field, operating under government regulations, dealing with health insurance, maintaining certification, and more. From the moment a physician makes an appointment with a new patient, he or she is participating in Systems-Based Practice. Therefore, residents must be aware of the health care systems in which they will operate and have the ability to provide high-quality, cost-effective medical care in the context of these systems and their attendant resources.

The ACGME Core Competencies: Systems-Based Practice Subcompetencies

Systems-Based Practice can be broken down into subcompetencies that represent the skills and attributes that a resident must demonstrate in order to show fulfillment of this ACGME Core Competency. These subcompetencies include the ability to:

  • Work effectively in various health care delivery settings and systems relevant to their clinical specialty
  • Coordinate patient care within the health care system relevant to their clinical specialty
  • Incorporate considerations of cost awareness and risk/benefit analysis in patient care
  • Advocate for quality patient care and optimal patient care systems
  • Work in interprofessional teams to enhance patient safety and improve patient care quality
  • Participate in identifying systems errors and in implementing potential systems solutions

Taken one by one, the subcompetencies of Systems-Based Practice make up the full picture of how a resident must learn to incorporate systems into their practice, and how they must also learn how to operate within (and perhaps even improve) the health care system in general. Residents must develop systems thinking; that is, they must understand how parts relate to a whole: how the system works, and how it can work better, with the ultimate goal of fewer errors and better performance. Using systems thinking, residents will approach problems with a goal of fixing the underlying system that causes the problem, not just creating a workaround that solves the problem at hand.

In order to work effectively in various health care delivery settings and systems relevant to their clinical specialty, residents must learn to work as part of a team, displaying good communication, engendering respect, and honing interpersonal skills. Working in various settings as related to their clinical specialty, residents will not only gain experience but also adaptability, which will serve them well as they learn how the systems work (or don’t work) in each of these settings. It will also help residents develop the skills necessary for the team approach that defines another subcompetency of Systems-Based Practice: the ability to work in interprofessional teams to enhance patient safety and improve patient care quality. At first, residents may be frustrated at the flaws in the system, but as they learn more, they should be able to move beyond frustration into the effective management of the system, and, finally, into the capability to amend and enhance these systems to increase patient safety and provide better quality medical care.

The next subcompetency of Systems-Based Practice is related to working in various health care delivery settings: a resident must demonstrate the ability to coordinate patient care within the health care system relevant to their clinical specialty. Again, strong communication skills will be necessary as a resident interacts not only with the patient but also with the patient’s family, caretakers, consultants, and fellow members of the medical care team. Add in service agencies, government resources, and health insurance, and a resident is now navigating the entire health care system for one patient. Health care decisions are often shared among these parties, and the resident must be able to take that into consideration. Residents will also need to exercise flexibility as situations change, requiring them to coordinate transition of care or understand the patient’s perspective as defined by his or her culture, education, and socioeconomic status.

A patient’s culture, education, and socioeconomic status will also come into play as a resident develops the following Systems-Based Practice subcompetency: incorporate considerations of cost awareness and risk/benefit analysis in patient care. A resident must be able to understand and weigh the risks and benefits of each procedure, treatment plan, and goal in patient care. They must then be able to communicate these risks and benefits to the patient in a way the patient will understand, advising and empowering the patient to make an appropriate decision. As the ACGME Core Competency of Systems-Based Practice is focused on delivering cost-effective medical care through improved systems, a resident who demonstrates this subcompetency will not just be aware of costs but be on the lookout for ways to alleviate them. Treatment costs may be mitigated through alternative treatment solutions, management of out-of-pocket costs, and solutions from available resources.

Often, it is cost awareness that prompts a physician to fight for what they know a patient needs, so a resident must be able to advocate for quality patient care and optimal patient care systems. The health care system is increasingly complex, and an important part of the physician’s role is to help patients understand and maneuver in it. However, residents must be inspired to do more than just work within the current system. Physicians can advocate for their patients through their professional organizations, which all have advocacy resources available; by becoming a health care advisor for policy makers; by interfacing with media to provide expert information for health care–related stories; and by leading initiatives within the health care field itself. All these activities and more show the physician as a force for change in the health care industry, fulfilling this subcompetency.

A better understanding of systems thinking will help residents demonstrate the ability to participate in identifying system errors and in implementing potential systems solutions. The subcompetencies of Systems-Based Practice show a resident moving along the path from understanding the system to seeing its flaws, advocating for change, and effecting that change. When errors occur, it is important not to blame others — the key is to find out why the error occurred, and how systems can be improved to reduce or eliminate such errors, therefore improving the quality of health care as a whole.

The ACGME Core Competency of Systems-Based Practice: A Necessary Mindset

Although the ACGME Core Competency of Systems-Based Practice is sometimes seen as esoteric and challenging to teach and to learn, it is an essential piece of medical training. At its heart is a simple concept: that in the case of many injuries and medical errors, the system is often at fault, and by fixing the system, these errors and injuries can be decreased or even eradicated.  Residents must recognize that their role as physician within the health care system carries a responsibility to the wider world. It is not simply about the patient or the problem in front of them; rather, it is about how a physician can understand, navigate, and improve the system. Understanding the system and their role in it will enable residents to seek out  ways to change the system for the better, resulting in improved safety and health care for the population.

Read more about the six ACGME Core Competencies: