A Joint Initiative of - ACGME · PDF fileThe Hematology Pathology Milestone Project A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American

The Hematology Pathology Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Pathology

July 2015

i

The Hematology Pathology Milestone Project

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.

ii

Hematology Pathology Milestones

Chair: Mark Brissette, MD

Working Group Advisory Group

Magdalena Czader, MD, PhD C. Bruce Alexander, MD

Laura Edgar, EdD, CAE Julia C. Iezzoni, MD

Raymond E. Felgar, MD, PhD Rebecca Johnson, MD

Steven H. Swerdlow, MD Wesley Y. Naritoku, MD, PhD

iii

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.

iv

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.

http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf

v

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

between levels indicates that milestones in

lower levels have been substantially

demonstrated as well as some milestones in

the higher level(s).

Selecting a response box in the middle of

a level implies that milestones in that

level and in lower levels have been

substantially demonstrated.

Version 5/2014 Hematology Pathology Milestones: ACGME Report Worksheet

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 Hematology Pathology Milestones on a non-exclusive basis for education purposes. 1

PC1 — Consultation: Analyzes, appraises, formulates, generates, and effectively reports consultation

Level 1 Level 2 Level 3 Level 4 Level 5

Understands the use of test

results in generating a

consultative report

Answers basic

hematopathology

questions with assistance

Prepares a draft consultative

report (verbal or written)

Answers routine

hematopathology questions,

drawing upon appropriate

resources

Prepares a full consultative

report with a written opinion

for common diseases under

supervision

Answers more complex

hematopathology questions,

drawing upon appropriate

resources

Independently prepares a

full consultative written

report with comprehensive

review of medical records on

common and uncommon

hematopathology disorders

Suggests evidence-based

management, prognosis, and

therapeutic

recommendations based on

the consultation

Proficient in

hematopathology

consultations with

comprehensive review of

medical records

Proficient at answering

complex hematopathology

questions

Comments:

Not yet achieved Level 1




PC2 — Reporting: Integrates complex data to generate accurate, complete but concise, easily understood, and timely reports


Brings appropriate materials, clinical history, and results of ancillary studies to sign-out Constructs report with assistance of attending staff that ultimately may still need significant corrections and editing, but which is grammatically correct Is aware of importance of turn-around times and general expectations

Brings appropriate materials, clinical history, and results of ancillary studies, together with formulated written interpretations, to sign-out Accesses and prepares material from literature needed for informative report Composes a microscopic description that may require editing Formulates a full written report, incorporating results from a multiparameter analysis, following sign-out; report may still need some corrections and editing Completes work to accommodate acceptable turn-around times Explains non-complex findings in reports to clinicians with oversight from staff

Brings a completed report to sign-out, incorporating all elements from a multiparameter approach and including integration of literature into report, as appropriate Prepares a complete microscopic description, even for more complex cases, requiring minimal, if any editing Prepares a report for non-complex cases requiring minimal, if any, corrections/editing; complex cases may require more staff input Assists more junior learners with preparation of accurate and complete reports Accepts responsibility for acceptable turn-around times Explains non-complex findings in reports to clinicians with limited coaching

Independently prepares a complete, easily understood report with accurate diagnosis for non-complex and moderately complex cases that requires minimal, if any, editing and corrections Prepares complete report for complex cases that highlights areas where additional consultation is required Prepares reports within departmental turn-around time guidelines Explains non-complex findings in reports to clinicians independently and complex findings with limited coaching Trains more junior pathologists in how to write high quality reports

Proficient at writing accurate and concise reports in non-complex and complex cases Explains complex findings in report to clinicians without guidance and with high satisfaction levels

Comments: Not yet achieved Level 1




PC3 — Procedure: Performing bone marrow aspiration and biopsy


Understands

procedures, and the

resultant specimens

and potential

complications

Understands the need

to evaluate adequacy of

bone marrow

aspirate/biopsy and to

triage bone marrow

material for ancillary

studies

Aware of a need to

obtain informed

consent, and observes

obtaining of informed

consent by other

service providers

Is aware of indications and

contraindications for

procedures, and follows

protocols and regulations

Participates in simulated

experience in bone marrow

aspiration/biopsy, including

slide preparation and staining;

actively observes and assists at

bone marrow aspiration/biopsy

procedures

Actively observes obtaining of

informed consent

Discusses with pathology

attending staff members any

requests that are

contraindicated

Assesses specimen and

procedure adequacy

Able to perform the

procedures and procure

adequate specimens with

supervision; consistently logs

bone marrow procedures in

the ACGME Case Log System

Efficiently triages bone

marrow material for ancillary

studies

Obtains informed consent

under supervision

Able to perform procedures with

minimal supervision

Competent in accurate

assessment of adequacy of bone

marrow aspirate/biopsy and in

efficient triage of bone marrow

material for ancillary studies

Competent in obtaining

informed consent independently

Performs bone marrow

aspiration/biopsy

independently

Proficient in accurate

assessment of adequacy

of bone marrow

aspirate/biopsy and in

efficient triage of bone

marrow material for

ancillary studies

Proficient in obtaining

informed consent

Comments:





MK1 — Interpretation of clinical laboratory hematology testing


Knows basics of normal

hematopoietic and

lymphoid systems,

coagulation system, and

immunologic concepts

Understands basic

methods used in varied

aspects of laboratory

hematology and other

hematopathology-related

testing (flow cytometry,

cytogenetic analysis, and

molecular testing) and the

concept of test utilization

Knows definitions of

common lab hematology

tests and expected test

results in non-disease

situations

Interprets individual

abnormal results and

suggests appropriate follow-

up testing

Knows implications of

clusters of tests in non-

complex situations

Knows basic laboratory

findings for major and less

common benign and

malignant hematologic

disorders, those in their

differential diagnosis, and

those that impact

hematologic parameters

based on standard texts

Draws upon more current

literature to enhance

interpretation on a case by

case basis

Suggests appropriate panel of

hematologic testing for non-

complex situations and knows

how to interpret the results and

the clinical/therapeutic

implications

Suggests appropriate follow-up

testing for abnormal results of

common tests

Discusses implications of

clusters of tests in more

complex situations

Troubleshoots aberrant-

appearing results

Knows standard and more

state-of-the art issues related

to major and less common

hematologic disorders, those in

their differential diagnosis, and

those that impact hematologic

parameters, having integrated

current literature with what is

in standard texts

Independently demonstrates

knowledge of appropriate

panel of hematologic testing

for majority of situations,

interprets the results and

knows the clinical/

therapeutic implications

Knows how to obtain

consultation to deal with the

most complex cases

Demonstrates in-depth

knowledge of normal and

abnormal hematopoiesis/

lymphopoiesis and

hemostasis together with

how non-hematopoietic

disorders affect the

hematopoietic/lymphoid

system and hemostasis

Proficient at selecting and

interpreting hematologic

testing, including

knowledgeable of its clinical

implications

Demonstrates knowledge

of active areas of

investigation related to

hematologic disorders that

may have clinical

implications in the future

Serves as an expert

consultant for general

pathologists and clinicians

Comments:





MK2 — Teaching


Actively observes teaching

of other learners and

medical technologists

Assists in teaching other

learners diagnostic

hematopathology

Actively teaches other

learners diagnostic

hematopathology

Participates in education of

medical technologists and

other health care personnel

Teaches medical students

Independently teaches other

learners, medical technologists,

and other health care personnel

diagnostic hematopathology

Teaches diagnostic

hematopathology to other

fully-trained pathologists

Develops educational

programs for technologists

Comments:





MK3 — Interprets and demonstrates diagnostic knowledge for tissue-based specimens and peripheral blood and fluid samples requiring an “anatomic”

diagnosis


Understands basic methods

used in diagnostic

hematopathology

(morphology, flow

cytometry, molecular/

cytogenetic testing)

Knows criteria for major

benign and malignant

hematopathologic

disorders and those in their

differential diagnosis based

on standard texts

Is able to access basic


interpretation

Knows what ancillary testing

to order in non-complex

cases

Interprets individual

components used in


and draws tentative

conclusions in non-complex

cases

Knows criteria for less

common benign and

malignant hematopathologic

disorders and those in their

differential diagnosis based

on standard texts

Draws upon more current


diagnostic interpretation on a

case-by-case basis

Knows what ancillary testing

to order in non-complex and

more complex cases

Incorporates all elements

from a multiparameter

approach, including

integration of literature into a

diagnosis in non-complex

cases and provides a limited

differential diagnosis in more

complex cases

Knows current issues related

to major and less common

benign and malignant

hematopathologic disorders

and those in their differential

diagnosis, having integrated

current literature with what

is in standard texts

Orders appropriate ancillary

testing required to make

definitive and precise

diagnoses

Independently arrives at

definitive diagnoses in the

majority of cases, and knows

how to obtain consultation

to deal with the most

complex cases

Proficient at analyses of

ancillary tests utilized in


Proficient at using

multiparameter approach to

make hematopathologic

diagnoses even in complex

circumstances

Knows active areas of

investigation related to

hematopathologic disorders

that may have clinical

implications in the future

Comments:





MK4 — Hematology Knowledge: Demonstrates attitudes, knowledge, and practices that incorporate evidence-based medicine and promote life-long

learning


Demonstrates knowledge

of major hematopathology-

related non-neoplastic and

neoplastic conditions faced

by general practice

pathologists

Demonstrates general

knowledge of normal

histology of peripheral

blood, lymph node, bone

marrow, spleen, and other

lymphoid tissues

Demonstrates basic

knowledge of coagulation

Demonstrates general

knowledge of more

specialized and rare


non-neoplastic and

neoplastic conditions, but

may not always consider

them in diagnosing cases

Demonstrates competence in

knowledge of normal

histology of peripheral blood,

lymph node, bone marrow,

spleen, and other lymphoid

tissues

Demonstrates competence in

knowledge of normal

coagulation

Demonstrates more

extensive knowledge of most


non-neoplastic and

neoplastic conditions

Understands clinical

implications of most

diagnoses

Consults medical literature

and colleagues when faced

with knowledge gap

May not always realize the

limitations of his/her disease-

based knowledge

Demonstrates competence

in knowledge in


non-neoplastic and

neoplastic conditions and

competence to practice

hematopathology

independently

Effectively consults medical

literature and colleagues

when faced with knowledge

gap

Knows own limitations

Demonstrates proficiency in

knowledge of


non-neoplastic and

neoplastic conditions

Actively keeps abreast of

progress in

hematopathology

Comments:





SBP1— Regulatory


Understands that

laboratories are regulated

by state, federal, and

professional organizations

Understands the use of

proficiency testing

Understands the basics of

quality assurance

Demonstrates compliance

with national regulations

for patient privacy and

confidentiality (e.g.,

HIPAA, state laws,

institutional policies)

With substantial guidance

implements state, federal,

and professional

organizations standards or

elements of checklists in the

laboratory

Reviews proficiency testing

results

With minimal guidance,

implements state, federal,

and professional

organizations standards or

elements of checklists in the

laboratory

Able to implement corrective

action based on proficiency

testing results

Participates as a team

member in mock or actual

inspection of a laboratory, or

equivalent (e.g., tracers, self-

inspection)

Actively participates in, or

performs, inspections of a

laboratory at an outside

facility

Able to lead an inspection of

a laboratory

Comments:





SBP2 — Health care teams


Understands the

importance of the

pathologist’s role in the

health care team


plays a role in the health care

team (e.g., case presentation,

consultation, test selection

guidance)

With minimal guidance plays

a role in the health care team

(e.g., case presentation,


guidance)

Independently plays a role in

the health care team (e.g.,

case presentation,


guidance)

Effectively plays a lead role

in the health care team

(e.g., case presentation,


guidance)

Comments:

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


Aware of the roles of a

pathologist in managing

personnel; interprets an

organizational chart

Recognizes different

budget types (e.g., capital

vs. operating budget)

Knows the personnel and

lines of reporting in the

laboratory

Describes the elements of a

budget (e.g., personnel,

capital equipment)

Describes the process of

personnel management and

employment laws (e.g.,

interview questions, Family

and Medical Leave Act,

termination policies)

Understands the basics of

pathology practice finance

(e.g., Part A and Part B,

Centers for Medicare &

Medicaid Services [CMS])

Participates in employee

interviews/performance

evaluation (real or simulated

experiences)

Participates in a budget cycle

exercise (draft, defend, and

propose logical cuts and/or

additions)

Manages personnel

effectively

Develops a budget

Comments:






SBP4 — Lab Management: Test Utilization: Explains, recognizes, summarizes, and is able to apply test utilization


Understands need for test

utilization review and

assessment of

inappropriate test orders

Identifies inappropriate test

ordering

Reviews test utilization

literature in

hematopathology

Intervenes in inappropriate

test ordering with supervision

Intervenes in inappropriate

test ordering independently

Identifies areas of potential

lab test overutilization

Independently intervenes in

over-utilization situations

Completes a test utilization

review project

Comments:





PBLI1 — Scholarly Activity


Has knowledge of the basic

principles of research

(demographics, IRB, human

subjects), including how

research is conducted,

evaluated, explained to

patients and applied to

patient care

Applies evidence-based

medicine in presentations

such as at journal club and,

as appropriate, identifies

research project early in

fellowship

Educates others through

hematopathology journal

clubs

Applies evidence-based

medicine in presentations at

local or regional meetings

Completes research project

if undertaken

Prepares for and presents at

national or international

meetings

Prepares and submits

articles for peer-reviewed

publications

Comments:

PBLI2 — Evidence-based Utilization


Understands the

importance of evidence-

based utilization of

laboratory tests and

results

With substantial guidance,

critically reviews the

literature addressing

evidence-based utilization of

laboratory tests and results


critically reviews the


evidence-based utilization

of laboratory tests and

results

Independently performs a

critical review of the


evidence-based utilization of


and designs utilization

guidelines

Implements institutional

utilization guidelines for


Comments:






PBLI3 — Process Improvement and Patient Safety


Demonstrates awareness

of common sources of

error in laboratory

processes and transitions

in care

Understands the

importance of identity and

integrity of the specimen

and requisition form, and

verifies the identity

Consistently demonstrates

work habits that minimize

error; consistently and

promptly communicates

discrepancies to clinicians

Consistently checks identity

and integrity of specimen;

independently obtains

clinical information when

needed; incorporates other

resources, such as EMR and

radiology; handles deviations

from policies (waivers) with

supervision

Contributes to practice

change based on an

identified error or

systematic problem (e.g.,

post-analytic, pre-analytic,

laboratory, or

interpretative)

Trouble-shoots pre-analytic

problems, including

deviations from policies

(waivers) with minimal

supervision

Participates in and completes

a laboratory quality

improvement project

Trouble-shoots patient safety

issues (including pre-analytic,

analytic and post-analytic)

Routinely uses identified

errors and discrepancies to

improve practice and

laboratory processes

Models patient safety

practices; able to write and

implement policies on

patient safety; completes

MOC patient safety module

Comments:





PROF1 — Receives and provides feedback


Receives feedback

constructively

Modifies practice in response

to feedback

Consistently receives

feedback and modifies

practice

Modifies and maintains

changes in practice based on

feedback

Provides constructive feedback

Encourages and actively

seeks and provides feedback

to improve performance

Comments:

PROF2 — Demonstrates accountability, honesty, and integrity


Completes assigned tasks

on time

Is honest and understands

the concepts of ethical

behavior; seeks counsel

when ethical questions

arise

Reliably completes assigned

tasks in a timely manner;

assists team members when

requested; respects assigned

schedules

Acknowledges personal

limitations, near misses and

errors, and puts the needs of

patients first; engages in

ethical behavior

Anticipates team needs and

steps in to assist as needed

Identifies personal

limitations and takes

responsibility for errors

Anticipates team needs and

takes leadership role to

independently implement

solutions

Institutes corrective measures

for errors

Is viewed by members of the

health care team as accepting

of personal responsibility, and

as always putting the needs of

the patient above his/her own

interests

Exemplifies effective

management of multiple

competing tasks, with

reliable follow-up; is source

of support/guidance to

other members of health

care team

Comments:






PROF 3 — Cultural Competency


Respects diversity and

autonomy; recognizes

vulnerable populations

Embraces diversity and

respects vulnerable

populations; aware of

potential for bias or cultural

differences to affect care and

the workplace

Understands and complies

with institutional policies

affecting cultural

competency

Demonstrates cultural

competency; recognizes

cultural differences that

may affect care and the

workplace and identifies

and avoids biases

Exemplifies cultural

competency; recognizes

cultural differences, identifies,

and avoids biases that may

affect care and the workplace

Models cultural

competency, recognizing

cultural differences that

may affect care and the

workplace; works with peers

to avoid biases

Comments:





ICS1 — Communicates with health care providers, families, and patients


Understands the

importance of timely and

effective communication

with health care

providers, families and

patients (as applicable)

Understands that the

written report is a form of

communication that must

be clear and

understandable

Effectively utilizes the

electronic health record


provides timely and effective

communication with health

care providers, families, and



produces a clear and

understandable written

report


provides timely and

effective communication

with health care providers,

families, and patients (as

applicable)


produces a clear and

understandable written

report

Effectively communicates

complex, difficult, or

challenging information (e.g.,

errors, complications, adverse

events, and bad news)

Independently and

consistently produces a clear

and understandable written

report

Serves as a role model for

effective and professional

communication to health

care providers, families, and


Comments:

ICS2 — Personnel Management and Conflict Resolution


Understands the

importance of conflict and

complaint resolution


manages conflicts and

complaints

With minimal guidance

manages conflicts and

complaints

Independently manages

conflicts and complaints

Anticipates, mitigates and

manages potential conflicts

and complaints

Comments:



A Joint Initiative of - ACGME · PDF fileThe Hematology Pathology Milestone Project A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American

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