Curated Milestones Evaluation Exhibit

Baystate Ambulatory Advancement Passports

Michael J. Rosenblum, MD, and Sudeep K. Aulakh, MD
Baystate Health

Program Size: 31-100 residents
Academic Setting: Community-Based
Clinical Setting: Outpatient continuity clinic


To help us objectively assess the competencies essential for ambulatory advancement we developed the Learner Advancement Passport (LAP), Manager Advancement Passport (MAP) and Teacher Advancement Passport (TAP).

At Baystate we adopted a competency-based progression model for ambulatory training in 2006. This model has three phases: Learner, Manager, and Teacher. Each phase allows increasing autonomy in the residents’ ambulatory practice.

We identified key transitions in ambulatory training and defined the essential elements required for advancement. We created the advancement passports based on these elements which reflect the ACGME/ABIM milestones using direct observation and multisource input.

One fundamental and critical transition is from direct to indirect supervision. LAP reflects key elements learners (interns) need to demonstrate before we allow them to see patients without direct supervision. The second key transition is when residents may safely discharge patients to home prior to precepting. MAP helps assess the skills required to do so safely. The third key transition is when residents progress to leadership roles. TAP helps assess academic and clinical leadership as well as clinical care skills. Upon completion, residents may see multiple patients; send appropriate individuals home and precept at the end of the session, creating a more “realistic” experience of “unsupervised practice." Teaching skills are directly observed during our ambulatory morning report and noon conferences as well as through resident-as-preceptor sessions.

LAP and MAP are divided into the six core competencies with multiple tasks for each competency. The TAP is divided into the three sections with multiple tasks for each.

They require direct observation, multiple observations (usually 4-5) and input from multiple team members; faculty, nurses, medical assistants, interpreters.

The passports are longitudinal assessment tools that facilitate direct observation and help inform milestones in the ambulatory setting. These tools clearly define expectations for successful resident advancement within our model and are an integral component of our assessment system. Our Learners (Interns) must complete LAP before they are allowed to see patients with indirect supervision. Our Managers must complete MAP before they are permitted to send patients home prior to discussing the case with their preceptor. Our Teachers must complete TAP before they are allowed to send a group of patient’s home prior to discussion with their team attending.

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