200
If healthcare spending continues to grow at a rate projected to be 5.8% from 2014
to 2024, this will lead to $5.4 trillion in expenditures by 2024 and represent 19.6%
of the gross domestic product [ 39 ]. Several studies have documented the association
of perioperative complications with increased hospital costs, increased length of
stay, and decreased hospital profit margins [ 10 , 19 , 20 , 33 , 56 , 78 ].
In addition to hospital costs, healthcare expenditures may also be reduced by
savings in malpractice claims. According to the most recent data available from the
Centers for Disease Control and Prevention published in 2007, an estimated 100
million surgical procedures are performed each year in the United States, including
53.3 million ambulatory and 45.0 million inpatient surgical procedures [ 16 , 32 ].
Surgical never events are defined as errors in surgical care that experts agree are
always avoidable; these events include retained foreign body, wrong-site, wrong-
patient, and wrong- procedure events [ 15 , 27 , 31 , 46 , 52 , 64 , 67 ]. A study published
in 2013 by Mehtsun et al. [ 51 ] utilized the National Practitioner Data Bank to
identify malpractice settlements and judgments of surgical never events. The
authors identified 9733 paid malpractice settlements and judgments for surgical
never events over a period of 20 years, with malpractice payments totaling $1.3
billion. Based on their findings, the authors estimated that more than 4000 surgical
never events likely occur each year in the United States and acknowledged that the
actual number of surgical never events is likely higher, as many events likely go
unreported. Furthermore, the malpractice payments do not take into account the
additional financial burden of legal fees, disability care, lost work days, or harm to
provider and hospital reputation.
ACGME Core Curriculum
In 1999, the Accreditation Council for Graduate Medical Education (ACGME) and
the American Board of Medical Specialties partnered to approve six general compe-
tencies that they deemed relevant to all medical specialties [ 4 ] as follows: patient
care, medical knowledge, professionalism, interpersonal and communication skills,
practice-based learning and improvement, and system-based practice. This was
later followed by the official launch of the Outcomes Project in 2001, which empow-
ered training programs to transition to an outcome-based (i.e., competency-based)
medical education. Recognizing that implementation of the core competencies was
difficult for programs that lacked models to teach, implement, and assess this new
curriculum, the ACGME moved the accreditation system to focus on a continuous
quality improvement philosophy [ 54 ]. Beginning in 2007, the specialties of internal
medicine, pediatrics, and surgery created developmental milestones to provide a
more detailed framework to assess the six competencies [ 30 , 62 , 69 ], which were
gradually expanded to include all specialties by 2014.
According to the ACGME, the purpose of the milestones is to guide curriculum
development, to provide well-defined learning objectives, and to identify underper-
forming learners early to support timely intervention. For residents and fellows,
ACGME milestones are intended to increase transparency of performance
S. Helo and C. Welliver