Physician Accountability for Physician Competence

The Alliance for Good Medical Practice

Related Information

The following resources are related to the various Summits. These documents can provide some history and context for ongoing discussions.

This document can be used as a briefing document for the whole initiative.


Summit I

Solving Tough Problems
An Open Way of Talking, Listening, and Creating New Realities
by Adam Kahane

Summary document
Containing the scenarios developed during the first Summit and distributed to the participants afterwards

Summit I Documentation
Summit I was held in March 2005 in Dallas, TX. This link is to the complete documentation developed at that summit.


Summit II

One From Many
VISA and the Rise of Chaordic Organization
by Dee Hock

Summit II Talking Points
Talking points developed after Summit II

Draft Table of Contents for Good Medical Practice
During Summit II participants developed a first draft definition of competence and a table of contents for Good Medical Practice

Summit II Documentation
Summit I was held in December 2005 in Chicago, IL. This link is to the complete documentation developed at that summit.

Summit III

Matrix of Key Quality Organizations - October 2005
This chart contains information about a number of national initiatives underway that seek to improve the quality and efficiency of patient care through the use of clinical performance measures. Source: The ABIM Foundation.

The following articles expose several of the existing conversations about Quality that are relative to physician competence.

The Movement for Improved Quality in Health Care
The New England Journal of Medicine, February 11, 1999

A Research Agenda For Bridging The ‘Quality Chasm’
Bridging the quality chasm requires a marriage between research and action.
by Rushika Fernandopulle, Timothy Ferris, Arnold Epstein, Barbara McNeil, Joseph Newhouse, Gary Pisano, and David Blumenthal
HEALTH AFFAIRS ~ Volume 22, Number 2, March/April 2003

Establishing Healthcare Performance Standards in an Era of Consumerism
by Kenneth W. Kizer, MD, MPH
JAMA September 12, 2001 – Vol. 286, No. 10

Five Years After To Err Is Human What Have We Learned?
by Lucian L. Leape, MD and Donald M. Berwick, MD
JAMA, May 18, 2005—Vol 293, No. 19

All-or-None Measurement Raises the Bar on Performance
by Thomas Nolan, PhD and Donald M. Berwick, MD, MPP
JAMA, March 8, 2006—Vol 295, No. 10

Paying For Quality: Providers' Incentives For Quality Improvement
An assessment of recent efforts to align providers' incentives with the quality improvement agenda
by Meredith B. Rosenthal, Rushika Fernandopulie, HyunSook Ryu Song, and Bruce Landon
HEALTH AFFAIRS - Volume 23, Number 2

How Good Is the Quality of Health Care in the United States?
The Milbank Quarterly, Vol. 83, No. 4, 2005 (pp. 843–95)

Summit IV

Good Medical Practice Draft

National Alliance for Physician Competence Proposal
Containing the draft proposal for the creation of the National Alliance for Physician Competence

Portfolio System Outline
A Physician Learning and Continuous Improvement System (PLACIS) to Support Lifelong Learning and External Reporting Requirements – DRAFT DOCUMENT October 27, 2006

Constitution of Chaordic Commons, Inc
This document is the constitution for a chaordic alliance created by Dee Hock and his group the Chaordic Commons.

Patients’ Perspectives on Ideal Physician Behaviors - NEELI M. BENDAPUDI, PHD; LEONARD L. BERRY, PHD; KEITH A. FREY, MD, MBA; JANET TURNER PARISH, PHD; AND WILLIAM L. RAYBURN, MD • Mayo Clin Proceedings• March 2006;81(3):338-344

Human Values as Strange Attractors: Coevolution of classes of governance principle - Paper prepared for the 13th World Conference (Finland, August 1993) of the World Futures Studies Federation (WFSF). Theme: Coherence and chaos in our uncommon futures -- visions, means, actions. Scheduled for presentation to the group "Creativity and Actors in Chaos". An abridged version entitled Values as Strange Human Attractors appeared in UNiS Journal (Dramatic University), 5, 1994, 3, pp 12-30

Thriving at the Edge of Chaos: What HealthCare Organizations Can Learn from Complexity Science - By: Sheri M. Gon (School of Public Health) Spring 2000

Working Paper: Some Emerging Principles for Managers of Complex Adaptive Systems (CAS) - by Paul E. Plsek © 1997 Paul E. Plsek & Associates, Inc. All rights reserved. Updated 23 September 1997. Uploaded to Internet 5 November 1997.

Complexity Theory: Fact-free Science or Business Tool? By David Berreby - Strategy & Business, 1st Quarter 1998 - Complexity theory is at the forefront of science and math. It is being used to map biological events and forecast earthquakes. Can it be useful in manufacturing? The answer is yes, but ...

Discovery Workshop

Innovation and Creativity

The Structure of Good Ideas
Keith Sawyer • June 22, 2007
I’ve just been reading a fascinating new doctoral dissertation by a recent Ph.D. from Washington University’s Olin School of Business: Chihmao Hsieh, now a professor at the University 0f Missouri. He asks a fascinating question about innovation: what is the structure of successful new ideas? If that sounds abstract, I’ll try to explain by drawing on some of the research from my book GROUP GENIUS.

Genetic Algorithms
Genetic algorithms are one of the best ways to solve a problem for which little is known. They are a very general algorithm and so will work well in any search space. All you need to know is what you need the solution to be able to do well, and a genetic algorithm will be able to create a high quality solution. Genetic algorithms use the principles of selection and evolution to produce several solutions to a given problem.

Genetic Algorithms (2)
by John H. Holland
Computer programs that "evolve" in ways that resemble natural selection can solve complex problems even their creators do not fully understand Living organisms are consummate problem solvers. They exhibit a versatility that puts the best computer programs to shame. This observation is especially galling for computer scientists, who may spend months or years of intellectual effort on an algorithm, whereas organisms come by their abilities through the apparently undirected mechanism of evolution and natural selection.


The See-Through CEO
Fire the publicist. Go off message. Let all your employees blab and blog. In the new world of radical transparency, the path to business success is clear.
By Clive Thompson • Wired Magazine Issue 15.04 - March 2007
Pretend for a second that you're a CEO. Would you reveal your deepest, darkest secrets online? Would you confess that you're an indecisive weakling, that your colleagues are inept, that you're not really sure if you can meet payroll? Sounds crazy, right? After all, Coke doesn't tell Pepsi what's in the formula. Nobody sane strips down naked in front of their peers. But that's exactly what Glenn Kelman did. And he thinks it saved his business.

Complexity and Healthcare

Education and debate • Complexity science
Coping with complexity: educating for capability
This is the last in a series of four articles
Sarah W Fraser, visiting professor, Middlesex University; Trisha Greenhalgh, professor of primary health care
Recent high profile scandals in the United Kingdom have highlighted the changing values by which the National Health Service is judged.1 The public expects, and the government has promised to deliver, a health service that is ever safer, constantly up to date, and focused on patients' changing needs. Successful health services in the 21st century must aim not merely for change, improvement, and response, but for changeability, improvability, and responsiveness.

Electronic Health Record Use and the Quality of Ambulatory Care in the United States
by Jeffrey A. Linder, MD, MPH; Jun Ma, MD, RD, PhD; David W. Bates, MD, MSc; Blackford Middleton, MD, MPH, MSc; Randall S. Stafford, MD, PhD • ARCH INTERN MED/ VOL 167 (NO. 13), JULY 9, 2007
Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. We assessed the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey.

The Practice of Medicine is in the Interactions: A Day with Robert A. Lindberg, M.D.
by Arvind Singhal • Plexus Institute
On the second floor of a plain-looking office building on 1500 Post Road in Darien, Connecticut, an unremarkable door announces the medical practice of Robert A. Lindberg, M.D. In the small reception area, a courteous employee sitting behind the counter extends a greeting as she signs a patient in. Soon, a patient -- a Mr. Rodriguez, or a Mrs. Crawford – is ushered from the reception area, through a door, into a long corridor lined with several examining rooms.

The Wisdom of Crowds

What Is Crowdsourcing?
by Jennifer Alsever • BNET
Despite the jargony name, crowdsourcing is a very real and important business idea. Definitions and terms vary, but the basic idea is to tap into the collective intelligence of the public at large to complete business-related tasks that a company would normally either perform itself or outsource to a third-party provider. Yet free labor is only a narrow part of crowdsourcing's appeal. More importantly, it enables managers to expand the size of their talent pool while also gaining deeper insight into what customers really want.

Innocentive: Crowdsourcing Diversity
What starts with the crowd ends in research and development
Randy Burge interviews Alpheus Bingham, co-founder of Innocentive, via telephone on May18th
Alpheus Bingham knew something big had to shift in the way invention and innovation happened at pharmaceutical giant, Eli Lilly. A top R&D executive at Lilly in the mid 1990s, Bingham, along with others, struggled to devise new ways to leverage knowledge to reduce the ridiculously high costs of developing new medicines.

Explaining the Wisdom of Crowds: Applying the Logic of Diversity
by Michael J. Mauboussin, Legg Mason Capital Management
Understanding diversity and leveraging its potential requires deeper understanding than we currently possess. We won’t get far with compelling anecdotes and metaphors . . . We need a logic of diversity.

Diverse Perspectives - How we See Things
Chapter 1 of The Difference by Scott Page
We all differ in how we see and interpret things. Whether considering a politician’s proposal for changes in welfare policy, a new front-loading washing machine, or an antique ceramic bowl, each of us uses a different representation. Each of us sees the thing, whatever it is, in our own way. We commonly refer to the ways we encode things as perspectives. But if asked what a perspective is, most of us would have only a crude idea. In this chapter I provide a formal definition, but before I get to that I’ll present an example of a famous perspective: the periodic table.

Research on Collective Decision Making
Los Alamos National Laboratory
What do riots, stampedes, Kool-Aid cults and black market Tuesday have in common? They are all collective decisions. These failed flashes of human potential can now be made successful through a variety of ignorant aggregation systems. Collective decision making systems utilize non-confrontational computer interfaces to facilitate the appropriate combination of the diverse bits of information and insight contained within us all. Here’s to white market Fridays!


John Holland on Emergence
John Holland answered viewer questions about the concept of emergence on July 16, 2007. One of the world's leading experts on emergence, John Holland is a professor of Psychology as well as of Computer Science and Engineering at the University of Michigan. He is also an external professor and member of the Board of Trustees at the Santa Fe Institute, a MacArthur Fellow, and a Fellow of the World Economic Forum. His two most recent books are Emergence: From Chaos to Order (Oxford University Press, 2000) and Hidden Order: How Adaptation Builds Complexity (Helix Books, 1996). Forty-nine students have received Ph.D.'s under his guidance.

PlexusCalls: Change in Complex Systems
Jun, 2003 - Allen, Peter
Peter will share with us his insights on the notion of change in relation to complex systems. For almost 20 years, Peter has been working on the modelling of change through mathematics and innovation in social, economic, financial and ecological systems. In addition, he has been working on the development of integrated systems models linking the physical, ecological and socio-economic aspects of complex systems as a basis for improved decision support systems.

What is complexity science, really?
Steven E. Phelan • University of Texas at Dallas
The need for a special issue of Emergence on the question “What is complexity science?” is disturbing on several levels. At one level, one could be forgiven for thinking that the voluminous literature generated in recent years on chaos and complexity theory must contain a clear exposition on the definition, mission, and scope of complexity science. That this exposition has not been forthcoming, or is the subject of controversy, is disconcerting. On another level, the inability to clearly differentiate science from pseudoscience in complexity studies is also problematic. Allowing pseudo-science to penetrate a field of study lowers the credibility of that field with mainstream scientists and hinders the flow of resources for future development.

Complexity Theory and Al-Qaeda: Examining Complex Leadership
Russ Marion & Mary Uhl-Bien • EMERGENCE, 5(1), 54–76 2003
[Osama bin Laden is] a product of a new social structure. A new social feeling in the Muslim world. Where you have strong hostility not only against America, but also against many Arab and Muslim regimes who are allying to America ... And that’s why if bin Laden was not there, you would have another bin Laden. You would have another name, with the same character, with the same role, of bin Laden now. That’s why we call it a phenomena not a person.

Complexity, Pattern, and Evolutionary Trade-Offs in Animal Aggregation
by Julia K. Parrish and Leah Edelstein-Keshet • SCIENCE VOL 284 2 APRIL 1999
One of the most striking patterns in biology is the formation of animal aggregations. Classically, aggregation has been viewed as an evolutionarily advantageous state, in which members derive the benefits of protection, mate choice, and centralized information, balanced by the costs of limiting resources. Consisting of individual members, aggregations nevertheless function as an integrated whole, displaying a complex set of behaviors not possible at the level of the individual organism. Complexity theory indicates that large populations of units can self-organize into aggregations that generate pattern, store information, and engage in collective decision-making. This begs the question, are all emergent properties of animal aggregations functional or are some simply pattern? Solutions to this dilemma will necessitate a closer marriage of theoretical and modeling studies linked to empirical work addressing the choices, and trajectories, of individuals constrained by membership in the group.

Large System Change

Leverage Points: Places to Intervene in a System
by Donella Meadows • Sustainability Institute 1999
Folks who do systems analysis have a great belief in 'leverage points.' These are places within a complex system (a corporation, an economy, a living body, a city, an ecosystem) where a small shift in one thing can big changes in everything.

Lessons of the Last Bubble
by Tim Laseter, David Kirsch, and Brent Goldfarb • 03/26/07 Strategy+Business
Quiz time: What percentage of dot-com start-ups have failed?

Deming's System of Profound Knowledge: Elements and Applications
by Robert Lamb • Process Management International (Australia)
Deming's "System of Profound Knowledge" suggests four key elements that underpin successful continuous improvement. This brief paper elaborates and explores on the nature of these elements and their implications for practice.

Organizational Models

Better Strategy Through Organizational Design
by Lowell Bryan and Claudia Joyce • McKinsey Quarterly
Redesigning an organization to take advantage of today's sources of wealth creation isn't easy, but there can be no better use of a CEO's time.

Chapter 1 from Mobilizing Minds
Creating Wealth from Talent in the 21st Century Organization
by Lowell Bryan and Claudia Joyce • McKinsey

The Deming Systems Model
from the Institute for Healthcare Improvement's web site.

The Viable System Model
by Trevor Hilder Cavendish Software Ltd. (Presentation v1.03 12-Jun-1995)
This presentation provides a brief introduction to Stafford Beer’s Viable System Model (VSM).

The Semco Management Model
The only way to communicate this is to walk through the companies web site and have your own experience. Please click on the link to the SEMCO Management Model and click through the presentation (flash needed). In addition, it might be valuable to explore this page:

Lessons from Semco on Structure, Growth and Change
Semco is one of the most interesting companies on the planet. There are no job titles and no personal assistants. People set their own salaries. Everybody shares in the profits.

CCA Global Partners
With 15 affiliated companies, over 3,600 stores producing $8.7 billion in aggregate annual sales, and 78 consecutive quarters of profitability, CCA Global Partners knows how to set progress in motion.

Visa International
Visa is not a traditional multinational corporation. Visa has an organizational structure whereby 20,000 member financial institutions are brought together through the Visa Association. These partnerships with financial institutions around the world allow Visa to meet the needs of local markets and to benefit from economies of scale. This model also allows Visa to adapt products and services to local culture and customs, which in turn allows Visa to meet the needs of buyers and sellers in each market. Internally, staff is governed by a Code of Conduct (PDF | 95k).

United Western Grocers
Unified Western Grocers, Inc. is a retailer-owned wholesale grocery cooperative that supplies independent retailers throughout the Western United States. Unified and its subsidiaries, which generated approximately $3 billion in sales during the 2000 fiscal year, offer independent retailers all the resources they need to compete in today's supermarket industry.

Housing Partnership Network
The Housing Partnership Network operates as a peer network and business alliance of high-capacity, entrepreneurial development nonprofits. By collaborating through the Network, our members share and spread the innovations that emerge from their local practice. They obtain more flexible and better priced capital that rewards their demonstrated performance and capabilities. And they create strategies and cooperative ventures that respond to the rapidly changing regulatory, policy, and economic environment.

CoopMetrics facilitates improvements in a member company's operation by working in partnership with cooperatives and associations to build virtual chains of similar enterprises. Members access comparisons of financial and operating data within a framework of peer collaboration, allowing them to take advantage of the knowledge and experience of their industry peers and make improvements in their organization.

Positive Deviance and Appreciative Inquiry

by Arvind Singhal and Karen Greiner
Heidi Walker stood by a gurney loaded with standard infection control supplies—gloves, gowns, nasal swabs, hand sanitizer—and an incongruous pile of 21 packages of uncooked macaroni. As a curious audience of patients, doctors, nurses, and other members of staff looked on, Ms Walker cracked open a bag, scooped out a handful, and let the pieces fall slowly and resoundingly into a plastic bowl.

The Power of Positive Deviance
by David R Marsh, Dirk G Schroeder, Kirk A Dearden, Jerry Sternin and Monique Sternin • BMJ VOLUME 329 13 NOVEMBER 2004
Identifying individuals with better outcome than their peers (positive deviance) and enabling communities to adopt the behaviours that explain the improved outcome are powerful methods of producing change

The Power of Positive Deviance
by Prucia Buscell, page 8 of Aug 04 Emerging from the Plexus Institute
Positive Deviance. Haven’t heard the term? You will. It is a powerfully simple process that has enabled results in the world’s poorest communities. And it may be coming to a board room near you.

The Positive Deviance Initiative
In every community there are certain individuals (the "Positive Deviants") whose special practices/ strategies/ behaviors enable them to find better solutions to prevalent community problems than their neighbors who have access to the same resources. Positive deviance is a culturally appropriate development approach that is tailored to the specific community in which it is used.

Appreciative Inquiry in Organizational Life
by David L. Cooperrider and Suresh Srivastva
This chapter presents a conceptual refiguration of action-research based on a "sociorationalist" view of science. The position that is developed can be summarized as follows: For action-research to reach its potential as a vehicle for social innovation it needs to begin advancing theoretical knowledge of consequence; that good theory may be one of the best means human beings have for affecting change in a postindustrial world; that the discipline's steadfast commitment to a problem-solving view of the world acts as a primary constraint on its imagination and contribution to knowledge; that appreciative inquiry represents a viable complement to conventional forms of action-research; and finally, that through our assumptions and choice of method we largely create the world we later discover.

The Appreciative Inquiry Commons
Welcome to the "AI Commons"--a worldwide portal devoted to the fullest sharing of academic resources and practical tools on Appreciative Inquiry and the rapidly growing discipline of positive change. This site is a resource for you and many of us--leaders of change, scholars, students, and business managers--and it is proudly hosted by Case Western Reserve University's Weatherhead School of Management.

Other Resources

The following two resources connect to the Good Medical Practice document developed in the UK

Good Medical Practice (pdf)
May 2001 Duties and responsibilities of doctors
This booklet describes the principles of good medical practice and standards of competence,care and conduct expected of you in all aspects of your professional work. Serious or persistent failures to meet the standards in this booklet may put your registration at risk.

Good Medical Practice for General Practitioners
Published by the Royal College of General Practitioners, September 2002


The following resources connect to projects that are taking place with output that relates to measuring physician competence or are similar to the Good Medical Practice document.

Charter of Professionalism - Good Medical Practices (Physician Charter_V2005)
A copy of the original charter, as published in Annals of Internal Medicine, is available at:

The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better care. Edited by: Jason R.Frank,MD MA (Ed) FRCPC
Office of Education The Royal College of Physicians and Surgeons of Canada

CanMEDS 2000
In 1996, the Royal College adopted an innovative framework for medical education called the CanMEDS framework of essential physician competencies. Fundamentally, CanMEDS is an initiative to improve patient care. The focus of CanMEDS is on articulating a comprehensive definition of the competencies needed for medical education and practice. Today, the CanMEDS model for physician competence is being adapted around the world as well as in other professions.

Policy D/5.4 Code of Good Practice for Postgraduate Research Studies and Supervision at QUT
The following Code of Good Practice is a mechanism for assuring quality in higher degree research training. It is based on a code published by the Australian Vice-Chancellors' Committee.

Crossing the Quality Chasm: The IOM Health Care Quality Initiative
In 1996, the Institute of Medicine (IOM) launched a concerted, ongoing effort focused on assessing and improving the nation's quality of care, which is now in its third phase. 

To Err is Human
available on the National Academies Press’ website

Crossing the Quality Chasm
available on the National Academies Press’ website

AAMC Medical School Objectives Project (MSOP)
Information is available on AAMC’s website

AAMC Report I: Learning Objectives for Medical Student Education
Guidelines for Medical Schools - 1998

AAMC Policy Guidance on Graduate Medical Education
Assuring Quality Patient Care and Quality Education
October 2001

The Assessment of Global Minimum Essential Requirements in Medical Education
David T. Stern - Departments of Internal Medicine and Medical Education University of Michigan, Ann Arbor, MI, USA
Using an international network of experts in medical education, the Institute for International Medical Education (IIME) developed the "Global Minimum Essential Requirements" ("GMER") as a set of competency-based outcomes for graduating students. To establish a set of tools to evaluate these competencies, the IIME then convened a Task Force of international experts on assessment that reviewed the "GMER". After screening seventy-five (75) potential assessment tools, they identified three (3) that could be used most effectively. Of the sixty (60) competencies envisaged in the "GMER", thirty-six (36) can be assessed using a 150-item multiple-choice question (MCQ) examination, 15 by using a 15-station Objective Structured Clinical Examination (OSCE) exam, and 17 by using a 15-item faculty observation form. In cooperation with eight (8) leading medical schools in China, the MCQ, OSCE, and Faculty Observation Form were developed to be used in an assessment programme that is scheduled to be given to all 7-year students in October 2003.

Healthcare Professionals Crossing Borders Agreement
The Agreement of the European Consensus Conference held in Edinburgh, Scotland, on 13/14October 2005 on the Exchange of Information on Healthcare Professionals Crossing Borders for Competent Authorities

Compact Between Resident Physicians and Their Teachers
TThe Compact Between Resident Physicians and Their Teachers is a declaration of the fundamental principles of graduate medical education (GME) and the major commitments of both residents and faculty to the educational process, to each other and to the patients they serve. The Compact's purpose is to provide institutional GME sponsors, program directors and residents with a model statement that will foster more open communication, clarify expectations and re-energize the commitment to the primary educational mission of training tomorrow's doctors.

Time for hard decisions on patient-centred professionalism
by Donald H Irvine; Medical Journal of Australia
Every one of us at some time will need medical attention, with potential consequences that may remain with us for life. So, it is not surprising that the public wants to be confident that doctors are skilled, competent, respectful and honest — in short, truly professional. Equally, the public expects the profession and its system of regulation to guarantee this. Indeed, how doctors and the medical profession function is critical to clinical quality and safety.

July 2005 - New South Wales Medical Board

The American College of Surgeons Continuous Quality Improvement
Continuous Quality Improvement (CQI), formerly the Office of Evidence-Based Surgery, promotes the highest standards of surgical care through evaluation of surgical outcomes in clinical practice. CQI provides the infrastructure for conducting health services research and clinical research, outcome studies, meta-analyses, research hypothesis generation, and the development of evidence based practice guidelines at the College. This area also collaborates with the Divisions of Education and Advocacy and Health Policy to provide educational programs and promote public policy initiatives in clinical research and forms partnerships with outside groups and organizations involved in evaluation of surgical outcomes.

AMA Council on Ethical and Judicial Affairs (CEJA)
Information about CEJA, their reports and publications from the AMA’s website.

CMSS Conjoint Committee on CME
Information available from CMSS’s website

Related Articles

Physician Voluntary Reporting Program
As part of its overall quality improvement efforts, CMS launched the Physician Voluntary Reporting Program (PVRP) on January 1, 2006. This new program builds on Medicare’s comprehensive efforts to substantially improve the health and function of our beneficiaries by preventing chronic disease complications, avoiding preventable hospitalizations, and improving the quality of care delivered. Under this voluntary reporting program, physicians who choose to participate will help capture data about the quality of care provided to Medicare beneficiaries.

States Become Health Care Reform Battleground
May 26, 2006 - Workforce Management
Passage of health care reform laws in Tennessee and Vermont means businesses and health care advocates are increasingly turning to state governments to solve the nation’s health insurance woes.

Multinationals slow to implement global health and productivity strategies
31 May 2006 Health & Wellbeing
Spiralling healthcare costs have encouraged two-thirds of multinational companies to develop health and productivity strategies for their operations in the United States. But they have been far to quick to do the same in other regions of the world.


last updated 20070924.124931