The push to require demonstrated competencies arose from several issues, Leach said, including public concerns about medical safety, variable patterns of care that aren’t based on science, and complaints about "poor customer service." The competency-measurement system that the ACGME has put in place gives residency programs "the flexibility to adapt to a harsh educational environment" and evaluates "actual rather than potential education," he explained. "Whatever we measure, we tend to improve. . . . What we attend to and how we attend to it define who we are."