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Forty-four individuals were interviewed across 16 programs (5 EM, 4 IM, 5 pediatrics, 3 FM). We identified 3 stages of Milestone-process implementation, including a resource-intensive early stage, an increasingly efficient transition stage, and a final stage for fine-tuning. Residency program leaders can use these findings to place their programs along an implementation continuum and gain an understanding of the strategies that have enabled their peers to progress to improved efficiency and increased resident and faculty engagement. Resi