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Accreditation Essentials: How to Prepare for and Pass a Site Visit

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Title: Accreditation Essentials: How to Prepare for and Pass a Site Visit


1
Accreditation Essentials How to Prepare for
and Pass a Site Visit
UPMC GME Nuts Bolts
February 25, 2005
  • Joseph E. Losee, MD, FACS, FAAP
  • Chief, Pediatric Plastic Surgery
  • Program Director, Plastic Surgery Residency

2
Moderators
  • Philip D. Orons, DO
  • Associate Professor of Radiology
  • Director, Radiology Residency and Fellowship
    Programs
  • Joseph E. Losee, MD, FACS, FAAP
  • Assistant Professor of Surgery and Pediatrics
  • Director, Plastic Surgery Residency and
    Craniofacial Fellowship

3
Program
  • Introduction
  • PIF preparation
  • Site Visit
  • preparation
  • performance
  • Citations action plans
  • Wrap-up

4
Introduction
5
Site Visit Goal
  • to assess compliance with the program
    requirements

6
Program Directors Goal
  • maintenance of accreditation

7
  • No annual program assessment meeting
  • No outpatient experience
  • Residents didnt evaluate the faculty
  • Unbalanced operative logs
  • Too much or too little surgery
  • No teaching conferences with curriculum
  • No semiannual written resident evaluations

8
Begin with the end in mind
9
Accreditation Dance
10
Application
Withhold
Provisional Accreditation
Full Accreditation
Continued Provisional Accreditation
Probational Accreditation
Withdraw
Continued Probation
Continued Full Accreditation
11
PIF preparation
12
Site Visit prep and perform
13
PD
ACGME
Chief
14
Chief
PD
Faculty
Success
Residents
15
5 Stages that Precede a Site Visit
  • Stage 1 Denial Theyre not coming again
    already?
  • Stage 2 Bargaining We can get a
    postponement!
  • Stage 3 Anger She is telling us to go ahead
    with the date.
  • Stage 4 Depression I have so much else to
    do, how will I fit this in?
  • Stage 5 Acceptance Well be ready.

Ingrid Phillbert, Director Field Activities, ACGME
16
Site Visit Competencies
  • Knowledge
  • Skill (Patient Care)
  • Practice-Based Learning Improvement
  • Interpersonal and Communication Skills
  • Professionalism
  • Systems-Based Practice

Susan Swing, PhD
17
Knowledge
  • program requirements
  • your program
  • rotations
  • curriculum
  • faculty and residents
  • unresolved/irresolvable issues
  • last Site Visit and Internal Review
  • citations
  • program changes
  • Competencies
  • Curriculum
  • Duty Hours
  • PIF

18
Skill Patient Care
  • PIF preparation
  • key to good site Visit
  • start EARLY
  • answer the question
  • the PD must answer narratives
  • your AA or the program coordinator can not do
    this
  • team of people
  • regular meetings
  • schedule for preparation
  • target dates
  • proof-read

19
Practice Based Learning Improvement
  • Learn from previous Site Visits and Internal
    Reviews
  • Improve areas cited previously
  • highlight in PIF and interviews your improvements
  • fix internal inconsistencies in the PIF
  • block diagram vs. rotation schedule
  • narrative vs. data/block diagrams
  • have faculty and residents review the PIF and
    suggest edits
  • improves PIF
  • educates the reviewers

20
Interpersonal and Communication Skills
  • well prepared PIF and well presented program
  • PD, Chief, Faculty, Residents
  • option introduction to the program
  • data triangulated PIF, observations, responses
  • PIF and interviews should demonstrate your
    knowledge and compliance with the program
    requirements
  • answer the question directly to the point
  • if you dont understand the questionkindly ask
    to have it restated
  • stay calm
  • address ambiguities and unresolved issues
  • prepare and anticipate questions

21
Interpersonal and Communication Skills
  • Residents Interview
  • explores educational program from their
    perspective
  • peer selected
  • Site Visitor seeks consensus
  • questions assess compliance
  • Have you ever seen/received a copy of the
    programs goals and objectives?
  • How and how often are you evaluated?
  • How are you supervised

22
Professionalism
  • honesty
  • PIF actually reflects the program
  • dont coach residents educate them
  • dont ask, How did we do?

23
Systems-Based Practice
  • we are part of a larger system
  • many hands make light work
  • seek support from DIO and GME office
  • ask colleagues
  • dont re-invent the wheel
  • attend PD retreats and workshops
  • utilize the ACGME web site
  • contact the ACGME with questions

24
Site Visit Timeline of Preparation
25
Site Visit Preparation Time-line
  • Immediately - Ongoing
  • read all previous ACGME correspondence with your
    program
  • review last Site Visit citations
  • implement all previous Site Visit recommendations
  • begin reading Program Requirements regularly
  • become familiar with ACGME web site
  • attend Program Directors meeting
  • maintenance of accreditation

26
Site Visit Preparation Time-line
  • Mid-Cycle
  • prepare for Internal Review
  • use this opportunity as dress rehearsal

27
Site Visit Preparation Time-line
  • 6 months
  • begin PIF preparation key to a good site
    visit
  • put together the Site Visit Prep Team
  • make sure that final PIF is in most current form
    at time submission

28
Site Visit Preparation Time-line
  • 3-4 months
  • ACGME letter announcing date, site visitor,
    important information
  • read this letter
  • re-read this letter
  • have faculty and residents reserve date
  • meet with faculty and residents
  • site-visit day
  • Program requirements
  • PIF
  • give Grand Rounds on GME

29
Site Visit Preparation Time-line
  • 4-6 weeks
  • make contact with Site Visitor
  • directions
  • arrangements
  • make arrangements for the day
  • reserve conference room
  • remind faculty and residents attendance is
    required
  • PIF to DIO

30
Site Visit Preparation Time-line
  • 2-3 Weeks
  • PIF to Site Visitor follow letters
    instructions

31
Site Visit Preparation Time-line
  • 1 week
  • large conference room
  • refreshments
  • catered luncheon
  • directions
  • itinerary

32
Site Visit Day
  • Meetings
  • PD
  • chief
  • chair
  • faculty
  • Luncheon
  • residents
  • Tour
  • Wrap-up session

33
Site Visit Day
  • if you dont understand the site visitors
    question, Can you please explain what you are
    looking for.
  • think before you speak
  • Site Visitor will triangulate responses
  • meetings with PD, Chief, Faculty, Residents
  • administrative support available

34
Site Visit Residents Luncheon
  • private room
  • catered
  • peer selected
  • no beepers or cell phones
  • questions address compliance with program
    requirements
  • report will reflect resident consensus

35
Successful Site Visit
  • Educate
  • faculty and residents
  • about your program, program requirements, PIF
  • Prepare
  • pre-site visit meetings - Site Visit Prep Team
  • educate (not coach) the residents
  • PIF comprehensive, clear, succinct, accurate
  • Organize
  • files and documentation
  • agenda
  • anticipate questions
  • Present
  • honestly present

36
After the Site Visit
  • Site Visitor completes the report
  • report forwarded to RRC
  • one or more RRC members review document, PIF,
    resident surveys, operative logs, etc.
  • primary reviewer presents program at RRC meeting
  • entire RRC decides on citations and accreditation
  • program notified in writing

37
working
together
38
Best Guarantee Successful Site visit
  • ongoing attention to the quality of resident
    education, to ensure that the program provides
    the best possible educational experiencemaintenan
    ce of accreditation

39
Best Guarantee Successful Site visit
  • ongoing attention to the quality of resident
    education, to ensure that the program provides
    the best possible educational experiencemaintenan
    ce of accreditation

40
Citations Action plans
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