Title: Accreditation Essentials: How to Prepare for and Pass a Site Visit
1Accreditation 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
2Moderators
- 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
3Program
- Introduction
- PIF preparation
- Site Visit
- preparation
- performance
- Citations action plans
- Wrap-up
4Introduction
5Site Visit Goal
- to assess compliance with the program
requirements
6Program 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
8Begin with the end in mind
9Accreditation Dance
10Application
Withhold
Provisional Accreditation
Full Accreditation
Continued Provisional Accreditation
Probational Accreditation
Withdraw
Continued Probation
Continued Full Accreditation
11PIF preparation
12Site Visit prep and perform
13PD
ACGME
Chief
14Chief
PD
Faculty
Success
Residents
155 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
16Site Visit Competencies
- Knowledge
- Skill (Patient Care)
- Practice-Based Learning Improvement
- Interpersonal and Communication Skills
- Professionalism
- Systems-Based Practice
Susan Swing, PhD
17Knowledge
- 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
18Skill 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
19Practice 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
20Interpersonal 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
21Interpersonal 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
22Professionalism
- honesty
- PIF actually reflects the program
- dont coach residents educate them
- dont ask, How did we do?
23Systems-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
24Site Visit Timeline of Preparation
25Site 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
26Site Visit Preparation Time-line
- Mid-Cycle
- prepare for Internal Review
- use this opportunity as dress rehearsal
27Site 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
28Site 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
29Site 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
30Site Visit Preparation Time-line
- 2-3 Weeks
- PIF to Site Visitor follow letters
instructions
31Site Visit Preparation Time-line
- 1 week
- large conference room
- refreshments
- catered luncheon
- directions
- itinerary
32Site Visit Day
- Meetings
- PD
- chief
- chair
- faculty
- Luncheon
- residents
- Tour
- Wrap-up session
33Site 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
34Site Visit Residents Luncheon
- private room
- catered
- peer selected
- no beepers or cell phones
- questions address compliance with program
requirements - report will reflect resident consensus
35Successful 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
36After 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
37working
together
38Best 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
39Best 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
40Citations Action plans