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The Holy Grail of the Paper Trail

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... faculty members in nephrology, GI, cardiology, ID, hematoogy, ... at least three accredited subspecialty programs (cards, GI, ID, nephrology, pulmonary ... – PowerPoint PPT presentation

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Title: The Holy Grail of the Paper Trail


1
The Holy Grail of the Paper Trail
  • Polly E. Parsons MD
  • University of Vermont College of Medicine
  • Fletcher Allen Health Care

2
Things Could Always Be Worse!
3
The Process
Request for input on existing program
requirements
APCCMPD ATS ACCP (SCCM)
Program requirements revised and distributed for
comment
New program requirements approved
Courtesy of Dr. S. Murin
4
The Process
Request for input on existing program
requirements
1. Remove requirement for onsite Trauma
Services Sleep and Rehab Micro lab 2. Get rid
of 2 key faculty /specialty rqmnt 3. Change
language re modes of ventilation 4. Remove
outdated rqmnts Pleural bx Transthoracic
needle bx Respiratory drive assessment Peritonea
l dialysis 5. Change from expertise to
competence Admin functions 6. Asked for less
continuity clinic
Program requirements revised and distributed for
comment
Adapted from Dr. S. Murin
5
The Process
Request for input on existing program
requirements
1. Nearly every one of our suggestions was
incorporated into new requirements, often
verbatim 2. A bunch of alarming and unexpected
additional changes were made 24 months of
block time 3 months non-MICU More clinic (2 more
yeas of continuity)
Program director at primary site Generous
support for program director
Program requirements revised and distributed for
comment
New program requirements approved
Adapted from Dr. S. Murin
6
Our Counter-Offer
  • 18 months of block time
  • 1-2 months of non-medical critical care (with
    caveats)
  • Less clinic, not more, allow for blocks

7
What Did We Get?
8
Common Themes
  • Documentation
  • Communication
  • Evaluation
  • Education (not service)
  • Competency
  • Research

9
Changes in General Program Requirements for
Fellowship education in the Subspecialties of
Internal Medicine
10
Sponsoring Institution
11
Not New But May be More Important
  • The sponsoring institutions must demonstrate a
    commitment to education and research sufficient
    to support the fellowship program
  • The institution must assure significant research
    in each subspecialty for which it sponsors a
    training program

12
  • The sponsoring institution must assure that
    adequate salary support is provided to the
    program director for the administrative
    activities of the subspecialty program. The
    program director must not be required to generate
    clinical or other income to provide this
    administrative support. It is suggested that
    this support be 25-50 of the program directors
    salary depending on the size of the program.

13
Proposed Change to Common Program Requirements
(for all ACGME Training Programs)
  • The sponsoring institution must provide the
    program director with sufficient financial
    support and protected time for his/her
    educational and administrative responsibilities
    to the program. The program director must not be
    required to generate clinical or other income to
    provide this support.
  • Approved by RRC Council of Chairs February
    2005
  • (effective date July 1, 2006)

14
Rationale
  • High turnover rate of program directors
  • Increased administrative burden due to ACGME
    mandates
  • Institutional demands to generate income

15
Participating Institution
16
  • Section expanded from previous program
    requirements
  • The Primary Training Site is defined as the
    health-care facility that provides the required
    training resources, should be the location of the
    program directors major activity, the location
    where the fellow spends the majority of their
    clinical training time and the primary location
    of the core program in internal medicine

17
Program Directors
18
Qualifications
  • 1. Must possess the requisite subspecialty
    expertise, as well as documented educational and
    administrative abilities
  • 2. Must be based at the primary teaching site.
  • 3. Must be responsible to the sponsoring
    organization.

19
Responsibilities
  • 1. 20 hours per week averaged over the year
    (not new) with sufficient time for administration
    of the program and receive institutional support
    for that administrative time
  • 2. The program director must participate in
    academic societies and in educational programs
    designed to enhance his or her educational and
    administrative skills

20
  • 3. Must implement a program of CQI in medical
    education for the faculty, especially as it
    pertains to teaching and evaluation of the ACGME
    competencies

21
Faculty
  • The responsibility for establishing and
    maintaining an environment of inquiry and
    scholarship rests with the faculty...
  • Each program must have an active research program.

22
Scholarship
  • 1. Discovery
  • - peer review funding/publications
  • 2. Dissemination
  • - review articles, textbook chapters
  • 3. Application
  • - presentation or publication of case reports,
    clinical series,

23
  • The majority of faculty must be involved in
    scholarship
  • The majority of key clinical faculty must
    demonstrate evidence of productivity in either
    Discovery or Dissemination
  • At least one faculty member must be active in
    the scholarship of discovery.

24
Questions
  • Does the individual active in the scholarship of
    discovery have to be a key clinical faculty
    member?
  • Can that individual be a nonphysician faculty
    member?

25
Resources
  • All deaths of patients who received care by
    fellows must be reviewed and autopsies performed
    whenever possible.

26
Curriculum
27
Research
  • Majority of fellows must demonstrate evidence of
    recent research productivity through
  • publication of manuscripts or abstracts in
    peer-reviewed journals
  • Abstracts presented at national specialty
    meetings
  • NOTE does not apply to CCM fellowships

28
The Six Competencies
  • 1. Patient care
  • 2. Medical knowledge
  • 3. Practice-based learning and improvement
  • 4. Interpersonal and communication skills
  • 5. Professionalism
  • 6. Systems-based practice

29
Didactics
  • 1. Total teaching time in combined
    management/teaching rounds must exceed by a
    minimum of 5 hours per week the time required to
    supervise the care of the patients
  • 2. Conferences
  • must have a weekly core curriculum conference -
    must cover basic science as well as clinical
    topics

30
Duty Hours SupervisionEvaluation
Independently review each of these sections
carefully!
31
  • At least 80 of fellows eligible for ABIM
    subspecialty certifying exams must have taken
    ABIM exam.
  • Pass rates for first time takers of ABIM cert
    exams will be examined at each program review

32
Experimentation and Innovation
  • Hidden here is the
  • Performance improvement process
  • - program must have one ongoing PI activity
    related to the competencies
  • - must involve fellows and faculty
  • - should result in measurable improvements in
    patient care or fellow education

33
Changes in Program Requirements for Fellowship
Education in Pulmonary Disease and Critical Care
Medicine
34
Educational Program
  • 18 clinical months still allowed
  • Programs with lt 24 months additional ambulatory
    care clinic for 6 months (not during the clinical
    months)
  • 3 months in care of critically ill non-medical
    patients. At least one month must be direct
    patient care activity

35
Clinic
  • 1. Must have continuity clinic for the length of
    training program
  • 2. Extra 1/2 day per week for six months
  • - cannot occur during the 18 clinical months
  • - suggestions longitudinal experience in
    CF, ILD

36
A Gift?
  • Fellows may be excused from their continuity
    care clinic experience while on critical care
    rotations

37
Faculty
  • The program director and critical care teaching
    staff must have primary responsibility for
    admission, treatment and discharge of all
    patients on critical care teaching service.
  • Must be ABIM subspecialty certified clinical
    faculty members in nephrology, GI, cardiology,
    ID, hematoogy, oncology, and geriatrics who
    participate in educational program.

38
Facilities and Resources PCCM
  • Must be present at primary training site
  • - thoracic surgery service
  • - at least three accredited subspecialty
    programs (cards, GI, ID, nephrology, pulmonary -
    ?)
  • - an active emergency service
  • - MICU - program director should be responsible
    for educational program

39
Program Content PCCM and Pulmonary
  • Review this section carefully!
  • Subtle changes
  • PE,post-op management of critically ill patients
  • Not so subtle changes
  • Minimum of 50 flexible fiber-optic bronchoscopy
    procedures
  • No more pleural biopsies

40
Common Citations
  • Lack of written goals and directives
  • All full-time faculty dont engage in active
    research
  • Clinics are not continuity clinics
  • Insufficient number of conferences
  • Non-compliance with evaluation requirements
  • Duty hours
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