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The Residency Review Committee


Committee assigns accreditation status along with review cycle, range of 1-5 years ... Review prior citations and make sure they have been addressed ... – PowerPoint PPT presentation

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Title: The Residency Review Committee

The Residency Review Committee
  • Jerry Vasilias, PhD, Executive Director
  • Caroline Fischer, Associate Executive Director

APPD 10/07
Setting the Stage
  • Overview to the RRC
  • Review of RRC work in 2006
  • Frequent Citations
  • New ACGME Changes
  • Preparing for the site visit
  • ACGMEs Strategic Priorities
  • Website

RRC Composition
  • 3 appointing organizations - AAP, ABP, AMA
  • 13 voting members
  • 4 from each appointing org 1 resident member
  • Members serve a term of 6 years -- except
  • Generalists, subspecialists, Chairs and DIOs
  • Critical Care Medicine, Hematology/Oncology,
    Pediatric Emergency Medicine, Gastroenterology,
    Neurology, Nephrology, Rheumatology
  • Geographic distribution CA, CT, DC, GA, MI, MD,
    OH, OR, PA
  • Ex-officio members from each appointing
    organization (non-voting)

RRC Review of Programs
  • Peer Review 2 reviewers
  • Reviewers use the following information when they
    review a program to determine whether it is in
    compliance with the requirements
  • Program Information Forms (PIF) prepared by the
  • The site visitors report
  • Board scores
  • Program Directors this is an open book test
  • Reviewers present program to Committee
  • Independent reviews followed by reconciliation
  • Committee assigns accreditation status along with
    review cycle, range of 1-5 years

Summary of Activities in 2006
  • The RRC meets twice a year Spring and Fall
  • Workload per meeting in 2006
  • approximately
  • 30 core programs
  • 120 subspecialty programs
  • 15 progress reports

Accreditation Decisions in 2006 -- Core
Most Frequent Citations in 2006 Core Pediatrics

New ACGME Changes
  • Requirements have been updated with new Common
  • Appear in bold font in document
  • Specialty specific content has not changed
  • However, during update some language in
    competencies was inadvertently removed the
    document on the website/distributed today is
  • E-mail status of programs on RRC agenda
  • 2-3 days after meeting will receive email w/
    status and review cycle.
  • Proposed adverse actions will receive notice as
  • E-mail that letter will be posted on
    Accreditation Data System (ADS)
  • Letter is posted one business day after the email
  • Printed copies of letters will not be provided
  • E-mail notification of site visit date

New ACGME Changes
  • More information will be collected/communicated
    through ADS.
  • Common PIF Common questions all specialties
    required to complete in ADS.
  • Along with information already collected in ADS
    (institutions used for training and resident
    info) will collect
  • Information on faculty/teaching staff
  • Evaluation (resident, faculty and program)
  • Duty hours
  • Board scores
  • ADS to be used for changes in complement, PD,
    institution /-, VW
  • Responses to previous citations will be done in
    ADS. 1st part of PIF.
  • Progress reports not yet in ADS.

New ACGME Changes
  • Common competency questions inserted in all
    specialties PIFs (common but not hard-wired into
  • Typical question asks PD to identify learning
    activity used to achieve a particular
  • Describe one learning activity in which residents
    engage to identify strengths, deficiencies and
    limits in their knowledge and expertise…
  • Describe… develop competence in communicating
    effectively with patients and families across a
    broad range of SES and cultural backgrounds
  • Questions like these in PIF since late fall of 05
  • PD Guide to the Common Requirements
  • PD Virtual Handbook
  • Webpage redesign

Update on Case Logs
  • All core Pediatrics programs have been required
    to have their residents enter data in the ACGMEs
    case log system
  • RRC has stated that it will not use for
    accreditation purposes until after its collected
    3 years of data
  • Can use this system to track continuity not
  • Committee will review 3 years worth of data at
    its upcoming meeting

Preparing for the Site Visit The Five Stages
that Precede the Site Visit
First Stage Denial……………………
Preparing for the Site Visit The Five Stages
that Precede the Site Visit
  • 1st Stage Denial No, way! Theyre not coming
  • 2nd stage Bargaining We can get a
  • 3rd stage Anger --We really have to go ahead
    with this!
  • 4th Stage Depression --I have sooooo much else
    to do? How will this get done?
  • 5th Stage Acceptance -- Well be ready.
  • With apologies to Elisabeth Kubler Ross

ACGME Expectations for Site Visits
  • Conducted in accord with established policies
  • Provide accurate, meaningful data for the RRC
  • Note the PIF is the focus of the site visit (not
    the program)
  • Verify/clarify info in the PIF
  • Address all relevant aspects of the program
  • Are educational and non-adversarial

Site Visit to Site Visit An Ideal Time Line
  • 6 to 18 months before the visit
  • Residents complete ACGME Resident Survey (all
    programs with 4 or more, surveyed every two
  • ACGME expects programs to reach a 70 threshold
  • Summary of results become available to PD and DIO
    only if reach 70 response rate
  • Intent of the survey
  • (1) focus and direct the resident interview, and
  • (2) identify potential areas of non-compliance
    with duty hour standards for RC follow-up

Site Visit to Site Visit An Ideal Time Line
  • On-going
  • Review and know the program requirements
  • ACGME web site, RRC specific updates and notices
  • Contact RRC executive director or staff for
  • Attend meetings/workshops
  • 1/2 way between last and next review
  • Internal review occurs
  • Involves a broad, representative group
  • Candidly explores strengths and weaknesses
  • Identifies improvements for implementation

Site Visit to Site Visit An Ideal Time Line
  • The next survey date on your last notification
    letter is an approximate
  • Site visit will take place between 2 4 months
    around the approximate date
  • 3 - 4 months before the actual visit
  • You will receive an email notification announcing
    actual site visit date
  • You should begin your PIF
  • If you havent already done so…

Site Visit to Site Visit An Ideal Time Line
  • 4 - 6 weeks before the visit
  • Site Visitor will contact you to set up schedule
    for site visit date
  • Here are a few of things the site visitor will
    probably ask for
  • List of required documents (policy manual, GOs
  • One large conference room
  • Be prepared to setup meetings with PD, faculty,
    residents, DIO
  • Large programs 10-12 residents should be peer
  • Small programs all residents should be present
  • Sometimes tour of facilities
  • If possible, no beepers and available for the
  • 14 days (10 business days) before the site visit
  • Mail PIF to the site visitor

Site Visit to Site Visit An Ideal Time Line
  • The Site Visit Occurs
  • 1 - 6 weeks after the visit
  • Site visit report is completed
  • Report is sent to RRC Staff
  • 2 - 8 months after the visit
  • Program is assigned to a RRC reviewers
  • The RRC meets, reviews your program and makes an
    accreditation decision and assigns review cycle

Preparing for the Visit The site visit date
  • The Question What if the site assigned site
    visit date is a problem?
  • The Answer There is never a good time for a
    site visit.
  • However, if its a major problem
  • Ingrid Philibert (312) 755-5003 or
  • Jim Cichon (312) 755-5015 or
  • Penny Lawrence (312) 755-5014 or
  • Do not call the site visitor, the RRC staff, or
    the RRC Chair.
  • Call soon after you receive your email/letter
    announcing the visit
  • Requesting a postponement does not guarantee one

A Few Pointers PIF Preparation
  • The PIF is a self study document that describes
    how your program complies with the requirements
  • Start EARLY!
  • Read questions carefully and start preparing
    initial responses
  • Review prior citations and make sure they have
    been addressed
  • Cross check information to avoid internal
  • Answer every question!
  • Think systems-based practice and improvement
    involve faculty and residents and other program
    personnel in the completion and editing of the

The Day of the Visit ACGME Interviews
  • ACGME interviews program director, faculty,
    residents and others.
  • Site visitors triangulate response to verify
    and clarify the PIF.
  • Compares responses in the PIF to interview data
    and actual observations (e.g., call rooms,
    libraries, exam rooms etc.)
  • Compares participants responses to each other
  • Discrepancies presented to the program director
    for clarification and resolution

The Day of the Visit Resident Interview
  • The resident interview explores the educational
    program from the residents perspective (as
  • Residents are peer selected (if small program,
    all residents)
  • Site visitor seeks consensus from residents
  • Sample Questions
  • Have you seen/received a copy of programs
    educational goals and objectives?
  • How and how often are you evaluated?
  • Do you evaluate your faculty and your rotations?
  • How are you supervised?
  • If you had due process concerns, where would
    you find the procedures? Whom would you contact?
  • What are the programs strengths? Areas for
  • What are the reasons you chose this program?

The Day of the Visit PIF Corrections
  • The PIF submitted to site visitor is
  • considered final. However,…..
  • If there are revisions on the day of the visit
  • Fix and provide SV with changed pages
  • Highlight changes made
  • Replace pages in copies to go to ACGME
  • If there are revisions after the site visit
    only if absolutely necessary
  • Always done as addendum to the PIF

After the Site Visit The site visitors report
  • What goes into the report?
  • Review of the program history
  • Review of previous actions and actions taken to
  • Review of institutional issues that pertain to
    the program
  • Clarification and verification of the PIF
  • Specialty specific content
  • What does not go into the report?
  • NO opinions or non-factual based comments
  • Just the facts…nothing but the facts…

After the visit If you have questions…
  • About the PIF/Case logs -- technical questions
  • Visit the ACGME web site at
  • Contact ACGME Help Desk or
  • For Part I of PIF off of WebADS
  • For Case logs
  • About PIF content/Program Requirements
  • For PIF questions or (312)
  • For program requirements questions or (312) 755-7477
  • or (312) 755-5044
  • Look on Peds webpage and FAQ
  • About the site visit/After the site visit
  • Call the site visitor or the Department of Field
  • Look at the site visit FAQ
  • Complete site visitor evaluation

ACGMEs Strategic Plan
  • In November 2005, ACGME endorsed 4 strategic
  • 1) Foster innovation and improvement in the
    learning environment
  • 2) increase the accreditation emphasis on
    educational outcomes
  • 3) Increase efficiency and reduce burden from
  • 4) Improve communication and collaboration with
    key internal and external stakeholders
  • Many of the changes ACGME has implemented in the
    recent past and will continue to roll out in the
    future can be seen from the vantage point of the
    4 strategic priorities.

Innovations and Improvements to the Learning
  • Committee on Innovation and the Learning
    Environment (CILE)
  • Recommendation 4 Develop a set of
    ACGME-supported pilots to assist the RC in
    advancing innovation in the learning environment
    and meeting ACGMEs strategic priorities.
  • CILE Pilots to help in refining/revising select
    common requirement standards, specifically duty
    hours and competencies.
  • RRC will decide whether to participate
  • ACGMEs Learning Innovation and Improvement
    Project studying the characteristics of
    institutions that foster innovation and sharing
    w/ others
  • Conversations between RRC and R3P

Increase Emphasis on Outcomes
  • Common Requirements are a move towards more
    outcome-focused requirements and less process.
  • Competency based G Os
  • Fuller/fleshed out language within the
  • Evaluation of program written to focus on how
    evaluation can improve program
  • RRC Companion Document
  • RRC front-runner in including competencies as
    organizing structure for requirements and
    competency questions in PIF
  • A different type of citation
    constructive/improvement based citations related
    to the competencies

Increase Efficiency and Reduce Burden
  • New Common Requirements less overall
    requirements outcomes focused
  • E-mail accreditation status of programs on agenda
    w/in 2-3 days
  • E-mail to inform you that notification letter is
    posted on ADS.
  • Standard letters of notification
  • Increased information being collected through ADS
  • Revised glossary of terms
  • PD Guide to Common Program Requirements
  • PD Virtual handbook
  • RRC removed request for documentation of
    continuity numbers site visitor will verify

Improve Communication and Collaboration
  • Redesigned webpage
  • Email updates when necessary
  • Post presentations on website
  • Newsletter will be implemented soon
  • Conversations related to innovation
  • Conversations related to the case log system

  • Staff contact information
  • ACGME Policies Procedures
  • Competencies/Outcomes Project
  • List of accredited programs
  • ADS
  • Duty hours Information/FAQ
  • Affiliation Agreements FAQ
  • General information on site visit process and
    your site visitor
  • Pediatrics Webpage
  • Resident complement increase
  • Program Requirements and PIFs
  • Case Log System
  • Archive of RRC Updates/Email Communications
  • Pediatrics FAQ


Completing a PIF is … Preparing for a site visit
is …
  • Simple Complicated