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The Next Accreditation System

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The Next Accreditation System It is important to identify the Core Faculty for the program. Faculty members that are identified as Core Faculty must complete the ... – PowerPoint PPT presentation

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Date added: 17 October 2019
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Title: The Next Accreditation System


1
The Next Accreditation System
2
Aims of the Next Accreditation System
  • Enhance the ability of the peer-review system to
    prepare physicians for practice in the 21st
    Century
  • To accelerate the movement of the ACGME toward
    accreditation on the basis of educational
    outcomes
  • Reduce the burden associated with the current
    structure and process-based approach

3
Competencies/Milestones Past Decade
  • Competency evaluation stalls at individual
    programmatic definitions
  • MedPac, IOM, and others question
  • the process of accreditation
  • preparation of graduates for the future health
    care delivery system
  • House of Representatives codifies New Physician
    Competencies
  • MedPac recommends modulation of IME payments
    based on competency outcomes
  • Macy issues two reports (2011)
  • IOM 2012-2013

4
The Next Accreditation System Background and
Rationale
5
How is Burden Reduced?
  • Most data elements are in place
  • Standards revised every 10 years
  • No PIFs
  • Scheduled (Self-Study) visits every 10 years
  • Site visits may be requested by the Review
    Committee in-between the 10-year Self-Study
    visits
  • Internal reviews no longer required

6
The Next Accreditation System
  • Instead of biopsies, annual data collection, that
    may include, but are not limited to
  • Trends in annual data
  • Milestones, Resident, Fellow and Faculty Surveys
  • Scholarly activity template
  • Operative and Case Log Data
  • Board pass rates
  • PIF replaced by Self-Study
  • High-quality programs will be free to innovate
    Requirements have been re-categorized (Core,
    Detail, Outcome)

7
The Conceptual Change from Do this or else...
  • The Current Accreditation System

8
What is Different?
9
The Next Accreditation System
Continuous Observations
Promote Innovation
Assess Program Improvement(s)
Identify Opportunities for Improvement
Program Makes Improvement(s)
10
Terminology
Core Requirements Statements that define
structure, resource, or process elements
essential to every graduate medical educational
program.
11
Terminology
Outcome Requirements Statements that specify
expected measurable or observable attributes
(knowledge, abilities, skills, or attitudes) of
residents or fellows at key stages of their
graduate medical education.
12
Terminology
Detail Requirements Statements that describe a
specific structure, resource, or process, for
achieving compliance with a Core Requirement.
Programs in substantial compliance with the
Outcome Requirements may utilize alternative or
innovative approaches to meet Core Requirements.
13
Terminology
  • Each requirement labeled
  • Core All programs must adhere
  • Outcome All programs must adhere
  • Detail Programs with status of Continued
  • Accreditation may innovate

14
Decisions on Program Standing in the NAS
Continued Accreditation
Application for New Program
Accreditation with Warning
Probationary Accreditation
10-15
75-80
2-4
STANDARDS Outcomes Core Process Detail Process
lt1
Withdrawal of Accreditation
1. NAS No Cycle Length 2. All programs with 1-2y
cycles in the old system placed in Continued
Accreditation with Warning Status 3. Percentages
represent approximations based on accreditation
status received by programs in the past
15
Data Collection in the Next Accreditation System
16
Annual Data Review Elements Policy 17.61 Review
of Annual Data
  • Continuous Data Collection/Review
  • ADS Annual Update
  • Resident Survey
  • Faculty Survey
  • Milestone data
  • Certification examination performance
  • Case Log data/Clinical experience
  • Hospital accreditation data
  • Faculty member and resident scholarly activity
    and productivity
  • Other

17
Other Data (Episodic)
  • ACGME complaints
  • Verified public information
  • Historical accreditation decisions/citations
  • Institutional quality and safety metrics

18
Curriculum Vitae
Except for the program director, faculty CVs
will no longer be collected
19
Core Faculty
  • For core programs, only physicians can count as
    Core Faculty
  • Only faculty members who spend 15 or more hours
    per week working on the residency program
    (including clinic work, didactics, research, and
    administration) are counted as Core Faculty
  • Core Faculty complete Scholarly Activity template
    in ADS
  • Core Faculty complete Faculty Survey

20
Core Faculty
  • Examples of faculty members that meet the
    definition of Core Faculty
  • A physician who works in the ICU with
    responsibilities that include clinical
    supervision of residents, who is a member of the
    Clinical Competency Committee, runs simulation,
    who helps write resident curriculum
  • A physician scientist who spends most of his time
    conducting clinical outcomes research, with only
    four weeks per year of clinical time, but in
    addition, spends 15 hours or more supervising
    residents in their research projects and writes
    and provides didactics related to scholarship
    writes the curriculum for scholarship (i.e.,
    statistics), and conducts evidence-based journal
    club.

21
Core Faculty
  • Examples of faculty members that do not meet the
    definition of Core Faculty
  • A physician who conducts rounds two weeks out of
    the whole year and has no other program
    responsibilities (administrative, didactics,
    research supervision) other than clinical work
    during those two weeks
  • A faculty member with a PhD, and who is not a
    physician, who works in the basic science
    laboratory

22
Faculty Scholarly Activity Template in ADS
23
Faculty Scholarly Activity
Enter Pub Med ID s
24
Faculty Scholarly Activity
Enter a number
25
Faculty Scholarly Activity
Enter a number
26
Faculty Scholarly Activity
Enter a number
27
Faculty Scholarly Activity
Enter a number
28
Faculty Scholarly Activity
Answer Yes or No
29
Faculty Scholarly Activity
Answer Yes or No
30
Resident Scholarly Activity
Similar to Faculty Template
31
What Happens in My Program?
  • Annual data submission
  • Self-Study visit every 10 years
  • Possible actions following Review Committee
  • Clarify information
  • Progress reports for potential problems
  • Focused site visit
  • Full site visit
  • Site visit for potential egregious violations

32
What Happens in My Program?
  • Core and subspecialty programs reviewed together
  • Existing Independent subspecialty programs that
    chose to remain independent are subject to
  • Program Requirements and program review
  • Institutional Requirements and institutional
    review
  • CLER visits
  • No new independent subspecialty programs allowed
    after July 2013

33
What Happens after Review of my Program?
  • Citations will still be issued (if necessary)
  • Programs have to provide response to citations in
    ADS annually
  • Areas of non-compliance
  • Citations issued after 7/1/13 (Phase I) and after
    7/1/14 (Phase II) will not be considered resolved
    until the Review Committee determines that they
    have been corrected

34
What Happens after Review of my Program?
  • Areas in need of improvement
  • General concern(s) identified from annual review
  • Written response not required
  • Will not have to be documented in ADS
  • PD, DIO/GMEC should act on these areas

35
NAS Whats Different?
  • No site visits (as we know them)
  • but
  • Focused site visits for an issue
  • Full site visit (no PIF)
  • Self-Study Visits every 10 years

36
What is a Focused Site Visit?
  • Assesses selected aspects of a program and may be
    used
  • to address potential problems identified during
    review of annually submitted data 
  • to diagnose factors underlying deterioration in a
    programs performance
  • to evaluate a complaint against a program
  • 30-day notification given

37
What is a Full Site Visit?
  • Application for a new core program
  • At the end of the initial accreditation period
  • Re-applications (withheld or withdrawn)
  • Review Committee identifies broad issues/concerns
  • Other serious conditions or situations identified
    by the Review Committee
  • 60-day notification given
  • Minimal document preparation
  • Team of site visitors

38
Ten-Year Self-Study Visit
  • Not to be confused with a focused or full site
    visit requested by the Review Committee after
    annual program review
  • Not a traditional site visit
  • Implementation
  • 2015 for Phase I and some Phase II specialties
  • 2016 for most Phase II specialties

39
Ten Year Self-Study Visit
  • Will review core and subspecialty programs
    together
  • Review Annual Program Evaluations (PR-V.C.)
  • Response to citations
  • Faculty development
  • Judge program success at Continuous Quality
    Improvement (CQI)
  • Learn future goals of program
  • Will verify compliance with Core requirements

40
Self-Study and Self-Study Visit
  • Self-Study
  • Conducted by the program
  • Annual Program Evaluation
  • Review of program goals and improvement efforts
  • Self-Study Visit
  • Conducted by ACGME Field Staff members

41
Ten-Year Self-Study and Self-Study Visit
AE Annual Program Evaluation
42
ACGME Webinars and Other Resources
  • ACGME webinars are available at
    http//www.acgme.org/acgmeweb/tabid/431/Programand
    InstitutionalAccreditation/NextAccreditationSystem
    /Webinars.aspx
  • CLER
  • Overview of Next Accreditation System
  • Milestones, Evaluation, CCCs
  • Specialty-Specific Webinars (Phase I)
  • Phase I Coordinator Webinars (surgical and
    non-surgical)
  • Specialty-specific Webinars (Phase II) Nov
    2013-Dec 2013
  • Slide presentations for distribution to the GME
    community NAS, CCC, Milestones, Annual Program
    Evaluation/PEC, Updates on Policy December 2013
  • Upcoming
  • Specialty-specific Webinars (Phase II) Jan
    2014-May 2014
  • CLER
  • Self-Study (what programs do)
  • Self-Study Visit (what ACGME site visitors do)
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