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PREPARING FOR AN ACGME SITE VISIT

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Associate Dean, Graduate and Continuing Medical Education. Designated ... requirements, citations, surveys; fatigue/seep deprivation education; duty hours ... – PowerPoint PPT presentation

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Title: PREPARING FOR AN ACGME SITE VISIT


1
PREPARING FOR AN ACGME SITE VISIT
  • Robert B. Baron, MD MS
  • Associate Dean, Graduate and Continuing Medical
    Education
  • Designated Institutional Official
  • UCSF
  • Declaration of full disclosure No conflict of
    interest

2
Todays Agenda
  • Preparing and conducting site visits
  • Preparing the PIF
  • Preparing for the site visit day
  • A view from the Residency Review Committee

3
Our Mission in GME
  • Provide the best possible patient care
  • Provide the best possible E in GME

4
Tying Education to Accreditation
  • There is also an E in accreditation
  • Use accreditation as an external lever that helps
    you do what you want to do

5
Accreditation Challenges
Extra work, risk of poor outcome
Opportunity to identify and build on assets and
strengthen weaknesses
6
(No Transcript)
7
UCSF GME RESOURCES
  • Heather Nichols 502-8936
  • Claire Brett 476-9694
  • Bobby Baron 476-3414
  • Claire Brett 719-9246
  • Amy Day 514-0146
  • Claire Brett 637-4408

8
OTHER RESOURCES
  • Call other UCSF program directors and
    coordinators
  • Call other programs in your specialty!
  • Call the RRC staff

9
Definitions
  • Accreditation determining whether a residency
    or fellowship is in substantial compliance with
    established educational standards. Responsibility
    of the ACGME and its Residency Review Committees
    (RRCs)
  • Certification determining whether a individual
    physician has met the requirements of a
    particular specialty. Responsibility of the
    member boards of the American Board of Medical
    Specialties (ABMS).

10
What are the 27 Residency Review Committees
(RRC)?
  • Two major responsibilities
  • Develop and approve training standards
  • Review and accredit residency and fellowship
    programs

11
What is the Review Process?
  • Site Visit 110 day notice. Should program wait
    until then?
  • Completion of Program Information forms (PIF)
  • RRC review consists of
  • Program (and Institutional) history
  • PIF
  • Site visit report
  • Resident and fellow survey

12
Site Visitor
  • Two types Field representatives and Specialist
    Site Visitors. (Field reps do 1900 of the 2000
    visits e.g. 120 each)
  • Bios on ACGME web site. 31 individuals 25 MDs,
    7 PhDs, one DMD
  • Role produce report that verifies and clarifies
  • Will interview program director, faculty,
    residents/fellows, and DIO
  • SITE VISITOR IS A FACT-FINDER, NOT THE
    DECISION-MAKER

13
Accreditation/maintenance of program quality is
a continuous process
  • Receive letter from ACGME Distribute
  • Response to GMEC (and ACGME) 1-2 months after
  • Annual program review/Annual 1 year, repeat
    update to GMEC
  • Annual ACGME resident Survey January to May
  • Mid-cycle internal review Mid-cycle
  • RRC Site visit prep
  • Outline approach to PIF 4-6 months prior
  • Strategize with program coordinator 3-4 months
    prior
  • Submit draft to DIO 4-6 weeks prior
  • Submit final draft to GME/DIO 3-4 weeks prior
  • Final PIF to site visitor 2 weeks prior
  • Meet with faculty 2-4 weeks prior
  • Meet with residents/fellows 2-4 weeks prior

14
Prerequisites for Accreditation
  • Institutional requirements
  • Common program requirements
  • Specialty-specific program requirements

15
Read your requirements…
16
Understanding Requirements
  • Must Present without fail
  • Should Absence justified by rationale
  • Desirable Viewed as enhancement

17
Understanding Requirements
  • Must Duty hours must be limited to 80 hours per
    week, averaged over a 4-week period.
  • Should Adequate time for rest and personal
    activities must be provided. This should consist
    of a 10-hour time period between duty hour
    periods.

18
Understanding Requirements
  • Old common requirements
  • Assessment should include …. evaluation by
    faculty, patients, peers, self, and other
    professional staff.
  • New common requirements (July 1, 07)
  • The program must… use multiple evaluators (e.g.,
    faculty, peers, patients, self, and other
    professional staff)

19
UCSF ACGME CITATIONS 2005-2008
  • Resident, faculty, and program evaluations 25
  • Inadequate didactics 21
  • Inadequate clinical experience 20
  • Internal review citations 16
  • Inadequate goals and objectives 12
  • Patient/procedure logs 9
  • Duty Hours 3

20
Know your requirements…
21
Read your PIF…
22
Call Heather…
23
Program Information Forms (PIF)
  • Common PIF
  • Accreditation info
  • Sites
  • Faculty
  • Resident/Fellow appointments
  • Evaluation
  • Duty Hours

24
Program Information Forms (PIF)
  • Specialty Specific PIF
  • Section for each competency
  • Duration and scope of education
  • General institutional information
  • Physician wellness
  • Faculty supervision and research projects
  • Duty hours and work conditions
  • Best practices
  • Comments
  • Goals and objectives

25
PIF Preparation
  • Review old PIF, internal review report, ACGME
    letters
  • Cannot just update old PIF. PIF format has
    changed!
  • Prepare PIF with current program requirements
    open side by side!

26
PIF Preparation
  • Write the PIF
  • Clear, in order, no missing information
  • Beware cut and paste errors
  • Follow instructions!
  • Third parties to proof
  • Must be accurate and concordant with
    resident feedback to visitor
  • Agreements are current, signed and
    available
  • Faculty CVs current, especially scholarly
    activity
  • Coordinate with site visitor as to when (and
    where) to mail the PIF

27
Call Claire…
28
Preparation practicalities
  • Schedule Chair, faculty, residents/fellows (peer
    selected), administrators (including DIO)
  • Review resident/fellow files (internal audit)
    application, educational plans (goals and
    objectives), rotation schedule and call
    schedules, conference attendance, evaluations
  • Group meetings
  • Key faculty review program requirements and
    PIF
  • Residents/fellows
  • - Review program requirements and how you are
    meeting them.
  • - Review ACGME resident survey

29
Also need available
  • Supervision policy
  • Duty hour policy
  • Moonlighting policy
  • Internal review report
  • Overall educational goals
  • Competency-based goals and objectives (each
    assignment, each level)
  • Letters of agreement
  • Evaluations of residents and fellows for each
    assignment
  • Evaluations showing multiple evaluators
  • Semi-annual evaluations
  • Summative evaluations
  • Confidential evaluations of faculty
  • Confidential evaluation of program by
    residents/fellows
  • Confidential evaluation of program by faculty
  • Documented program evaluation and written
    improvement plan
  • Documentation of resident duty hours
  • Files of current residents/fellows, and most
    recent graduates

30
ACGME Resident Survey
  • Content from common requirements
  • Administered annually, January to May
  • NOT linked to site visit schedule
  • Program Directors receive aggregate data if
    response rate gt 70
  • Site visitor will use to focus questions with
    residents during visit
  • Thus review survey with residents and address
    all concerns!

31
Engaging residents and fellows
  • Site visitor will want to meet with 10-12 must
    be peer selected, with representation from all
    years
  • Review requirements, citations, surveys
    fatigue/seep deprivation education duty hours
    guidelines competencies rotation goals and
    objectives evaluation of residents, faculty, and
    program.
  • What would you like to see improved?
  • Consider mock session with other PD
  • Arrange coverage, exclude those post call, hand
    off pagers
  • Site visit is not optimal time to have new
    grievances aired for first time!

32
Preparation practicalities
  • Prepare one location with all required documents
    for review
  • Arrange for tours of key facilities as requested
    by the site visitor

33
Day or Two Prior
  • Give everyone a copy of the schedule
  • Review files with coordinator
  • Clean up residency office, residency room, sleep
    rooms, etc

34
Site Visit Day
  • Prepare conference room
  • Text page everyone 1-2 hours prior
  • Additional staff standing by
  • Look organized
  • Have everything at fingertips
  • 3 copies of PIF (identical to that sent)
  • Resident files
  • Other binders, other information

35
The RRC Decision
  • Citations/areas of noncompliance
  • Accreditation action
  • Provisional (new application)
  • Continued full accreditation
  • Adverse decisions (subject to appeal)
  • Probation (proposed)
  • Withdraw (proposed)
  • Withhold (proposed)

36
Progress Reports and Letters
  • RRC may request a response to major concerns
  • Use tone of program improvement, not defensive
  • Must be reviewed by GMEC and DIO, sent in
    triplicate, sent on time
  • Only send responses to RRC when requested
  • Written response to other concerns sent to GMEC

37
What can Programs Do Between Cycles to Improve?
  • Annual program review (a must)
  • Internal review (also a must)
  • GMEC meetings, program coordinator meetings,
    workshops
  • National meetings

38
Summary
  • PLAN Allocate enough time
  • Learn (and have others learn) the Institutional,
    Common and Program-specific requirements
  • Write the PIF side by side with the requirements
  • Anticipate the unanticipated during the site
    visit
  • Engage residents in the process early
  • Call Heather and Claire!

39
Accreditation Challenges
Extra work, risk of poor outcome
Opportunity to identify and build on assets and
strengthen weaknesses
40
(No Transcript)
41
Getting Through the Site Visit Day with a Smile
on Your Face
  • Preparing the Files, Forms,
  • Policies, and People

Amy C. Day Director Office of Graduate Medical
Education
42
The PIF is Done, Now What?
  • Preparation before the big day
  • The day of the visit

ORGANIZATION!!!
43
Site Visitor
Preparation for the Day
  • Letter from ACGME
  • Make contact immediately
  • Be very accommodating
  • Site Visitor will make specific scheduling
    requests
  • Who should attend
  • Timeline for the day
  • Additional information that should be provided
  • Offer
  • Help with travel plans
  • Parking at UCSF
  • Detailed directions and location information
  • Breakfast/coffee/lunch

44
Schedule
Preparation for the Day
  • Date is not flexible
  • All people requested by Site Visitor must be
    present
  • Inform him/her immediately if someone is
    unavailable
  • Clear, precise, organized email to Site Visitor
  • Once its set dont change…especially on the day
    of the visit
  • Schedule one conference room for entire day

45
Preparing the People
Preparation for the Day
  • Residents/fellows and participating faculty
  • Distribute the PIF should be read several times
    prior
  • Review
  • ACGME Resident Survey
  • Policies
  • Evaluation process
  • ACGME competencies
  • Goals and objectives
  • Etc.
  • Prepare everyone, but dont
  • tell them what to say

46
Preparing the Documentation
Preparation for the Day
  • Two types
  • Resident/Clinical Fellow personnel files
  • Program documentation
  • Organized
  • No loose paper (binders or folders)
  • Be able to find things quickly when requested
  • Make sure all documentation
  • matches what was reported
  • in the PIF

47
Resident/Clinical Fellow Files
Preparation for the Day
  • Personnel files one file per trainee
  • Can organize by year, type of document, or both
  • Transfers include copies of correspondence
    between Program Directors
  • Include
  • Appointment paperwork
  • (each year)
  • Evaluations of trainee
  • Divided by competency and complete set
  • Final evaluation for program graduates
  • 360 evaluations
  • 6-month evaluations by Program Director
  • Other educational information, including
  • Procedure logs
  • PowerPoint presentations
  • In-service exam scores
  • Conference attendance
  • Rotation schedules
  • Published articles and other scholarly activities
  • Records of disciplinary actions
  • Moonlighting records

48
Program Documentation
Preparation for the Day
  • PIF
  • Program policies, including
  • Supervision
  • Duty hours
  • Moonlighting
  • Etc.
  • Evaluations (templates)
  • Of trainees for each rotation
  • Semi-annual of trainee by Program Director
  • Summative evaluations of trainee completing
    program
  • Of faculty by trainees
  • Of program by trainees
  • Of program by faculty
  • Rotation and call schedules
  • Faculty CVs
  • Binders and dividers
  • Documentation of Internal Review (not full
    report)
  • Program educational goals
  • Competency-based goals and objectives (by
    rotation and PGY)
  • Program Letters of Agreement (PLAs)
  • Conference schedules and attendance
  • Duty hour reports

49
Day of Visit
Day of the Site Visit
  • Conference room
  • Private and quiet
  • Make sure room is clean
  • Sign on door
  • Refreshments
  • Computer and phone access if possible
  • All binders and files should be in room, ready
    upon request
  • Page/email reminders for all participants
  • 1 week prior, day before, and/or morning of Site
    Visit
  • Program Coordinator should participate
  • Additional help for Coordinator to serve as a
    runner
  • 3 copies of PIF
  • Stick to schedule be on time
  • Again, be as accommodating as possible

50
Most Importantly…
  • Be organized and stay calm!
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