1 / 87

Residency Review Committee for Internal Medicine RRC-IM Update

Table of Contents . General Description of the RRC-IMSummary of Actions Taken in 2009RRC/ACGME CommunicationsNew Common RequirementsNew Use for Resident Survey. RRC Composition. 3 appointing organizations - ABIM, ACP, AMACurrently19 voting members 6 year terms -- except resident (2 years)G

abel
Download Presentation

Residency Review Committee for Internal Medicine RRC-IM Update

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Residency Review Committee for Internal Medicine (RRC-IM) Update Dennis Boulware, MD, Chair, RRC-IM Jerry Vasilias, PhD, Executive Director, RRC-IM Felicia Davis, Associate Executive Director, RRC-IM Karen Lambert, Associate Executive Director, RRC-IM APDIM October 2010

    2. Table of Contents General Description of the RRC-IM Summary of Actions Taken in 2009 RRC/ACGME Communications New Common Requirements New Use for Resident Survey

    3. RRC Composition 3 appointing organizations - ABIM, ACP, AMA Currently19 voting members 6 year terms -- except resident (2 years) Generalists and subspecialists Cardiology, Critical Care Medicine, Endocrinology, Gastroenterology, General Internal Medicine, Geriatric Medicine, Hematology-Oncology, Infectious Diseases, Medicine-Pediatrics, Nephrology, Pulmonology/Critical Care Medicine, Sleep Medicine, Rheumatology, Geographic Distribution AZ, CA, CT, DC, HI, IN, MA, NY, NM, PA, RI, SC, TX, WA, WI Ex-officio members from each appointing organization (non-voting)

    4. Who is the RRC-IM? Committee Members

    5. New Members Dennis Boulware, MD – new Chair Eileen Reynolds, MD – new Vice Chair 11 new members since July 2009 James Arrighi, MD – cardiology Heather Brislen, MD – resident Stephanie Campbell, MD – resident Ben Clyburn, MD – general internal medicine John Fisher, MD – cardiology, CCEP Andrew Gersoff, MD- general internal medicine Sara Grethlein, MD - hematology Susan Murin, MD – pulmonology/critical care medicine Victor Navarro, MD – transplant hepatology Andrea Reid, MD - gastroenterology Jennifer Thompson, MD – infectious disease

    7. Committee’s Activities in 2009 Four meetings annually: January, May, July, September Program reviews at 3 meetings with July meeting for policy and business issues Executive committee conference call 1-2 times between meetings Full committee conference calls as needed Expedited reviews done electronically

    8. Committee Member Activities Attend four meetings annually: 13 days (executive committee 16 days) Travel time to meetings: 4-8 days annually Time to review programs for January, May and September: 30-40 hours each meeting Conference calls, electronic reviews, email, non-review preparation: ? Hours TOTAL: 17-24 days plus 100-200 hours preparation time per year

    9. RRC-IM Oversight *

    10. RRC-IM Oversight

    11. The review process is NOT akin to a dart board. The review process is NOT akin to a dart board.

    12. RRC Review of Programs Peer review Reviewers use the following information to determine whether it is in compliance with the requirements: A Program Information Form (PIF) prepared by the program Site visitor’s report Board scores Resident Survey Results Program Directors: this is an open book test The questions in the PIF correspond to program requirements Reviewers present program to Committee Committee agrees on areas of non-compliance (citations) and assigns accreditation status and review cycle, range of 1-5 years

    14. Proposed Adverse Actions First, an adverse action is “proposed” Citations include following references: PR, PIF & SVR Only situation where SVR is shared with PD Program director has opportunity to rebut citations information revising, correcting or expanding previously submitted information; challenging the findings of the site visitor; rebutting the interpretation of the RC; demonstrating that the cited areas of non-compliance did not exist at time of review; or contending that the program is in compliance with requirement

    17. Summary of Actions Core Internal Medicine

    18. Most Frequent Citations in 2009 Core Internal Medicine

    19. Summary of Actions in 2009 Subspecialty Programs

    20. Most Frequent Citations in 2009 Subspecialty Programs

    21. ACGME: Data Collection Core IM PIF is entirely electronic – application and continued accreditation All core programs and subspecialty programs (with 4 or more fellows) participate in the resident survey ANNUALLY ADS Common PIF = Questions all programs need to complete Information on faculty/teaching staff Residents/fellows - # completed; # transfer, withdraw; dismissed Evaluation (resident, faculty and program) Duty hours Responses to previous citations Complement increases, PD/Institution changes Voluntary withdrawal

    22. ACGME: Enhancing Communication Weekly e-communication Contains GME information: New requirements, newsletters; updates on ACGME issues/initiatives E-mail status of programs on RRC agenda 2-3 days after meeting will receive email w/status and review cycle Notification letter will be posted on Accreditation Data System (ADS). Email to let you know its available. Hard copies of letters not provided Letter is posted approximately 8 weeks following meeting Proposed adverse actions posted within 4 weeks of meeting Notification letters: greater ‘transparency’ with citations Citations have Program Requirement (PR) reference

    23. ACGME: Assisting PDs with Common Reqs Common competency questions inserted in all specialty PIFs (common but not hard-wired into ADS). PD Guide to the Common Requirements: http://www.acgme.org/acWebsite/navPages/nav_commonpr.asp Provides PDs: Explanations of the intent of most of the common requirements (particularly competency-based) Suggestions for implementing requirements and types of documentation expected.

    24. RRC Communications Core FAQs In April, many new core FAQs posted to website http://www.acgme.org/acWebsite/RRC_140/Internal_Medicine_Residency_Programs_FAQ.pdf How can programs minimize “conflict” between inpatient and outpatient rotations ? What’s necessary to be in compliance with the ‘simulation’ requirement ? What are examples of electronic medical records? What are expectations for continuity clinic? Who can supervise residents in MICU? What is acceptable training for core faculty who will serve as competency evaluators ? What are expectations with regards to multi-source evaluation? What are expectations regarding Neurology ? What are expectations regarding non-IM subspecialties?

    25. RRC Communications Newsletter Communication tool to provide updates on RRC and ACGME initiatives Sent to all core, med-peds and subspecialty program directors, coordinators, and designated institutional officials Annual newsletter Newsletter postings announced in the weekly e-communications email

    26. RRC Communications Highlights from August 2010 Newsletter August 2010 newsletter: http://www.acgme.org/acWebsite/RRC_140_news/Internal_Medicine_Newsletter_Aug10.pdf As of January 1, 2010, all sleep medicine programs will be accredited by RRC-IM Regardless of which core program aligned with, RRC-IM will review + accredit New subspecialty for Advanced Heart Failure and Transplant Cardiology Draft of requirements expected by early 2011 New Core and Subs FAQs Summary of RRC-IM work in 2009 Updates on revisions to subspecialty requirements Introductions to new RRC members and staff

    27. Highlight from August 2010 Newsletter New FAQ Item for Core Programs

    28. New FAQs Faculty Performance Data QUESTION: For the purpose of a program evaluation, what type of inpatient and outpatient faculty performance data must the department share with the program director? (PR V.C.3.) ANSWER: The RRC-IM believes that it is essential that all faculty are role models for excellent medical practice. It is the department’s responsibility to monitor the quality of medical practice of its members, and take appropriate action if there is substandard performance. The department must provide the program director with information regarding substandard individual practice performance data by the program’s faculty. Such information can be presented in summary form. Detailed encounter level information is not required.

    29. New FAQs WH-PC Clinics QUESTION: Can a Department of Veterans Affairs (VA) Women’s Health Primary Care (WH-PC) clinics serve as a part of the required (30 months, 130 sessions) longitudinal continuity experience if (in order to assure gender diversity) the WH-PC clinic is combined with a VA primary care clinic at the same (PR IV.A.2.c).(1).(f) & (g).(i-ii).(a-f)? ANSWER: Programs with WH-PC clinics can include them as a part of the required 33% ambulatory experience, either as block or continuity experiences However, to qualify as part of the longitudinal continuity experience in which residents develop a continuous, long-term therapeutic relationship with a panel of general internal medicine patients (occurring for at least 130 session over 30 months of training), the program would need to request a waiver to the requirement that the continuity clinic experience takes place at a single site. The waiver form is found on ACGME’s website. Background:  Many VAs have a Women’s Health Clinics (WH-PC) where women veterans receive their continuity care.  The site of these clinics is usually separate from, but in the same complex as that of the primary care clinics where residents usually do their continuity primary care (PC) clinics (and where the vast majority of their patients are men).  To improve the gender diversity of the panel (s) of patients required for residents to provide their longitudinal continuity experience, several VAs would like to make these women’s clinics a part of the experience. Background:  Many VAs have a Women’s Health Clinics (WH-PC) where women veterans receive their continuity care.  The site of these clinics is usually separate from, but in the same complex as that of the primary care clinics where residents usually do their continuity primary care (PC) clinics (and where the vast majority of their patients are men).  To improve the gender diversity of the panel (s) of patients required for residents to provide their longitudinal continuity experience, several VAs would like to make these women’s clinics a part of the experience.

    30. New FAQs “Opportunities” QUESTION: Are goals and objectives and a written curriculum required for all elective clinical experiences designated as ‘opportunities (i.e., psychiatry, A/I, dermatology, medical ophthalmology, office gynecology, otorhinolaryngology, non-operative orthopedics, palliative medicine, sleep medicine, and PM&R)?(PR V.C.3.) ANSWER: No.  However, if written goals and objectives for the experience are not in place, then each resident who elects one of these clinical experiences should have a personalized learning plan.  This plan should include goals and objectives mutually agreed upon by the resident and supervising faculty, it should be included in the resident’s file, and should include an assessment by the resident at the end of the of rotation whether the resident’s goals and objectives were met.

    31. New FAQs Documenting Direct Observation QUESTION: What is an acceptable method for documenting direct observation? (PR V.A.1.b).(1).(a)) ANSWER: Direct observation is fulfilled when an attending uses a structured assessment tool (like a mini-CEX, OSCE or checklist) to evaluate a discrete patient-resident encounter (e.g. history, examination, teaching activity, or procedure). The attending must directly observe a resident’s performance, and immediately assess performance using an established or locally developed tool. The tool should identify the standard that defines competence in performing the activity. This will ensure that residents and evaluators know what standards need to be met in order to be judged competent.

    32. New FAQs Competency-Based Semi-Annual Evaluations QUESTION: Do semi-annual evaluations have to be competency-based ? (PR V.A.1.b.1; V.A.1.b.4) ANSWER: Yes. In addition to the program director personally performing the evaluations, feedback on performance related to each of the six ACGME competencies must be documented either using a standardized form or by narrative.

    33. Common Program Requirements New Duty Hour and Supervision PRs Define licensed independent practitioners PGY-1: direct supervision available Specify optimal clinical workload Define elements of teamwork Define intermediate and residents in final years Define circumstance with 8 hours duty free Consecutive weeks and annual cap of night float

    34. 1. Define licensed independent practitioners In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care.

    35. Define licensed independent practitioners RRC-IM action: No new language. A licensed independent practitioner as a resident supervisor is addressed in two existing FAQs. Allowed: specialized outpatient settings for specific learning experiences (i.e., GYN clinic, STD clinic, wound care clinic, home visits, nursing homes, etc.). Not allowed: inpatients, continuity clinics, subspecialty or general medicine clinics.

    36. 2. PGY-1: direct supervision available In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available.]

    37. Definitions of supervision VI.D.3.a-c Levels of supervision (by attending or more senior resident physician) Direct supervision Indirect supervision Direct supervision immediately available Direct supervision available Oversight

    38. Definitions of supervision VI.D.3.a-c Levels of supervision (by attending or more senior resident physician) Direct supervision Indirect supervision Direct supervision immediately available Direct supervision available Oversight

    39. Definition of direct supervision Direct Supervision – the supervising physician is physically present with the resident and patient.

    40. Definitions of supervision VI.D.3.a-c Levels of supervision (by attending or more senior resident physician) Direct supervision Indirect supervision Direct supervision immediately available Direct supervision available Oversight

    41. Definition of indirect supervision with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.

    42. Definition of indirect supervision with direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.

    43. Definitions of supervision VI.D.3.a-c Levels of supervision (by attending or more senior resident physician) Direct supervision Indirect supervision Direct supervision immediately available Direct supervision available Oversight

    44. Definition of oversight Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

    45. 2. PGY-1: direct supervision available In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available.]

    46. Definitions of supervision VI.D.3.a-c Levels of supervision (by attending or more senior resident physician) Direct supervision Indirect supervision Direct supervision immediately available Direct supervision available Oversight

    47. Definitions of supervision VI.D.3.a-c Levels of supervision (by attending or more senior resident physician) Direct supervision Indirect supervision Direct supervision immediately available Direct supervision available Oversight

    48. PGY-1: direct supervision available RRC-IM Action: No new language. Existing core requirement I.A.2.m).8.(h) says: “second- or third-year internal medicine residents or other appropriate supervisory physicians (e.g., subspecialty residents or attendings) with documented experience appropriate to the acuity, complexity, and severity of patient illness must be available at all times on site to supervise first-year residents;”

    49. 3. Specify optimal clinical workload The clinical responsibilities for each resident must be based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. [Optimal clinical workload will be further specified by each Review Committee.]

    50. 3. Specify optimal clinical workload RRC-IM Action: No new language. The existing program requirements address limitations on admissions, ongoing care, and available support services.

    51. 4. Define elements of teamwork Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty. [Each Review Committee will define the elements that must be present in each specialty.]

    52. 4. Define elements of teamwork RRC-IM action: No new language. The existing program requirements address residents working in multidisciplinary and interdisciplinary teams.

    53. 5. Define intermediate and residents in final years Intermediate-level residents [as defined by the Review Committee] should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty. Residents in the final years of education [as defined by the Review Committee] must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.

    54. 5. Define intermediate and residents in final years RRC-IM Action: Intermediate-level residents and residents in the final years of education are defined as PGY-2 and PGY-3 residents. “PGY-2 and PGY-3 residents should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.”

    55. 6. Define circumstance with 8 hours duty free Applies to resident in final years of training: This preparation must occur within the context of the 80-hour, maximum duty period length, and one-day-off-in seven standards. While it is desirable that residents in their final years of education have eight hours free of duty between scheduled duty periods, there may be circumstances [as defined by the Review Committee] when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty.

    56. 6. Define circumstance with 8 hours duty free RRC-IM Action: Adopted earlier language that referred to PGY-2 and higher residents who may remain on duty beyond 24 hours. Allows for unusual and rare circumstances (care for severely ill, learning opportunity, humanitarian, etc) that are initiated by the resident with reporting and tracking by the program director.

    57. 6. Define circumstance with 8 hours duty free (1 of 2) In unusual circumstances, residents may remain beyond their  scheduled period of duty or return after their scheduled period of duty to provide care to a single patient.  Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of the patient or family.  Such episodes should be rare, must be of the residents own initiative, and  need  not initiate a new ‘off duty period’  nor require a change in the scheduled ‘off duty period’

    58. 6. Define circumstance with 8 hours duty free (2 of 2) Under those circumstances, the resident must: Appropriately hand over the care of all other patients to the team responsible for their continuing care; and document the reasons for remaining or returning to care for the patient in question and submit that documentation in every circumstance to the program director. The program director must review each submission of additional service and track both individual resident and program wide episodes of additional duty.

    59. 7. Consecutive weeks and annual cap of night float Residents must not be scheduled for more than six consecutive nights of night float. [The maximum number of consecutive weeks of night float, and maximum number of months of night float per year may be further specified by the Review Committee.]

    60. 7. Consecutive weeks and annual cap of night float RRC-IM Action: No new language. Existing program requirements address night float: “residents must not be assigned more than two months of night float during any year of training, or more than four months of night float over the three years of residency training. Residents must not be assigned to more than one month of consecutive night float rotation;”

    61. Common Program Requirements New Duty Hour and Supervision PRs Define licensed independent practitioners PGY-1: direct supervision available Specify optimal clinical workload Define elements of teamwork Define intermediate and residents in final years Define circumstance with 8 hours duty free Consecutive weeks and annual cap of night float

    62. New Use of the Resident Survey in Accreditation

    64. Resident Survey Content Five main areas: Faculty Educational Content Evaluation Resources Duty Hours

    65. Resident Survey: Faculty Do the (or your) faculty: . . . spend sufficient time teaching? . . . spend sufficient time supervising? . . . regularly participate in organized clinical discussions? . . . regularly participate in rounds? . . . regularly participate in journal club?

    66. Resident Survey: Educational Content Access to program’s written goals and objectives. Access to written goals and objectives for each rotation and major assignment. Fatigue and sleep deprivation education. Opportunity for research or scholarly activity. Emphasis of education over service obligation

    67. Resident Survey: Evaluation Opportunity to evaluate faculty annually. Opportunity to evaluate program annually. Receive rotation or assignment feedback. Ability to review current and past evaluations. Opportunity to assess program for improvement purposes.

    68. Resident Survey: Resources Do non-program trainees interefere with your education? Mechanisms available to raise and resolve issues without fear of intimidation or retaliation. How often are you able to access needed specific and reference materials?

    69. 80 hour week 1 in 7 duty free 10 hour rest period In-house call <1 in 3 24/6 consecutive duty New patients after 24 hours Home call frequency Home call 1 in 7 duty free Home call included in 80 hour week Moonlighting counted Resident Survey: Duty Hours

    70. Resident Survey Content Five main areas: Faculty Educational Content Evaluation Resources Duty Hours Reference: Holt, K, Miller, RS, The ACGME Resident Survey Aggregate Reports: An Analysis and Assessment of Overall Program Compliance. Journal of Graduate Medical Education, 2009, 1(2): 327-333. Provided reference for where PDs can learn more about the analysis for this. Provided reference for where PDs can learn more about the analysis for this.

    71. Resident Survey Thresholds Threshold is set at 2 standard deviations for each area within survey. Programs are triaged into five categories based on non-compliance over past three years for duty hours and two years for other four RS areas.

    72. Category 1: The worst Definition: Duty hour non-compliance in two consecutive years of the last three years or Duty hour non-compliance in two of the last three years and non-compliance in >4 RS areas last year, or Duty hour non-compliance last year and non-compliance in >4 FS areas last year, AND problems in >2 FS areas over the last two years.

    73. Category 1: The worst Definition: Duty hour non-compliance in two consecutive years of the last three years or Duty hour non-compliance in two of the last three years and non-compliance in >4 RS areas last year, or Duty hour non-compliance last year and non-compliance in >4 FS areas last year, AND problems in >2 FS areas over the last two years. RRC-IM Action: If not already scheduled, site visit in 6 months. Affects 1 core program already scheduled in 2011.

    74. Programs w Multiple Years of DH + Other Issues Prog #1 is a sub program Prog #2 is a core program Prog #3 is a sub programProg #1 is a sub program Prog #2 is a core program Prog #3 is a sub program

    75. Prog #3

    76. Category 2: The Distressed Definition: Duty hour non-compliance in last year, and Non-compliance in >4 RS areas in last year.

    77. Category 2: The Distressed Definition: Duty hour non-compliance in last year, and Non-compliance in >4 RS areas in last year. RRC-IM Action: If not already scheduled, site visit in 6 months. Affects 1 core program (already scheduled for 2011).

    78. Programs w DH + Other Issues Prog #4 is a core program Prog #5 is a sub programProg #4 is a core program Prog #5 is a sub program

    79. Prog #5

    80. Category 3: The Warned Definition: Duty hour non-compliance in one of the last three years, and Non-compliance in 1 - 3 of RS areas in the past year.

    81. Category 3: The Warned Definition: Duty hour non-compliance in one of the last three years, and Non-compliance in 1 - 3 of 5 RS areas in last year. RRC-IM Action: Letter from the RRC Executive Director and the IRC Executive Director cautioning programs and institutions. Affects 6 core programs.

    82. Category 4: The Fence Definition: Duty hours compliant. Non-compliance in 2+ RS areas in two consecutive years, or Non-compliance in 4 RS areas on one of last two years.

    83. Category 4: The Fence Definition: Duty hours compliant. Non-compliance in 2+ RS areas in two consecutive years, or Non-compliance in 4 RS areas on one of last two years. RRC-IM Action: If site visit >1 year, Committee will review the specific program and consider shortening the cycle or a cautionary letter from the RRC Executive Director. Affects 3 core programs all receiving a letter. RC did not support shortening cycles of these programs at this point in time – too new and different from the status quo. Need to educate community of new stance and way of using RS prior to shortening cycle. Should see further communication from ACGME about this --- in e-communication, newsletter. RC did not support shortening cycles of these programs at this point in time – too new and different from the status quo. Need to educate community of new stance and way of using RS prior to shortening cycle. Should see further communication from ACGME about this --- in e-communication, newsletter.

    84. Category 5: The Watched Definition: Duty hours compliant. Non-compliance in 2 or 3 RS areas.

    85. Category 5: The Watched Definition: Duty hours compliant. Non-compliance in 2 or 3 RS areas. RRC-IM Action: Letter from the RRC Executive Director that “we are watching you.” Affects 3 core programs.

    86. Resident Survey Monitoring Distribution of categories: Category 1: 1 (already scheduled for 2011) Category 2: 1 (already scheduled for 2011) Category 3: 6 (letters) Category 4: 3 (letters) Category 5: 3 (letters) Everyone else: 365

    87. Questions?

More Related