Preparing for Internal Reviews and Site Visits

1. Preparing for Internal Reviews and Site Visits Robert J. Nolan, MD

2. Preliminary Considerations • Check the ACGME Website for PIF revisions on a routine basis • PIFs now have two sections – the “Common PIF” (Part I) and the “Specialty Specific PIF” (Part 2) • Preparing for an internal review ideally should be identical to preparing for a site visit – but your GME office consists of friends…your RRC, not.

3. Preliminary Considerations • Create a PIF team • Program Director • Relevant Faculty • Program Coordinator • Trainees • Hospital/Clinic Data Folk

4. Program Director • “The program director must …prepare and submit all information required and requested by the ACGME, including but not limited to the program information forms and annual program resident updates to the ADS, and ensure that the information submitted is accurate and complete.” (CR II.A.4.f)

5. Create a Time Line • The Internal Review Process begins your Site Visit PIF preparation process (With a 1 or 2 year cycle, the LON starts the process) • Address previous citations and current compliance issues • Review Curriculum and Evaluation Processes • Review Data Collection processes

6. Create a Time Line • Patient Volume Data, Procedure Numbers, etc. come from a consistent base year – most recent academic year or the most recent calendar year • Example: Site Visit – August 2010, base year will be 2009-2010 or calendar year 2009. So…accurate data collection systems need to be in place by the end of 2009!

7. Create a Time Line • For site visits in the November/December 2010, the data year should probably be the 2009 – 2010 academic year rather than calendar year 2009 – otherwise the PD may have some explaining to do (“My Hospital/Clinic’s IT system is really third-rate” is an excuse, not an explanation)

8. Create a Time Line • Compliance is judged at the time of the site visit, but… • It is helpful to have annual reviews of program effectiveness (ARPE), ARPE action plans, evaluation systems, quality improvement projects, ILPs, portfolios, competency didactics in place for more than a couple days – word might not get around!

9. Writing the PIF – Practical Guidance • Read the PIF instructions • Follow the instructions • Avoid internal inconsistencies • Typos and poor grammar are signs of sloppy work, so… • Consider composing in Word and “cutting and pasting” … the PIF doesn’t have spellcheck

10. Numerical Data • The current resident list must be accurate • Past resident list must be accurate – this may not be a trivial task if both the program director and program coordinator are new since the last site visit • The past resident lists (graduating residents) must be consistent with lists of residents taking the board examination

11. Numerical data – cont’d • In Part I – each resident must be accounted for. Residents starting = Residents finishing (3 or 4 or 5 years later) – Residents leaving during the program + Residents transferring into that class • All graduating residents either have taken the board or have not; those who have, either have passed (1st attempt) or not

12. CVs - Bibliographies • Ideally one person should be responsible constructing the Part I CVs and Bibliographies based on CVs provided by the faculty • Follow the instructions – time limits, # of citations, etc. • Use the same citation style for each CV • Use the same formatting and font on each CV – (a plain font: Arial, Tahoma, etc.)

13. Reacting to “The Letter” 12 weeks to the site visit • View site visit preparation as “party preparation” • An Opportunity to celebrate your program’s success and compliance with the ACGME Program Requirements! • Establish a timeline

14. Timeline Working backwards, set dates for: • The site visit – that date is set for you! • The final briefing of all site visit participants • Final prep work on program documentation • Mailing the finished PIF • Communicating with the site visitor • Completing each major section of the PIF • Collecting the relevant site visit documents • Arranging for a mock site visit • Finalizing the schedule of events • Identifying your team to plan and implement the site visit

15. 11 weeks to the site visit • The Program Director meets with Key Faculty, Program Coordinator, and other Administrative Staff to discuss the accreditation process • The Program Director decides what to delegate and sets clear timelines

16. 10 weeks to the site visit • Continue organizing documents • Final polishing of the PIF – e.g., adding patient or procedure data from most recent calendar or academic year – this part shouldn’t be hard as you have been working on the PIF on and off for months/years, as you have known the approximate date of the site visit for years

17. 8 weeks to the site visit • Faculty preparation in groups or individually – remember the program gets to select the faculty for the site visit !!! • Resident preparation – the residents for the site visit are peer selected – “coaching” vs. preparation; i.e., briefing • All residents need some preparation – remember the site visitor may encounter the “unselected” on his/her tour

18. 8 weeks to the site visit – cont’d • Chairman Briefing! • Adjust resident call schedules – no participating resident should be post-call! • Finalize PIF – internal consistency, all blanks filled, format, font, spell check, proper English • 7 to 8 weeks prior to site visit – PIF to GME office for initial review (Drs. Nolan and Peel)

19. 6 weeks to the site visit • Incorporate revisions of GME office into PIF • Contact the site visitor (per his/her instructions) to confirm the day’s agenda • Keep in mind that the agenda is the site visitor’s, not yours! • Inquire about any special dietary restrictions • Ask if s/he wants advice on hotels, etc • Ask if s/he will want to tour the program’s facilities

20. 6 weeks to the site visit – cont’d • Designate a meeting room for the site visit • plenty of space, quiet, comfortable chairs, no distractions • Confirm lunch plans

21. 5 weeks to the site visit • Have DIO read and sign the PIF • Give the DIO at least 10 business days to read and comment on the PIF • Modify PIF with DIO suggestions

22. 3 -4 weeks to the site visit • Mail the PIF to the site visitor (per his/her instructions!) • Send the requested number of copies • Don’t staple if instructions specify not to staple • Bind with a rubber band if so instructed • Send only the requested number of attachments • Include a cover letter confirming the agenda and contact numbers Send the PIF on Time!

23. 1 – 2 weeks before the site visit • PD to reread his/her PIF • PD should know your PIF cold • PC: have all potential documents ready– portfolios, files, policies, didactic schedules, documentations of conference attendance, patient logs, etc. – per your site visitor’s instructions and your RRC’s requirements

24. 1 – 2 weeks before the site visit • Consider creation of binders for required supporting documents with clear (large font) binder labels • Consider creation of binders for special supplementary materials – material that support your responses to PIF questions or address anomalies in your program

25. 1 – 2 weeks before the site visit • Consider a “re-inoculation” briefing of participating faculty and residents • Have participants read the relevant portions of the PIF? • Consider a re-brief your chairman!

26. The day before the site visit • PD to review his/her PIF - again • PD/PC to personally remind all participants to arrive 30 minutes early – do not rely on email reminders! • Set up SV room – all documents/binders should be in the room the day before the SV begins

27. The day before the site visit • Create “tent cards” for all participants (some visitors may not want these) – some visitors just want resident’s PGY level on the tent card, not their name; for faculty: name and role in program (i.e., continuity clinic supervisor, director of L&D, chief of Hospitalist’ Group, etc.)

28. The Day of the Site Visit • Meet the site visitor at a pre-arranged place – do not allow the site visitor to wander around lost! (Corollary – do not let the visitor out of your sight!) • Call all participants one hour before their meeting with the site visitor – do not rely on email or text mail reminders!

29. The Day of the Site Visit • Collect all pagers, cell phones, blackberries, other electronic bric-a-brac, and visible Pharma stuff (from residents, faculty and yes, Chairman)at the SV room door! • PD should discretely debrief participants as they leave – consider having a debriefing room prepared (out of the direct sight of the visitor) • PD should rapidly prepare to address any unexpected lines of questioning raised with the faculty and residents in the PD’s closing session with the visitor

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