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ACGME Accreditation Site Visit Preparation Guide for Jobst Vascular Center

This article provides a comprehensive guide on how to prepare for an ACGME accreditation site visit, including tips on locating previous site visit documents, conducting internal reviews, assembling a team, reviewing the curriculum and rotations, and completing the PIF application forms.

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ACGME Accreditation Site Visit Preparation Guide for Jobst Vascular Center

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  1. ACGME Accreditation Preparing for a Site Visit by Peggy Mauer, MEd Jobst Vascular Center, Toledo, Ohio

  2. Preparing for RRC Site Visits or Internal Reviews

  3. START EARLY! • Not a surprise • Decision letter for the last site visit, and the ACGME Web site, give the length of accreditation • Approximate date of next site visit is available – contact the RRC and ask. • This does NOT speed up the process

  4. Check the ACGME Web Site http://www.acgme.org

  5. Check the ACGME Web Site

  6. Check the ACGME Web Site

  7. Check the ACGME Web Site

  8. Check the ACGME Web Site

  9. Check the ACGME Web Site

  10. Locate the files • You want me to find what where? from the previous site visit!

  11. Previous Site Visit Documents • Locating the previous site visit documents is extremely important. Especially if you are new to your role. • Even if you have gone through a site visit previously – DO YOU KNOW WHERE YOUR FILES ARE STORED? • Both electronic and hard copies

  12. Any previous problems? • Review your program’s history of problems or citations • Review your program’s last 2 internal reviews • Review any interim correspondence with ACGME • Maintain a problem list

  13. Internal Review • Should be half way between site visits • Must be initiated by GME office • Reviewers must be from outside department • Gives early notice if improvements are needed • Enough in advance for time to address issues • Checks to see if prior problems have been resolved

  14. Internal Review • Summary of the internal review • Should provide guidance about what needs to be done to improve program • Should be read by both Program Director and Program Coordinator • NOTE: Site visitor can ask anyone about summary, but most do not ask to see it (not supposed to)

  15. Follow all the rules, including • Yearly or periodic review of Program by faculty with resident representation • Evaluation of educational effectiveness of program • Yearly evaluations of program by residents

  16. Work with program director • Be part of a Team • Decide (with director) which things • can be done by the two of you • need help from others, such as section chiefs, associate program directors • You’re the Coordinator; you coordinate the accreditation paperwork.

  17. Assemble a Team • Get key players in your dept. involved early in the preparation process • Analyze the program’s strengths and weaknesses • Start lists of things to be done • Choose leaders carefully

  18. Recruit 4 or 5 Helpers • Assemble 4 or 5 individuals to write or rewrite different sections of the PIF and review evidence supporting different requirements • Circulate the final PIF to key members of the education team

  19. Review the Curriculum & Rotations • Review past resident evaluations of the rotation • Examine yearly reviews of the program by “representative group” and the issues identified • Were the issues resolved?

  20. Begin work on forms early • Start a year in advance • Review application from the last site visit • Some things don’t change (number of rooms, where faculty graduated from medical school, etc.) • Same format might be used – if not available in WebADS • Helpful example

  21. Helpful resource • Application Forms (PIF) downloadable from web site • http://www.acgme.org

  22. Helpful resource • Application Forms (PIF) downloadable from web site • http://www.acgme.org • Web ADS – • downloadable PIF partially pre-filled • Institution and Hospital listing • Resident and Faculty listing • Procedures (already available for some specialties) • PIF Competency & Assessment Form

  23. “Essentials of Accredited Residencies in Graduate Medical Education” Program Requirements can be • Found on the Internet (http://www.acgme.org/) • Found in Graduate Medical Education Directory (Green Book) • Faxed to you by ACGME (when requested) • They do change, so check back periodically • Latest change for Pediatrics is July 2003 • Latest change for Vascular Surgery was July 2006

  24. Download PIF Application Forms

  25. Download PIF Application Forms

  26. Download PIF Application Forms

  27. When downloading PIF Application Forms • Use appropriate form (New program or Continuing accreditation) • Keep pagination the same • Don’t go over 11 pt. Font • Answers should fit in space provided • Do not leave blanks • Instead, use “Not applicable”

  28. Completing the PIF • Use clear and brief answers • Comprehensive accurate answers • “Correct” answers to questions (use program requirements when necessary) • Watch vocabulary • Define abbreviations

  29. Keep a Positive Impression of Your Program • Consistent tone and style • Use “must” instead of “should” • Be positive and assertive

  30. Paperwork needed Evidence of ‘substantial compliance’ with • Procedures and criteria • Equipment • Facilities

  31. Paperwork needed (cont’d.) Evidence of ‘substantial compliance’ with • Staff • Required resident activities (logs, etc.) • Competencies – not optional • Resident duty hours – not optional

  32. Faculty (Full & Part Time) • Number of Faculty & Residents • Biographical sketch forms completed on • Faculty (both Full- and Part-Time) • Residents • If Web ADS is kept current for your program, this can be downloaded from http://www.acgme.org

  33. Curriculum • Rotation schedules • Conference schedules • Lecture schedules • Research activities and requirements

  34. Letters of Agreement • Affiliation Agreements • Sponsoring Institution • Any Affiliated Hospitals

  35. Letters of Agreement • See Institutional Requirements, Program Requirements, and consult with central GME office (DIO) – concerning wording about malpractice and reimbursement

  36. Institutional Requirements • The agreements should • identify the faculty who will assume both educational and supervisory responsibilities for residents; • specify their responsibilities for teaching, supervision, and formal evaluation of residents, as specified later in this document; • specify the duration and content of the educational experience; and • state the policies and procedures that will govern resident education during the assignment. • From COMMON PROGRAM REQUIREMENTS, ACGME Web site, February 2003 Effective: July 1, 2004 Editorial Revision: February 2004

  37. Signatures on Application Form • DIO of Parent Institution • Chairman of Department • Program Director (s)

  38. Use the time effectively • You will need all of the time • site visits occur any time of the year • during • applicant interview season • National meeting • Match Week • Graduation • Orientation

  39. Think ‘Project Management’ • Begin work prior to formal notice of site visit • 3 months prior to visit as a minimum • Best preparation is ongoing • documentation of adherence to Institutional and RRC requirements

  40. Work backward from mailing date • Final version to mail to site visitor • at least 14 days prior to site visit • Allow ample time for unexpected delay • no matter how much time is given, you’ll somehow need it all

  41. Request curriculum vitae from faculty early • Ask for them on disk! (or by e-mail) • Minimizes errors • Saves retyping • Saves file space • Saves paper

  42. Request information early about • Equipment • Numbers of cases • Procedures • Facilities • Collect needed statistical reports • monthly or quarterly, to be sure to have them

  43. Who would have the information: • Administrator • Clinic & Nursing personnel • Librarian • Medical Records • Billing Department • GME Office

  44. Request copies of agreement letters early • Consult your DIO and work with GME office on format for letters • Make sure people who signed letters previously are still there.

  45. Keep a file • Date stamp all drafts (except final) • Use date on electronic document name • Locate copies of schedules • teaching conferences, lecture schedules, rotation schedules (planned & actual) • Check ahead that people who need to sign will be there • (not out of town - or country!)

  46. Have checklist of requested information • Received, not yet received • Tracks completeness of application • Provides early warning of missing information

  47. Follow up with gentle reminders • Be gracious • Remember, these people are doing You a favor

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