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. Today�s Agenda Preparing and conducting site visits Preparing the PIF Preparing for the site visit day A view from the Residency Review Committee 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

3. Our Mission in GME Provide the best possible patient care Provide the best possible �E� in GME 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

5. Accreditation Challenges

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

8. OTHER RESOURCES Call other UCSF program directors and coordinators Call other programs in your specialty! Call the RRC staff 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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). 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

10. What are the 27 Residency Review Committees (RRC)? Two major responsibilities: Develop and approve training standards Review and accredit residency and fellowship programs 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

14. Prerequisites for Accreditation Institutional requirements Common program requirements Specialty-specific program requirements 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

15. Read your requirements� 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

16. Understanding Requirements Must: Present without fail Should: Absence justified by rationale Desirable: Viewed as enhancement 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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. 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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); 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 3 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

20. Know your requirements� 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

21. Read your PIF� 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

22. Call Heather� 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

23. Program Information Forms (PIF) Common PIF Accreditation info Sites Faculty Resident/Fellow appointments Evaluation Duty Hours 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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! 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

27. Call Claire� 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 > 70% Site visitor will use to focus questions with residents during visit Thus: review survey with residents and address all concerns! 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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! 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

32. Preparation practicalities Prepare one location with all required documents for review Arrange for tours of key facilities as requested by the site visitor 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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) 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

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! 800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million800 million odn�t have enough to eat Actually it�s now 1.1 billion and 312 million

39. Accreditation Challenges

41. Getting Through the Site Visit Day with a Smile on Your Face Preparing the Files, Forms, Policies, and People

42. The PIF is Done, Now What? Preparation before the big day The day of the visit

43. Site Visitor 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 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 it�s set don�t change�especially on the day of the visit Schedule one conference room for entire day

45. Preparing the People 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 don�t tell them what to say

46. Preparing the Documentation 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 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 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 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

49. Day of 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!