James A. Arrighi, MD, FACC Chair-Elect, Medicine RRC Program Director, Cardiology Alpert Medical School of Brown Univers

1. James A. Arrighi, MD, FACC Chair-Elect, Medicine RRCProgram Director, CardiologyAlpert Medical School of Brown University Conversations with the Residency Review Committee for Internal Medicine: Understanding the Program Requirements & Preparing for the Future

2. Table of Contents • General Description of the RRC-IM • Summary of Actions Taken in 2011 • Guidance on Complying with Program Requirements • New Subspecialty Program Requirements • Resident Survey • The Future…Next Accreditation System

3. RRC Composition • 3 nominating organizations - ABIM, ACP, AMA • Currently 18 voting members • 6 year terms -- except resident (2 years) • Generalists and subspecialists Cardiology, CCEP, Critical Care Medicine, Endocrinology, Gastroenterology, General Internal Medicine, Geriatric Medicine, Hematology/Oncology, Infectious Disease, Medicine-Pediatrics, Nephrology, Pulmonary/Critical Care Medicine, Sleep Medicine, Transplant Hepatology • Geographic Distribution CA, CT, DC, FL, LA, MA, NY, MN, NM, PA, RI, SC, TX, WA • Ex-officio members from each nominating organization (non-voting)

4. Who is the RRC-IM? • Committee Members • Lynne M. Kirk, MD – Chair • James A. Arrighi, MD – Chair elect • Beverly M.K. Biller, MD • Heather Brislen, MD * • Andres Carrion, MD* • E. Benjamin Clyburn, MD – Vice-Chair elect • John Fisher, MD * • John Fitzgibbons, MD • * New to RRC since July 2010 • Andrew S. Gersoff, MD * • Betty Lo, MD * • Furman McDonald, MD * • Elaine A. Muchmore, MD * • Susan Murin, MD • Victor J. Navarro, MD • Andrea Reid, MD * • Ilene Rosen, MD * • Stephen M. Salerno, MD • Jennifer C. Thompson, MD

5. RRC-IM Oversight

6. Summary of Activities 2011 • The RRC-IM meets three times a year – January, May, and September • A fourth summer meeting is a business/policy meeting • The RRC-IM reviewed 560 programs • Average per meeting: • 28 core • 136 subspecialty programs • 22 interim reports • (progress & duty hours reports)

7. Summary of Actions in 2011Subspecialty Programs

8. Summary of Actions:Sub Review Cycles

9. Guidance on Interpretation of IM Program Requirements • FAQ contain clarification and interpretation of program requirements • Core IM FAQ http://www.acgme.org/acWebsite/RRC_140/Internal_Medicine_Residency_Programs_FAQ.pdf • General Subspecialty FAQ http://www.acgme.org/acWebsite/downloads/RRC_FAQ/General_Subspecialty_Fellowship_FAQs.pdf • Specific Subspecialty FAQ Very Important!

10. New FAQ Evaluation of Faculty by Fellows • Question: Are fellows expected to evaluate faculty at end of each rotation? What are the expectations? • ANSWER: The RC acknowledges that some attending assignments to teaching activities may not be tightly linked to the month-long delimited rotations/assignments. For such situations, evaluations of faculty do not need to not take place at the end of the monthly rotation, since the fellow may not have had enough exposure to a particular attending to meaningfully evaluate the attending.  However, at a minimum, the RC expects that fellows will evaluate the faculty member’s performance/teaching ability at least quarterly. (July 2011 RC Meeting)

11. New Subspecialty PRs • At Feb 2011 ACGME mtg, Board approved revisions to subspecialty requirements in following areas: • Cardio, CCEP, IC, Hem, Onc, Hem/Onc, GI, TH, Rheum, Endo, Nephro, ID, Pulm, Pulm/CCM, and Sleep Medicine were all approved and go into effect July 1, 2012. • Advanced Heart Failure and Transplant Cardiology PRs were approved at the February 2012 ACGME Board meeting. • Applications will be made available on website • Will be reviewed at September RC meeting • Duty hours PR’s had been revised for 7/1/11

12. Interpreting the Document on Requirements • Common requirements (BOLD) • General subspecialty requirements(italics) • Cardiology-specific requirements(regular font)

13. PD salary support “The sponsoring institution must: provide the program director with adequate salary support for the administrative activities of the fellowship. The program director must not be required to generate clinical or other income to provide this administrative support. This support should be 25-50% of the program director's salary, or protected time, depending on the size of the program.” Rationale: The change is from a “suggested” to a “should” requirement. The RC-IM has long expected that sponsoring institutions provide adequate salary support for the program director. Adequate salary support for administration of the program enhances the program director’s ability to provide direct advocacy for the fellows’ learning experiences.

14. Associate PD “Appointment of one KCF to be an associate program director is suggested.” Rationale: This requirement is not mandatory; it appears as “is suggested.” It was added in response to suggestions from many program director groups to allow the program directors to delegate some of their many responsibilities to other key members within the program.

15. Other PD PR’s “PD must be available at the primary clinical site.” Rationale: No longer “located” at primary site. “PD must establish a reporting relationship between him or herself and the dependent accredited sub-subspecialty programs.” Rationale: Cardiology PD is a resource to Interventional and EP PD’s.

16. KCF and Fellow Scholarship “ At least 50% of the KCF must demonstrate evidence ofproductivity in scholarship, specifically, peer-reviewed funding; publication of original research, review articles, editorials, or case reports in peer-reviewed journals; or chapters in textbooks.” Rationale: No real change. Fellows: Majority must demonstrate scholarly activity Pubs in peer-review journals Peer-reviewed grants Peer-reviewed abstract (regional, state, or national)

17. KCF Evaluator “At least one of the KCF must be knowledgeable in the evaluation and assessment of the ACGME competencies; and, spend significant time in the evaluation of fellows including the direct observation of fellows with patients.” FAQ Question (to be posted): What is acceptable education for KCF who will serve as competency evaluators? Answer: These faculty must be knowledgeable in the evaluation and assessment of the ACGME competencies. This can be achieved through participation in workshops offered through program director groups, the ABIM, the ACGME, or through local GME faculty development programs that focus on competency assessment. The evaluators are expected to have ongoing training in these areas.

18. Conference Format “The core curriculum must include a didactic program based upon the core knowledge content and areas defined as a fellow’s outcomes. The program must afford each fellow an opportunity to topics covered in conferences that he or she was unable to attend. Fellows must participate in clinical case conferences, journal clubs, research conferences and morbidity and mortality (or quality improvement) conferences. All required core conferences must have at least one faculty member present and must be scheduled as to ensure peer-peer and peer-faculty interaction.” Rationale: Not a new requirement but a modified one that provides programs with more flexibility. Rigid requirements on frequency, numbers of conferences, etc are gone.

19. Deleted Program Requirements • Current “general requirements” were combined with individual subspecialty program requirements – so, not really deleted, more integrated. • Death reviews and autopsy reports – deleted • Specifics of the written curriculum (teaching methods, reading lists, disease mix, etc) – deleted • Teaching rounds of five hours a week – deleted • Conference specificity (types and numbers of conferences per month) – deleted #s

20. Multisource Evaluation “The program must use both direct observation and multi-source evaluation, including patients, peers and non-physician team members, to assess fellow performance in: Interpersonal communication, Professionalism and System-Based Practice.” FAQ Question: What is expected for multi-source evaluation of fellows? Answer: Multi-source evaluations are important in the assessment for several competencies. The goal is to obtain feedback from multiple evaluators who interact with the fellow being assessed. These must include at least patients, peers, and non-physician team members (nurses, clerical staff, therapists, etc.). Forms distributed to these individuals do not have to ask each the same items, but should reflect the same general domain(s) being assessed (e.g., interpersonal and communication skills, professionalism, systems-based practice).

21. Practice Management “Fellows must receive instruction in practice management relevant to their subspecialty.” FAQ Question (to be posted): What constitutes adequate instruction in practice management? Answer: Instruction in practice management includes the organization and financing of clinical practice including personnel and business management, scheduling, billing and coding procedures, telephone and telemedicine management, and maintenance of an appropriate confidential patient record system. Programs can comply with this requirement by developing/implementing a lecture series related to this topic.

22. Procedures No change DCCV 10, Echo 75/150, ETT 50, Cath 100, Pacer/ICD interrogation (no #), ECG 3500, Nuc 100 ModifiedTemp pacers: removed min # 10Holter: removed min # 150 RemovedCMR 25, CCT 50 AddedConscious sedation

23. Instruction/Experience (not competency) • CT • IABP • CCT, CMR • EP • PCI • Pericardiocentesis

24. Medical Knowledge(not competency) • Rehab • Cerebrovasc disease • Adult congenital HD • Trauma • Geriatric cardiology (not complete list)

25. Rotations, ClinicNo Change Rotations (24 mos clinical)4 cath6 noninvasive2 EP9 non-lab (ward) ClinicMin 6 month blocks4-8 pts/sessionMay interrupt 1 mo./yr (excl vacation)

26. Evaluation ProcessSmall Changes • Procedural competence • Direct observation • Objective formative assessment x 2 ACC In-training Exam!! • Multisource eval (includes patients, peers, non-MD’s) • Clinic evals every 6 months • Faculty evals • Program review process

27. Environment and Duty Hours • Culture of safety • Lifelong learning • Involve fellows in QI, PI • Transitions of carePatient safety Structured process • SupervisionDirect Indirect – immediate Indirect – available remotely

28. Duty Hours 80 hrs/wk No change 1 day off/wk No change Max 24+4 hrs shifts Replaces 24+6 hrs Min 8 hrs btwn shifts Replaces 10 hrs PR’s allow breaking rules on shifts if fellow-initiated, rare, monitored by PD (documentation), and justified.

29. Other PR’s “Fellows must participate in training using simulation.” “Fellows must receive instruction in practice management relevant to their subspecialty.”

30. One-Year ProgramsDifferent Common PR’s • Focus on Patient Care and Medical Knowledge • Much shorter sections on PBLI, Interpersonal/Communication, Systems-based practice, Professionalism • Fellow Scholarship = “opportunity” to participate (research, QI project) • Evaluations at least Q3 mo if no monthly rotations

31. Update on Program Requirements Core Program Requirements Revisions Core requirements will be undergoing categorization for Next Accreditation System(NAS) More when discuss the NAS at end of presentation Other Program Requirement Revisions All sub requirements revised and go into effect 7/1/2012, except Geriatric Medicine Advanced Heart Failure & Transplant Cardiology Approved at February 2012 ACGME Meeting Applications will be made available on website Likely will be reviewed at September RC meeting

32. Resident Survey (RS):General Information • Administered annually Jan-May • 70% completion rate to see summary report • Question in RS relate to 5 content areas: Faculty, Educational Content, Evaluation, Resources, Duty Hours. • In 2009: All core programs and fellowships with 4 or more need to complete survey annually • In 2010: several difficult questions in RS were modified • In 2011: RS was revised based on input from residents and survey experts • In 2012: RS revised again to align with new PRs. In prep for NAS, all residents & fellows will be surveyed.

33. Resident Survey (RS) • In 2006: ACGME Board gave Monitoring Committee (Mon Com) responsibility to oversee duty hour (DH) • Review national reports and made recommendations to RCs re how to handle program outliers = programs with substantial non-compliance rates • In 2010 & 2011: Mon Com made recommendations for programs w/ significant non-compliance w/ • DH as well as issues with other parts of the RS; and • DH issues over multiple years (2 of 3). • In 2010: Mon Com made recommendations for programs w/ significant issues w/ the non-DH sections of RS • In 2011: Mon Com identified programs w significant issues w/ non-DH sections of the RS, but did not make recommendations for action. RC reviewed and decided these.

36. Top Citations of Consequence • Evaluation system • Fellows • Faculty • Program • Didactics • Procedures

37. The “Next Accreditation System”

38. Goals of The “Next Accreditation System” • To begin the realization of the promise of Outcomes • To free good programs to innovate • To assist poor programs to improve • To reduce the burden of accreditation • To provide accountability for outcomes (in tandem with ABMS) to the Public

39. The “Next Accreditation System” in a Nutshell • Continuous Accreditation Model – annually updated • Based on annual data submitted, other data requested, and program trends • On site review of “Institutional Learning Environment” every 18 months • Scheduled Site Visits replaced by 10 Year Goal Setting Self Study Visit • Standards revised every 10 years • Standards Organized by • Structure • Resources • Core Processes • Detailed Processes • Outcomes

40. Categorization of PR’sPreparatory Year • The RC will spend much of 2012 “preparing” for the NAS • Need to categorize common program requirements (CPRs): • Outcome PRs – PRs written as outcomes • Example: Residents must be able to demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well the application of the knowledge of patient care (CPR IV.A.5.b) • Core Process PRs – PRs that are fundamental to maintain an quality educational program • Example: There must be a single program director with authority and accountability for the operation of the program (CPR II.A.1). • Detailed Process PRs – PRs that provide additional details or an explanation for core process PRs • Example: Program Director should continue in position for length of time adequate for continuity of leadership and program stability. (CPR II.A.2)

41. Preparatory Year Question: Why is the categorization of PRs into Outcome, Core and Detailed Process so important? • Answer: Programs identified as being in “good standing” based on performance metrics (resident survey, faculty survey, board scores, other data, etc.) will be allowed to “innovate”, meaning they will not need to adhere to detailed process PRs. • Detailed process PRs do not go away. PDs will not need to demonstrate compliance to these PRs unless its evident that a particular outcome or core process is not achieved. EXAMPLE: Continuity Clinic Experience. The outcome is for fellows to achieve a continuity experience that exposes them to the depth and breath of cardiovascular disease. The “particulars” in the PRs are the detailed process that programs can be relieved if, it is evident that the outcome is being achieved.

42. Preparatory Year • Once CPRs are categorized, all IM core and sub PRs be categorized into Outcome, Core, and Detailed process • As was noted earlier, the RC tracking data on each program annually: • Milestone performance data • Resident survey data • Faculty survey data • Board certification performance data • Other ADS data • Other data elements identified as important by the RC • RC will spend much of 2012 discussing what data elements are important and will need to be reviewed annually

43. Conceptual Model of Standards Implementation Across the Continuum of Programs in a Specialty Accreditation with Warning New Programs, Accredited Programs with Major Concerns Probationary Accreditation Initial Accreditation New Programs Maintenance of Accreditation Accredited Programs without Major Concerns Maintenance of Accreditation with Commendation 2-4% 15% 75% 6-8% STANDARDS Structure Resources Core Process Detailed Process Outcomes Structure Resources Core Process Detailed Process Outcomes Structure Resources Core Process Detailed Process Outcomes Structure Resources Core Process Detailed Process Outcomes Withhold Accreditation Withdrawal of Accreditation

44. The “Next Accreditation System” Institutional Visit Program – Patient Safety, Quality Improvement Supervision, Transitions in Care, Duty Hours Institutional Review Committee Review Committee Institution Oversight Program Program Program Review Committee Review Committee Program Program Program Review Committee Program Program Program Review Committee Review Committee Program Review Committee Review Committee Review Committee Review Committee

45. Next Accreditation System (NAS)Big picture… • Less prescriptive ACGME program requirements • Less frequent standards revision • Continuously monitors outcomes and other predictive measures • Continuously holding sponsoring institutions responsible for oversight of educational and clinical systems • Promoting curricular innovation • Enhance curricular and rotation design flexibility

46. Next Accreditation System (NAS) Elements • Formal in depth self study and site visit every 10 years • RC receives data continuously • RC tracks data on each program • Milestone performance data • Resident survey data • Faculty survey data • Board certification performance data • Other ADS data • Other data elements identified as important by the RC

47. Next Accreditation System (NAS) Milestones – what are they?? • Observable developmental steps moving from Novice to Expert/Master • Organized under the rubric of the six domains of clinical competency • Describe a trajectory of progress from neophyte towards independent practice • Articulate shared understanding of expectations • Set aspirational goals of excellence • Provide a framework and language for discussions across the continuum

48. Next Accreditation System (NAS) Milestones • Tracks what is important – outcomes • Begins using existing tools and observations of the faculty • Clinical Competency Committee triangulates progress of each resident • Milestones – Nationally developed expectations • ABMS Board tracks the individual’s development • ACGME Review Committee tracks unidentified individuals’ trajectories • ACGME and ABMS are able to provide accountability for effectiveness of educational program

49. Next Accreditation System (NAS)Timeline • In 2011, the ACGME Board approved the framework for NAS and its phased implementation. • Phase 1 specialties: Pediatrics; Internal Medicine; Diagnostic Radiology; Emergency Medicine; Orthopedic Surgery; Neurological Surgery; Urological Surgery • Phase 1 specialties will enter preparatory year 7/2012 • Phase 1 specialties “go live” 7/2013 • Phase 2 specialties enter preparatory year 7/2013 • Phase 2 specialties “go live” 7/2014