PREPARING FOR AN ACGME SITE VISIT

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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

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Todays Agenda

• Preparing and conducting site visits
• Preparing the PIF
• Preparing for the site visit day
• A view from the Residency Review Committee

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Our Mission in GME

• Provide the best possible patient care
• Provide the best possible E in GME

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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

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Accreditation Challenges
Extra work, risk of poor outcome
Opportunity to identify and build on assets and
strengthen weaknesses
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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

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OTHER RESOURCES

• Call other UCSF program directors and
  coordinators
• Call other programs in your specialty!
• Call the RRC staff

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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).

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What are the 27 Residency Review Committees
(RRC)?

• Two major responsibilities
• Develop and approve training standards
• Review and accredit residency and fellowship
  programs

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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

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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

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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

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Prerequisites for Accreditation

• Institutional requirements
• Common program requirements
• Specialty-specific program requirements

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Read your requirements
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Understanding Requirements

• Must Present without fail
• Should Absence justified by rationale
• Desirable Viewed as enhancement

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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.

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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)

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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

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Know your requirements
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Read your PIF
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Call Heather
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Program Information Forms (PIF)

• Common PIF
• Accreditation info
• Sites
• Faculty
• Resident/Fellow appointments
• Evaluation
• Duty Hours

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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

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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!

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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

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Call Claire
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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

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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

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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 gt 70
• Site visitor will use to focus questions with
  residents during visit
• Thus review survey with residents and address
  all concerns!

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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!

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Preparation practicalities

• Prepare one location with all required documents
  for review
• Arrange for tours of key facilities as requested
  by the site visitor

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Day or Two Prior

• Give everyone a copy of the schedule
• Review files with coordinator
• Clean up residency office, residency room, sleep
  rooms, etc

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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

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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)

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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

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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

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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!

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Accreditation Challenges
Extra work, risk of poor outcome
Opportunity to identify and build on assets and
strengthen weaknesses
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Getting Through the Site Visit Day with a Smile
on Your Face

• Preparing the Files, Forms,
• Policies, and People

Amy C. Day Director Office of Graduate Medical
Education
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The PIF is Done, Now What?

• Preparation before the big day
• The day of the visit

ORGANIZATION!!!
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Site Visitor
Preparation for the Day

• 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

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Schedule
Preparation for the Day

• 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 its set dont changeespecially on the day
  of the visit
• Schedule one conference room for entire day

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Preparing the People
Preparation for the Day

• 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 dont
• tell them what to say

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Preparing the Documentation
Preparation for the Day

• 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

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Resident/Clinical Fellow Files
Preparation for the Day

• 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

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Program Documentation
Preparation for the Day

• 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

• 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

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Day of Visit
Day of the Site 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

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Most Importantly

• Be organized and stay calm!