acgme accreditation preparing for a site visit by peggy mauer, med jobst vascular center, toledo,...
TRANSCRIPT
ACGMEAccreditation
Preparing for a Site Visitby
Peggy Mauer, MEdJobst Vascular Center, Toledo,
Ohio
Preparing for RRC Site Visits Preparing for RRC Site Visits or Internal Reviewsor Internal Reviews
START EARLY!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
Check the ACGME Web Site
http://www.acgme.org
Check the ACGME Web Site
Check the ACGME Web Site
Check the ACGME Web Site
Check the ACGME Web Site
Check the ACGME Web Site
Locate the files
You want me to find what where? from the previous site visit!
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
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
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
neededEnough in advance for time to address issues
Checks to see if prior problems have been resolved
Internal Review
Summary of the internal reviewShould provide guidance about what needs to
be done to improve programShould be read by both Program Director and
Program CoordinatorNOTE: Site visitor can ask anyone about
summary, but most do not ask to see it (not supposed to)
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
Work with program director
Be part of a TeamDecide (with director) which things
can be done by the two of youneed help from others, such as section chiefs,
associate program directors You’re the Coordinator; you coordinate the accreditation
paperwork.
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
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
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?
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
WebADSHelpful example
Helpful resource
Application Forms (PIF) downloadable from web site• http://www.acgme.org
Helpful resource
Application Forms (PIF) downloadable from web site
• http://www.acgme.org Web ADS –
• downloadable PIF partially pre-filledInstitution and Hospital listingResident and Faculty listingProcedures (already available for some specialties)PIF Competency & Assessment Form
“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 2003Latest change for Vascular Surgery was July 2006
Download PIF Application Forms
Download PIF Application Forms
Download PIF Application Forms
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”
Completing the PIF
Use clear and brief answers Comprehensive accurate answers “Correct” answers to questions (use program
requirements when necessary) Watch vocabulary Define abbreviations
Keep a Positive Impression of Your Program
Consistent tone and style Use “must” instead of “should” Be positive and assertive
Paperwork needed
Evidence of ‘substantial compliance’ with Procedures and criteria Equipment Facilities
Paperwork needed (cont’d.)
Evidence of ‘substantial compliance’ with Staff Required resident activities (logs, etc.) Competencies – not optional Resident duty hours – not optional
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
Curriculum
Rotation schedules Conference schedules Lecture schedules Research activities and requirements
Letters of Agreement
Affiliation Agreements Sponsoring Institution
Any Affiliated Hospitals
Letters of Agreement
See Institutional Requirements, Program Requirements, and consult with central GME office (DIO) – concerning wording about malpractice and reimbursement
Institutional Requirements
A. The agreements should a. identify the faculty who will assume both educational and supervisory
responsibilities for residents;b. specify their responsibilities for teaching, supervision, and formal
evaluation of residents, as specified later in this document;c. specify the duration and content of the educational experience;
andd. 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
Signatures on Application Form
DIO of Parent Institution Chairman of Department Program Director (s)
Use the time effectively
You will need all of the timesite visits occur any time of the year
– during applicant interview season National meeting Match Week Graduation Orientation
Think ‘Project Management’
Begin work prior to formal notice of site visit3 months prior to visit as a minimum
Best preparation is ongoingdocumentation of adherence to Institutional and
RRC requirements
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
Request curriculum vitae from faculty early
Ask for them on disk! (or by e-mail)Minimizes errorsSaves retypingSaves file spaceSaves paper
Request information early about
Equipment Numbers of cases Procedures Facilities Collect needed statistical reports
monthly or quarterly, to be sure to have them
Who would have the information:
Administrator Clinic & Nursing personnel Librarian Medical Records Billing Department GME Office
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.
Keep a file
Date stamp all drafts (except final)Use date on electronic document name
Locate copies of schedulesteaching conferences, lecture schedules,
rotation schedules (planned & actual) Check ahead that people who need to sign
will be there (not out of town - or country!)
Have checklist of requested information
Received, not yet received Tracks completeness of application Provides early warning of missing
information
Follow up with gentle reminders
Be graciousRemember, these people are
doing You a favor
Enter information
Enter in final form as soon as it is receivedIt doesn’t get staleIt’s already done
Type early -- avoid the Type early -- avoid the rushrush
Common PIF Errors
Incorrect program name Omission of program number Missing signatures Missing letters of agreement Missing Competencies Addendum Information omitted – questions unanswered
Common PIF Errors
Inconsistent data Common rotations not indicated on block
diagram for programs with multiple tracks Incorrect pagination Extraneous information that was not
requested
Check for Consistency
Number of residents in program match list of names of residents in the Web ADS
Number of full-time teaching faculty activity with number of months in block diagram
Number of months residents spend in a specific rotation with number of months on block diagram
Run spell check for the word “will”
Make copies
But wait until the last draftSaves confusion, time and paper
Save final draft -- for next time!
File in a safe place If on computer, keep disks
When mailing to Site Visitor
Things not to do –Do not include anything not asked forDo not include oversized or reprinted materialsDo not send in a 3-ring binder or perfectly boundDo not send in a fancy folder
When mailing to Site Visitor
Things to doKeep everything 8 ½ x 11 inchesBind with heavy duty rubber bandsMake 1 sided copies
Information for Site Visitor
Send good map to hospital and written directions
Send hotel and restaurant recommendations Ask if they have any dietary restrictions Arrange VP parking space if needed Offer to meet him/her at front desk
The VISIT
Dress Rehearsal Actual Visit
Dress Rehearsal
Meet with those who will see site visitorMake sure all are informed about the
department Give them copies of PIF (or relevant sections)
Schedule a conference or class room for Visit Day (ask early!)
Make sure key people know the contents of the last internal review summary
The Site Visitor Might Be
ACGME Field Representative (97% of the time)
Specialist in your discipline(3% of the time) “Eyes” and “Ears” of the RRC
The Site Visitor
Unbiased observer Verifies information provided by program
director in the PIF Conducts interviews with administrators,
faculty, residents
The Site Visitor
Reports what was said in meetings with faculty, residents, and program administrator
Files a written report describing errors or oversights with the PIF and what they were told or saw during the visit
Does not participate in final decision or recommendation of review committee
Getting Ready for Company
Organize and schedule the site visit day as completely as possible
The program director shouldContact site visitor as soon as you know their name.Ask ahead what arrangements they would like made;
who they want to meet, if they want lunch provided or time off for lunch (include maps, parking passes, etc.)
Check and re-check that key people will be available
Site Visit Day!!
Make sure all are alerted to the fact that it is the site visit day
Cancel all patient care activities for the PD Coordinator should be available all day in
case additional information is needed for the site visitor
Attend details of the site visitor
Site Visit Day
Make an office or suitable space available Coordinator should monitor how the day
is flowing and let people know if schedule changes
It all comes down to organization
All pertinent documents available at your finger tips
Have someone take you through your documents
Don’t get flustered – you know you have everything
Site Visit Day
Samples of Resident filesCopies of schedules, attendance tracking
method, etc.Written policies and proceduresCommittee meeting minutes
Site Visit Day
Tip: Keep a log who the site visitor met withwhat they saw (where they toured)what they were told
At end of Day – debrief
Meet with program directorGo over what went right or wrongAreas for change
“That’s what I should have said . . .”
Ask for help (if things did not go well)
Evaluate
Complete site visit evaluation survey
Results
Notification of results emailed to Program Director, Chairman, Sponsoring
Institution
Accreditation letters posted in ADS www.acgme.org
Within 1 month following RRC Committee Mtg (meets quarterly) that reviews the site visit report
Time frame: about 3 - 9 months from initiation
Citations or Recommendations
Can be effective tools to bring about change Must not be ignored
After the RRC Letter
Celebrate your success Have a party
Thank all those who contributed