acgme accreditation preparing for a site visit by peggy mauer, med jobst vascular center, toledo,...

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