updates from the residency review committee for pediatrics€¦ · • clinical learning...

© 2014 Accreditation Council for Graduate Medical Education (ACGME)

Updates from the Residency Review Committee for Pediatrics

Joseph Gilhooly, MD, Chair, RRC for Pediatrics Caroline Fischer, MBA, Executive Director


Reporting & RC Review Timelines AY 2012-2013


Reporting & RC Review Timelines AY 2013-2014


Annual Update Submission Confirmation of Accuracy


Findings from RC Annual Data Review Incomplete/Inaccurate Data

• Response to Citations • Explain how corrected/progress made toward

correction/what is the action plan • Include data, if applicable • Keep up-to-date

• Not limited to providing updates at the time of the annual review


Faculty Roster Instructions Pediatric Programs

• In addition to the members of the core faculty, be sure to include the following faculty members on the roster: • at least one faculty member in each of the following:

• developmental behavioral pediatrics • adolescent medicine • neonatal-perinatal medicine • pediatric critical care medicine • pediatric emergency medicine

• faculty members from at least five of the pediatric subspecialties listed in section IV.A.6.b).(3).(c) of the Program Requirements

• any other pediatric faculty members who play a significant role in the program (i.e., anyone responsible for a required experience)


Faculty Roster Instructions Subspecialty Pediatric Programs

• Identify only the divisional faculty members, regardless of the amount of time devoted to the program, on the Faculty Roster, (e.g., pediatric cardiology programs should only list the pediatric cardiology faculty members).

• Do not list any faculty members from other disciplines.


= 57 hrs.

= 70 hrs.

Doctor Overtime, MD

Doctor Overtime, MD

No Board certification

provided

Findings from RCs Annual Data Review Incomplete/Inaccurate Data – Faculty Roster

• Faculty Roster • Certification information • Hours devoted to the program


Findings from RCs Annual Data Review Incomplete/Inaccurate Data – Scholarly Activity

Note: data

entered into the

CV doesn’t transfer

to the SA table

Indicates that zeroes were entered into the SA table in each category


Annual Data Review Element Faculty Scholarly Activity

•John Smith •12433 •32411 •3 •1 •1 •3 •Y •N


Annual Data Review Element Resident/Fellow Scholarly Activity

•John Smith •12433 •1


Duty Hours not compliant with

PRs

No key provided for

abbreviations

ROM (OP)

1

ROM (OP)

1

ROM (OP)

1

Findings from RCs Annual Data Review Incomplete/Inaccurate Data – Core Block Diagram

• Block Diagram • Non-standard format • Duty Hours • Abbreviations


Smith Brown Jones Wilson Lee Doe

Only 1

year provided

% of time spent on

research/clinical

No key provided for

abbreviations

Findings from RCs Annual Data Review Incomplete/Inaccurate Data – Subspecialty Block Diagram

• Block Diagram • Abbreviations • Non-standard format • Research time


Block Diagram Instructions

• Include the participating site in which a rotation takes place, as well as the name of the rotation.

• If the name of the rotation does not clearly indicate the nature of the rotation, then clarifying information should be provided as a footnote to the block diagram or elsewhere in the document.

• Group the rotations by site. The site numbers listed in the Accreditation Data System (ADS) should be used to create the block diagram.

• When “elective” time is shown in the block diagram, the choice of elective rotations available for residents should be listed below the diagram. Elective rotations do not require a participating site.

• For each rotation, the percentage of time the resident spends in outpatient activities should be noted.

• The percentage of time devoted to structured research on a clinical rotation should be noted. If a block is purely research, it should be labeled as such, and should not be associated with a participating site.


Findings from RCs Annual Data Review Examples of Accurate/Complete Block Diagrams


Clinical Experience Review

• Review specialty survey results and identify potential deficiencies • Review the number and mix of procedures


Resident Survey

• Minimum 70% participation required • Results not available to programs until June

• Working on a revised timeline for next year


Faculty Survey

• Core programs – all faculty identified as “core” • Subspecialty programs – faculty who devote

significant time to the program • Minimum 60% participation required


Review of Annual Data Decisions Available to the RC

• Confirm existing accreditation status based on data review

• Change existing status based on data review

• Request additional information from program • Clarifying information • Site Visit


Citations

• Identify areas of noncompliance • Linked to a specific requirement • Response to citations required in ADS • Responses reviewed annually by the RC • Remain active until corrected


Areas for Improvement

• Result from annual review of program data elements

• May not be specifically linked to a requirement • May be a general concern • Written response not required, rather data will

be reviewed


Departmental Notification Letter


Departmental Notification Letter cont.


Citations

• New – based on current review • Extended – previous citations that have not been

fully addressed* • Resolved – Corrected

*Citations issued prior to July 1, 2013 may not have been reviewed by the RC.


Webinars

• Previous webinars available for review on ACGME website • Clinical Learning Environment Review (CLER) • Overview of Next Accreditation System • Milestones, Evaluation, CCCs • Specialty-specific Webinars • Phase I Coordinator Webinars (surgical and non-surgical) • Specialty-specific Webinars (Phase II) : Nov 2013 – Feb 2014 • Stand-alone slide decks for GME community: NAS, CCC, PEC,

Milestones, Update on Policies

• Upcoming • Self-Study (what programs do) • Self-Study Visit (what site visitors do)


Program Resources ACGME Contacts

• Questions related to ADS: • Kirsten Woebbeking ([email protected]) 312.755.7443;

[email protected]

• Questions related to site visit: • Ingrid Philibert ([email protected]) 312.755.5003 • Jane Shapiro ([email protected]) 312.755.5015 • Penny Lawrence ([email protected]) 312.755.5014

• Questions related to requirements or notification letter: • Caroline Fischer ([email protected]) 312.755.5046 • Denise Braun-Hart ([email protected]) 312.755.7478 • Kim Rucker ([email protected]) 312.755.7054 • Luz Barrera ([email protected]) 312.755.5077

mailto:[email protected]�










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