How to Sail through an Internal Review

1. How to Sail through an Internal Review October 28, 2011

2. Conflict of Interest Statement We have no financial relationships or support from commercial interests that are relevant to this educational activity.

3. Are you ready for this trip?

4. The Essentials • Letter of Notification • Program Requirements • List of required documents • Survey results

5. The Process … step by step

6. The Process

7. NOTE • If the review is not completed by the date stated on your LON, you and the institution can be cited.

8. The Meetings • Meeting with the Program Director • Meeting with the Faculty • Should be core faculty members • Should be faculty that are actively involved in teaching the residents/fellows • Meeting with the residents/fellows • Should be peer selected group • Could be all of them • Should be not be chosen few THESE MEETINGS ARE NOT OPTIONAL.

9. “How does the internal review help to eliminate future citations..?”

10. Why do we make you do this? Internal Review Accreditation Visit • Self-study document is like a PIF • Review of program requirements • Survey monitoring for red flag issues • Review of policies • Goals and objectives, competency based, by level of training – we can help you! • Program Information Form (PIF) • Meetings with residents and faculty • Policies are reviewed – and you can be cited if out of compliance • Goals and objectives, competency based, by level of training - and you can be cited if out of compliance

11. “What are the roles of the Coordinators and Program Directors in this process?”

12. Thoughts • Think of the internal review as an early site visit. If you pass your review without issues, then your site visit will probably go smoothly. • If you are asked for follow up, it’s to help you to resolve issues before the site visit. • All programs need to continue monitoring after the review and stay vigilant of issues ….

13. What to look out for … • Clear and complete answers • Look for multi-part questions • New ACGME questions • Duty hour violations • Survey results • Especially those shaded areas • Lack of documentation of annual meetings with residents • Lack of documentation of annual review of the curriculum by faculty

14. What the internal review won’t do • Case log data • Volume – total #’s • Equal experiences - variation between trainees • Key diagnosis • License updates • Board pass rates • Number of trainees in your program • Faculty credentials/CVs • Resident scholarly activity

15. “What’s new in the Core Requirements?”

16. “Core” Requirements • Common program requirements • Program requirements • Common sub-specialty requirements • Specific subspecialty requirements • Institutional requirements

17. What works – Being Prepared! • 100% completion on surveys, with no areas out of compliance • Complete and organized files • Updated Policies & Protocols • Documentation of improvement plans & resident evaluations • Minutes of meetings • Happy residents • Happy faculty

18. “How do we evaluate and document progress of the trainee in a one year training program?”

19. Resources • UCLA GME website • Fatigue videos • Resident self-assessment form • General resources • ACMGE website • Newsletters • Common program citations • New policies and protocols

20. Happy SAILING! THANKS FOR COMING!