Cuc Mai MD FACP August 2014

1. Program Evaluation Committees (PEC), Annual Evaluations, and the 10 year Self Study and Visit in the Next Accreditation System Cuc Mai MD FACP August 2014

2. Disclaimers • No part of my salary is supported by ACGME. • I am only a messenger and also a program director. • Information may change in the Next Best Accreditation System.

3. Goals and Objectives • Review the goals of the accreditation process in the Next Accreditation System for Maintenance of Accreditation • Define current description of the Annual Program Evaluation, the 10 year self study, and 10 year self study visit • Define the requirements for the Program Evaluation Committee • Describe some actions programs should consider for the 10 year self study

4. The Old Days… • Internal Reviews • Program Information Form • Duration between Site Visits based on Results of Accreditation Visit

5. Maintenance of Accreditation in the Next Accreditation System • Annual Program Evaluation (PR-V.C.) • Resident performance • Faculty development • Graduate performance • Program quality • Documented improvement plan Self- Study visit Self- Study Ongoing Improvement Yr 1 Yr 0 Focused assessments possible at any time based on data from AE. Full site visit at any time if data from AE eggregious. Yr 2 Yr 7 Yr 9 Yr 10 Yr 8 Yr 6 Yr 5 Yr 3 Yr 4 AE AE AE AE AE AE AE AE AE AE AE: Annual Program Evaluation

6. Aims of the Next Accreditation System • Enhance the ability of the peer-review system to prepare physicians for practice in the 21st Century • To accelerate the movement of the ACGME toward accreditation on the basis of educational outcomes • Reduce the burden associated with the current structure and process-based approach

7. 10 Self-Study and Self-Study Visit • Self-Study • Conducted by the program • Annual Program Evaluation • Review of program goals and improvement efforts • Self-Study Visit • Conducted by ACGME Field Staff members

8. Annual Data Review ElementsPolicy 17.61 Review of Annual Data • Continuous Data Collection/Review • ADS Annual Update • Resident Survey • Faculty Survey • Milestone data • Certification examination performance • Case Log data/Clinical experience • Hospital accreditation data • Faculty member and resident scholarly activity and productivity • Other: ACGME complaints, Institutional Quality Metrics

9. The Next Accreditation System Continuous Observations Promote Innovation Assess Program Improvement(s) Identify Opportunities for Improvement Program Makes Improvement(s)

10. Next Accreditation System: Ten-Year Self-Study and Self-Study Visit Self- Study visit Ongoing Improvement Yr 1 Yr 0 Yr 2 Yr 7 Yr 9 Yr 10 Yr 8 Yr 6 Yr 5 Yr 3 Yr 4 AE AE AE AE AE AE AE AE AE AE AE: Annual Program Evaluation

11. Objectives of the Ten Year Self-Study Visit • A comprehensive review of the program • Using the Annual Program Evaluation and 10 year self study • Information on how the program creates an effective learning and working environment • How this leads to desired educational outcomes

12. Objectives of the Ten Year Self Study Visit • Judge program success at Continuous Quality Improvement • Learn future goals of program • Will verify compliance with CORE requirements • Core and subspecialty programs will be reviewed together

14. Next Accreditation System: Ten-Year Self-Study and Self-Study Visit Self- Study Ongoing Improvement Yr 1 Yr 0 Yr 2 Yr 7 Yr 9 Yr 10 Yr 8 Yr 6 Yr 5 Yr 3 Yr 4 AE AE AE AE AE AE AE AE AE AE AE: Annual Program Evaluation

15. Objectives of the 10 year Self Study • Conducted one year before self study visit • Assess ongoing compliance and improvement in all dimensions, specifically on outcomes • Consider program aims and strengths/weakness/opportunities/threats (SWOT) of program • Uses annual program evaluations and ACGME data to review program improvement activities, successes achieved, and areas still in need of improvement

27. Next Accreditation System: Ten-Year Self-Study and Self-Study Visit • Annual Program Evaluation (PR-V.C.) • Resident performance • Faculty development • Graduate performance • Program quality • Documented improvement plan Self- Study visit Self- Study Ongoing Improvement Yr 1 Yr 0 Yr 2 Yr 7 Yr 9 Yr 10 Yr 8 Yr 6 Yr 5 Yr 3 Yr 4 AE AE AE AE AE AE AE AE AE AE AE: Annual Program Evaluation

28. Annual Program Evaluation • Annual but may be more frequent • Done by Program Evaluation Committee • Document Review of Program Outcomes from Annual Data • Document Review of Program Achievement of Aims, Program Strengths, Program Threats, and Program Opportunities • Develop Continuous Program Improvement Projects and Track/Document Follow-up

30. Maintenance of Accreditation in the Next Accreditation System • Annual Program Evaluation (PR-V.C.) • Resident performance • Faculty development • Graduate performance • Program quality • Documented improvement plan Self- Study visit Self- Study Ongoing Improvement Yr 1 Yr 0 Focused assessments possible at any time based on data from AE. Full site visit at any time if data from AE eggregious. Yr 2 Yr 7 Yr 9 Yr 10 Yr 8 Yr 6 Yr 5 Yr 3 Yr 4 AE AE AE AE AE AE AE AE AE AE AE: Annual Program Evaluation

31. Program Considerations for the 10 Year Self Study Visit • How are you and your subspecialty programs working together?

32. Program Considerations for the 10 year Self Study • Do you have defined program aims? • Have you ever analyzed your program with a SWOT analysis?

33. Program Considerations for the Annual Evaluation? • Do you have a Program Evaluation Committee and policy? • Are you reviewing all the Program Outcomes evaluated by the ACGME and looking for areas of program improvements? • Do you create, follow through on, and document program improvement projects?

34. The Next Accreditation System Continuous Observations Promote Innovation Assess Program Improvement(s) Identify Opportunities for Improvement Program Makes Improvement(s)

35. ACGME Webinars and Other Resources • ACGME webinars are available at: http://www.acgme.org/acgmeweb/tabid/431/ProgramandInstitutionalAccreditation/NextAccreditationSystem/Webinars.aspx • CLER • Overview of Next Accreditation System • Milestones, Evaluation, CCCs • Specialty-Specific Webinars (Phase I) • Phase I Coordinator Webinars (surgical and non-surgical) • Specialty-specific Webinars (Phase II): Nov 2013-Dec 2013 • Slide presentations for distribution to the GME community: NAS, CCC, Milestones, Annual Program Evaluation/PEC, Updates on Policy– December 2013 • Upcoming • Specialty-specific Webinars (Phase II): Jan 2014-May 2014 • CLER • Self-Study (what programs do) • Self-Study Visit (what ACGME site visitors do)