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ACGME. Accreditation Preparing for a Site Visit by Peggy Mauer, MEd Jobst Vascular Center, Toledo, Ohio. Preparing for RRC Site Visits or Internal Reviews. START EARLY!. Not a surprise Decision letter for the last site visit, and the ACGME Web site, give the length of accreditation
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ACGME Accreditation Preparing for a Site Visit by Peggy Mauer, MEd Jobst Vascular Center, Toledo, Ohio
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
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 needed • Enough in advance for time to address issues • Checks to see if prior problems have been resolved
Internal Review • Summary of the internal review • Should provide guidance about what needs to be done to improve program • Should be read by both Program Director and Program Coordinator • NOTE: 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 Team • Decide (with director) which things • can be done by the two of you • need 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 WebADS • Helpful 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-filled • Institution and Hospital listing • Resident and Faculty listing • Procedures (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 2003 • Latest change for Vascular Surgery was July 2006
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 • The agreements should • identify the faculty who will assume both educational and supervisory responsibilities for residents; • specify their responsibilities for teaching, supervision, and formal evaluation of residents, as specified later in this document; • specify the duration and content of the educational experience; and • 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 time • site 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 visit • 3 months prior to visit as a minimum • Best preparation is ongoing • documentation 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 errors • Saves retyping • Saves file space • Saves 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 schedules • teaching 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 gracious • Remember, these people are doing You a favor
