The Holy Grail of the Paper Trail

1. The Holy Grail of the Paper Trail Polly E. Parsons MD University of Vermont College of Medicine Fletcher Allen Health Care

2. Things Could Always Be Worse!

3. The Process Request for input on existing program requirements APCCMPD ATS ACCP (SCCM) Program requirements revised and distributed for comment New program requirements approved Courtesy of Dr. S. Murin

4. The Process Request for input on existing program requirements 1. Remove requirement for onsite: Trauma Services Sleep and Rehab Micro lab 2. Get rid of 2 key faculty /specialty rqmnt 3. Change language re modes of ventilation 4. Remove outdated rqmnts: Pleural bx Transthoracic needle bx Respiratory drive assessment Peritoneal dialysis 5. Change from expertise to competence: Admin functions 6. Asked for less continuity clinic Program requirements revised and distributed for comment Adapted from Dr. S. Murin

5. The Process Request for input on existing program requirements • 1. Nearly every one of our suggestions • was incorporated into new requirements, • often verbatim • 2. A bunch of alarming and unexpected • additional changes were made: • 24 months of block time • 3 months non-MICU • More clinic (2 more yeas of continuity) • Program director at primary site • Generous $ support for program director Program requirements revised and distributed for comment New program requirements approved Adapted from Dr. S. Murin

6. Our “Counter-Offer” • 18 months of block time • 1-2 months of non-medical critical care (with caveats) • Less clinic, not more, allow for blocks

7. What Did We Get?

8. Common Themes • Documentation • Communication • Evaluation • Education (not service) • Competency • Research

9. Changes in General Program Requirements for Fellowship education in the Subspecialties of Internal Medicine

10. Sponsoring Institution

11. Not New But May be More Important “ The sponsoring institutions must demonstrate a commitment to education and research sufficient to support the fellowship program” “The institution must assure significant research in each subspecialty for which it sponsors a training program”

12. The sponsoring institution must assure that adequate salary support is provided to the program director for the administrative activities of the subspecialty program. The program director must not be required to generate clinical or other income to provide this administrative support. It is suggested that this support be 25-50% of the program director’s salary depending on the size of the program.

13. Proposed Change to Common Program Requirements (for all ACGME Training Programs) “The sponsoring institution must provide the program director with sufficient financial support and protected time for his/her educational and administrative responsibilities to the program. The program director must not be required to generate clinical or other income to provide this support.” Approved by RRC Council of Chairs February 2005 (effective date: July 1, 2006)

14. Rationale • High turnover rate of program directors • Increased administrative burden due to ACGME mandates • Institutional demands to generate income

15. Participating Institution

16. Section expanded from previous program requirements “The Primary Training Site is defined as the health-care facility that provides the required training resources, should be the location of the program director’s major activity, the location where the fellow spends the majority of their clinical training time and the primary location of the core program in internal medicine”

17. Program Directors

18. Qualifications 1. Must possess the requisite subspecialty expertise, as well as documented educational and administrative abilities 2. Must be based at the primary teaching site. 3. Must be responsible to the sponsoring organization.

19. Responsibilities 1. 20 hours per week – averaged over the year (not new) with sufficient time for administration of the program and receive institutional support for that administrative time 2. “The program director must participate in academic societies and in educational programs designed to enhance his or her educational and administrative skills”

20. 3. Must implement a program of CQI in medical education for the faculty, especially as it pertains to teaching and evaluation of the ACGME competencies

21. Faculty “The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the faculty...” Each program must have an active research program.

22. Scholarship 1. Discovery: - peer review funding/publications 2. Dissemination: - review articles, textbook chapters 3. Application: - presentation or publication of case reports, clinical series,

23. “The majority of faculty must be involved in scholarship” • The majority of key clinical faculty must demonstrate evidence of productivity in either Discovery or Dissemination • “At least one faculty member must be active in the scholarship of discovery.”

24. Questions • Does the individual active in the scholarship of discovery have to be a key clinical faculty member? • Can that individual be a nonphysician faculty member?

25. Resources “All deaths of patients who received care by fellows must be reviewed and autopsies performed whenever possible.”

26. Curriculum

27. Research Majority of fellows must demonstrate evidence of recent research productivity through: • publication of manuscripts or abstracts in peer-reviewed journals • Abstracts presented at national specialty meetings NOTE: does not apply to CCM fellowships

28. The Six Competencies 1. Patient care 2. Medical knowledge 3. Practice-based learning and improvement 4. Interpersonal and communication skills 5. Professionalism 6. Systems-based practice

29. Didactics 1. Total teaching time in combined management/teaching rounds “must exceed by a minimum of 5 hours per week the time required to supervise the care of the patients” 2. Conferences: must have a weekly core curriculum conference - must cover basic science as well as clinical topics

30. Duty HoursSupervisionEvaluation Independently review each of these sections carefully!

31. At least 80% of fellows eligible for ABIM subspecialty certifying exams must have taken ABIM exam. • Pass rates for first time takers of ABIM cert exams will be examined at each program review

32. Experimentation and Innovation Hidden here is the: Performance improvement process - program must have one ongoing PI activity related to the competencies - must involve fellows and faculty - should result in measurable improvements in patient care or fellow education

33. Changes in Program Requirements for Fellowship Education in Pulmonary Disease and Critical Care Medicine

34. Educational Program • 18 clinical months still allowed • Programs with < 24 months: additional ambulatory care clinic for 6 months (not during the clinical months) • 3 months in care of critically ill non-medical patients. At least one month must be direct patient care activity

35. Clinic 1. Must have continuity clinic for the length of training program 2. Extra 1/2 day per week for six months - cannot occur during the 18 clinical months - suggestions: longitudinal experience in CF, ILD

36. A Gift? “Fellows may be excused from their continuity care clinic experience while on critical care rotations”

37. Faculty • The program director and critical care teaching staff must have primary responsibility for admission, treatment and discharge of all patients on critical care teaching service. • Must be ABIM subspecialty certified clinical faculty members in nephrology, GI, cardiology, ID, hematoogy, oncology, and geriatrics who participate in educational program.

38. Facilities and Resources: PCCM Must be present at primary training site: - thoracic surgery service - at least three accredited subspecialty programs (cards, GI, ID, nephrology, pulmonary - ?) - an active emergency service - MICU - program director should be responsible for educational program

39. Program Content: PCCM and Pulmonary Review this section carefully! Subtle changes: PE,post-op management of critically ill patients Not so subtle changes: Minimum of 50 flexible fiber-optic bronchoscopy procedures No more pleural biopsies

40. Common Citations • Lack of written goals and directives • All full-time faculty don’t engage in active research • Clinics are not continuity clinics • Insufficient number of conferences • Non-compliance with evaluation requirements • Duty hours