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Preparation for the ACGME Site Visit. Stanley Dea, MD Associate Program Director UCLA Integrated Training Program in Gastroenterology. Objectives. Learn how our program prepared for the 2010 ACGME site visit Review what ACGME will emphasize Learn to prepare critical ACGME requirements.

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preparation for the acgme site visit

Preparation for the ACGME Site Visit

Stanley Dea, MD

Associate Program Director

UCLA Integrated Training Program in Gastroenterology

  • Learn how our program prepared for the 2010 ACGME site visit
  • Review what ACGME will emphasize
  • Learn to prepare critical ACGME requirements
frame off restoration
“Frame-Off Restoration”

Given new requirements, what was adequate previously is no longer acceptable

where to start
Where to Start
  • Insiders Guide to the ACGME Site Visit: Second Edition
  • Kathryn Andolsek, MD
  • $149 on
keys to a successful visit
Keys To A Successful Visit
  • Program Requirements
  • Program Information Form (PIF)
  • Resident Documentation
  • Faculty and Housestaff Education
go electronic
Go Electronic!

There is a vast amount of documentation

Storage and retrieval is best done electronically

We have adopted Verinform

Programming Verinform can be tricky

  • Program Letters of Agreement
  • Any site that is part of an official rotation must have a PLA!
  • Reviewed and up-to-date
  • Correct signatures on PLA
policies and procedures
Policies and Procedures
  • Be sure all policies exist and have been recently reviewed
  • Don’t re-invent the wheel – UCLA may have an existing policy
  • You need a program policy as well as institutional (may be the same)
  • Must be distributed to residents (can use Verinform)
policies and procedures9
Policies and Procedures

At a mininum:

  • Duty hours / Fatigue
  • Working environment
  • Moonlighting
  • Selection / Evaluation / Promotion
  • Supervisory
  • Disciplinary action / Due process
resident documentation
Resident Documentation
  • Document:
    • Rotation evaluations / Bi-annual review
    • Duty hours
    • Procedures
    • Scholarly activity / Research
  • Keep files up-to-date and organized (Go electronic!)
  • Need paper copies for site visit
program information form pif
Program Information Form (PIF)
  • The PIF is the foundation of your program
  • Every detail about the program of interest to the ACGME is in the PIF
  • Include highlights/unique features!
  • Usually written by one primary author but should be read (and re-read) by everybody
  • PIF should be updated regularly (not just before site visit)

Teaching and Assessment are based on competencies!

  • Patient Care (PC)
  • Medical Knowledge (MK)
  • Professionalism (P)
  • Interpersonal and Communication Skills (ICS)
  • System-Based Practice
  • Practice-Based Learning
professionalism ics
Professionalism & ICS


Patient care rounds

Professionalism lecture series

Ethics lecture

Participation in journal club, case conference

Mock patient oral examinations

  • Assess:
  • Patient care rounds
  • Review H&Ps, reports
  • Formal 360 evaluations, esp. patient evaluations
  • Mock patient oral examinations
  • Biannual program director meeting
  • Core curriculum attendance (P only)
resident evaluations
Resident Evaluations
  • Verinform will give monthly e-mail reminders
  • Evaluations must be available to residents
  • Must be a 360o evaluation
  • Four months before site visit, run an evaluation audit

Usually program director is the only one who knows ACGME requirements

Faculty (at least those meeting with the site visitor) should be aware as well

Residents also need education (information, not indoctrination!)

say what
Say What?
  • Describe an activity that fulfills the requirement for experiential learning in identifying system errors.
  • Explain what dyads you evaluate.
  • ACGME requirements are vast
  • Learning terminology has steep learning curve
  • Honestly, material ispretty dry and boring
  • Created a six page “FAQ” with questions and answers
  • E-mailed daily quiz questions to faculty meeting with site visitor
  • Intensive (1-2 hour) “Boot Camp” sessions to cover material
  • Mock site visits with Dr. Parker and Dr. Baillie
  • The site visitor will look for consistent answers
  • PIF = Program Director = Faculty = Residents
  • Site visitor is more likely to believe residents in a discrepancy
  • Education is key
take home points
Take Home Points
  • Everything must be based on the ACGME competencies
  • The PIF is your foundation
  • Address any citations
  • Keep extensive and accurate documents (Go Electronic!)
there is no i in team
There Is No “I” in Team
  • Brennan Spiegel, MD – Program Director
  • Stanley Dea, MD – APD
  • Kathy Oka – Fellowship Coordinator
  • Bradley Snyder – Assistant Coordinator
  • Curriculum Action Committee
  • Fellow Action Committee
  • Key Clinical Faculty Members

“I love it when a plan comes together.”

- Col. John “Hannibal” Smith