Peggy Simpson, EdDExecutive DirectorResidency Review Committees for Surgery Residency Review Committee UpdateAPDVS and Residency Coordinators Meeting Chicago, ILApril 16, 2010
Thomas V. Whalen, MD, Chair J. Patrick O’Leary, MD, Vice Chair Adeline Deladisma, MD, Resident Timothy R. Billiar, MD G. Patrick Clagett, MD Peter J. Fabri, MD Linda M. Harris, MD George W. Holcomb, MD James C. Hebert, MD Mark A. Malangoni, MD Marshall V. Schwartz, MD Charles W. Van Way III, MD Marc K. Wallack, MD Frank Lewis, MD, Ex-Officio ABS Patrice Blair, MPH, Ex-Officio ACS RRC—Surgery Members
Types of Accreditation Standards Specialty-Specific Program Requirements Compliance Assessed by Institutional Review Committee Compliance Assessed by Residency Review Committee (Specialty Committee) Institutional Requirements Common Program Requirements
Navigating the Requirements* • Must: A term used to identify a requirement which is mandatory or done without fail. This term indicates an absolute requirement. • Shall: (See must) • Should: Term used to designate requirements so important that their absence must be justified. A program or institution may be cited for failing to comply with a requirement that includes the term ‘should’. *From ACGME “Glossary of Terms” (acgme.org)
Accreditation Decisions Application Initial Accreditation Accreditation Withheld Accreditation Withdrawn Continued Accreditation Continued Accreditation Probation Accreditation Withdrawn Continued Accreditation
Defer • RRC needs clarification of major issues • Accreditation decision remains “open” • Result: Additional information will be requested. RRC will consider request after information has been received.
Progress Reports • RRC needs a response to major concerns • Report must be: • Responsive • Reviewed/signed by the institution’s DIO • Sent only when requested
Progress Reports: Reasons to Request • RRC seeks improvement/attention to an issue and believes site visit is not necessary to bring issue to a state of compliance with program requirements. • RRC sees an issue has reoccurred over time and believes progress report will focus program and institutional attention on the issue.
Notification of RRC Decisions • 2-4 days after RRC meeting (informal notification via e-mail) • 60 days after RRC meeting (formal Letter of Notification (LON) posted) • LONS are available only through ADS • Notifications sent to PD and DIO of record.
Preparing for your Site Visit • Start Early • Ensure Annual Update is accurate • Faculty Information • Resident Information • Participating Site Information • When in doubt, let us know.
Resident Duty Hours 80 hour limit - averaged over 4 weeks, includes in-house call • One day our of seven free • In-house call no more than 1 day in 3 averaged over 4 weeks • 24-hour duty maximum • Provide at least 10 hours for rest between duty periods • In-house moonlighting counts
Monitoring Duty Hour Compliance • Non-compliant Programs Identified through: • Program Self-reports • Resident Questionnaire • Resident Complaints • Actions taken by RRCs: • Additional Monitoring (change in Site Visit date) • Requests for Progress Reports • Shortened Accreditation Cycle
Resident Complements • Temporary or Permanent?? • Changes to Resident Complements • To request change to total number • To request change to number at a PGY level • Any reallocation must be approved by RRC prior to implementation
Site Visit Results 2009 • Common Citations • Evaluation– Residents, Faculty, Program • Procedural Experience • Duty Hours
Evaluation and the Competencies 4. Assess Outcomes—analyze evaluation results; refine G&Os, take additional actions; add improvements 1. Educational G&Os 3. Evaluation Activities (observer, 360, self, etc.) 2. Clinical & Didactic Experiences
Agenda Closing Dates • Meeting: June 24-25, 2010 Agenda Closing: April 15, 2010 • Meeting: October 28-29, 2010 • Agenda Closing: August 19, 2010 • Meeting: February 24-25, 2011 • Agenda Closing: December 16, 2011 • Meeting: June 23-24, 2011 • Agenda Closing: April 14, 2011
Program Information Form Updates • Scholarly Activities • Resident Activities • Faculty Activities • Conferences
PIF Updates (cont.) • Resident Publications • abstracts/publications • presentations (local, regional, national) • grand rounds • basic science • multidisciplinary institutional educational conferences • dedicated research experience (protected time) teaching awards • teaching skills lab session • formal medical student teaching (i.e. anatomy courses, scientific and/or clinical lectures)
PIF Updates (cont.) • Faculty Information • Basic Science Research • Educational Research (includes development of teaching materials) • Faculty Name • Project Name • Funded • Not Funded
PIF Updates (cont.) • Conferences • Basic and Clinical Sciences • Grand Rounds • Morbidity and Mortality Conferences • Multidisciplinary (e.g., pediatric radiology, surgical pathology and tumor conferences) • Faculty/Resident Name • Title of Presentation • Frequency • Sessions Presented (Y/N) • Sessions Directed (Y/N) • Site #
RRC Surgery Resources • www.acgme.org (Review Committee Surgery page) • Program requirements • PIFs • Newsletters
When to Contact ACGME via ADS • Progress Report requested • Upcoming changes in program - All requests must be made through ADS • Notify change in Program Director and/or PD contact information • Request any change resident complement • Request participating site changes (add or delete) • Request changes to approved rotations • Response to Citations • Annual Updates
When to Contact Staff • Any time you need clarification and/or consultation • Any time major changes are occurring • Change in sponsorship/ownership
RRC Surgery Staff Contact Information • Peggy Simpson, EdD, Executive Director 312.755.5499 firstname.lastname@example.org • Cathy Ruiz, MA, Senior Accreditation Administrator 312.755.5495 email@example.com • Allean Morrow-Young, Accreditation Assistant 312.755.5038 firstname.lastname@example.org
THANK YOU ????????