Program Director Guide to Common Program
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Transcript Program Director Guide to Common Program
Program Director’s Guide to
Common Program
Requirements
Cuc Mai MD
GME Director of Faculty Development
November 2011
Goals & Objectives
Improve in-depth understanding of ACGME common
program requirements
Correlate ACGME common program requirements to the
program information form (PIF)
Correlate ACGME common program requirements to the
resident survey
Why is this important?
Compliance with requirements = Accreditation
Common Program Requirements
Speciality Specific
Requirement
Program
Information
Form (PIF)
Site Visitor’s
Report
Resident Survey
Results
Monitoring
Committee of
ACGME board
Board Scores
Resources
www.acgme.org
Step 1
Step 2
Step 3
More fun
reading !!!
When you need clarification…
If unclear directive, see FAQs or speciality specific RRC
guidelines
3 types of requirements
“Must”: no exceptions
“Should”: almost a must; need to have a strong
educational rationale for not doing
“Suggested”: is not required and not citable
ACGME Common Program Requirements Outline
I. Institutions
II. Program Personnel and Resources
III. Resident Appointments
IV. Education Programs
V. Evaluation
VI. Resident Duty Hours
VII. Innovative Projects
I. Institutions
I.A. Sponsoring Institution
I.B. Participating Sites
I. A. Sponsoring Institution
Must assume responsibility for the program and must
ensure that the PD has sufficient protected time and
financial support
Internal Review: formal mid-cycle review conducted by
the GMEC. Reviewer group must include at least one
faculty member and one resident from sponsoring
institution not from program being reviewed.
I.B. Participating Sites
A program letter of agreement (PLA) must exist between the
program and each participating site providing a required
assignment.
Document needs to be renewed at least every 5 years.
Additions or deletions need to be update from the ACGME
Accreditation Data Systems (ADS)
See handout.
I.B. Participating Sites
PLA
Identify faculty who assumes education and supervisory
responsibility for residents
Specify faculty responsibilities for teaching, supervision,
and formal evaluation of residents
Specify the duration and content of the education
experience
State the policies and procedures that will govern resident
education during that assignment
II. Program Personnel & Resources
II. A. Program Director
II. B. Faculty
II. C. Other Program Personnel
II. D. Resources
II. E. Medical Information Access
II. A. Program Director
Qualifications expertise acceptable to Review committee,
Board Certification, and Current Medical licensure and Staff
appointment
Provide each resident with documented semiannual
evaluation of performance with feedback
Evaluate program faculty and approve the continued
participation of program faculty based on evaluation
II. A. Program Director
Comply with sponsoring institution’s written policies and
procedures
Review with DIO before submitting ACGME information or
requests for the following
Changes in resident complement
Major changes in program structure or length of training
Progress reports requested by the Review committee
Responses to proposed adverse actions
Requests for increases or change to resident duty hours
Voluntary withdrawal of ACGME accredited programs
Requests for appeal of an adverse action
Proposals to ACGME for approval of innovative educational
approaches
Correspondence about program citations
II. B. Faculty
Must be a sufficient number of faculty with documented
qualifications to instruct and supervise all residents at that
location.
Establish and maintain an environment of inquiry and scholarship
with an active research component
Must regularly participate in organized clinical discussions,
rounds, journal clubs, and conferences.
Demonstrate scholarship
Encourage and support residents in scholarly activities
Accreditation Data System (ADS)
III. Resident Appointments
III. A. Eligibility Criteria
III. B. Number of Residents
III. C. Resident Transfers
III. D. Appointment of Fellows and Other Learners
III. B. Number of Residents
Increasing number of residents require PRIOR residency
review committee and DIO approval
Request for change should be documented in ADS
IV. Educational Programs
IV. A. 5. ACGME Core Competencies
IV. B. Residents’ Scholarly Activities
IV. Educational Program
Goals for the program must be distributed to residents and
faculty annually
Competency based goals and objectives for each assignment at
each educational level must be distributed to residents and
faculty annually. These should be reviewed by residents at the
start of each rotation
Regularly scheduled didactic sessions
Delineation of resident responsibilities for patient care,
progressive responsibility for patient management, and
supervision of residents over the continuum of the program
IV. Educational Program
Resident Survey Questions:
Has your program provided you with goals and
objectives for each rotation and major
assignment in either a hard copy or electronic
form?
Has your program provided you with its
general goals and objectives in either a hard
copy or electronic form?
IV. Educational Program
Resident Survey:
How sufficient is the supervision you receive from
faculty and staff in your program?
How often do your faculty and staff provide an
appropriate level of supervision for residents?
How often has your clinical education been
compromised by excessive service obligations?
IV. A. 5. ACGME competencies
Patient Care
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-based practice
IV. A. 5. ACGME competencies
ACGME Outcomes Project
Minimal Threshold model
Competency Based model
IV. A. 5. ACGME competencies
Patient Care
Provision of learning experiences can be
documented through rotation schedules, written
goals and objectives, and resident files.
Completed procedure/case logs
IV. A. 5. ACGME competencies
Medical Knowledge
Documentation by written didactic curriculum,
lecture schedule, reading assignments
IV. A. 5. ACGME competencies
Practice Based Learning and Improvement
Residents must demonstrate the ability to investigate and evaluate
their care of patients, to appraise and assimilate scientific evidence, to
improve patient care based on constant self evaluation and life-long
learning
Identify strengths, deficiencies, and limits in one’s knowledge and
expertise
Set Learning and improvement goals
Identify and perform appropriate learning activities
Analyze practice using quality improvement methods and
implement changes with the goal of practice improvement
Locate, appraise, and assimilate evidence
Use information technology to optimize learning
Participate in the education of patients, families, students, residents,
and other health professionals
IV. A. Practice based learning
improvement
PIF question
Describe one learning activity in which residents
engage to identify strengths, deficiencies, and
limits in their knowledge and expertise; set
learning and improvement goals; identify and
perform appropriate learning activities to
achieve self identified goals.
IV. A. Practice based learning
improvement
PIF question
Describe one example of a learning activity in
which residents engage to develop the skills
needed to use information technology to locate,
appraise, and assimilate evidence from scientific
studies and apply it to their patients’ health
problems. The description should include a)
locating information b) using information
technology c) appraising information d)
assimilating evidence information 3) applying
information to patient care
IV. A. Practice based learning
improvement
PIF question
Give one example and the outcome of a planned
quality improvement activity or project in which
at least one resident participated in the past
year that required the resident to demonstrate
an ability to analyze, improve, and change
practice or patient care. Describe planning,
implementation, evaluation, and provisions of
faculty support and supervision that guided this
process.
IV. A. Practice based learning
improvement
PIF question
Describe how residents: A) develop teaching
skills necessary to educate patients, families,
students, and other residents B) Teach patients,
families, and others C) Receive and incorporate
formative evaluation feedback into daily
practice.
IV. A. Interpersonal and
Communication Skills
Residents must demonstrate interpersonal and
communication skills that result in the effective
exchange of information and collaboration with
patients, their families, and health professionals.
IV. A. Interpersonal and
Communication Skills
PIF question
Describe one learning activity in which residents
develop competence in communicating
effectively with patients and families across a
broad range of socioeconomic and cultural
backgrounds, and with physicians, other health
professionals, and health related agencies.
IV. A. Interpersonal and
Communication Skills
PIF question
Describe one learning activity in which residents
develop their skills and habits to work
effectively as a member or leader of a health
care team or other professional group. In the
example, identify the members of the team,
responsibilities of the team members, and how
team members communicate to accomplish
responsibilities.
IV. A. Interpersonal and
Communication Skills
PIF question
Explain (a) how the completion of
comprehensive, timely, and legible medical
records is monitored and evaluated, and (b) the
mechanism for providing residents feedback on
their ability to competently maintain medical
records.
IV. A. Professionalism
Residents must demonstrate a commitment to
carrying out professional responsibilities and an
adherence to ethical principles.
IV. A. Professionalism
PIF question
Describe at least one learning activity, other
than lecture, by which residents develop a
commitment to carrying out professional
responsibilities and an adherence to ethical
principles.
How does the program promote professional
behavior by the residents and faculty?
How are lapses in these behaviors addressed?
IV. A. Professionalism
Resident Survey:
To what extent does your program provide an
environment where residents/fellows can raise
problems or concerns without fear of
intimidation or fear of retaliation?
IV. A. Systems-based Practice
Residents must demonstrate an awareness of and
responsiveness to the larger context and system of
health care, as well as the ability to call
effectively on other resources in the system to
provide optimal health care.
IV. A. Systems based Practice
PIF question:
Describe the learning activity through which
residents achieve competence in the elements of
systems-based practice; work effectively in
various health care delivery settings and
systems, coordinate patient care within the
health care system; incorporate considerations
of cost-containment and risk-benefit analysis in
patient care; advocate for quality patient care
and optimal patient care systems; and work in
interprofessional teams to enhance patient
safety and care quality.
IV. A. Systems based Practice
PIF question:
Describe an activity that fulfills the requirement
for experiential learning in identifying system
errors. Important elements include faculty
guidance and active engagement by residents
with written goals and objectives; resident
assessment; and aggregated resident outcomes.
IV. B. Residents’ Scholarly
Activities
Curriculum MUST advance residents’ knowledge of the
basic principles of research, including how research is
conducted, evaluated, explained to patients, and
applied to patient care.
Should participate in scholarly activity
Sponsoring institution and program should allocate
adequate educational resources to facilitate resident
involvement in scholarly activities.
IV. B. Residents’ Scholarly
Activities
Resident Survey:
Does your program offer you the opportunity to
participate in research or scholarly activities?
V. Evaluation
V. A. Resident
V. B. Faculty
V. C. Program
V. A. Resident Evaluation
Faculty must evaluate resident performance in a timely
manner and document evaluation at completion of the
assignment. Evaluations must be accessible for review
Program
Provide objective assessments of all ACGME competencies
Use multiple evaluators
Document progressive resident performance improvement
appropriate to educational level
Provide each resident with documented semiannual
evaluation of performance with feedback
V. A. Resident Evaluation
Resident Survey:
Overall, how satisfied are you with the written
or electronic feedback you receive after you
complete a rotation or major assignment?
If you want to review feedback on your
performance, are you able to access your
evaluations?
V. B. Faculty Evaluation
Must provide faculty with evaluation ANNUALLY
MUST include annual written confidential
resident evaluations
SHOULD include a review of faculty’s clinical
teaching abilities, commitment to the
educational program, clinical knowledge,
professionalism, and scholarly activities.
V.B. Faculty Evaluations
PIF question:
Describe the system used by the residents to provide
annual confidential written evaluations of the teaching
faculty
Describe the program’s system for evaluating and
providing feedback to the teaching faculty
V.B. Faculty Evaluations
Resident Survey:
Do you have the opportunity to evaluate faculty
members at lease once a year?
How satisfied are you that your program treats
your evaluations of faculty members
confidentially?
V. C. Program Evaluation
MUST document formal, systematic evaluation of
curriculum ANNUALLY
MUST monitor and track
Resident performance
Faculty Development
Graduate Performance
Program Quality: assessed by residents in writing
annually and this must be used to improve
program. SHOULD document action plan if
deficiencies found.
V. C. Program Evaluation
PIF question:
Describe the approach used for program evaluation.
Describe one example of how the program used the
aggregated results of residents’ performance and/or
other program evaluation results to improve the
program
V. C. Program Evaluation
PIF question:
Describe the improvement efforts currently
undertaken in the program based on feedback
from the ACGME resident survey. What
improvements, if any, has the program
undertaken to address potential issues
identified by the most recent ACGME resident
survey summary report? Review your survey
summary.
Board Pass Rates for past three years
V. C. Program Evaluation
Resident Survey:
Do you have the opportunity to evaluate your
overall program at least once a year?
How satisfied are you that your program treats
your evaluations of the program confidentially?
How satisfied are you with the way your
program uses the evaluations that
residents/fellows provide to improve the
program?
VI. Resident Duty Hours in the Learning
and Work Environment
VI. A. Professionalism, Personal Responsibility, and Patient
Safety
VI. B. Transitions of Care
VI. C. Alertness Management & Fatigue Mitigation
VI. D. Supervision of Residents
VI. E. Clinical Responsibilities
VI. F. Teamwork
VI. G. Resident Duty Hours
VI. Resident Duty Hours in the
Learning and Work Environment
From: www.acgme.org
VI. Resident Duty Hours in the Learning &
Working Environment
Must educate residents & faculty concerning the
professional responsibilities of the physician to
appear for duty rested and fit
Must be committed to and responsible for patient
safety and resident well being in a supportive
educational environment
VI. Resident Duty Hours in the
Learning & Working Environment
Must ensure a culture of professionalism that supports patient
safety and personal responsibility.
Must demonstrate an understanding and acceptance of their
personal role in the following:
Assurance of their fitness for duty
Recognition of impairment, including illness and fatigue, in
themselves and in their peers
Attention to lifelong learning
Monitoring of their patient care performance improvement
indicators
Honest and accurate reporting of duty hours, patient outcomes,
and clinical experience data
VI. B. Transitions of Care
Must design clinical assignments to minimize the
number of transitions of patient care.
Must ensure and monitor effective, structured handover processes to facilitate both continuity of care and
patient safety.
Must ensure that residents are competent in
communicating with team members in the hand-over
process
Must ensure the availability of schedules that inform all
members physicians responsible for patient’s care
VI. C. Alertness Management/Fatigue
Mitigation
Must educate faculty members and residents to
recognize the signs of fatigue and sleep deprivation
Educate all faculty members and residents in alertness
management and fatigue mitigation processes
Adopt fatigue mitigation processes
Must have a process to ensure continuity in the event
resident is unable to perform
Must have adequate sleep facilities and/or safe
transportation options for residents who may be too
fatigued
VI. D. Supervision of Residents
Each patient must have an identifiable attending who is
ultimately responsible for patient care.
Must demonstrate appropriate level (graded) of
supervision in place for residents and must use
appropriate classification of supervision.
Direct: supervisor is physically present with patient and
resident
Indirect: a) direct supervision immediately available b)
with direct supervision available
Oversight: supervisor is available to provide review of
encounter after care is delivered
VI. G. Resident Duty Hours
Maximum Hours per week is 80, averaged over a 4 week
period, inclusive of all in-house call and moonlighting.
Moonlighting must not interfere with educational
program and PGY-1 not permitted to moonlight.
Must have minimum of one day free of duty every week,
when averaged over 4 weeks. No at home call on these
days.
VI. Resident Duty Hours
PGY-2 residents and above
Must be scheduled for in-house call no more frequently
than every third night, averaged over a 4 week period.
May be schedule to a maximum of 24 hours of continuous
duty.
Strategic napping especially after 16 hours of continuous
duty and between the hours of 10 pm and 8 am is strongly
suggested.
Time for transitions of care must be no longer than an
additional four hours.
Must not have additional clinical responsibilities after 24
hours of continuous in-house duty
VI. Resident Duty Hours
PGY 1 residents must not exceed 16 hours per duty
period length.
Should have 10 hours
Must have 8 hours free of between duty periods
VI. Resident Duty Hours
Resident Survey:
How often did you break the rule that duty hours must
be limited to 80 hours per week, averaged over a fourweek period, inclusive of all in-house call activities?
How often did you break the rule that residents/fellows
must be scheduled for a minimum of 1 day in 7 free
from all residency related duties, averaged over a 4week period?
How often did you break the rule that there should be a
10-hour time period provided between all daily duty
periods and after in house call?
VI. Resident Duty Hours
Residents, on their own initiative, may remain
beyond their duty to continue to provide care for
single patient if severely ill, academic importance,
humanistic attention. Resident must document
reasons for maintaining care and submit
documentation to program director.
Program director must review each submission and
track both individual and program wide episodes of
additional duty
Conclusions
It is important that GME faculty have an in-depth
understanding of common program requirements.
PIFs and Resident survey questions correspond directly
to these requirements.
It is important that GME faculty are aware of additional
resources to review.