Transcript What is Accreditation? (March 1996)

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
 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
Check the ACGME Web Site
Check the ACGME Web Site
Check the ACGME Web Site
Check the ACGME Web Site
Check the ACGME Web Site
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
Download PIF Application Forms
Download PIF Application Forms
Download PIF Application Forms
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
A.
The agreements should
a.
identify the faculty who will assume both educational and supervisory
responsibilities for residents;
b.
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.
c.
d.

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

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
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
Equipment
Numbers of cases
Procedures
Facilities
Collect needed statistical reports
monthly or quarterly, to be sure to have
them
Who would have the information:


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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
Enter information

Enter in final form as soon as it is received
It doesn’t get stale
It’s already done
Type early -- avoid the rush
Common PIF Errors
Incorrect program name
 Omission of program number
 Missing signatures
 Missing letters of agreement
 Missing Competencies Addendum
 Information omitted – questions unanswered

Common PIF Errors
Inconsistent data
 Common rotations not indicated on block
diagram for programs with multiple tracks
 Incorrect pagination
 Extraneous information that was not
requested

Check for Consistency

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Number of residents in program match list of
names of residents in the Web ADS
Number of full-time teaching faculty activity
with number of months in block diagram
Number of months residents spend in a
specific rotation with number of months on
block diagram
Run spell check for the word “will”
Make copies

But wait until the last draft
Saves confusion, time and paper
Save final draft -- for next time!
File in a safe place
 If on computer, keep disks

When mailing to Site Visitor

Things not to do –
Do not include anything not asked for
Do not include oversized or reprinted materials
Do not send in a 3-ring binder or perfectly bound
Do not send in a fancy folder
When mailing to Site Visitor

Things to do
Keep everything 8 ½ x 11 inches
Bind with heavy duty rubber bands
Make 1 sided copies
Information for Site Visitor
Send good map to hospital and written
directions
 Send hotel and restaurant recommendations
 Ask if they have any dietary restrictions
 Arrange VP parking space if needed
 Offer to meet him/her at front desk

The VISIT
Dress Rehearsal
 Actual Visit

Dress Rehearsal

Meet with those who will see site visitor
Make sure all are informed about the
department
Give them copies of PIF (or relevant sections)
Schedule a conference or class room for
Visit Day (ask early!)
 Make sure key people know the contents of
the last internal review summary

The Site Visitor Might Be



ACGME Field Representative (97% of the
time)
Specialist in your discipline(3% of the time)
“Eyes” and “Ears” of the RRC
The Site Visitor
Unbiased observer
 Verifies information provided by program
director in the PIF
 Conducts interviews with administrators,
faculty, residents

The Site Visitor
Reports what was said in meetings with
faculty, residents, and program administrator
 Files a written report describing errors or
oversights with the PIF and what they were
told or saw during the visit
 Does not participate in final decision or
recommendation of review committee

Getting Ready for Company


Organize and schedule the site visit day as
completely as possible
The program director should
Contact site visitor as soon as you know their name.
Ask ahead what arrangements they would like made;
who they want to meet, if they want lunch provided or
time off for lunch (include maps, parking passes, etc.)

Check and re-check that key people will be
available
Site Visit Day!!
Make sure all are alerted to the fact that it is
the site visit day
 Cancel all patient care activities for the PD
 Coordinator should be available all day in
case additional information is needed for the
site visitor
 Attend details of the site visitor

Site Visit Day
Make an office or suitable space available
 Coordinator should monitor how the day
is flowing and let people know if schedule
changes

It all comes down to organization



All pertinent
documents available at
your finger tips
Have someone take
you through your
documents
Don’t get flustered –
you know you have
everything
Site Visit Day
Samples of Resident files
Copies of schedules, attendance tracking
method, etc.
Written policies and procedures
Committee meeting minutes
Site Visit Day

Tip: Keep a log
who the site visitor met with
what they saw (where they toured)
what they were told
At end of Day – debrief

Meet with program director
Go over what went right or wrong
Areas for change
 “That’s what I should have said . . .”
Ask for help (if things did not go well)
Evaluate

Complete site visit
evaluation survey
Results

Notification of results
emailed to Program Director, Chairman, Sponsoring
Institution

Accreditation letters posted in ADS
 www.acgme.org


Within 1 month following RRC Committee Mtg
(meets quarterly) that reviews the site visit report
Time frame: about 3 - 9 months from initiation
Citations or Recommendations
Can be effective tools to bring about change
 Must not be ignored

After the RRC Letter
Celebrate your success
 Have a party

Thank all those who contributed