Transcript Workshop Overview  Optimizing your “PIF-manship”  Day of Reckoning: The visit Itself  Behind the Scenes (ACGME / RRC)  Avoiding the MOST.

Workshop Overview
 Optimizing your “PIF-manship”
 Day of Reckoning: The visit Itself
 Behind the Scenes (ACGME / RRC)
 Avoiding the MOST Common Citations
 How the GME Office Can Help!
Optimizing Your “PIF-manship”
 Why it matters
 Understanding the rules
 Timeline for completion
 Attachments and Supporting Documents
 Avoiding the most common errors
*****Group Exercise: Common PIF Competency Ideas
The PIF is the KEY!
 Majority of ultimate citations result directly from
information provided in the PIF (others primarily from
resident interview, resident survey, and document
review)
 A well-written PIF can minimize a multitude of sins!
 A platform to prepare all survey day participants (best
completed as a group effort for optimal buy-in…)
 Ideally functions as a self-study to help ID areas of
“opportunity”
Understand the RULES:
 Review your CURRENT program requirements before
beginning work on your PIF
 All PIF questions track DIRECTLY to a program requirement
(common or specialty)
 There ARE many PIF questions with RIGHT and WRONG
answers!
 READ (and follow!) THE DIRECTIONS!!!!!!!! (“one” examples
means ONE, “describe” means DESCRIBE)
 NEVER send extra attachments or unsolicited information
with the PIF
 Be CLEAR, CONCISE, & CONSISTENT!
Timeline for PIF completion:
 Many experts recommend beginning formal writing at
the point of Internal Review (response to last citations,
etc.)
 On-going prep is best (track data, keep files organized,
example folders of key requirements, etc.
 ALWAYS at least 6-12 months before anticipated
review date
Timeline Reminders:
 Site surveyor must receive PIF and attachments 2
weeks before site visit
 DIO must review and sign off before document can be
mailed to surveyor
 Optimally DIO reviews polished draft 4-6 weeks before
survey, recommends changes, and signs final copy 3
weeks before survey date ***
 Dept Chair, Chief Residents, Key Faculty should read
and edit PIF prior to sending to DIO
SO…
 Anticipated Date of Next Review: 4/2010
 Send to Site surveyor:
3/15/2010
 Send draft to DIO:
2/15 - 3/1/2010
 Draft for CR/key Faculty review:
2/1 – 3/1/2010
 90-120 Day survey date notice:
 Best you start writing by:
12/15/2009
10 – 11/ 2009
Getting started:
 Acgme.org
 Web-ads sign-in and print out PIF
 Part 1 is pre-populated program description; check for
accuracy, make changes as needed thru web-ads
 Part 2 is questions and narrative specific to your
programs
 Tackle the PIF in small bites / sections
 JUST DO IT!!! (procrastination compromises product!)
Common PIF Errors:
 Unanswered questions / Missing information
 Failure to follow directions
 Spelling / Grammar / Structure Structure errors
 Including unformatted faculty CV’s, manuscripts, etc.!!!!!!
 PIF faculty CV’s with publications from the 70’s & 80’s, (last 5 years
ONLY!!!)
 Pages incorrectly numbered
 Inconsistent data
 Inaccurate block diagrams
 Failure to fully explain unique approached to satisfying requirements
 Failure to TELL the TRUTH!!!
Common “inconsistencies”:
 # residents in ACGME database = number of names on
resident list = #of residents listed in PIF
 Months / FTE’s at each participating site = number of
rotations on block diagram
 # of resident evaluations in folders = frequency of resident
reviews reported
 Institution mentioned in narrative is not referenced
elsewhere
 Faculty List / Faculty Credentials = faculty CV’s attached
 Procedures listed for individual residents = numbers of total
program procedures
Attachments:
 May be slightly different for different RRC’s
 Usually:
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Policy for resident supervision
Moonlighting policy
Duty Hours Policy
Competency Assessment Tools
Evaluation tools
Overall Educational Goals for the Program
Sample Goals & Objectives for a rotation
Program Letters of Agreement
Supporting Documentation:
 Policy for Supervision of residents
 Program Policies for duty hours and work environment
 Moonlighting policy
 Documentation of internal review (DIO provides)
 Overall Program Goals
 Competency Based Goals & Objectives by rotation and level of trainee
 Current Program Letters of Agreement
 Files of current residents (sample transfer & problems)
 File of recent program graduate (final summative eval, “competent to
practice independently”)
Supporting Documentation (cont’d):
 Evaluations of residents at end of rotation
 Examples of completed 360* evaluations
 Sample of written semi-annual evaluation by PD
 Completed confidential evals of faculty by residents
 Completed confidential evals of program by residents
 Completed confidential evals of program by faculty
 Minutes of annual program evaluations and written
improvement plan
 Resident duty hour tracking
Supporting Documentation (cont’d):
 Complete Program Curriculum
 Examples of scholarly activity (resident and faculty)
 Documentation of program improvement projects
 Conference schedules with documentation of attendance
 Board Exam Results of graduates
 Copies of alumni surveys if done
 Trainee handbooks
 Any other examples of “special” things you do!
Day of Reckoning: The Site Visit
 The site visitor
 Preparation
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Program Director Prep
Program Administrator Prep
Faculty / Chair Prep
RESIDENT PREP
 Last Minute Reminders
 The Schedule
The Site Visitor:
 Professional profile of your surveyor available on
acgme.org
 Confirms and clarifies the PIF (Does NOT make
accreditation decision!)
 Documents the data and the processes
 Writes fair, objective, and accurate report
 Does NOT make recommendations regarding
accreditation action
 Will have a specific structure they wish to follow for
the day---ACCOMMODATE them!!!!
Survey Day Prep - General
 Make sure everyone meeting with the surveyor has read the
PIF (and agrees with its content!!!)
 Design the day’s schedule as directed by your site surveyor
 Communicate any changes or problems directly to your
surveyor
 Identify and schedule a room for the survey day which can
accommodate all interviews
 Have three copies of PIF for surveyor
 Decide who will hold / answer pagers for participants!
Survey Day Prep – PD/PA
 Know your Program Requirements inside / out,
forwards & backwards!
 Know your PIF/ prep your people
 Have all supportive documentation, well-organized
and optimally ordered by PIF topics
 Have interview room neat and stocked with water
 Surveyor may also wish to tour lounge and call rooms
(make sure they are clean, too!)
Survey Day Prep - Residents
 Hold peer election in larger programs to select who will
meet with the surveyor (Surveyor will tell you how many;
usually 10-12)
 Provide PIF to residents for review 2-4 weeks prior
 Meet with residents 1-2 weeks prior and review anticipated
surveyor questions
 Make sure they understand how previous citations have
been addressed
 Make certain ALL “non-compliant” issues in ACGME
resident surveys have been addressed, and be sure
residents feel efforts have been effective for all remedies
Survey Day Prep - Faculty
 Select faculty per site surveyor directions
 Provide PIF to faculty for review 2-4 weeks prior
 Meet with faculty 1-2 weeks prior and review
anticipated surveyor questions
 Make sure they understand how previous citations
have been addressed
 Pagers must be OFF (or absent) during the meeting
The Typical Schedule
 PD / PA meeting with review of PIF / Documents
 Chair Meeting
 DIO Meeting
 Key Faculty Meeting
 Resident Meeting
 Wrap Up meeting with PD
Behind the Scenes: ACGME / RRC
 Site Surveyor completes a written report- just the facts, designed to verify
PIF information, summarize document review, and clarify issues raised in
the ACGME resident survey
 Surveyor report is forwarded to designated RRC to be added to next open
agenda (agendas usually finalized 2 months in advance of actual meeting)
 RRC committee members (1-3) are assigned PIF and surveyor report for
review & to present at meeting (actual surveyors do not participate)
 Committee discusses and determines status and cycle length
 E-mail notice received within 2 weeks of meeting re status decision and
cycle length
 Full Letter of Report (LOR) with citations received 8-12 weeks after RRC
meeting
The Common Problem Areas
 Nationally Most Common Citations
 UMC Most Common Citations
 The Nine Red Flags
Most Common Citations:
 Duty Hour Violations
 Service versus Education Issues
 Evaluation problems
 Board Pass Rate Citations
 Written Curriculum Inadequacies
UMC Most Common Citations:
 Qualifications and Number of Faculty (14)
 Procedural Experience (13)
 Patient Care Experience (12)
 Institutional Support (10)
 Evaluation of Program (9)
 Scholarly Activities (9)
 Responsibilities of Program Director (9)
 Performance on Board Exams (8)
Nine “Red Flags” in
Accreditation Surveys
 From ACGMe-Bulletin February 2008
 Barbara Bush, William Robertson, Ingrid Philibert
authors
 Key issues to AVOID in program & site surveys
 These problems most likely to result in adverse
accreditation citations
Red Flag #1: Lack of
Program Leadership
 PD and Faculty fail to advocate for residents on
important education and patient care issues
 Lack of response to issues raised by residents/fellows
 Too much reliance on communication and preparation
PIF by program coordinator or other staff members
 Repeat citations on successive reviews
Red Flag #2: Lack of Program
Infrastructure for Teaching and
Evaluation
 Insufficient clinical or didactic curriculum
 Insufficient systems for evaluation of residents, faculty
or program
Red Flag #3: Lack of Appropriate
Volume and Variety of Patients
 Insufficient volume or balance of patients (diagnoses,
clinical problems, acuity and demographics)
 Disputes with other disciplines affecting numbers of
patients available to the teaching program
 Too many residents, fellows, other learners competing
for same patient populations
Red Flag #4: Problems with Resident
Recruitment or Retention
 High Resident Turn-over
 Unfilled resident positions
 Poor record for graduates sitting for and passing board
exam (reflects poorer quality applicants / trainees?)
 May be due to geography, program or institutional
reputation, interest in specialty, etc.
Red Flag #5: Lack of
Dedicated Teachers
 Faculty unwillingness or inability to devote added time
required for effective teaching (at the bedside and in
operating room, during conferences, rounds, and other
didactics)
 Problem may present with low numbers of board-certified
faculty or not enough key faculty
 Too much or too little supervision
 Failure to provide meaningful feedback and evaluation
 Fellows doing all the teaching
Red Flag #6: Lack of
Meaningful Didactics
 Didactics don’t cover the essential body of knowledge
required by RRC (basic science and clinical)
 Frequent cancellation of conferences
 Lack of sufficient faculty attendance or participation in
conferences
 Over-reliance on residents or fellows to organize and
present at conferences
Red Flag #7: Lack of Financial and
Human Resources
 Inadequate or outdated facilities
 Excessive clinical demands on faculty / PD
 Excessive clinical demands on faculty including PD
 Excessive “services needs” / Residents need to “cover”
too many hospitals
 Inadequate number of administrative and ancillary
staff for size of program
 Lack of funding for program
Red Flag #8: Service has a Higher
Priority than education
 Undue reliance on residents to provide service
including clinical services that cannot run without the
presence of residents
 Residents being “pulled” to “cover” services regularly
 Duty hour violations affecting a significant percentage
of the residents
 Residents being required to provide coverage or crosscoverage on inpatient units during their ambulatory,
subspecialty, or research rotations.
Red Flag #9: Lack of Preparation
for the Accreditation Process
 On site survey day, a program leader or faculty
member who does not understand, argues about the
standards, or lacks “buy-in” for the requirements
 Poorly prepared PIF
 Obvious errors, inconsistencies or failure to follow
instructions
 Missing documents
 PIF that arrives late to site visitor
Not Germane to ALL:
(BUT Frequent Area of Citation in many specialty areas)
Too MUCH or too LITTLE
Scholarly Activity
on the part of
Faculty or Residents
How the GME Office Can Help!
 Many required topics are covered in orientation annually
 We provide notification of campus wide activities that offer
opportunities to meet program requirements
 Evaluation Tools ; Faculty Development Opportunities
 Problem Resident / Faculty Intervention
 Anonymous Resident Complaint Line
 internal reviews/ Annual Survey/ Duty Hours Survey designed to
help you maintain compliance and identify problems early
 Resident Focus Groups convened as needs identified
 PIF REVIEW!!!! (in draft form!)
 Mock Surveys on request or consultant visits
Keys to Success:
 Start early
 Review and know Program and Institutional
Requirements
 Correct ALL previous citations
 Have on-going program improvement processes
 Good communication and preparation with residents
and faculty
 Convey the strengths and unique attributes of your
program clearly to the surveyor!