Accreditation Council for Graduate Medical Education ... · Reporting Expectations Neurosurgery...

Accreditation Council for Graduate Medical Education

Neurological Surgery RRC Update:

II. Reporting Expectations

Neurosurgery Resident Coordinators MeetingJune 7, 2013

Pamela L. Derstine, PhD, MHPERRC Executive Director

Topics

• Annual RRC Program Review• Annual Program Evaluation• Clinical Competency Committee• Site Visits

© 2013 Accreditation Council for Graduate Medical Education (ACGME)

Annual RRC Program Review

• Annual ADS UpdateProgram Changes – Structure and resourcesProgram Attrition – PD / core faculty / residentsScholarly Activity – Faculty and residents

• Board Pass Rate – 7 year rolling average• Clinical Experience – Case logs• Resident Survey – Common and specialty elements• Faculty Survey• Semi-Annual Resident Evaluation and FeedbackMilestones

• Omission of data© 2013 Accreditation Council for Graduate Medical Education (ACGME)


• Annual ADS Update Program Changes – Structure and

resources Participating Site information (e.g., PLA on file, distance

from primary site, rationale, rotation months) Current Block Schedule: programs must follow

instructions and use the block schedule template provided

https://www.acgme.org/ads/Content/Downloads/BlockDiagramInstructions.pdf Sponsoring institution information (e.g., DIO,

participating sites, other sponsored programs)© 2013 Accreditation Council for Graduate Medical Education (ACGME)


• Annual ADS Update Program Changes – Structure and

resources Major changes Response to current citations (if resolved on annual

review, will be removed and stored in program history) Duty Hour, Patient Safety, Learning Environment

(17 items) Overall evaluation methods (6 items)



• Annual ADS UpdateProgram Attrition – PD / core faculty / residents Program director change history since 2000 Program director CV Program faculty basic information Resident basic information Change requests



• Annual ADS Update Scholarly Activity – Faculty and residents CV used for program director Scholarly activity templates used for faculty and

residents Scholarly activity is reported for the most recently

completed academic year (12 month period, not a 5 year period) for all but the PD



Program Director CVsame information requested but entered online


Scholarly Activity Template


Faculty Scholarly Activity

Enter Pub Med ID #’s



Enter a number



Answer Yes or No



AnswerYes or No


Resident Scholarly Activity


• Board Pass Rate: 5 year ADS self-report



• Board Pass Rate – 7 year rolling average ABNS has provided pass rates to the ACGME

electronically for each year beginning with 2003 through 2012 for parts 1 and 2 for all programs

ABNS will provide an annual electronic update to the ACGME, beginning with the 2013 exam results

Annual ABNS reports to ACGME may preclude the need for programs to provide this information



• Clinical Experience – Case logs 2012-2013 program review

- minimum numbers for defined case categories reviewed and feedback provided (no citations based on min. numbers)

2013-2014; 2014-2015 program reviews- graduates expected to comply with minimum number requirements for all categories except critical care (DC20-28) and endovascular (DC3b)

- level-specific reports will be reviewed to monitor progress towards compliance

2015-2016 program review and beyond - graduates expected to comply with all categories



• Resident Survey – Common and specialty elements 7 survey question domains: duty hours; faculty;

evaluation; educational content; resources; patient safety; teamwork

70% response rate required Aggregated non-compliant survey responses for

each domain are reviewed; thresholds for non-compliance

Exception: programs with DHE and non-compliant responses for intimidation and service-over-education will be cited © 2013 Accreditation Council for Graduate Medical Education (ACGME)


• Resident Survey – Common and specialty elements Programs with DHE and non-compliant

responses to 88-hour question- first time non-compliance: warning- second time non-compliance: action plan required

- third time non-compliance: DHE canceled; program may not reapply for DHE



• Faculty Survey 5 question domains:

- supervision and teaching- educational content- resources- patient safety- teamwork

Intended to mirror most resident survey questions and provide opportunity to compare responses by question domain

First survey completed: spring 2013 First RRC review of faculty survey data: spring 2014 Compliance metrics not yet developed



• Milestones First milestone evaluation period: July – December

2013- Residents evaluated as usual by the program (competency-based, multiple evaluators)

First milestone reports to ACGME: Nov/Dec 2013- Collected evaluations reviewed by the CCC- CCC determines milestone level for each resident for each milestone

- Milestone reporting will be done through a link in ADS (not yet available)

Second milestone reports to ACGME: May/June 2014 First RRC review of milestone data: spring 2015



• Annual ADS Update Omission of data If any required annual ADS update information is

missing, a program will be flagged by the NAS data system

Data omission could result in an altered accreditation status




Annual Program Evaluation

New proposed Common Program Requirements for Annual Program Evaluation (V.C.1)

• Program director must appoint Program Evaluation Committee (PEC)

• PEC members: at least 3 program faculty; representation from residents

• Written description of PEC responsibilities

• PEC plans, develops implements evaluates program activities, develops competency-based goals and objectives, conducts annual program review, ensures areas of non-compliance are corrected



New proposed Common Program Requirements for Annual Program Evaluation (V.C.2)

• The program, through the PEC, must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a full, written annual program evaluation (APE).



• Annual Program Evaluation must includeFormal, systematic evaluation of the curriculumMonitor and track resident performance Monitor and track faculty development (recommend faculty

development related to resident assessment and use of milestones)

Monitor and track graduate performance (incl. ABNS certification)

Identification of areas to improveDevelopment of action planReview of action plan activities and documentation of results



• Annual program evaluation reports will be key data reviewed at the time of the self-study visit

• A process should be in place now to ensure the annual program review takes place and is documented.




Clinical Competency Committee

New proposed Common Program Requirements for Resident Evaluation (V.A.1)

• The program director must appoint the Clinical Competency Committee.

• CCC must have at least three program faculty

• CCC members may also include non-physician members of the health care team and residents in their final year



New proposed Common Program Requirements for Resident Evaluation (V.A.1)

• CCC activities include:

reviewing all resident evaluations completed by all evaluators semi-annually

preparing and ensuring the reporting of Milestones evaluations of each resident semi-annually to the ACGME

making recommendations to the program director for resident progress, including promotion, remediation, and dismissal



• Milestone data will be reported semiannually (Nov/Dec and May/June) via a link in ADS

• Programs should be forming their CCC now• Faculty should be oriented to the milestones

and faculty development in assessment should be provided



• Faculty Development opportunities for assessing milestones: SNS program director workshop June 8, 2013 CNS workshop October 19, 2013 San Francisco

(no additional charge for this workshop) ACGME Educational Conference Feb 27 –

Mar 2, 2014 National Harbor, Maryland Webinars (e.g., see ACGME Webinar 3:

Milestones, Clinical Competency Committee, and Assessment)



Site Visits

Site Visits• Focused• Full• Self-Study• Site Visit FAQs updated May 2013:

http://www.acgme.org/acgmeweb/GraduateMedicalEducation/SiteVisitandFieldStaff/SiteVisitFAQ.aspx


Site Visits• When is my program’s next site visit? Most programs have received notice of their

approximate self-study date. The announced self-study date is the program’s next scheduled site visit.

At the time of the annual RRC program review, a focused or full site visit may be requested. If so, the self-study date will remain the same but the focused or full site visit will be the program’s next site visit.

No site visits of any kind will require a PIF© 2013 Accreditation Council for Graduate Medical Education (ACGME)

Site Visits• How is the program notified of the site

visit date? Focused Site Visit: announcement letter with a

minimum of 30 days advance notice (email) Full Site Visit: announcement letter with a

minimum of 60 days advance notice (email) Self-study Visit: announcement letter with 12-15

months advance notice of the approximate month and 90-110 day advance notice of the specific date and detailed information about the self-study visit (email)


Site Visits• What happens during a focused or full site

visit? Field staff: use ADS information, resident and faculty

survey information, case log data; review documentation made available by the program (as directed in the letter announcing the site visit)

Information is verified and clarified via document review, interviews, inspection of facilities as needed

Field staff will provide a preliminary summary to the program at the end of the visit (key strengths, areas in need of improvement based on site visitor’s impressions; this summary does not predict the accreditation outcomes or feedback from the RRC


Site Visits• What about self-study visits? The self-study site visit program is under development

with several pilot visits already completed. An ACGME webinar on the self-study program will take

place later this summer. As with past ACGME webinars, the announcement will be

sent to program directors and DIOs Program coordinators are advised to work with their program

directors to ensure that they learn about the webinar date Program coordinators may attend the webinar by registering using

the information obtained from the program director Groups (PD, PC, faculty, etc.) may attend under a single

registration by videoconferencing the webinar at their own site


Site Visits• How should a program set up the schedule

for the day of the site visit? Site visits for larger programs will be conducted by a

team; site visits for smaller programs may or may not be conducted by a team; the site visit announcement letter will indicate the type of visit and who the site visitor(s) are.

On the day of the site visit, the site visitor(s) will meet with residents, faculty, program director, and the DIO (or representative).

Site visitor(s) will notify the program of specific schedule requirements as they do now


Accreditation Council for Graduate Medical Education ... · Reporting Expectations Neurosurgery...

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