Accreditation Council for Graduate Medical Education Residency Review Committee Update APDVS and...
-
Upload
winifred-hardy -
Category
Documents
-
view
222 -
download
1
Transcript of Accreditation Council for Graduate Medical Education Residency Review Committee Update APDVS and...
Accreditation Council for Graduate Medical Education
Residency Review Committee Update
APDVS and Residency Coordinators Meeting Chicago, ILApril 16, 2010
Peggy Simpson, EdDExecutive DirectorResidency Review Committees for Surgery
RRC—Surgery Members
• 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
Compliance Assessed by Residency Review Committee (Specialty Committee)
Types of Accreditation Standards
Specialty-SpecificProgram Requirements
Common Program RequirementsCompliance
Assessed byInstitutional Review Committee
InstitutionalRequirements
Navigating the Requirements*
1. Must: A term used to identify a requirement which is mandatory or done without fail. This term indicates an absolute requirement.
2. Shall: (See must)
3. 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
Continued Accreditation
ProbationProbation
Continued Accreditation
Accreditation Accreditation WithdrawnWithdrawn
Accreditation Accreditation WithheldWithheld
Initial Accreditation
Continued Accreditation
Accreditation Accreditation WithdrawnWithdrawn
Application
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
1. One day our of seven free 2. In-house call no more than 1 day in 3 averaged over
4 weeks3. 24-hour duty maximum4. Provide at least 10 hours for rest between duty
periods5. 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
Surgery RRC 2010 Program Status
Specialty# of
AccreditedPrograms
Full Accreditation
InitialAccreditation
ProbationaryAccreditation
General Surgery 249 237 5 7
Vascular Surgery -Independent
101 90 10 1
Vascular Surgery -Integrated
24 2 22 0
Surgical Critical Care 97 83 14 0
Pediatric Surgery 38 32 6 0
Hand Surgery 1 1 0 0
Totals 510 445 57 8
Surgery RRC 2010 Program Data
Specialty Total # Programs
Total # Approved Residents
Total # Filled
Residents
%age of Filled/
Approved
General Surgery 249 8372 7395 89.01%
Vascular Surgery -Independent
101 266 246 92.48%
Vascular Surgery -Integrated
24 120 40 33.33%
Surgical Critical Care 97 214 156 72.89%
Pediatric Surgery 38 76 72 94.73
Hand Surgery 1 8 8 100%
Totals 510 9056 7917 87.42%
Site Visit Results 2009
• Common Citations • Evaluation– Residents, Faculty, Program• Procedural Experience• Duty Hours
Surgery RRC Vascular Surgery
Programs Surveyed 121 33
Administrative Requests 120 13
Citations Issued 237 44
Citations/Program 1.91 1.33
Average Cycle Length 3.43 3.55
Evaluation and the Competencies
1. Educational G&Os
2. Clinical & Didactic Experiences
4. Assess Outcomes—analyze evaluation results; refine G&Os, take additional actions; add improvements
3. Evaluation Activities (observer, 360, self, etc.)
Agenda Closing Dates
• Meeting: June 24-25, 2010Agenda 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 Director312.755.5499 [email protected]
• Cathy Ruiz, MA, Senior Accreditation Administrator 312.755.5495 [email protected]
• Allean Morrow-Young, Accreditation Assistant312.755.5038 [email protected]