surviving your site visit Arthur L Day Department

surviving your site visit Arthur L. Day Department of Neurological Surgery Brigham and Women’s Hospital Harvard Medical School Boston, MA

site visit: timeline site visit ACGME website other ongoing preparations IGME program review ACGME resident survey (6 -18 mo) site visit notification (3 -4 mo) site visit 5 years

site visit: timeline site visit ACGME website other ongoing preparations IGME program review ACGME resident survey (6 -18 mo) site visit notification (3 -4 mo) site visit 5 years

ACGME website http: //www. acgme. org

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System) last site review date next site review date

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System)

site visit: ADS (Accreditation Data System)

site visit: timeline site visit ACGME website other ongoing preparations IGME program review ACGME resident survey (6 -18 mo) site visit notification (3 -4 mo) site visit 5 years

ACGME website: ongoing preparations Review and know the program requirements AND companion documents Attend meetings/workshops (SNS) Contact RRC executive director or staff if uncertain

ACGME website: ongoing preparations Review and know the program requirements AND companion documents Attend meetings/workshops (SNS website) Contact RRC executive director or staff if uncertain GENERAL (312) 755 -5000

ACGME website: ongoing preparations Review and know the program requirements AND companion documents Attend meetings/workshops (SNS/website) Contact RRC executive director or staff if uncertain GENERAL (312) 755 -5000 Larry Sulton Ph. D (312) GO-ACGME (office) (312) GO-AWAAY (home)

site visit: timeline site visit ACGME website other ongoing preparations IGME program review ACGME resident survey (6 -18 mo) site visit notification (3 -4 mo) site visit 5 years

site visit: IGME review 1. half- way between site visits 2. initiated by GME office; reviewers from outside department 3. candidly explores strengths and weaknesses; checks to see if prior problems have been resolved; provides early notice if improvements needed, in advance enough to address issues 4. summary of the internal review 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)

site visit: timeline site visit ACGME website other ongoing preparations IGME program review ACGME resident survey (6 -18 mo) site visit notification (3 -4 mo) site visit 5 years

site visit: ACGME resident survey 1. 6 -18 months before the visit 2. participation initiated by and through the program 3. at least 70% response expected; programs with <70% will be resurveyed the following year 4. results available to both Program and DIO INTENT: (a) focus resident interview (b) identify serious non-compliance with duty hour standards

site visit: timeline site visit ACGME website other ongoing preparations IGME program review ACGME resident survey (6 -18 mo) site visit notification (3 -4 mo) site visit 5 years

site visit: notification 1. 3 -4 months before the visit 2. letter arrives, announcing: a. date b. site visitor name and contact information c. other important information d. addendum for the general competencies If date is major problem, call ACGME within 14 days of date of letter (312) 755 -5003 or jphilibert@acgme. org (312) 755 -5014 or pil@acgme. org Do not call site visitor, RRC staff, or RRC chair

site visit: timeline site visit ACGME website other ongoing preparations IGME program review ACGME resident survey (6 -18 mo) site visit notification (3 -4 mo) site visit 5 years

site visit: RRC review 2 reviewers - peers reviewers use the following information to determine whether the program is in compliance with the requirements: Program Information Forms (PIF) site visitor’s report Board scores Reviewers present program to Committee assigns accreditation status/review cycle (1 -5 years)

site visit: PIF Preparation The PIF is a self study document that describes how your program complies with the requirements Start EARLY! Involve faculty and residents and other program personnel Read questions carefully and start preparing initial responses Responses clear, concise, accurate and complete; provide key to abbreviations; check spelling and proof carefully for content Review prior citations; make sure they have been addressed Cross check information and fix any internal inconsistencies in the PIF # of residents in the program vs resident roster; block diagram vs rotation schedule; narrative should agree with data/blocks

site visit: PIF Preparation “You never get a second chance to make a good first impression” site visitor/RRC do not know your program site visitor/RRC must review many PIF’s Make your PIF clean, crisp, complete and easy to read to make a good first impression “When a site visitor reads a poorly prepared PIF he/she comes prepared for the worst” John Gienapp, M. D. Former Executive Director ACGME

site visit: Citations CITATION: 1. no documented/provided evidence of compliance with requirements 2. an area identified by the site visitor as non-compliant CATEGORIES: 1. Didn’t Have: resources, patients (# & types); required experience; facilities/equipment; time/support; other program personnel 2. Didn’t Do: lack of evidence of development of goals and objectives; continuity experience; subspecialty experience; critical care experience; evaluations (fellow, faculty, program); supervision; monitor/track residents procedures; comply with duty hours. 3. Didn’t Bother: proof/edit PIF; incomplete or inconsistent information (insufficient details of educational experiences in compliance with the requirements)

site visit: new requirements went into effect January 1, 2006 requirements are “heavy” with the competencies form the skeleton for much of the requirements transition document – away from process to one of outcomes. emphasis on documentation faculty and administrative support needed depending on size of program new types of competencies citations are coming

T minus One Year • • • review Program & Institutional Requirements preview the PIF keep conference sign-in sheets document biannual resident meetings get resident evaluations of faculty & program document education meetings Revise goals & objectives as needed • have residents read goals & objectives • complete “Final Evaluations” • update Letters of Agreement w/ hospitals • iron out resident “issues”

T minus 6 Months Begin/write the Program Information Form

T minus 2 months • Re-read requirements and PIF • Schedule Institutional Official(s) • Schedule “Key Faculty” • Schedule appropriate room • Schedule transport/lodging/meals • Have residents selected

T minus 1 month Prepare: 1. 2. 3. 4. 5. Residency coordinator Secretaries Clinical nurses Faculty Residents/Fellows 14 days (10 business days) before the site visit Mail PIF to site visitor (no email or fax) Assemble/organize all documentation Visit call rooms / lounge(s) / libraries

Required Documentation • copy of PIF • • • educational Goals & Objectives written Supervisory Lines Responsibility acceptance/promotion/dismissal policies • Program Requirements conference attendance sheets resident evaluations of faculty/program • Institutional Requirements • GME Committee minutes prior RRC letters • Resident Rotations resident Contract & Manual affiliation agreements Institutional Review; Letters of Agreement resident files (group and individual) – include a few graduates w/ final (summary) evaluations • surgical operative logs

Sample Schedule 8: 00 – 9: 30 am 9: 30 – 9: 45 am 9: 45 – 10: 15 am 10: 15 – 11: 00 am 11: 00 – 11: 45 am 11: 45 am– 1: 00 pm 1: 00 – 1: 45 pm Program Director Department Chair DIO Other Core Faculty Tour of Hospital Lunch with Residents Program Director

site visit: results (previous) Letter of Notification mailed to Program Director, Chairman, Sponsoring Institution Within 1 month following RRC Committee Mtg that reviews the site visit report Time frame 3 - 9 months from initiation

site visit: results (new changes) • E-mail status of programs on RRC agenda • Within two weeks of an RRC meeting programs on the agenda will receive an email notification with the accreditation status and review cycle. • Programs that received an adverse action/proposed adverse action will not get such an email • E-mail to notify you that your notification letter is posted on ADS. • Will no longer send notification letters in the mail. You will receive email to check ADS for letter.