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Ready, Set, GO! Power Prep for the ACGME Site Survey!

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Presentation on theme: "Ready, Set, GO! Power Prep for the ACGME Site Survey!"— Presentation transcript:

1 Ready, Set, GO! Power Prep for the ACGME Site Survey!
Shirley Schlessinger, MD University of Mississippi Medical Center

2 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!

3 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

4 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”

5 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!

6 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

7 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

8 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 Day survey date notice: 12/15/2009 Best you start writing by: 10 – 11/ 2009

9 Getting started: 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!)

10 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!!!

11 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

12 Attachments: May be slightly different for different RRC’s Usually:
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

13 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”)

14 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

15 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!

16 Day of Reckoning: The Site Visit
The site visitor Preparation Program Director Prep Program Administrator Prep Faculty / Chair Prep RESIDENT PREP Last Minute Reminders The Schedule

17 The Site Visitor: Professional profile of your surveyor available on 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!!!!

18 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!

19 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!)

20 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

21 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

22 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

23 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 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

24 The Common Problem Areas
Nationally Most Common Citations UMC Most Common Citations The Nine Red Flags

25 Most Common Citations:
Duty Hour Violations Service versus Education Issues Evaluation problems Board Pass Rate Citations Written Curriculum Inadequacies

26 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)

27 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

28 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

29 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

30 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

31 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.

32 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

33 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

34 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

35 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 cross- coverage on inpatient units during their ambulatory, subspecialty, or research rotations.

36 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

37 Not Germane to ALL: Too MUCH or too LITTLE Scholarly Activity
(BUT Frequent Area of Citation in many specialty areas) Too MUCH or too LITTLE Scholarly Activity on the part of Faculty or Residents

38 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

39 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!

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