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, MDUniversity of Mississippi Medical Center
2 Workshop Overview Optimizing your “PIF-manship” Day of Reckoning: The visit ItselfBehind the Scenes (ACGME / RRC)Avoiding the MOST Common CitationsHow the GME Office Can Help!
3 Optimizing Your “PIF-manship” Why it mattersUnderstanding the rulesTimeline for completionAttachments and Supporting DocumentsAvoiding 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 PIFAll 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 PIFBe 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 visitDIO must review and sign off before document can be mailed to surveyorOptimally 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: 3/15/2010Send draft to DIO: 2/15 - 3/1/2010Draft for CR/key Faculty review: 2/1 – 3/1/2010Day survey date notice: 12/15/2009Best you start writing by: 10 – 11/ 2009
9 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-adsPart 2 is questions and narrative specific to your programsTackle the PIF in small bites / sectionsJUST DO IT!!! (procrastination compromises product!)
10 Common PIF Errors: Unanswered questions / Missing information Failure to follow directionsSpelling / Grammar / Structure Structure errorsIncluding unformatted faculty CV’s, manuscripts, etc.!!!!!!PIF faculty CV’s with publications from the 70’s & 80’s, (last 5 years ONLY!!!)Pages incorrectly numberedInconsistent dataInaccurate block diagramsFailure to fully explain unique approached to satisfying requirementsFailure to TELL the TRUTH!!!
11 Common “inconsistencies”: # residents in ACGME database = number of names on resident list = #of residents listed in PIFMonths / FTE’s at each participating site = number of rotations on block diagram# of resident evaluations in folders = frequency of resident reviews reportedInstitution mentioned in narrative is not referenced elsewhereFaculty List / Faculty Credentials = faculty CV’s attachedProcedures listed for individual residents = numbers of total program procedures
12 Attachments: May be slightly different for different RRC’s Usually: Policy for resident supervisionMoonlighting policyDuty Hours PolicyCompetency Assessment ToolsEvaluation toolsOverall Educational Goals for the ProgramSample Goals & Objectives for a rotationProgram Letters of Agreement
13 Supporting Documentation: Policy for Supervision of residentsProgram Policies for duty hours and work environmentMoonlighting policyDocumentation of internal review (DIO provides)Overall Program GoalsCompetency Based Goals & Objectives by rotation and level of traineeCurrent Program Letters of AgreementFiles 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 rotationExamples of completed 360* evaluationsSample of written semi-annual evaluation by PDCompleted confidential evals of faculty by residentsCompleted confidential evals of program by residentsCompleted confidential evals of program by facultyMinutes of annual program evaluations and written improvement planResident duty hour tracking
15 Supporting Documentation (cont’d): Complete Program CurriculumExamples of scholarly activity (resident and faculty)Documentation of program improvement projectsConference schedules with documentation of attendanceBoard Exam Results of graduatesCopies of alumni surveys if doneTrainee handbooksAny other examples of “special” things you do!
16 Day of Reckoning: The Site Visit The site visitorPreparationProgram Director PrepProgram Administrator PrepFaculty / Chair PrepRESIDENT PREPLast Minute RemindersThe Schedule
17 The Site Visitor:Professional profile of your surveyor available on acgme.orgConfirms and clarifies the PIF (Does NOT make accreditation decision!)Documents the data and the processesWrites fair, objective, and accurate reportDoes NOT make recommendations regarding accreditation actionWill 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 surveyorCommunicate any changes or problems directly to your surveyorIdentify and schedule a room for the survey day which can accommodate all interviewsHave three copies of PIF for surveyorDecide who will hold / answer pagers for participants!
19 Survey Day Prep – PD/PAKnow your Program Requirements inside / out, forwards & backwards!Know your PIF/ prep your peopleHave all supportive documentation, well-organized and optimally ordered by PIF topicsHave interview room neat and stocked with waterSurveyor 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 priorMeet with residents 1-2 weeks prior and review anticipated surveyor questionsMake sure they understand how previous citations have been addressedMake 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 directionsProvide PIF to faculty for review 2-4 weeks priorMeet with faculty 1-2 weeks prior and review anticipated surveyor questionsMake sure they understand how previous citations have been addressedPagers must be OFF (or absent) during the meeting
22 The Typical Schedule PD / PA meeting with review of PIF / Documents Chair MeetingDIO MeetingKey Faculty MeetingResident MeetingWrap 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 surveySurveyor 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 lengthnotice received within 2 weeks of meeting re status decision and cycle lengthFull Letter of Report (LOR) with citations received 8-12 weeks after RRC meeting
24 The Common Problem Areas Nationally Most Common CitationsUMC Most Common CitationsThe Nine Red Flags
25 Most Common Citations: Duty Hour ViolationsService versus Education IssuesEvaluation problemsBoard Pass Rate CitationsWritten 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 2008Barbara Bush, William Robertson, Ingrid Philibert authorsKey issues to AVOID in program & site surveysThese 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 issuesLack of response to issues raised by residents/fellowsToo much reliance on communication and preparation PIF by program coordinator or other staff membersRepeat citations on successive reviews
29 Red Flag #2: Lack of Program Infrastructure for Teaching and Evaluation Insufficient clinical or didactic curriculumInsufficient 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 programToo many residents, fellows, other learners competing for same patient populations
31 Red Flag #4: Problems with Resident Recruitment or Retention High Resident Turn-overUnfilled resident positionsPoor 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 facultyToo much or too little supervisionFailure to provide meaningful feedback and evaluationFellows 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 conferencesLack of sufficient faculty attendance or participation in conferencesOver-reliance on residents or fellows to organize and present at conferences
34 Red Flag #7: Lack of Financial and Human Resources Inadequate or outdated facilitiesExcessive clinical demands on faculty / PDExcessive clinical demands on faculty including PDExcessive “services needs” / Residents need to “cover” too many hospitalsInadequate number of administrative and ancillary staff for size of programLack 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 residentsResidents being “pulled” to “cover” services regularlyDuty hour violations affecting a significant percentage of the residentsResidents 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 requirementsPoorly prepared PIFObvious errors, inconsistencies or failure to follow instructionsMissing documentsPIF 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 LITTLEScholarly Activityon the part ofFaculty or Residents
38 How the GME Office Can Help! Many required topics are covered in orientation annuallyWe provide notification of campus wide activities that offer opportunities to meet program requirementsEvaluation Tools ; Faculty Development OpportunitiesProblem Resident / Faculty InterventionAnonymous Resident Complaint Lineinternal reviews/ Annual Survey/ Duty Hours Survey designed to help you maintain compliance and identify problems earlyResident Focus Groups convened as needs identifiedPIF REVIEW!!!! (in draft form!)Mock Surveys on request or consultant visits
39 Keys to Success: Start early Review and know Program and Institutional RequirementsCorrect ALL previous citationsHave on-going program improvement processesGood communication and preparation with residents and facultyConvey the strengths and unique attributes of your program clearly to the surveyor!