1. RRC-EM: EMS Fellowship ACGME Accreditation NAEMSP® EMS Fellowship Forum January 2014 Tucson, AZ
Wallace Carter, MD
Chair, Residency Review Committee for Emergency Medicine
Louis Ling, MD
Senior Vice-President, Hospital Based Accreditation

2. Disclosure
Carter: New York Presbyterian Columbia University and Weill Cornell Ling: Hennepin County Medical Center University of Minnesota Textbooks: Rosen, Harwood-Nuss

3. Learning Objectives Next Accreditation System (NAS)
Quick Review
Update and New Developments
EMS Specific Information
Introduction to Self-Study Visits

4. NAS The Next Accreditation System: A quick review

5. What is the NAS and when does it start?
The Next Accreditation System began July 1, 2013 for all core EM and EM subspecialty programs
NAS Strategic Plan:
Foster innovation and improvement in the learning environment
Increase the accreditation emphasis on educational outcomes
Increase efficiency and reduce burden in accreditation
Improve communication and collaboration with key internal and external stakeholders

6. The Building Blocks of The Next Accreditation System
Self
Study
Institutional Review
prn Site Visits
(Program or Institution)
Continuous RRC Oversight and Accreditation
Sponsor Oversight
CLER Visits

7. NAS and Quality Improvement…
The “Next Accreditation System”
“Continuous”
Observations
Assure that the Program Number of Potential Fixes the Problem Problems
Promote
Innovation
Diagnose
the Problem
(If there is one)
© 2012 Accreditation Council for Graduate Medical Education (ACGME)

8. NAS Instead of biopsies, annual data collection
Trends in key performance measurements
Milestones, Residents, fellows and faculty survey
Scholarly activity template
Operative & case log data
Board pass rates
Scheduled accreditation visits every 10 years
Focused site visits if annual data trends suggest problems
PIF replaced by self-study

9. NAS and ADS Annual Updates
Each year, programs data will be required to entered in ADS such as:
Faculty information
Fellow information
Block diagrams/curricular information
Scholarly activity information
Participating site information
Responses to previous citations
Duty Hour, Patient Safety and Learning Environment information
Evaluation information
Reporting of major changes in the program

10. All 9,022 ACGME Accredited Residency and Fellowship Programs
All 9,022 ACGME Accredited Residency and Fellowship Programs* January 1, 2013
Adding short cycles (<3 years), approximately 4.0%
* Excludes programs with Initial Accreditation
@ 2013 Accreditation Council for Graduate Medical Education (ACGME)
@ 21213Accreditation Council for Graduate Medical Education (ACGME)

11. All 9,022 ACGME Accredited Residency and Fellowship Programs
All 9,022 ACGME Accredited Residency and Fellowship Programs* January 1, 2013
95.7%
Adding short cycles (<3 years), approximately 4.0% 4%
0.3%, n=27
* Excludes programs with Initial Accreditation
@ 2013 Accreditation Council for Graduate Medical Education (ACGME)
@ 21213Accreditation Council for Graduate Medical Education (ACGME)

12. NAS Ongoing data collection and trend analysis
Enhance oversight to ensure high quality education and a safe and effective learning environment
High-quality programs will be freed to innovate – detailed process standards
Programs with continued accreditation in good standing will not have to demonstrate compliance with the “detail” program requirements as written, but are allowed to innovate

13. What are core, detail and outcome program requirements?
Core Requirements: Statements that define structure, resource, or process elements essential to every graduate medical educational program.
Detail Requirements: Statements that describe a specific structure, resource, or process, for achieving compliance with a Core Requirement. Programs in substantial compliance with the Outcome Requirements may utilize alternative or innovative approaches to meet Core Requirements.
Outcome Requirements: Statements that specify expected measurable or observable attributes (knowledge, abilities, skills, or attitudes) of residents or fellows at key stages of their graduate medical education.

14. What are core, detail and outcome program requirements?
II.A.2. Qualifications of the program director must include:
II.A.2.b) current certification in the subspecialty by the American Board of Emergency Medicine, or specialty qualifications that are acceptable to the Review Committee; and, (Core)
II.A.2.d) at least three years’ experience as a core physician faculty member in an ACGME-accredited emergency medicine program or emergency medical services program; (Detail)
IV.A.2.a).(2).(b).(i) participation in a mass casualty/disaster triage at an actual event or drill; (Outcome)

15. Do I have to adhere to the “detail” program requirements?
Programs that have initial accreditation or are in trouble must demonstrate compliance with all “detail” program requirements as written.
Programs that have continued accreditation will be allowed to “innovate” on those program requirements that are identified as “detail”.

16. Trended Data Elements Annual ADS Update
Program Attrition – Changes in PD/Core Faculty/Residents
Program Characteristics – Structure and Resources
Scholarly Activity
Board Pass Rate – Rolling Rates
Resident Survey – Common and Specialty Elements
Clinical Experience – Case Logs or other
Faculty Survey – Core Faculty
Semi-Annual Resident Evaluation and Feedback
Milestones
Annual Sponsor Site Visit (CLER)

17. Annual Data Collected and Reviewed (Focus on Existing Information)
Annual ADS Update - Streamlined
Program Attrition
Program Characteristics – Structure and Resources
Scholarly Activity
Board Pass Rate – Rolling multi-year rates
Clinical Experience
Resident Survey
Faculty Survey – Core Faculty
Semi-Annual Resident Evaluation and Feedback
Milestones
Clinical Competency Committees
Sponsor Site Visit (CLER) TBD-total picture

18. Maintenance of Accreditation with Commendation
Conceptual Model of Standards Implementation Across the Continuum of Programs in a Specialty
Initial
Accreditation
New Programs
Core and Detailed:
Structure
Resources
Process
Outcomes
Accreditation with Warning
New Programs,
Accredited Programs with Major Concerns
Probationary Accreditation
Core and Detailed:
Structure
Resources
Process
Outcomes
Maintenance of
Accreditation
Accredited Programs without Major Concerns
Maintenance of Accreditation with Commendation
Core:
Structure
Resources
Process
Outcomes
2-4% % 75%-80%
2.8%
STANDARDS
Core and Detailed:
Structure
Resources
Process
Outcomes
Withhold Accreditation
Withdrawal of Accreditation
© 2012 Accreditation Council for Graduate Medical Education (ACGME)

19. Annual evaluation of program outcome data (modified from TJN)
Applications for New Programs
Initial Accreditation
Accreditation with Warning
Continued
Accreditation
Structure
Core Process
Detailed Process
Outcomes
Structure
Core Process
Detailed Process
Outcomes
Structure
Core Process
Detailed Process
Outcomes
STANDARDS
Structure
Core Process
Detail Process
Outcomes
Adverse Actions

20. Accreditation Actions in NAS
Accreditation Policies and Procedures
Effective date: 7/1/2013
Copyright Accreditation Council for Graduate Medical Education 2013

21. Accreditation Status Options
Actions not open to appeal
Continued Accreditation - GREEN
Continued Accreditation with Warning - YELLOW
Initial Accreditation - BLUE
Initial Accreditation with Warning - BLUE
Voluntary Withdrawal of Accreditation
Administrative Withdrawal of Accreditation
Administrative Withdrawal due to withdrawal of sponsoring institution’s accreditation

22. Accreditation Status Options
Adverse actions open to appeal- RED
Accreditation Withheld
Probationary Accreditation
Withdrawal of Accreditation
Withdrawal of Accreditation Under Special Circumstances
Non-voluntary reduction in resident complement by the RRC is also open to appeal

23. Continued Accreditation (AO)
Continued Accreditation - substantial compliance with requirements
Can follow
Initial Accreditation
Initial Accreditation with Warning
Continued Accreditation with Warning
Probationary Accreditation

24. Continued Accreditation with Warning
Continued Accreditation with Warning – areas of non-compliance jeopardize accreditation status
Can follow
Continued Accreditation
Probationary Accreditation
No permanent increase in complement

25. Initial Accreditation (IA) Core programs
Core programs will have site visit prior to review. RRC options:
Withhold
Initial Accreditation
Within 2 years of granting IA, full site visit and review. RRC options:
Continued Accreditation
Initial Accreditation with Warning – 1 year only
Withdrawal

26. Initial Accreditation (IA) Fellowships
Fellowship applications are reviewed without a site visit. Within 2 years of granting IA, a site visit will be scheduled
RRC options when reviewing application
Initial Accreditation
Withhold
RRC options following IA site visit
Continued Accreditation
Initial Accreditation with Warning – 1 year only
Withdrawal

27. Site Visits Focused: isolated concern about data elements
Full: for IA or general concern about program, more than one isolated issue
No PIF to prepare
Issues will be known for focus
30 day notice
Teams for larger than 4 residents/fellows
Self-studies after 2015

28. Adverse Actions: What has changed
No proposed adverse actions
Adverse accreditation status can only be conferred following a site visit
Programs with adverse accreditation status cannot request an increase in resident complement
Probation cannot exceed 2 consecutive annual reviews

29. Adverse Actions: What hasn’t changed
A program on Withdrawal can complete the current academic year
With RRC approval can complete 1 more year
No new residents can be appointed
If program re-applies within 2 years, they must address previous citations
A site visit is needed for all applications following a withdrawal

30. Relationship of Core and Subs
Fellowships must have a relationship with a core residency program
Self-study visits of core and associated fellowships will occur at the same time
Adverse action in core results in the same status for their associated fellowships
Withdrawal of core means withdrawal of all associated fellowships
New fellowships can only be granted IA status if core status is Continued Accreditation
NO attached programs can be on Probation or in appeal

31. Building the case for milestones……… Defer to Laura Edgar, EdD
NAS
Building the case for milestones……… Defer to Laura Edgar, EdD

32. RRC-EM: EMS Fellowship ACGME Accreditation NAEMSP® EMS Fellowship Forum January 2014 Tucson, AZ
Wallace Carter, MD
Chair, Residency Review Committee for Emergency Medicine
Louis Ling, MD
Senior Vice-President, Hospital Based Accreditation

33. New Application Process as of July 1, 2013
All new program applications must be initiated in ADS by the DIO of your institution

34. New Application Process as of July 1, 2013
The program director must complete 2 parts
Part 1 – Complete the ADS electronic portion initiated by the DIO
Part 2 – Download and complete the new application specialty specific Word document from the website and upload into ADS
The completed application is submitted electronically in ADS

35. New Application Process as of July 1, 2013
The new application specialty specific Word document can be found on the ACGME EM Web page:

36. Information: RC-EM Web Page Recommended Links
Program Requirements: Currently In Effect
New Applications – Word documents
FAQs
Common Resources:
ACGME Glossary of Terms
Apply for Accreditation in Eight Easy Steps
Program Director Guide to Common Program Requirements
Program Directors’ Virtual Handbook

37. Faculty Roster
When completing the faculty roster in ADS, enter core EMS faculty that have at least 5 hours per week and any other non-EMS physicians who provide at least 10 hours per week

38. Faculty Qualifications
If faculty members are ABOEM boarded and obtain the specialty certificate in EMS from the ABOEM, does the RC view this as being “acceptable”?
A CAQ in EMS by the ABOEM is viewed as being acceptable

39. For Requested Positions, can I ask for a range, e.g. 1-2?
The RC-EM does not accept ranges of positions, only a specific number, so instead of requesting 1-2 position, you should request 2 positions (you are not required to fill all positions). 
You need to demonstrate in your application that you have enough resources to support the number of fellows requested.  (e.g. you would need to have enough opportunity to have each fellow lead a disaster drill if that is part of your program so you provide the same experience for both fellows.) 

40. How do I know if I need a PLA?
Here is an FAQ regarding Master Affiliation Agreements and PLAs.  There is a PLA template at the end of the document/site:
Program letters of agreement originate at the program (instead of the institutional) level and are required for each participating site providing a required assignment.
Program letters of agreement are required between the residency program and all sites to which residents rotate for required education or assignments.

41. How do I know if I need a PLA?
However, if the two sites operate essentially as one entity, that is, they are governed by one governing body (e.g. Board of Directors) neither a master affiliation agreement nor a program letter of agreement would be necessary.  Program letters of agreement are not necessary if the following on-campus or off-campus site is under the governance of the sponsoring institution or is an office of a physician who is a member of the sponsoring institution’s teaching faculty/medical staff: nursing and assisted-living homes; hospice facilities; faculty patient care offices; private physicians’ offices (volunteer faculty); ambulatory surgical centers; diagnostic centers, e.g. imaging, laboratory, etc.; treatment centers, e.g. dialysis, rehabilitation, chemotherapy, etc.; other similar sites.

42. New EMS FAQ for PLAs
Question When is it necessary for a program to obtain a Program Letter of Agreement (PLA) with an EMS agency? [Program Requirement I.B.1]

43. New EMS FAQ for PLAs Answer:
There must be a program letter of agreement (PLA) between the program and each participating site providing a required assignment. A fellow may interact with a number of EMS agencies in different capacities.
The Review Committee guidelines on PLAs specify:
A PLA is required for any EMS agencies with which the fellow provides in person participation as part of the required curriculum
If the sponsoring institution owns the company, no PLA is needed.
If the participating site is an independent company, a PLA is still needed for liability reasons even if the program director or a faculty member of the EMS program is the medical director (and is signing the document on behalf of the program and on behalf of the participating site) at the participating site/independent company.

44. Medical School Letter of Understanding
I.B.6. The program must be affiliated with a medical school. I.B.6.a) The program must have a written letter of understanding which documents the duties and responsibilities of both the medical school and the program.
This is similar to an affiliation agreement.
May state that the program will be compliant with the regulations and rules of the institution in matters related to the functioning of the program and that the institution will provide appropriate oversight to assure compliance with accreditation standards as well as hospital and state rules, regulations and laws
See the following web page for more information:

45. Information: Application Deadline
Applications received by April 28th, 2014 will be reviewed at the June 23-24, 2014 RC Meeting

46. Information: Application Review Process
Completed application and all attachments uploaded in ADS
No site visit required
Application reviewed based upon program requirements at an upcoming RC meeting.
In 2014 RC meets February and June
Programs are not reviewed by RC members in same state or with a conflict of interest

47. Information: Application Review Process
Within 5 business days after the meeting, s will be sent regarding the RC’s decision
Initial Accreditation OR Withhold
Within 60 days after the meeting, a Letter of Notification (LON) will be available.

48. Initial Accreditation: EMS Effective Dates
EMS Program Requirements were approved and were given an effective date of 9/30/2012
For applications reviewed at both the February and June 2014 meetings and granted initial accreditation, programs may choose to have an effective date of either 7/1/2013 or 7/1/2014.

49. What about current EMS fellows?
Q)     If my program is accredited at the February 2014 RC meeting and I chose an effective date of July 1, 2014, what does that mean for my current fellows scheduled to finish June 30, 2014?
If they finish the program on or before June 30, 2014, they will not graduate from an accredited program and will be ineligible to take ABEM’s EMS CAQ exam.

50. EMS Applications Reviewed
24 applications reviewed in February 2013
13 applications reviewed in September 2013
6 applications scheduled for February 2014
33/37 - Total EMS applications approved to date

51. Top 3 Most Common EMS Citations
Lack of PLAs
PD responsibility – Inaccurate Application Form
Scholarly Activity – Core faculty

52. Phase I and Phase II Programs
Phase I, aka Early Adopters, Early 7:
Internal Medicine
Pediatrics
Urology
Orthopedic Surgery
Emergency Medicine
Diagnostic Radiology
Neurologic Surgery
Phase II – All remaining specialties

53. Self Study & Program Improvement
ACGME self study visits begin 2015
Fellowships will be reviewed with their core programs
Tool for program improvement
Individualized Learning Plan (ILP) on steroids
© 2012 Accreditation Council for Graduate Medical Education (ACGME)

54. Self Study & Program Improvement
NOT A PIF
Tool for improvement
Regular goal setting
Longer term: 3-5 years
Includes self-reflection/self-study
Consider SWOT (strengths/weaknesses/ opportunities and threats)/stakeholders
Consider program outcome trends
Don’t have to wait until ACGME announces visit
© 2012 Accreditation Council for Graduate Medical Education (ACGME)

55. Questions??