1. How to Survive a Self-Study!!
Kathy Julian, MD
Director for Outcomes and Optimization, GME
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

2. 9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

3. Objectives List the 8 steps of the self-study process.
Describe best practices in the self-study process.
Describe how completion of the Annual Program Evaluation will assist the self-study process.

4. 9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

5. ACGME Oversight Self-Study Institutional Reviews As-Needed Site Visits
Continuous Accreditation (Annual ADS Update/Surveys)
CLER Visits (every months)
ADS includes
Clinical Experience
Scholarly Activity
Surveys
Board Pass Rates
Case Logs
Survey Changes
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

6. SELF-STUDY TIMELINE Self-Study Process PDSA Cycles
Prepare for Site Visit
Notification
Self-Study Report
Site Visit
Month 0
Month 6
Month 18-24

7. 8 Steps to the Self-Study…
Assemble the self-study workgroup
Identify program aims
Complete a SWOT analysis
Aggregate and analyze data
Obtain stakeholder input
Interpret data and aggregate self-study findings
Discuss findings with stakeholders
Develop succinct self-study document

8. #1: Assemble the Self-Study Team
Program Director
Associate Program Directors
Core Faculty (choose a few)
Chief Residents
PEC Members
Program Coordinator and Administrators
Others? Coordinate with subspecialty programs/core program
Schedule all your meetings in advance and be efficient!
10 sixty-minute meetings
Other members: education expert, assessment expert, CCC members, coordinate with subspecialty programs
Record everything!
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

9. #2: Program Aims What is our vision and mission statement?
What does our program strive to produce?
What makes us unique?
Who are our residents/fellows?
What do we prepare them for?
Who are the patients and populations we care for?
To what do we aspire?
What will take our program to the next level?
What does the program strive to produce? How does the program differentiate itself from other programs?
Programs will have multiple aims
Aims should be measurable
Core programs: consider cross-linkages with subspecialty programs
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

10. A Good Annual Program Evaluation (APE) Will Make The Self-Study Process Easier…
Next APE will include program AIMS

11. #2: Program Aims Programs should have multiple aims
Aims should be measurable
Consider cross-linking program aims with specialty/core programs

12. #3: Conduct SWOT Analysis
Opportunities-external factors not entirely under the control of the program that, if acted upon, will help the program flourish (ex: partnering with an institution with a simulation center)
Threats – external factors threatening the program (ex: cost of living in SF)
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

13. #3: Conduct SWOT Analysis
These answers matter. Should be cohesive review of the program
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

14. #4: Gathering Data 5 Years Annual Program Evaluations (APE)
Program/Learner Evaluations
Board Pass Rates
Graduate Trajectories
ACGME Resident/Fellow Surveys
ACGME Faculty Surveys
Faculty Teaching Evaluations
Graduate Surveys
Faculty Retention
Resident Demographics (Diversity, Research)
5 Years

15. #4: Gathering Data--Remember Your APE
Should be reviewing all of these as part of robust Annual Program Evaluation
Will help you with later self-studies
If you’re not reviewing one of these data sources---why not?
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

16. #5: Get Stakeholder Input
Questions
Residents/Fellows
Faculty
Department Leadership
Fellowship Directors/Core Director
Allied Health Staff (Nursing, Social Work, etc.)
Program Administrators
Alumni
Others?
Get feedback on:
Program Aims
SWOT Analysis
Method for feedback
Surveys
Retreats
Meetings
KEY: BROAD INPUT
Others: community partners, organizations who hire graduates
BROAD input is key!!!
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

17. #6: Interpret Data/Aggregate Findings
AGGREGATE DATA 1
CREATE PDSA’S 5
UPDATE AIMS 2
Clarify problems- id self-improvement plans
How will you improve weaknesses?
How will you take advantage of opportunities?
How will you mitigate threats?
PDSA’s = What will take this program to the next level? 4 3
Clarify Problems
UPDATE SWOT
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

18. #7: Discussion of Findings with Stakeholders

19. #7: Discussion of Findings with Stakeholders
Questions
Will PDSA’s take program “to the next level”?
PDSA’s
Who?
What?
Where?
When?
How?
KEY: BE ABLE TO MONITOR IMPROVEMENT
Present Updated Aims
Present Updated SWOT
Present Improvement Plans
Get Input on PDSA’s
9/10/2019
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

20. #6: Aggregate Findings/PDSA’s – Look at Your APE’s

21. #7: Example

22. #8: Develop Self-Study Document
Complete the ACGME Template
Share the Long Form/Short Forms across residency and fellowship programs
Process >> Content
Review with GME Office 2 weeks before submission
Submit in ADS

23. GET ANSWERS FROM THE EXPERTS!!!