Annual IC Training Director’s Workshop May 15, 2002

Accreditation Process Thomas A. Blackwell, M.D. Past Chair, Current Member Residency Review Committee for Internal Medicine

Accreditation Council for Graduate Medical Education l 5 Parents –American Board of Medical Specialties –American Hospital Association –American Medical Association –Association of American Medical Colleges –Council of Medical Specialty Societies l 3 Meetings per year –February, June and September

Accreditation Council for Graduate Medical Education l 26 Residency Review Committees –27 specialties l 74 areas of training l About 7,600 programs and 99,000 residents l 23% are Internal Medicine programs

Setting Standards l Program Requirements for Residency Education in the Subspecialties of Internal Medicine –RRC Members –RRC-IM Parents l ABIM, ACP-ASIM, CME-AMA –Subspecialty Organizations –ACGME Parents l ABMS, AHA, AMA, AAMC, CMSS –Other interested parties

Forms l Program Information Forms –Collects relevant data on program. l Data - Quantitative l Narrative - Qualitative –Basis for data entry l Computer Assisted Accreditation Review l Resident Questionnaire –Qualitative

Site Visit l Field Representative l Purpose –Verify information submitted. –Collect additional information. l Program Director l Faculty l Residents (Fellows) l Facilities –Unbiased and balanced report.

Program Review l Program File –Correspondence –Field Representative Report l CAAR Report –Program Information Forms –History of actions and changes l Assigned RRC Member l Reviewer Recommendations l RRC-IM Action

Notification l Actions of the meeting l Pre-notification by Fax to PD of Medicine –Action and cycle l Draft text l Chair Document l Notification Letters l Program notifies faculty and residents

Internal Medicine 2001 l 389 Core residency l 1,421 Subspecialty residencies –Cardiovascular disease (174) l Clinical Cardiac Electrophysiology (73) l Interventional Cardiology (82) –Critical Care Medicine (36) –Endocrinology, diabetes and metabolism (117) –Gastroenterology (156) –Hematology (21)

2001 –Infectious disease (138) –Oncology (27) –Nephrology (128) –Pulmonary Disease (32) –Rheumatology (104) –Geriatric medicine (97) –Sports Medicine (2) –Hematology and Oncology (113) –Pulmonary and Critical Care Medicine (121)

Change l l Core l Subs l IC –82 programs –195 Positions Offered –151 Filled

Dependent Subspecialties l Accreditation status of linked subspecialty training program –Clinical Cardiac Electrophysiology to Cardiovascular Disease training program –Interventional Cardiology to Cardiovascular Disease training program

Actions l Accreditation –Continued full l Cycle with core residency –Dependent subspecialty –Accreditation with warning l 1 or 2-year cycle l Adverse actions –Withdrawal –Withhold –Reduce resident complement

Accreditation with Warning l The accredited subspecialty program has been found to have one or more areas of noncompliance with the Essentials that are of sufficient substance to require correction. –If not corrected will lead to withdrawal of accreditation. –1 or 2-year review cycle –Not an adverse action l No appeal of action

Adverse Action l Subspecialty program is not in substantial compliance with the Essentials and has received a warning about areas of noncompliance. –Proposed adverse action l Rebuttal –To meeting after next –Adverse action l 2 RRC reviewers l Can appeal to the ACGME

Progress Report l Provides program an opportunity to address serious issues in a report. l Avoids warning and short cycle. l Requires review and approval of the report by the sponsor’s Graduate Medical Education Committee. l If report is not acceptable, the program will receive a shorter review cycle.

Subspecialties 2001 l New programs 33 (12%) l Full Accreditation 173 (62%) l Warning54 (19%) l Withhold 1 (0.3%) l Withdraw 5 ( 2%) l Reduce Complement 1 (0.3%)

Proposed Actions Subspecialties 2001 l Withhold 6 ( 2%) l Withdraw 5 ( 2%) l Reduce number 1 (0.3%)

IC Actions 2001 l New programs 15 (54%) l Full Accreditation 9 (32%) l Warning1 ( 0.4%) l Proposed Withhold3 (11%) l Progress Reports4

Common 2001 IC Citations l Procedures/Site l Outpatient follow up l Research l Evaluations l Enrollees

III. Facilities and Resources l III.B. There must be a cardiac catheterization laboratory at each training site wherein a minimum of 400 interventional procedures of the heart must be performed per year.

Specific IC Citation l The number of procedures performed at the primary or participating sites are insufficient to provide an adequate educational experience for residents. There must be a cardiac catheterization laboratory at each training site wherein a minimum of 400 interventional procedures of the heart are performed per year.

Principle Clinical Training Institution (PCTI) l a.The training institutions must serve as a functionally integrated clinical campus, with physical proximity and shared services. l b.There must be a single teaching faculty across the entire campus. l c.The program director must exercise administrative authority over teaching faculty appointments and assignments, and resident appointment and assignments, across the entire campus.

PCTI l d.There must be a single set of core clinical conferences offered to the residents across the entire campus. l e.This level of integration must be present for the general internal medicine residency program, as well as each of the sponsored subspecialty residency programs. –Draft Proposed Program Requirements for Subspecialties of Internal Medicine (1/02)

IV.A. Clinical Experience l IV.A.3.d Residents must have clinical experiences involving outpatient follow-up of patients treated with drugs, interventions, devices, or surgery.

Specific IC Citation l The program does not provide residents with an adequate experience involving outpatient follow-up of patients treated with drugs, devices or surgery. There must be an organized and systematic follow-up program for residents to learn the consequences and outcomes of coronary interventions on their patients.

V.L. Research V.L. Research l As part of the academic environment, an active research component must be included within each accredited subspecialty program. The program must ensure a meaningful, supervised research experience with appropriate protected time--either in blocks or concurrent with clinical rotations--for each resident, while maintaining the essential clinical experience. Evidence of recent productivity by both the program faculty and by the residents as a whole, will be required, including publication in peer-reviewed journals.

Specific Citation l As part of the academic environment, an active research component must be included within each accredited subspecialty program. The program did not provide adequate evidence of recent productivity by the program faculty. The Committee judged that the number of publication in peer-reviewed journals by the faculty as a whole, was inadequate.

Specific Citation l At the time of the site visit, resident research was not required. In addition, the Committee judged that the current two months for research activities is inadequate for all residents to develop research questions, collect data, and analyze and formally report their findings.

Evaluations –End of assignment (or periodic) l written l verbal feedback –Formative semi-annual l Program Director meeting l Appropriate counseling or remedial effort –Summative-annual l Program Director meeting l Due process for detrimental outcomes

Specific Citation l All faculty members do not provide written and verbal feedback to residents at the end of an assignment or at reasonable periods. At the time of the site visit, only 75 percent of the faculty routinely provided written evaluations. Verbal feedback was highly variable across attendings.

Specific Citation l The program does not demonstrate that at least semiannually, the program provides to the resident appropriate structured feedback on performance, including appropriate counseling and other necessary remedial effort. These evaluations must be done by the program director. At the time of the site visit, it was unclear that either the evaluations or counseling were routinely occurring.

Specific Citation l Provision is not made for residents to evaluate the faculty and the program (confidentially) in writing at least annually. The results of the faculty evaluations should be used for faculty counseling and for selecting faculty members for specific teaching assignments.

I. Educational Program l I.D. All applicants entering interventional cardiology must have completed an ACGME-accredited cardiovascular disease program or equivalent.

Specific IC Citation l The program begins the interventional training residents before they complete the three years of cardiovascular disease residency. Enrollees must have completed training before starting the one-year training program.

Revised Program Requirements l September 2001 –RRC Subcommittee for the revisions of the Program Requirements for Residency Education in the Subspecialties of Internal Medicine (General Requirements) is formed. l June-July 2002 –RRC Subcommittee presents proposed revision of the General Requirements. l July 2002 –RRC develops 1 st draft of General and Subspecialty Specific Subspecialty Requirements.

Revised Program Requirements l August 2002 – December 2002 –Draft requirements out for comment l January 2003 –RRC reviews comments and drafts final General and Subspecialty Requirements l June 2003 –ACGME reviews documents and approves l July –Effective date for new General and Subspecialty Requirements

Questions? l –RRC-IM l Staff l Committee Members l RRC Information –FAQ –Tables l Program Requirements –Current –Approved not currently in effect –Out for Comment