Preparing for a Successful Site Visit Lelan F. Sillin, MD, MS(Ed), FACS ACS EI Consortium Meeting Administration & Management Workshop March 15, 2013.

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Presentation transcript:

Preparing for a Successful Site Visit Lelan F. Sillin, MD, MS(Ed), FACS ACS EI Consortium Meeting Administration & Management Workshop March 15, 2013

Disclosures None

Preparing for the Site Visit Application Surveyor Reviewer Accreditation Review Committee (ARC)

Role of the Reviewer Presents a summary of the application & “tells the story” of the EI to the rest of the ARC Presents assessment of whether the EI application meets each of the Standards & Criteria Makes initial accreditation recommendation to the ARC and then has to explain why

Role of the Reviewer Understand the “story” of the site; To assess if the materials, personnel, resources, activities, etc. required by the accreditation criteria are present at the site; To determine if the site meets each of the accreditation criteria.

Reviewer: Resources Used Application Surveyor’s report Supplementary Materials provided Standards & Criteria

Purpose of the Site Visit Corroborate the materials & statements in the application Clarify ambiguities in the application Communicate to the surveyor(s) (ARC) the EI’s “story” Advocate for the EI

Role of the Surveyor To corroborate the information in the application; To assess if the materials, personnel, resources, activities, etc. required by the accreditation criteria are present at the site; To listen to and try to understand the “story” of the site; Ask questions and clarify ambiguities; Explain the program to the reviewer (ARC)

What Does a Surveyor Want? To understand the program To understand, follow, and be able to articulate the EI’s “story” To identify the supporting evidence that the EI meets each of the criteria; To be able to ask questions

Application: Surveyor’s Perspective Clearly written Easy to follow narrative (logical progression) No jargon (particularly local jargon) Pertinent examples and supporting documents Appropriately placed references to supporting documents in easy to find attachments Attachments focused to address specific criterion Clear explanation of organizational relationships

Site Visit: Surveyor’s Perspective Clear presentation of the EI’s “story” Clarity Transparency Time to ask questions of each of key people Time to ask questions of representatives of the key groups (staff, faculty, learners, etc.)

How to Schedule the Site Visit Identify the people that must be at the visit Survey them for available dates Pick 2 or 3 dates Have them hold those dates open Notify the ACS staff of the dates Once a date is chosen be sure that it is “fixed” on the schedule of your participants Free the other dates on their schedules

How to Structure a Site Visit Develop a draft agenda Feature your key programs & key people Call the lead surveyor & discuss the draft agenda Be sure the surveyor has time to talk with the key people and to ask questions Remember: it is essential that the surveyor understands your program

Sample Agenda 7:00 AM Breakfast 7:30 AM Introductions, Welcome 8:00 AM Overview 8:30 AM Review of EI’s Programs Administration Medicine, CCM, Cardiology, IR Nursing Surgery, Anesthesia, Emergency Medicine Operations Staff

Sample Agenda 11:00 AM Tour 12:00 PM Lunch (working) Learner Attendees Surgical, Medical, Gyn residents; medical students; MDs; nurses; Respiratory Therapists, etc. Instructor Attendees Surgical, Medical, Nursing, ED, etc. 1:00 PM Document Review & Final Questions 1:30 PM Survey Team Writes Report 3:00 PM Closing Comments & Departure

Summary Clarity Transparency Be able to tell your “story” easily Provide access to your people Showcase your programs Articulate your educational processes Make the surveyor & reviewer your advocate Preparing for the Site Visit