Common Program Citations and What a Program Coordinator Can Help Avoid

Identify the more frequently cited program citations Describe the role of the program coordinator in avoiding citations by  Developing methods to correct areas of noncompliance  Identifying strategies to prevent areas of noncompliance

The Top 10 List Frequently Cited Program Citations

Institutional Support439 Patient Care Experience429 Evaluation of Program, Residents, and Faculty346 Procedural Experience 323 Curricular Development287 Program Director Responsibilities252 Scholarly Activities151 ACGME Competencies143 Faculty Qualifications136 Duty Hours/Working Environment 129

Tips for Success

1.Read the requirements 2.Know the numbers 3.Learn your PIF 4.Take charge of resident files 5.Manage documentation

Read the Requirements Know where to find them and the differences in: –Program –Common Program –Institutional –Subspecialty Program Learn the vocabulary Bookmark ACGME.org and visit the site regularly

Know the numbers When there are numbers, they are important Keep track of numbers –Procedures/documentation of –Patient visits –Number of residents (WebAds) –Number of faculty (board certification dates)

Learn your PIF Get help –Start with your GME Office and the DIO Read the PIF—is it describing your your program? Make sure there is documentation for what is written Start early—it always takes longer Gather faculty CVs – Consistent and accurate

Learn your PIF... Do the three checks –Check addresses, institution numbers –Check spelling and grammar –Check pagination Follow instructions –Do not staple or bind, 1 page cv’s, limited number of words –10 days before = 10 working days

Take charge of Resident files Include essential documents (transfer residents, ECFMG residents, etc.) –Portfolio documentation –Semi-annual evaluations with program director –Final evaluation with ACGME-required wording Verify that the resident has demonstrated sufficient competence to enter practice without direct supervision

What are the Coordinator’s duties regarding the PIF? 1.Write statistical descriptions 2.Write narrative descriptions 3.Read it for consistency 4.All of the above 5.None of the above

What are the Coordinator’s duties regarding the PIF? 1.Write narrative descriptions 2.Write statistical descriptions 3.Read it for consistency 4.All of the above 5.None of the above

Don’t Perform the Program Director’s job, no matter how hard s/he begs Don’t write the PIF Don’t write program policies, action plans, or responses to citations

Do Meet with your Program Director - divide and conquer the PIF Read your PIF when complete – and again! Make sure you know where your program policies, action plans, etc. are and that your PD has responded to citations Document scholarly activities; annual and semi- annual meetings with the PD Follow through with collecting evaluations of the residents, faculty and the program Up-date your annual WebAds survey – Document scholarly activity in resident files and/or a database

Other suggestions?