ACGME Institutional Accreditation Paul Foster Johnson, MFA Executive Director, Institutional Review Committee ACGME DIO/DME Forum Billings, Montana November 6, 2017

Disclosures I am a full-time employee of the ACGME. I have no conflicts of interest or financial relationships to disclose.

Objectives Review ACGME Institutional Accreditation Describe required structural elements and qualities of Sponsoring Institutions (SIs) that oversee and support ACGME-accredited graduate medical education (GME) programs Recognize the roles, responsibilities and activities associated with institutional sponsorship Describe common challenges in institutional applications

ACGME Mission Statement We improve health care and population health by assessing and advancing the quality of resident physicians' education through accreditation.

831 Sponsoring Institutions ACGME Statistics 831 Sponsoring Institutions About 2/3 have >1 accredited program 10,672 ACGME-accredited residency/fellowship programs 4,383 residencies, 6,174 fellowships 129,720 residents/fellows in ACGME-accredited programs 107,013 residents, 22,707 fellows ~150 Specialties and Subspecialties

Institutional Accreditation Sponsoring Institutions must apply for and receive institutional accreditation before applying for program accreditation Application is the same for all Sponsoring Institutions Institutional Review Committee (IRC) uses peer review process to determine Sponsoring Institutions’ substantial compliance with ACGME Institutional Requirements

IRC Leadership, 2017-18 Chair Susan E. Kirk, MD Associate Dean for Graduate Medical Education University of Virginia Medical Center Vice Chair Ronald Amedee, MD, FACS Designated Institutional Official Ochsner Clinic Foundation

ACGME-Accredited Sponsoring Institution Definition: The organization (or entity) that assumes the ultimate financial and academic responsibility for a program of graduate medical education. The sponsoring institution has the primary purpose of providing educational programs and/or health care services. Examples: a university; a medical school; a hospital; a school of public health; a health department; a public health agency; an organized health care delivery system; a medical examiner’s office; a consortium; an educational organization.

www.ACGME.org > Designated Institutional Officials > Institutional Review Committee

Accreditation Data System (ADS)

Application Uploads Initial Institutional Application Organizational charts Statement of commitment to GME GMEC minutes GMEC membership AIR performance indicators Special Review protocol

Institutional Applications Reviewed by the Institutional Review Committee (IRC) for substantial compliance with ACGME Institutional Requirements No initial site visit (unlike core program applications) Considered on a first-come, first-serve basis at one of three annual meetings Sponsoring Institution remains in “Application” status until IRC review Possible decisions: Initial Accreditation Accreditation Withheld IRC letter of notification and citations within 60 days

Institutional Accreditation Leadership (Oversight and Support) Operational Structure (Personnel and Systems) Clinical Learning Environment (All Residents and Fellows, All Faculty, All Participating Sites, All Programs)

ACGME Institutional Requirements I. Structure for Educational Oversight II. Institutional Resources III. Resident/Fellow Learning and Working Environment IV. Institutional GME Policies and Procedures

I. Structure for Educational Oversight One Sponsoring Institution has ultimate authority and responsibility for its ACGME-accredited programs The DIO, in collaboration with GMEC, has authority and responsibility for oversight and administration. The Sponsoring Institution must identify a Governing Body.

Designated Institutional Official

Designated Institutional Official

Designated Institutional Official

Designated Institutional Official ACGME compliance Resident education (e.g., orientation) Program director mentorship GME finance and budget GME Office administration Legal and Human Resources issues Patient safety and quality improvement Well-being

Graduate Medical Education Committee (GMEC) DIO must be a member, but does not have to be the chair Program Director(s) At least 2 peer-selected residents Quality improvement/patient safety officer Other stakeholders in GME

Graduate Medical Education Committee (GMEC) Must meet at least quarterly Must keep detailed minutes that reflect fulfillment of required responsibilities Can have subcommittees Resident representatives GMEC review and approval

GMEC Responsibilities Oversight of program accreditation, learning environments, education, program improvement, and major program decisions Review and approval of policies, procedures, recommendations for resident stipends/benefits, ACGME submissions Annual Institutional Review (AIR) Special Review process

I.B.4.a) GMEC Responsibilities: Oversight Accreditation status of the Sponsoring Institution and each program Quality of learning and working environment with the Sponsoring Institution, each program, and its participating sites Quality of educational experiences in each program that lead to measurable achievement of educational outcomes as identified in the ACGME Common and specialty-/subspecialty-specific Program Requirements Programs’ annual evaluation and improvement activities All process related to reductions and closures of the Sponsoring Institution, programs, and participating sites

I.B.4.b) GMEC Responsibilities: Review and Approval GME policies/procedures Stipends/benefits New program applications Changes in complement Program structure or duration of education Site additions/deletions New Program Directors Progress reports Duty hour exceptions Voluntary withdrawal of accreditation Requests for appeal of adverse action Appeal presentations

I.B.5 Annual Institutional Review (AIR)

I.B.5 Annual Institutional Review (AIR) Continuous quality improvement at the level of the Sponsoring Institution Performance indicators can be anything but must include: Institutional self-study results ACGME Resident/Faculty Survey Program accreditation status

Evidence of AIR Oversight AIR must have monitoring procedures for action plans Monitoring should be documented in the GME minutes Written executive summary of AIR submitted by DIO to governing body each year

I.B.6 Special Review

Effective oversight of underperforming programs I.B.6 Special Review Effective oversight of underperforming programs Special Review Protocol Establishes criteria for underperformance Results in report describing quality improvement goals, corrective actions, process for GMEC monitoring of outcomes

Oversight via Special Review GMEC establishes approved Special Review (SR) protocol GMEC minutes serve as a source that documents: Need for SR based on protocol criteria SR completed, reviewed and approved by GMEC Monitoring of program quality improvement goals/corrective actions

II. Institutional Resources The Institutional Requirements focus on the relationship of the Sponsoring Institution to its programs, as well as to the participating sites where the programs’ residents rotate. The Sponsoring Institution must ensure that resources are available, even in instances when it does not directly provide the resources.

II.A-B Institutional Resources Institutional GME Operations DIO Support/Time DIO Professional Development Institutional GME Administration Ensuring Program Resources Program Director/Faculty Support Faculty Professional Development Program Staff Program Physical Resources and Space

II.C Resident/Fellow Forum

II.C Resident/Fellow Forum Only applies to SIs that will have >1 program Can be an organization, council, town hall, or other forum (electronic) Must be organized so that any resident can directly participate in the forum and does not need to communicate through representatives Must have option to conduct the forum without others present (DIO, faculty members, administration) Must have a mechanism to present forum’s concerns to the DIO and GMEC

III.A Resident Learning and Working Environment The Sponsoring Institution and each of its ACGME-accredited programs must provide a learning and working environment in which residents/fellows have the opportunity to raise concerns and provide feedback without intimidation or retaliation and in a confidential manner as appropriate. Resident and Faculty Survey Complaints/Concerns

III.B Resident Learning and Working Environment SI requirements related to resident experiences with: Patient Safety Quality Improvement Transitions of Care Supervision Work Hours and Fatigue Mitigation Professionalism

IV. Institutional GME Policies and Procedures Resident eligibility Terms and conditions of appointment Available to applicant by time of interview Inclusion in resident agreement/contract Promotion/Renewal/Dismissal Grievances Benefits

IV. Institutional GME Policies and Procedures Work Hours Supervision Various subject-specific policies vendors non-competition disasters closure/reduction

Institutional Requirements: Focused Revision (Proposed) Patient Safety Well-Being Professionalism

Institutional Requirements: The Big Picture Institutional oversight by the Sponsoring Institution: extends to all programs at all participating sites involves clearly defined administrative structure for oversight of the clinical learning environment Oversight is demonstrated through: Deployment of institutional resources DIO/GMEC collaboration Program accreditation outcomes

Common Concerns in Institutional Applications Connections between application questions and Institutional Requirements (Check the margins!) Defining the proposed SI: participating sites, number of programs, resident complements Governing body, senior leadership and reporting relationships within the SI Statement of commitment language/signatures

Common Concerns in Institutional Applications GMEC minutes Attendance records Time range Reflect fulfillment of required responsibilities (not only IR Section I) Resident peer selection process (GMEC and subcommittees) GME program administration elements

Common Concerns in Institutional Applications Resident forum (all required elements in one body) SI oversight extends to all requirements and participating sites

ACGME Accreditation System Use of outcomes in accreditation Annual ACGME review in parallel with annual improvement efforts within Sponsoring Institutions/programs Shift away from administrative process management allows flexibility to innovate

ACGME Accreditation System for Sponsoring Institutions Annual accreditation decisions Use of data to identify Sponsoring Institutions for IRC annual review Self-study and 10-year accreditation site visit (under development) CLER site visits: important for improving clinical learning environments, but unrelated to accreditation

Clinical Learning Environment Review (CLER) Not part of the IRC’s accreditation review process Not applicable to SIs with Pre-Accreditation, Continued Pre- Accreditation or Initial Accreditation statuses Periodic, short-notice site visits of one participating site within the SI Assessment of six focus areas: Patient Safety, Healthcare Quality, Transitions of Care; Supervision; Duty Hours, Fatigue Management and Mitigation (now Well-Being); and Professionalism. Methodology includes meetings with GME stakeholders, Audience- Response System and “Walk Rounds”

Annual Accreditation Decisions Continued Accreditation (Keep on overseeing, improving, innovating!) Continued Accreditation w/ Warning Probationary Accreditation Accreditation Withdrawn

Continued Accreditation Evidence of substantial compliance with Institutional Requirements Continue documentation in ADS Annual Update DIO/GMEC/Sponsoring Institution should continue oversight process Annual Institutional Reviews (AIRs) Special Review Protocol GMEC Minutes Locally defined oversight mechanisms

Continued Accreditation with Warning Not subject to ACGME appeal process In next annual review, IRC could grant Continued Accreditation or Continued Accreditation w/ Warning without site visit Sponsoring Institution should address concerns (and document in ADS Annual Update) before subsequent annual review Document corrective action and monitoring whenever possible: GMEC minutes, Annual Institutional Review, Special Review

Probationary Accreditation Subject to ACGME appeal process Automatic site visit within one year Sponsoring Institution should address concerns (and document in ADS Annual Update) before subsequent annual review Document corrective action and monitoring whenever possible: GMEC minutes, Annual Institutional Review, Special Review

Accreditation Withdrawn Subject to ACGME appeal process Failure to demonstrate: Substantial Compliance with Institutional Requirements Effective GME structure, oversight and/or support

Annual Institutional Review Screening Data Indicators, 2016-17 Sponsoring Institution accreditation status Unresolved complaints Referrals from specialty Review Committees DIO/CEO changes in past year Program Director changes in past year Institution-level 2015–16 Resident Survey results Performance of programs in the aggregate Trends (above indicators repeated from 2015-16)

Annual Institutional Review Data Components for 2016-2017 Sponsoring Institution accreditation status Unresolved complaints Referrals from specialty Review Committees DIO/CEO changes in past year Program Director changes in past year Institution-level 2014–2015 Resident Survey results Performance of programs in the aggregate Trends in all of the above

Annual Institutional Review, 2016-17 629 of 822 Sponsoring Institutions Consent Agenda: 586 (93.2%) Progress Report: 9 (1.4%) Clarifying Information: 16 (2.5%) Site Visit: 18 (2.9%)

Sponsoring Institution 2025 (SI2025) 18-month project commissioned by the ACGME Board of Directors Task: develop a future vision for accredited Sponsoring Institutions 19-member task force including DIOs, CEOs, CMOs, residents, public members Spring/Summer 2016: Data gathering and listening sessions December 2017: Final report and recommendations in JGME supplement

Accreditation, CLER: tools, not ends in themselves SI2025 in Context Accreditation, CLER: tools, not ends in themselves Common Program Requirements: Major Revision Section VI Sections I-V Institutional Requirements: Focused Revision, 2017 Completion of Single Accreditation System, 2020

Take-away Points First things first: structure, leadership and capacity Planning is essential The ACGME Requirements tell you the minimum standards Understanding NAS concepts from the outset will help in the long run Call us

Institutional Accreditation Staff Kevin B. Weiss, MD, MPH Senior Vice President, Institutional Accreditation (312)755-7042 or kweiss@acgme.org Paul Foster Johnson, MFA Executive Director, IRC (312)755-5005 or pjohnson@acgme.org Victoria Shaffer Accreditation Administrator, IRC (312)755-5011 or vshaffer@acgme.org

Thank you! IRC@ACGME.ORG