ACGME Accreditation Preparing for a Site Visit by Peggy Mauer, MEd Jobst Vascular Center, Toledo, Ohio

Preparing for RRC Site Visits or Internal Reviews

START EARLY! l Not a surprise l Decision letter for the last site visit, and the ACGME Web site, give the length of accreditation l Approximate date of next site visit is available – contact the RRC and ask. This does NOT speed up the process

Check the ACGME Web Site

Check the ACGME Web Site

Locate the files l You want me to find what where? from the previous site visit!

Previous Site Visit Documents l Locating the previous site visit documents is extremely important. Especially if you are new to your role. l Even if you have gone through a site visit previously – DO YOU KNOW WHERE YOUR FILES ARE STORED? Both electronic and hard copies

Any previous problems? l Review your programs history of problems or citations l Review your programs last 2 internal reviews l Review any interim correspondence with ACGME l Maintain a problem list

Internal Review l Should be half way between site visits l Must be initiated by GME office Reviewers must be from outside department l Gives early notice if improvements are needed Enough in advance for time to address issues l Checks to see if prior problems have been resolved

Internal Review l Summary of the internal review Should provide guidance about what needs to be done to improve program Should be read by both Program Director and Program Coordinator NOTE: Site visitor can ask anyone about summary, but most do not ask to see it (not supposed to)

Follow all the rules, including l Yearly or periodic review of Program by faculty with resident representation Evaluation of educational effectiveness of program l Yearly evaluations of program by residents

Work with program director l Be part of a Team Decide (with director) which things can be done by the two of you need help from others, such as section chiefs, associate program directors ØYoure the Coordinator; you coordinate the accreditation paperwork.

Assemble a Team l Get key players in your dept. involved early in the preparation process l Analyze the programs strengths and weaknesses l Start lists of things to be done l Choose leaders carefully

Recruit 4 or 5 Helpers l Assemble 4 or 5 individuals to write or rewrite different sections of the PIF and review evidence supporting different requirements l Circulate the final PIF to key members of the education team

Review the Curriculum & Rotations l Review past resident evaluations of the rotation l Examine yearly reviews of the program by representative group and the issues identified l Were the issues resolved?

Begin work on forms early l Start a year in advance l Review application from the last site visit Some things dont change (number of rooms, where faculty graduated from medical school, etc.) Same format might be used – if not available in WebADS Helpful example

Helpful resource l Application Forms (PIF) downloadable from web site

Helpful resource l Application Forms (PIF) downloadable from web site l Web ADS – downloadable PIF partially pre-filled Institution and Hospital listing Resident and Faculty listing Procedures (already available for some specialties) PIF Competency & Assessment Form

Essentials of Accredited Residencies in Graduate Medical Education Program Requirements can be l Found on the Internet ( l Found in Graduate Medical Education Directory (Green Book) l Faxed to you by ACGME (when requested) l They do change, so check back periodically Latest change for Pediatrics is July 2003 Latest change for Vascular Surgery was July 2006

Download PIF Application Forms

When downloading PIF Application Forms l Use appropriate form (New program or Continuing accreditation) l Keep pagination the same l Dont go over 11 pt. Font l Answers should fit in space provided l Do not leave blanks Instead, use Not applicable

Completing the PIF l Use clear and brief answers l Comprehensive accurate answers l Correct answers to questions (use program requirements when necessary) l Watch vocabulary l Define abbreviations

Keep a Positive Impression of Your Program l Consistent tone and style l Use must instead of should l Be positive and assertive

Paperwork needed Evidence of substantial compliance with l Procedures and criteria l Equipment l Facilities

Paperwork needed ( contd.) Evidence of substantial compliance with l Staff l Required resident activities (logs, etc.) l Competencies – not optional l Resident duty hours – not optional

Faculty (Full & Part Time) l Number of Faculty & Residents l Biographical sketch forms completed on Faculty (both Full- and Part-Time) Residents l If Web ADS is kept current for your program, this can be downloaded from

Curriculum l Rotation schedules l Conference schedules l Lecture schedules l Research activities and requirements

Letters of Agreement l Affiliation Agreements l Sponsoring Institution Any Affiliated Hospitals

Letters of Agreement l See Institutional Requirements, Program Requirements, and consult with central GME office (DIO) – concerning wording about malpractice and reimbursement

Institutional Requirements A. The agreements should a.identify the faculty who will assume both educational and supervisory responsibilities for residents; b.specify their responsibilities for teaching, supervision, and formal evaluation of residents, as specified later in this document; c.specify the duration and content of the educational experience; and d.state the policies and procedures that will govern resident education during the assignment. l From COMMON PROGRAM REQUIREMENTS, ACGME Web site, February 2003 Effective: July 1, 2004 Editorial Revision: February 2004

Signatures on Application Form l DIO of Parent Institution l Chairman of Department l Program Director (s)

Use the time effectively l You will need all of the time site visits occur any time of the year –during l applicant interview season l National meeting l Match Week l Graduation l Orientation

Think Project Management l Begin work prior to formal notice of site visit 3 months prior to visit as a minimum l Best preparation is ongoing documentation of adherence to Institutional and RRC requirements

Work backward from mailing date l Final version to mail to site visitor at least 14 days prior to site visit l Allow ample time for unexpected delay no matter how much time is given, youll somehow need it all

Request curriculum vitae from faculty early l Ask for them on disk! (or by ) Minimizes errors Saves retyping Saves file space Saves paper

Request information early about l Equipment l Numbers of cases l Procedures l Facilities l Collect needed statistical reports monthly or quarterly, to be sure to have them

Who would have the information: l Administrator l Clinic & Nursing personnel l Librarian l Medical Records l Billing Department l GME Office

Request copies of agreement letters early l Consult your DIO and work with GME office on format for letters l Make sure people who signed letters previously are still there.

Keep a file l Date stamp all drafts (except final) Use date on electronic document name l Locate copies of schedules teaching conferences, lecture schedules, rotation schedules (planned & actual) l Check ahead that people who need to sign will be there (not out of town - or country!)

Have checklist of requested information l Received, not yet received l Tracks completeness of application l Provides early warning of missing information

Follow up with gentle reminders l Be gracious Remember, these people are doing You a favor

Enter information l Enter in final form as soon as it is received It doesnt get stale Its already done

Type early -- avoid the rush

Common PIF Errors l Incorrect program name l Omission of program number l Missing signatures l Missing letters of agreement l Missing Competencies Addendum l Information omitted – questions unanswered

Common PIF Errors l Inconsistent data l Common rotations not indicated on block diagram for programs with multiple tracks l Incorrect pagination l Extraneous information that was not requested

Check for Consistency l Number of residents in program match list of names of residents in the Web ADS l Number of full-time teaching faculty activity with number of months in block diagram l Number of months residents spend in a specific rotation with number of months on block diagram l Run spell check for the word will

Make copies l But wait until the last draft Saves confusion, time and paper

Save final draft -- for next time! l File in a safe place l If on computer, keep disks

When mailing to Site Visitor l Things not to do – Do not include anything not asked for Do not include oversized or reprinted materials Do not send in a 3-ring binder or perfectly bound Do not send in a fancy folder

When mailing to Site Visitor l Things to do Keep everything 8 ½ x 11 inches Bind with heavy duty rubber bands Make 1 sided copies

Information for Site Visitor l Send good map to hospital and written directions l Send hotel and restaurant recommendations l Ask if they have any dietary restrictions l Arrange VP parking space if needed l Offer to meet him/her at front desk

The VISIT l Dress Rehearsal l Actual Visit

Dress Rehearsal l Meet with those who will see site visitor Make sure all are informed about the department Give them copies of PIF (or relevant sections) l Schedule a conference or class room for Visit Day (ask early!) l Make sure key people know the contents of the last internal review summary

The Site Visitor Might Be l ACGME Field Representative (97% of the time) l Specialist in your discipline(3% of the time) l Eyes and Ears of the RRC

The Site Visitor l Unbiased observer l Verifies information provided by program director in the PIF l Conducts interviews with administrators, faculty, residents

The Site Visitor l Reports what was said in meetings with faculty, residents, and program administrator l Files a written report describing errors or oversights with the PIF and what they were told or saw during the visit l Does not participate in final decision or recommendation of review committee

Getting Ready for Company l Organize and schedule the site visit day as completely as possible l The program director should Contact site visitor as soon as you know their name. Ask ahead what arrangements they would like made; who they want to meet, if they want lunch provided or time off for lunch (include maps, parking passes, etc.) l Check and re-check that key people will be available

Site Visit Day!! l Make sure all are alerted to the fact that it is the site visit day l Cancel all patient care activities for the PD l Coordinator should be available all day in case additional information is needed for the site visitor l Attend details of the site visitor

Site Visit Day l Make an office or suitable space available l Coordinator should monitor how the day is flowing and let people know if schedule changes

It all comes down to organization l All pertinent documents available at your finger tips l Have someone take you through your documents l Dont get flustered – you know you have everything

Site Visit Day Samples of Resident files Copies of schedules, attendance tracking method, etc. Written policies and procedures Committee meeting minutes

Site Visit Day l Tip: Keep a log who the site visitor met with what they saw (where they toured) what they were told

At end of Day – debrief l Meet with program director Go over what went right or wrong Areas for change Thats what I should have said... Ask for help (if things did not go well)

Evaluate l Complete site visit evaluation survey

Results l Notification of results ed to Program Director, Chairman, Sponsoring Institution l Accreditation letters posted in ADS Swww.acgme.orgwww.acgme.org l Within 1 month following RRC Committee Mtg (meets quarterly) that reviews the site visit report l Time frame: about months from initiation

Citations or Recommendations l Can be effective tools to bring about change l Must not be ignored

After the RRC Letter l Celebrate your success l Have a party Thank all those who contributed