How to Survive a Self-Study!! Kathy Julian, MD Director for Outcomes and Optimization, GME 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Objectives List the 8 steps of the self-study process. Describe best practices in the self-study process. Describe how completion of the Annual Program Evaluation will assist the self-study process.

9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

ACGME Oversight Self-Study Institutional Reviews As-Needed Site Visits Continuous Accreditation (Annual ADS Update/Surveys) CLER Visits (every 18-24 months) ADS includes Clinical Experience Scholarly Activity Surveys Board Pass Rates Case Logs Survey Changes 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

SELF-STUDY TIMELINE Self-Study Process PDSA Cycles Prepare for Site Visit Notification Self-Study Report Site Visit Month 0 Month 6 Month 18-24

8 Steps to the Self-Study… Assemble the self-study workgroup Identify program aims Complete a SWOT analysis Aggregate and analyze data Obtain stakeholder input Interpret data and aggregate self-study findings Discuss findings with stakeholders Develop succinct self-study document

#1: Assemble the Self-Study Team Program Director Associate Program Directors Core Faculty (choose a few) Chief Residents PEC Members Program Coordinator and Administrators Others? Coordinate with subspecialty programs/core program Schedule all your meetings in advance and be efficient! 10 sixty-minute meetings Other members: education expert, assessment expert, CCC members, coordinate with subspecialty programs Record everything! 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

#2: Program Aims What is our vision and mission statement? What does our program strive to produce? What makes us unique? Who are our residents/fellows? What do we prepare them for? Who are the patients and populations we care for? To what do we aspire? What will take our program to the next level? What does the program strive to produce? How does the program differentiate itself from other programs? Programs will have multiple aims Aims should be measurable Core programs: consider cross-linkages with subspecialty programs 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

A Good Annual Program Evaluation (APE) Will Make The Self-Study Process Easier… Next APE will include program AIMS

#2: Program Aims Programs should have multiple aims Aims should be measurable Consider cross-linking program aims with specialty/core programs

#3: Conduct SWOT Analysis Opportunities-external factors not entirely under the control of the program that, if acted upon, will help the program flourish (ex: partnering with an institution with a simulation center) Threats – external factors threatening the program (ex: cost of living in SF) 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

#3: Conduct SWOT Analysis These answers matter. Should be cohesive review of the program 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

#4: Gathering Data 5 Years Annual Program Evaluations (APE) Program/Learner Evaluations Board Pass Rates Graduate Trajectories ACGME Resident/Fellow Surveys ACGME Faculty Surveys Faculty Teaching Evaluations Graduate Surveys Faculty Retention Resident Demographics (Diversity, Research) 5 Years

#4: Gathering Data--Remember Your APE Should be reviewing all of these as part of robust Annual Program Evaluation Will help you with later self-studies If you’re not reviewing one of these data sources---why not? 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

#5: Get Stakeholder Input Questions Residents/Fellows Faculty Department Leadership Fellowship Directors/Core Director Allied Health Staff (Nursing, Social Work, etc.) Program Administrators Alumni Others? Get feedback on: Program Aims SWOT Analysis Method for feedback Surveys Retreats Meetings KEY: BROAD INPUT Others: community partners, organizations who hire graduates BROAD input is key!!! 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

#6: Interpret Data/Aggregate Findings AGGREGATE DATA 1 CREATE PDSA’S 5 UPDATE AIMS 2 Clarify problems- id self-improvement plans How will you improve weaknesses? How will you take advantage of opportunities? How will you mitigate threats? PDSA’s = What will take this program to the next level? 4 3 Clarify Problems UPDATE SWOT 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

#7: Discussion of Findings with Stakeholders

#7: Discussion of Findings with Stakeholders Questions Will PDSA’s take program “to the next level”? PDSA’s Who? What? Where? When? How? KEY: BE ABLE TO MONITOR IMPROVEMENT Present Updated Aims Present Updated SWOT Present Improvement Plans Get Input on PDSA’s 9/10/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

#6: Aggregate Findings/PDSA’s – Look at Your APE’s

#7: Example

#8: Develop Self-Study Document Complete the ACGME Template Share the Long Form/Short Forms across residency and fellowship programs Process >> Content Review with GME Office 2 weeks before submission Submit in ADS

GET ANSWERS FROM THE EXPERTS!!!