Accreditation Council for Graduate Medical Education Residency Review Committee Update APDVS and Residency Coordinators Meeting Chicago, IL April 16, 2010 Peggy Simpson, EdD Executive Director Residency Review Committees for Surgery

RRC—Surgery Members Thomas V. Whalen, MD, Chair J. Patrick O’Leary, MD, Vice Chair Adeline Deladisma, MD, Resident Timothy R. Billiar, MD G. Patrick Clagett, MD Peter J. Fabri, MD Linda M. Harris, MD George W. Holcomb, MD James C. Hebert, MD Mark A. Malangoni, MD Marshall V. Schwartz, MD Charles W. Van Way III, MD Marc K. Wallack, MD Frank Lewis, MD, Ex- Officio ABS Patrice Blair, MPH, Ex- Officio ACS

Compliance Assessed by Residency Review Committee (Specialty Committee) Types of Accreditation Standards Specialty-Specific Program Requirements Common Program Requirements Compliance Assessed by Institutional Review Committee Institutional Requirements

Navigating the Requirements* 1.Must: A term used to identify a requirement which is mandatory or done without fail. This term indicates an absolute requirement. 2.Shall: (See must) 3.Should: Term used to designate requirements so important that their absence must be justified. A program or institution may be cited for failing to comply with a requirement that includes the term ‘should’. *From ACGME “Glossary of Terms” (acgme.org)

Accreditation Decisions Continued AccreditationProbation Accreditation Withdrawn Accreditation Withheld Initial Accreditation Continued Accreditation Accreditation Withdrawn Application

Defer RRC needs clarification of major issues Accreditation decision remains “open” Result: Additional information will be requested. RRC will consider request after information has been received.

Progress Reports RRC needs a response to major concerns Report must be: Responsive Reviewed/signed by the institution’s DIO Sent only when requested

Progress Reports: Reasons to Request RRC seeks improvement/attention to an issue and believes site visit is not necessary to bring issue to a state of compliance with program requirements. RRC sees an issue has reoccurred over time and believes progress report will focus program and institutional attention on the issue.

Notification of RRC Decisions 2-4 days after RRC meeting (informal notification via ) 60 days after RRC meeting (formal Letter of Notification (LON) posted) LONS are available only through ADS Notifications sent to PD and DIO of record.

Preparing for your Site Visit Start Early Ensure Annual Update is accurate Faculty Information Resident Information Participating Site Information When in doubt, let us know.

Resident Duty Hours 80 hour limit - averaged over 4 weeks, includes in- house call 1.One day our of seven free 2.In-house call no more than 1 day in 3 averaged over 4 weeks 3.24-hour duty maximum 4.Provide at least 10 hours for rest between duty periods 5.In-house moonlighting counts

Monitoring Duty Hour Compliance Non-compliant Programs Identified through: Program Self-reports Resident Questionnaire Resident Complaints Actions taken by RRCs: Additional Monitoring (change in Site Visit date) Requests for Progress Reports Shortened Accreditation Cycle

Resident Complements Temporary or Permanent?? Changes to Resident Complements To request change to total number To request change to number at a PGY level Any reallocation must be approved by RRC prior to implementation

Surgery RRC 2010 Program Status Specialty # of Accredited Programs Full Accreditation Initial Accreditation Probationary Accreditation General Surgery Vascular Surgery - Independent Vascular Surgery - Integrated Surgical Critical Care Pediatric Surgery Hand Surgery1100 Totals

Surgery RRC 2010 Program Data SpecialtyTotal # Programs Total # Approved Residents Total # Filled Residents %age of Filled/ Approved General Surgery % Vascular Surgery - Independent % Vascular Surgery - Integrated % Surgical Critical Care % Pediatric Surgery Hand Surgery188100% Totals %

Site Visit Results 2009 Common Citations Evaluation– Residents, Faculty, Program Procedural Experience Duty Hours Surgery RRCVascular Surgery Programs Surveyed12133 Administrative Requests12013 Citations Issued23744 Citations/Program Average Cycle Length

RRC 2009 Top 10 Citations

Vascular Surgery 2009: Top Citations

Evaluation and the Competencies 1. Educational G&Os 2. Clinical & Didactic Experiences 4. Assess Outcomes— analyze evaluation results; refine G&Os, take additional actions; add improvements 3. Evaluation Activities (observer, 360, self, etc.)

Tools for Evaluation

Evaluation Tools

Evaluation Tools (cont)

Example Evaluation Tool

Agenda Closing Dates Meeting: June 24-25, 2010 Agenda Closing: April 15, 2010 Meeting: October 28-29, 2010 Agenda Closing: August 19, 2010 Meeting: February 24-25, 2011 Agenda Closing: December 16, 2011 Meeting: June 23-24, 2011 Agenda Closing: April 14, 2011

Program Information Form Updates Scholarly Activities Resident Activities Faculty Activities Conferences

PIF Updates (cont.) R ESIDENT P UBLICATIONS abstracts/publications presentations (local, regional, national) grand rounds basic science multidisciplinary institutional educational conferences dedicated research experience (protected time) teaching awards teaching skills lab session formal medical student teaching (i.e. anatomy courses, scientific and/or clinical lectures)

PIF Updates (cont.) F ACULTY I NFORMATION Basic Science Research Educational Research (includes development of teaching materials) Faculty Name Project Name Funded Not Funded

PIF Updates (cont.) C ONFERENCES Basic and Clinical Sciences Grand Rounds Morbidity and Mortality Conferences Multidisciplinary (e.g., pediatric radiology, surgical pathology and tumor conferences) Faculty/Resident Name Title of Presentation Frequency Sessions Presented (Y/N) Sessions Directed (Y/N) Site #

RRC Surgery Resources (Review Committee Surgery page) Program requirements PIFs Newsletters

When to Contact ACGME via ADS Progress Report requested Upcoming changes in program - All requests must be made through ADS Notify change in Program Director and/or PD contact information Request any change resident complement Request participating site changes (add or delete) Request changes to approved rotations Response to Citations Annual Updates

When to Contact Staff Any time you need clarification and/or consultation Any time major changes are occurring Change in sponsorship/ownership

RRC Surgery Staff Contact Information Peggy Simpson, EdD, Executive Director Cathy Ruiz, MA, Senior Accreditation Administrator Allean Morrow-Young, Accreditation Assistant