1. Ready, Set, GO! Power Prep for the ACGME Site Survey!
Shirley Schlessinger, MD
University of Mississippi Medical Center

2. Workshop Overview Optimizing your “PIF-manship”
Day of Reckoning: The visit Itself
Behind the Scenes (ACGME / RRC)
Avoiding the MOST Common Citations
How the GME Office Can Help!

3. Optimizing Your “PIF-manship”
Why it matters
Understanding the rules
Timeline for completion
Attachments and Supporting Documents
Avoiding the most common errors
*****Group Exercise: Common PIF Competency Ideas

4. The PIF is the KEY!
Majority of ultimate citations result directly from information provided in the PIF (others primarily from resident interview, resident survey, and document review)
A well-written PIF can minimize a multitude of sins!
A platform to prepare all survey day participants (best completed as a group effort for optimal buy-in…)
Ideally functions as a self-study to help ID areas of “opportunity”

5. Understand the RULES:
Review your CURRENT program requirements before beginning work on your PIF
All PIF questions track DIRECTLY to a program requirement (common or specialty)
There ARE many PIF questions with RIGHT and WRONG answers!
READ (and follow!) THE DIRECTIONS!!!!!!!! (“one” examples means ONE, “describe” means DESCRIBE)
NEVER send extra attachments or unsolicited information with the PIF
Be CLEAR, CONCISE, & CONSISTENT!

6. Timeline for PIF completion:
Many experts recommend beginning formal writing at the point of Internal Review (response to last citations, etc.)
On-going prep is best (track data, keep files organized, example folders of key requirements, etc.
ALWAYS at least 6-12 months before anticipated review date

7. Timeline Reminders:
Site surveyor must receive PIF and attachments 2 weeks before site visit
DIO must review and sign off before document can be mailed to surveyor
Optimally DIO reviews polished draft 4-6 weeks before survey, recommends changes, and signs final copy 3 weeks before survey date ***
Dept Chair, Chief Residents, Key Faculty should read and edit PIF prior to sending to DIO

8. SO… Anticipated Date of Next Review: 4/2010
Send to Site surveyor: 3/15/2010
Send draft to DIO: 2/15 - 3/1/2010
Draft for CR/key Faculty review: 2/1 – 3/1/2010
Day survey date notice: 12/15/2009
Best you start writing by: 10 – 11/ 2009

9. Getting started: Acgme.org Web-ads sign-in and print out PIF
Part 1 is pre-populated program description; check for accuracy, make changes as needed thru web-ads
Part 2 is questions and narrative specific to your programs
Tackle the PIF in small bites / sections
JUST DO IT!!! (procrastination compromises product!)

10. Common PIF Errors: Unanswered questions / Missing information
Failure to follow directions
Spelling / Grammar / Structure Structure errors
Including unformatted faculty CV’s, manuscripts, etc.!!!!!!
PIF faculty CV’s with publications from the 70’s & 80’s, (last 5 years ONLY!!!)
Pages incorrectly numbered
Inconsistent data
Inaccurate block diagrams
Failure to fully explain unique approached to satisfying requirements
Failure to TELL the TRUTH!!!

11. Common “inconsistencies”:
# residents in ACGME database = number of names on resident list = #of residents listed in PIF
Months / FTE’s at each participating site = number of rotations on block diagram
# of resident evaluations in folders = frequency of resident reviews reported
Institution mentioned in narrative is not referenced elsewhere
Faculty List / Faculty Credentials = faculty CV’s attached
Procedures listed for individual residents = numbers of total program procedures

12. Attachments: May be slightly different for different RRC’s Usually:
Policy for resident supervision
Moonlighting policy
Duty Hours Policy
Competency Assessment Tools
Evaluation tools
Overall Educational Goals for the Program
Sample Goals & Objectives for a rotation
Program Letters of Agreement

13. Supporting Documentation:
Policy for Supervision of residents
Program Policies for duty hours and work environment
Moonlighting policy
Documentation of internal review (DIO provides)
Overall Program Goals
Competency Based Goals & Objectives by rotation and level of trainee
Current Program Letters of Agreement
Files of current residents (sample transfer & problems)
File of recent program graduate (final summative eval, “competent to practice independently”)

14. Supporting Documentation (cont’d):
Evaluations of residents at end of rotation
Examples of completed 360* evaluations
Sample of written semi-annual evaluation by PD
Completed confidential evals of faculty by residents
Completed confidential evals of program by residents
Completed confidential evals of program by faculty
Minutes of annual program evaluations and written improvement plan
Resident duty hour tracking

15. Supporting Documentation (cont’d):
Complete Program Curriculum
Examples of scholarly activity (resident and faculty)
Documentation of program improvement projects
Conference schedules with documentation of attendance
Board Exam Results of graduates
Copies of alumni surveys if done
Trainee handbooks
Any other examples of “special” things you do!

16. Day of Reckoning: The Site Visit
The site visitor
Preparation
Program Director Prep
Program Administrator Prep
Faculty / Chair Prep
RESIDENT PREP
Last Minute Reminders
The Schedule

17. The Site Visitor:
Professional profile of your surveyor available on acgme.org
Confirms and clarifies the PIF (Does NOT make accreditation decision!)
Documents the data and the processes
Writes fair, objective, and accurate report
Does NOT make recommendations regarding accreditation action
Will have a specific structure they wish to follow for the day---ACCOMMODATE them!!!!

18. Survey Day Prep - General
Make sure everyone meeting with the surveyor has read the PIF (and agrees with its content!!!)
Design the day’s schedule as directed by your site surveyor
Communicate any changes or problems directly to your surveyor
Identify and schedule a room for the survey day which can accommodate all interviews
Have three copies of PIF for surveyor
Decide who will hold / answer pagers for participants!

19. Survey Day Prep – PD/PA
Know your Program Requirements inside / out, forwards & backwards!
Know your PIF/ prep your people
Have all supportive documentation, well-organized and optimally ordered by PIF topics
Have interview room neat and stocked with water
Surveyor may also wish to tour lounge and call rooms (make sure they are clean, too!)

20. Survey Day Prep - Residents
Hold peer election in larger programs to select who will meet with the surveyor (Surveyor will tell you how many; usually 10-12)
Provide PIF to residents for review 2-4 weeks prior
Meet with residents 1-2 weeks prior and review anticipated surveyor questions
Make sure they understand how previous citations have been addressed
Make certain ALL “non-compliant” issues in ACGME resident surveys have been addressed, and be sure residents feel efforts have been effective for all remedies

21. Survey Day Prep - Faculty
Select faculty per site surveyor directions
Provide PIF to faculty for review 2-4 weeks prior
Meet with faculty 1-2 weeks prior and review anticipated surveyor questions
Make sure they understand how previous citations have been addressed
Pagers must be OFF (or absent) during the meeting

22. The Typical Schedule PD / PA meeting with review of PIF / Documents
Chair Meeting
DIO Meeting
Key Faculty Meeting
Resident Meeting
Wrap Up meeting with PD

23. Behind the Scenes: ACGME / RRC
Site Surveyor completes a written report- just the facts, designed to verify PIF information, summarize document review, and clarify issues raised in the ACGME resident survey
Surveyor report is forwarded to designated RRC to be added to next open agenda (agendas usually finalized 2 months in advance of actual meeting)
RRC committee members (1-3) are assigned PIF and surveyor report for review & to present at meeting (actual surveyors do not participate)
Committee discusses and determines status and cycle length
notice received within 2 weeks of meeting re status decision and cycle length
Full Letter of Report (LOR) with citations received 8-12 weeks after RRC meeting

24. The Common Problem Areas
Nationally Most Common Citations
UMC Most Common Citations
The Nine Red Flags

25. Most Common Citations:
Duty Hour Violations
Service versus Education Issues
Evaluation problems
Board Pass Rate Citations
Written Curriculum Inadequacies

26. UMC Most Common Citations:
Qualifications and Number of Faculty (14)
Procedural Experience (13)
Patient Care Experience (12)
Institutional Support (10)
Evaluation of Program (9)
Scholarly Activities (9)
Responsibilities of Program Director (9)
Performance on Board Exams (8)

27. Nine “Red Flags” in Accreditation Surveys
From ACGMe-Bulletin February 2008
Barbara Bush, William Robertson, Ingrid Philibert authors
Key issues to AVOID in program & site surveys
These problems most likely to result in adverse accreditation citations

28. Red Flag #1: Lack of Program Leadership
PD and Faculty fail to advocate for residents on important education and patient care issues
Lack of response to issues raised by residents/fellows
Too much reliance on communication and preparation PIF by program coordinator or other staff members
Repeat citations on successive reviews

29. Red Flag #2: Lack of Program Infrastructure for Teaching and Evaluation
Insufficient clinical or didactic curriculum
Insufficient systems for evaluation of residents, faculty or program

30. Red Flag #3: Lack of Appropriate Volume and Variety of Patients
Insufficient volume or balance of patients (diagnoses, clinical problems, acuity and demographics)
Disputes with other disciplines affecting numbers of patients available to the teaching program
Too many residents, fellows, other learners competing for same patient populations

31. Red Flag #4: Problems with Resident Recruitment or Retention
High Resident Turn-over
Unfilled resident positions
Poor record for graduates sitting for and passing board exam (reflects poorer quality applicants / trainees?)
May be due to geography, program or institutional reputation, interest in specialty, etc.

32. Red Flag #5: Lack of Dedicated Teachers
Faculty unwillingness or inability to devote added time required for effective teaching (at the bedside and in operating room, during conferences, rounds, and other didactics)
Problem may present with low numbers of board-certified faculty or not enough key faculty
Too much or too little supervision
Failure to provide meaningful feedback and evaluation
Fellows doing all the teaching

33. Red Flag #6: Lack of Meaningful Didactics
Didactics don’t cover the essential body of knowledge required by RRC (basic science and clinical)
Frequent cancellation of conferences
Lack of sufficient faculty attendance or participation in conferences
Over-reliance on residents or fellows to organize and present at conferences

34. Red Flag #7: Lack of Financial and Human Resources
Inadequate or outdated facilities
Excessive clinical demands on faculty / PD
Excessive clinical demands on faculty including PD
Excessive “services needs” / Residents need to “cover” too many hospitals
Inadequate number of administrative and ancillary staff for size of program
Lack of funding for program

35. Red Flag #8: Service has a Higher Priority than education
Undue reliance on residents to provide service including clinical services that cannot run without the presence of residents
Residents being “pulled” to “cover” services regularly
Duty hour violations affecting a significant percentage of the residents
Residents being required to provide coverage or cross- coverage on inpatient units during their ambulatory, subspecialty, or research rotations.

36. Red Flag #9: Lack of Preparation for the Accreditation Process
On site survey day, a program leader or faculty member who does not understand, argues about the standards, or lacks “buy-in” for the requirements
Poorly prepared PIF
Obvious errors, inconsistencies or failure to follow instructions
Missing documents
PIF that arrives late to site visitor

37. Not Germane to ALL: Too MUCH or too LITTLE Scholarly Activity
(BUT Frequent Area of Citation in many specialty areas)
Too MUCH or too LITTLE
Scholarly Activity
on the part of
Faculty or Residents

38. How the GME Office Can Help!
Many required topics are covered in orientation annually
We provide notification of campus wide activities that offer opportunities to meet program requirements
Evaluation Tools ; Faculty Development Opportunities
Problem Resident / Faculty Intervention
Anonymous Resident Complaint Line
internal reviews/ Annual Survey/ Duty Hours Survey designed to help you maintain compliance and identify problems early
Resident Focus Groups convened as needs identified
PIF REVIEW!!!! (in draft form!)
Mock Surveys on request or consultant visits

39. Keys to Success: Start early
Review and know Program and Institutional Requirements
Correct ALL previous citations
Have on-going program improvement processes
Good communication and preparation with residents and faculty
Convey the strengths and unique attributes of your program clearly to the surveyor!