1. 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

2. 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

3. 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

4. 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)

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 Accreditation Decisions Continued AccreditationProbation Accreditation Withdrawn Accreditation Withheld Initial Accreditation Continued Accreditation Accreditation Withdrawn Application

6. 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.

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

8. 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.

9. Notification of RRC Decisions 2-4 days after RRC meeting (informal notification via e-mail) 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.

10. 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.

11. 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

12. 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

13. 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

14. Surgery RRC 2010 Program Status Specialty # of Accredited Programs Full Accreditation Initial Accreditation Probationary Accreditation General Surgery24923757 Vascular Surgery - Independent 10190101 Vascular Surgery - Integrated 242220 Surgical Critical Care9783140 Pediatric Surgery383260 Hand Surgery1100 Totals 510445578

15. Surgery RRC 2010 Program Data SpecialtyTotal # Programs Total # Approved Residents Total # Filled Residents %age of Filled/ Approved General Surgery2498372739589.01% Vascular Surgery - Independent 10126624692.48% Vascular Surgery - Integrated 241204033.33% Surgical Critical Care9721415672.89% Pediatric Surgery38767294.73 Hand Surgery188100% Totals 5109056791787.42%

16. Site Visit Results 2009 Common Citations Evaluation– Residents, Faculty, Program Procedural Experience Duty Hours Surgery RRCVascular Surgery Programs Surveyed12133 Administrative Requests12013 Citations Issued23744 Citations/Program1.911.33 Average Cycle Length3.433.55

17. RRC 2009 Top 10 Citations

18. Vascular Surgery 2009: Top Citations

19. 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.)

20. Tools for Evaluation

21. Evaluation Tools

22. Evaluation Tools (cont)

23. Example Evaluation Tool

24. 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

25. Program Information Form Updates Scholarly Activities Resident Activities Faculty Activities Conferences

26. 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)

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

28. 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 #

29. RRC Surgery Resources www.acgme.org (Review Committee Surgery page) Program requirements PIFs Newsletters

30. 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

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

32. RRC Surgery Staff Contact Information Peggy Simpson, EdD, Executive Director 312.755.5499 psimpson@acgme.orgpsimpson@acgme.org Cathy Ruiz, MA, Senior Accreditation Administrator 312.755.5495 cruiz@acgme.orgcruiz@acgme.org Allean Morrow-Young, Accreditation Assistant 312.755.5038 amh@acgme.orgamh@acgme.org