1. Accreditation Council for Graduate Medical Education © 2015 Accreditation Council for Graduate Medical Education (ACGME) Update from the Internal Medicine (RC-IM) Andrew Dentino, MD, FACP, AGSF, FAPA, FAAHPM University of Oklahoma HSC

2. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Plan for Session Brief review of NAS NAS Y2 Targeted Update New Approach for Self-Study Update on SAS Q&A

3. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Continuous Improvement Y1 Y2 Y3 Y4 Y5 Y6 Y7 Y8 Y9 SELF STUDY ● Annual Data Submission ● Annual ACGME Feedback ● Annual Program Evaluations ● Annual Written Action Plans Y10

4. © 2015 Accreditation Council for Graduate Medical Education Delivers on promise of outcomes-based accreditation Provides annual RRC review to identify “problem programs” and help them improve Changes the workflow of the process of accreditation Site visits only every 10 years (or as needed) Internal Reviews are no longer *required* Annual ADS data entry replaces PIFs “Detail” PRs allow for innovation NAS: Why?

5. © 2015 Accreditation Council for Graduate Medical Education NAS: Innovation + Accreditation IM PRs vs. Common PRs (% Outcome, % Core, % Detail) INNOVATE!!

6. © 2015 Accreditation Council for Graduate Medical Education Some see that NAS allows for experimentation…. e.g., Continuity experience But…there is concern: is it really OK? If programs can demonstrate compliance with Core and Outcome PRs, they will not be asked to demonstrate compliance with Detail PRs. Program must: be in good standing CA (without warning) not have issues with the PR(s) to be innovated around have an educational rationale (noncompliance ≠ innovation) No waiver requests necessary NAS: Innovation & Detail PRs

7. © 2015 Accreditation Council for Graduate Medical Education NAS: Innovation + Accreditation IM PRs vs. Common PRs (% Outcome, % Core, % Detail) INNOVATE!!

8. © 2015 Accreditation Council for Graduate Medical Education (ACGME) NAS: Program* Review Is program on Warning or Probation? NO Does program have NAS citations** ? Do annual data indicate potential issues? Continued Accreditation NO Further Review YES Further Review YES Further Review YES * = applies to established programs (not on Initial Accreditation) ** = citations given after July 1, 2013

9. © 2015 Accreditation Council for Graduate Medical Education (ACGME) NAS Revisited: Primary Data Elements

10. © 2015 Accreditation Council for Graduate Medical Education (ACGME) ADS: Annual Update Update can begin after the ADS rollover (late June), but cannot be submitted until the window is open email will be sent with window open/close dates Core IM Residency: August 4-September 4, 2014 Subspecialty programs: September 8-October 9, 2014 Required Information: Duty Hour/Learning Environment/Evaluation Responses Major Changes Responses to Citations Resident/Faculty Rosters Resident/Faculty Scholarship (for previous year) Sites (and Block Diagram) “Omission of Data” is a data point.

11. © 2015 Accreditation Council for Graduate Medical Education (ACGME) ADS: Scholarly Activity Data entry can begin after the ADS rollover (late June), but update cannot be submitted until the window is open Data entry is for current faculty roster, but for last year’s productivity. 2013-2014 presentations and publications are entered now (during 2014-2015). Definitions for scholarly activity are included in ADS and on a downloadable template General Scholarly Activity FAQs are available in ADS Internal Medicine FAQs are available on the IM page. http://www.acgme.org/acgmeweb/portals/0/pdfs/faq/140_internal_medicine_faqs.pdf

12. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Milestones: (Future) Data Element All IM reported during last reporting window (Nov – early Jan) Not a data element yet… (Cannot be fully used for several years) Important to remember: Will be one aspect of accreditation Initially, ascertain that programs are reporting Next, check for completeness of data Ultimately, patterns or trends will be important

13. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Specific Curriculum EPAs Curricular (“Developmental”) Milestones Reporting Milestones Curricular (“Developmental”) Milestones Milestones: Reporting vs. “Other” X Reporting MilestonesX X X EPAs Specific Curriculum

14. © 2015 Accreditation Council for Graduate Medical Education (ACGME) New language effective 7/1/2015 Broad flexibility for PD to appoint “health professionals” to CCC beyond the minimum 3 faculty Typical IM chief residents (not R3’s) will be allowed No rules on who may attend the CCC meeting, participate in discussion, etc. Program coordinators are not called out specifically in the PRs Milestones: CCC

15. © 2015 Accreditation Council for Graduate Medical Education (ACGME) NEW: CCC Guidebook Milestones: CCC

16. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Obtain feedback, learn what works Boundaries, common elements Especially for the “common” competencies SBP, PBLI, IC, P Subspecialties? Implementation, logistics, resource utilization Validation Emergency medicine example Milestones Version 2 Milestones v1.0: A Work-in-Progress

17. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Reporting Clinical Experience Along with the common ACGME survey items, there are IM specific questions that get at clinical experience They are broad and brief Resident (Core IM) questions include questions about all major subspecialty areas and also “general questions” Fellow questions includes only general questions plus general questions about competency in subspecialty

18. © 2015 Accreditation Council for Graduate Medical Education (ACGME) identify areas of non-compliance are linked to specific requirements require response in ADS are given (and removed) by RRC (not by staff) Citations received in NAS (after July 1, 2013) –will require an RRC member to review annually; –can be given from annual review of data – that is, with or without a site visit Citations received pre-NAS (prior to July 1, 2013) have been either: –systematically removed after two cycles of “clean screens” (no issues identified through data review) –removed or extended following a recent RC review (extended citations are now NAS citations) Citations…

19. © 2015 Accreditation Council for Graduate Medical Education (ACGME) are new in NAS represent “general concerns” may be given (or removed) by RRC or by staff might not be specifically linked to a requirement do not require written response in ADS, but… will be monitored locally will be tracked by RRC will likely be used more frequently than citations Areas for Improvement (AFIs)…

20. © 2015 Accreditation Council for Graduate Medical Education (ACGME) NAS “Intermittent” Site Visits Full Application for a new core program At the end of the initial accreditation period RC identifies broad issues/concerns Serious conditions or situations identified by the RC Focused Potential problems identified during annual review To diagnose reason for deterioration in performance To evaluate complaint Both One month notification Minimal document preparation expected Team of site visitors

21. © 2015 Accreditation Council for Graduate Medical Education (ACGME) NAS Ten-Year Site Visits

22. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Self-Study/10-year Site Visits How described in the past… Scheduled to begin in the late spring of 2015 for IM Departmental – core + subs together Scheduled every 10 years TWO purposes (‘elements’), ONE visit: Self-study element: to assess continuous improvement within department/program; analyze strengths, weaknesses, opportunities and threats Full site visit element: to asses compliance with “core” + “outcome” PRs Elements may have not been clearly stated in the past

23. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Self-Study/10-year Site Visit NEW APPROACH – Feb, 19, 2015

24. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Self-Study/10-year Site Visit NEW APPROACH The two purposes (elements) are now more fully demarcated Programs will be notified that they will need to complete a self study document, and then, 12-18 months later, will undergo a full site visit - now called the 10-year site visit. The time lag between completing the self-study and the 10 year site visit is intentional to give programs time to make improvements

25. © 2015 Accreditation Council for Graduate Medical Education (ACGME) A small number of programs initially informed by RC that their self-study will be between April 2015 and July 2016 are eligible to be in a pilot study: Programs will be asked if they want to volunteer for a self- study site visit after completing the self-study document. Participation in the self-study visit is strictly voluntary Self study visit is not an accreditation visit. Strengths and areas for improvement identified during the visit will not be shared with the RC. If there are subs, they can opt in or out of the visit Field staff with added training will offer feedback on program strengths and areas for improvement, both verbally and in writing. Self-Study/10-year Site Visit Pilot Study

26. © 2015 Accreditation Council for Graduate Medical Education (ACGME) All other programs with tentative self-study/10-year visit dates between April 2015 and July 2016 will receive a 5-7 month delay Will be asked to begin self study document in the month/year RC indicated the self study/10-year visit would take place – date that appears in ADS Punchline: All programs will do a self study and have a 10 year visit 12-18 months later. Self-Study/10-year Site Visit Non-Pilot Study Programs

27. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Accredited Program Continued Accreditation CA w/Warning Site Visit Probationary Accreditation Withdrawal of Accreditation CA w/Warning Continued Accreditation Accreditation Status Schema

28. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Core always receives LON Either after Jan/Feb meeting, or, after May meeting Sub always copied/listed on core’s LON Every Sub is Dependent on Core (or “Parent”) 10 year/self-study involves the entire department Probation for core = “administrative probation” for subs Subs’ annual review data affect core’s review Most subs will not receive individual LONs Sub sometimes receive individual LON Probation for sub, separate letter LON (RC Communication to Program)

29. © 2015 Accreditation Council for Graduate Medical Education (ACGME) To: core PD Cc: sub PDs, DIO Sub 1: Continued Accreditation Sub 2: Probation. Program will receive separate letter : LTR designation Sub 3: Program not reviewed at meeting because it received initial in 2012, and has no/limited NAS data. ** designation The “Departmental LON”

30. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Data Reported – what information programs submit in ADS Data Reviewed – what information RC reviews NAS: Data Reported vs. Data Reviewed

31. © 2015 Accreditation Council for Graduate Medical Education (ACGME) 2014 2014 - 2015 2015 julaugsepoctnovdecjanfebmaraprmayjun Data Review by RC staff RC Meeting 1 ● 2013 2013 - 2014 2014 julaugsepoctnovdecjanfebmaraprmayjun RC Meeting 2 ● 2013-2014 Milestones Reporting 1 2011-2013 ABIM pass rate data (reported by ABIM) ● 2012-2013 Faculty and Resident Scholarly Activity Reporting – updated until ADS Rollover 2013-2014 Faculty/Resident Roster Reporting (Attrition) - updated until ADS Rollover 2013-2014 Resident Survey (including Clinical Experience) 2013-2014 Faculty Survey 2013-2014 Milestones Reporting 2 2014 ADS Rollover ● RC Review RC1 LONs RC2 LONs Site Visits/Clarifying Information SVs/CI RC Review Data Analysis 2014 Annual Update Responses to Citations ■ Major Changes ■ Sites/Block Diagram ■ “Common” Questions ■ Evaluations □ Duty Hours □ Patient Safety □ Learning Environment □ NAS: Data Reported vs. Data Reviewed

32. © 2015 Accreditation Council for Graduate Medical Education (ACGME) 2014 2014 - 2015 2015 julaugsepoctnovdecjanfebmaraprmayjun RC Meeting 1 ● RC Meeting 2 ● RC1 LONs RC2 LONs “Annual Accreditation” reported via the Letter of Notification NAS: Communication of Status Decision Core programs will receive results of RC’s annual review after either the RC’s 1 st or 2 nd meeting This year, either after the Feb or the May meeting Vast majority will receive status decision after 1 st meeting

33. © 2015 Accreditation Council for Graduate Medical Education (ACGME) (Single Accreditation System) ACGME + AOA = SAS

34. © 2015 Accreditation Council for Graduate Medical Education (ACGME) ACGME + AOA = SAS What does this mean for IM? Numbers # of AOA accredited IM programs 129 # of dually accredited IM programs 27 # of AOA accredited IM subs118 # of dually accredited IM subs 2 RC-IM can likely see ~ 100 core applications from AOA Core applications will require a site visit All apps will receive “Pre-Accreditation” upon submission Subs will not be reviewed until core receives Initial Accreditation Subs will not require a site visit Spring 2016 meetings will likely expand by 1 day

35. © 2015 Accreditation Council for Graduate Medical Education (ACGME) MOU provides exceptions of two ACGME CPRs for AOA-approved programs with matriculated residents as of July 1, 2015 that apply for ACGME accreditation: 1)programs can have co-PDs, one certified by a member Board of the ABMS; and, 2)AOA Board certification will be considered acceptable for faculty members Although the MOU allows for co-PD, the RC-IM decided that either ABIM or AOBIM certification is acceptable for an AOA program seeking ACGME accreditation. What does this mean for these AOA programs applying?? No need to identify co-program directors AOA faculty are acceptable ACGME + AOA = SAS Provisions of MOU

36. © 2015 Accreditation Council for Graduate Medical Education (ACGME) ACGME + AOA = SAS Timeline Institutions can start applying April 1, 2015 AOA-approved programs - July 1, 2015 Both will receive ‘Pre-Accreditation Status” –Core will get a site visit before reviewed by RC –Sub will not be reviewed until receives Initial Accreditation AOA Application window closes June 30, 2020 New applications will be treated like any new application No ‘Pre-Accreditation” status AOA ceases accreditation June 30, 2020

37. © 2015 Accreditation Council for Graduate Medical Education (ACGME) New status for any AOA approved programs applying to ACGME AOA approved before July 1, 2015 = get Pre-Accreditation AOA approved after July 1, 2015 = do NOT get Pre-Accreditation Includes institutions Core app can be submitted only if sponsor has Pre-Accreditation, Initial or Continued Accreditation Granted upon receipt of completed application Will not require RC review Status will be acknowledged on ACGME website Not synonymous with Initial Accreditation ACGME + AOA = SAS “Pre-Accreditation”: What?

38. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Biggest + : AOA applications that do not receive Initial Accreditation will not have withhold of accreditation (WH) –Pre-Accreditation remains in effect –No re-application fee – b/c application will not be WH –Pre-Accreditation goes away when receive Initial Accreditation, or application is withdrawn, or, June 30, 2020 Allows use of either 2013 or 2016 eligibility PRs, whichever less restrictive –Not an issue for IM: AOA grads are allowed in subs now under the “75% over 5 years” PR Important to ACGME: program will be in ADS –Will participate in annual update, RS, FS, Milestones ACGME + AOA = SAS “Pre-Accreditation”: Why?

39. © 2015 Accreditation Council for Graduate Medical Education AOA-Approved 7/1/2015 YesNo Matriculated Residents 7/1/2015 Yes13 No23 Can have Pre-Accreditation Status Can have AOA-certified Co-PD AOA-certified faculty systematically “acceptable” 1 +++ 2 +-- 3 --- ACGME + AOA = SAS Applications—Who gets what?

40. © 2015 Accreditation Council for Graduate Medical Education (ACGME) RC-IM will have 3 new members Approved by ACGME Board last month; RC observers in May ACGME Board By 2020, 4 from AACOM and 4 from AOA AACOM and AOA will each seat 2 members in 2015; Then one additional form each in 2018, and again in 2020 Osteopathic Neuromusculoskeletal Medicine RC New RC - Delegated authority for accreditation of Neuromusculoskeletal and Osteopathic Manipulative Medicine residency programs; Eight members Chair will sit on CRC Osteopathic Principles Committee Not an RC. Recognition committee. Responsible for review of the osteopathic principles dimension of programs that seek ongoing Osteopathic Recognition; 17 Members Chair will sit on CRC ACGME + AOA = SAS Changes to ACGME

41. © 2015 Accreditation Council for Graduate Medical Education (ACGME) What could this mean for geriatrics? Currently are 9 AOA-approved Internal Medicine- Geriatric Medicine Fellowships nationally FL (2), IL, MI (2), NJ, NY, PA (2) ACGME + AOA = SAS Changes to ACGME

42. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Currently are 15 AOA-approved Family Medicine- Geriatric Medicine Fellowships nationally CA, FL (2), MI (4), NJ, NY, PA (3), VA, WV (2) ACGME + AOA = SAS Changes to ACGME

43. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Therefore, up to 24 currently AOA-approved Geriatric Medicine Fellowships may possibly apply to join the geriatric fellowship program community CA, FL (4), IL, MI (6), NJ (2), NY (2), PA (5), VA, WV (2) ACGME + AOA = SAS Changes to ACGME

44. © 2015 Accreditation Council for Graduate Medical Education (ACGME) Jerry Vasilias jvasilias@acgme.org 312.755.7477 Karen Lambert kll@acgme.org 312.755.5785 William (billy) Hart whart@acgme.org 312.755.5002 Lauren Johnson lajohnson@acgme.org 312.755.5085 ? ? ? Questions ? ? ?