2008 saaa presentation, anesthesiology rrc update by lois - acgme

AN_AA_11_13_2008AN_AA_11_13_2008

ACGME Anesthesiology ACGME Anesthesiology RRC UpdateRRC UpdateSAAA 2008 Annual Meeting - SAAA 2008 Annual Meeting - 11/2/0811/2/08

Lois L. Bready, M.D.Lois L. Bready, M.D.Anesthesiology RRC ChairAnesthesiology RRC ChairProfessor and Vice Chair, Professor and Vice Chair, AnesthesiologyAnesthesiologyAssociate Dean for GME Associate Dean for GME UTHSC San AntonioUTHSC San Antonio

AN_AA_11_13_2008AN_AA_11_13_2008

What’s New What’s New

Anesthesiology programsAnesthesiology programs– New core PRs - effective 7/1/08New core PRs - effective 7/1/08– Electronic case log – online 7/1/09Electronic case log – online 7/1/09– Progress on phase 3Progress on phase 3– Update on Innovative ProjectsUpdate on Innovative Projects– International rotationsInternational rotations– Common citationsCommon citations– UpdatesUpdates

Fellowship programsFellowship programs

Core 130

ACT 42

Peds 45

CCA 48

PM 94

Total 359

AN_AA_11_13_2008AN_AA_11_13_2008

Executive Committee

SpecialtyReview Committee






















Transitional YearReview Committee




The Complexity of Relationships withinThe Complexity of Relationships withinthe ACGMEthe ACGME

MonitoringCommittee

RequirementsCommittee

(Ad Hoc) AppealsCommittees

Institutional ReviewCommittee

Council of Review Committee Chairs

Policies and Procedures


AccreditationCouncil

(BOD)

AwardsCommittee

CommitteeOn Innovation

ByLaws

Strategic Initiatives

FinanceCommittee

AN_AA_11_13_2008AN_AA_11_13_2008

What’s NewWhat’s New

Update on Update on Core ProgramsCore Programs 7/07-6/087/07-6/08 131 programs, 5266 positions filled131 programs, 5266 positions filled

7/08-6/097/08-6/09 130 programs, 5337 positions filled130 programs, 5337 positions filled

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New Anesthesiology New Anesthesiology Requirements – 7/1/08Requirements – 7/1/08

Increased options for entry into AN Increased options for entry into AN programs:programs:

Integrated CBY (4 year program)Integrated CBY (4 year program) PGY–1 + 3-year programPGY–1 + 3-year program Transfer after 1+ years of GMETransfer after 1+ years of GME

New requirements strictly applied to:New requirements strictly applied to: 7/08 beginning 7/08 beginning PGY1PGY1 residents – residents – yesyes 7/08 beginning 7/08 beginning CA-1CA-1 residents – residents – nono

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Additional ComponentsAdditional Components

All All PGY-1 residentsPGY-1 residents must have: must have: 6 months6 months of of inpatientinpatient care including care including

internal medicine, surgery, pediatrics, internal medicine, surgery, pediatrics, surgical specialties, OB/Gyn, surgical specialties, OB/Gyn, Neurology, Family Medicine or a Neurology, Family Medicine or a combinationcombination

1 -2 months1 -2 months of emergency medicine of emergency medicine and critical care medicineand critical care medicine

May have May have up to 1 monthup to 1 month of of anesthesiologyanesthesiology

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CA-1 – CA-3 YearsCA-1 – CA-3 Years

Minimum of 2, 1-month rotations in peds, Minimum of 2, 1-month rotations in peds, cardiac, neuro, and OB anesthesiacardiac, neuro, and OB anesthesia

4 months of CCM – up to 2 months in 4 months of CCM – up to 2 months in PGY-1; take in at least one month PGY-1; take in at least one month intervalsintervals

3 months of PM – up to 1 month in PGY-1; 3 months of PM – up to 1 month in PGY-1; taken in at least one month intervalstaken in at least one month intervals

1 month of perioperative medicine; taken 1 month of perioperative medicine; taken in at least one week intervalsin at least one week intervals

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Elective ExperiencesElective Experiences

6 mo of elective time6 mo of elective time Can be used to finish all required PGY-1 Can be used to finish all required PGY-1

experiences for residents who transfer experiences for residents who transfer from other specialtiesfrom other specialties

ResearchResearch Advanced anesthesia rotationsAdvanced anesthesia rotations Other activities related broadly to Other activities related broadly to

perioperative medicineperioperative medicine

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Educational ProgramEducational Program

The program must contain:The program must contain:Overall Overall educational goalseducational goals that must be that must be

distributed to residents and faculty distributed to residents and faculty annuallyannually

Competency-based goals and objectivesCompetency-based goals and objectives for for each assignmenteach assignment at at each educational leveleach educational level

Regularly scheduled Regularly scheduled didacticdidactic sessions sessionsDelineation of resident responsibilitiesDelineation of resident responsibilities for for

patient care, progressive responsibility for patient care, progressive responsibility for patient management, and supervision of patient management, and supervision of residents over the continuum of the residents over the continuum of the programprogram

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Residents’ Scholarly Residents’ Scholarly ActivitiesActivities

Curriculum must advance students’ Curriculum must advance students’ knowledge of the basic principles of knowledge of the basic principles of research, including how research is research, including how research is conducted, evaluated, and explained conducted, evaluated, and explained to patients, and applied to patient careto patients, and applied to patient care

Residents should participate in Residents should participate in scholarly activityscholarly activity

Sponsoring institution and program Sponsoring institution and program should allocate adequate educational should allocate adequate educational resources to facilitate residents resources to facilitate residents involvement in scholarly activitiesinvolvement in scholarly activities

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Resident EvaluationResident Evaluation

FormativeFormative – faculty must evaluation resident – faculty must evaluation resident performance in a timely manner during each performance in a timely manner during each rotation or similar educational assignment, and rotation or similar educational assignment, and document this evaluation at completion of each document this evaluation at completion of each assignmentassignment

Program must provide Program must provide objective assessmentsobjective assessments of of competence in patient care, medical knowledge, competence in patient care, medical knowledge, practice-based learning and improvement, practice-based learning and improvement, interpersonal and communion skills, interpersonal and communion skills, professionalism, and system-based practiceprofessionalism, and system-based practice

Use Use multiple evaluatorsmultiple evaluators Document progressive performance and Document progressive performance and

improvement appropriate to education levelimprovement appropriate to education level Document semiannual evaluation of performance Document semiannual evaluation of performance

with with feedbackfeedback

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Summative EvaluationSummative Evaluation

Program Director must provide a summative Program Director must provide a summative evaluation for each resident upon completion evaluation for each resident upon completion of the programof the program

Evaluation must become part of the Evaluation must become part of the resident’s permanent record that is resident’s permanent record that is maintained by the institution; must be maintained by the institution; must be accessible for review by the resident accessible for review by the resident

Must document the resident’s performance Must document the resident’s performance during the final period of educationduring the final period of education

Must verify that the resident has Must verify that the resident has demonstrated demonstrated sufficient competence to enter sufficient competence to enter practice without direct supervisionpractice without direct supervision

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Faculty EvaluationFaculty Evaluation

At least annually, At least annually, the programthe program must must evaluate evaluate faculty performancefaculty performance as it as it relates to the educational programrelates to the educational program

Evaluations should include a review of Evaluations should include a review of clinical teaching abilitiesclinical teaching abilities, , commitment commitment to the educational programto the educational program, , clinical clinical knowledgeknowledge, , professionalismprofessionalism, and , and scholarly activitiesscholarly activities

Must include at least annual written Must include at least annual written confidential evaluations by the confidential evaluations by the residentsresidents

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Program Evaluation & Program Evaluation & ImprovementImprovement

Program must document formal, Program must document formal, systematic evaluation of the systematic evaluation of the curriculumcurriculum annuallyannually

Program must monitor and track:Program must monitor and track:– resident performanceresident performance– faculty developmentfaculty development– graduate performance on certifying graduate performance on certifying

examinationexamination– resident and faculty confidential evaluationsresident and faculty confidential evaluations– use residents’ assessments and other use residents’ assessments and other

evaluations to improve the programevaluations to improve the program

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Resident Duty HoursResident Duty Hours

Program must be committed to and be Program must be committed to and be responsible for promoting patient responsible for promoting patient safety and resident well-being and to safety and resident well-being and to provide a supportive educational provide a supportive educational environmentenvironment

Program learning objectives must not Program learning objectives must not be compromised by excessive reliance be compromised by excessive reliance on resident to fulfill service obligationson resident to fulfill service obligations

Priority for didactic and clinical Priority for didactic and clinical educationeducation

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Electronic case log – online 7/1/09Electronic case log – online 7/1/09– Developed over past year Developed over past year – Aligns with program requirementsAligns with program requirements– Piloted by __ programsPiloted by __ programs– Training resources online early 2009Training resources online early 2009– Will require entry of cases by Will require entry of cases by

residentsresidents

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Outcome Project - Phase 3Outcome Project - Phase 3– Programs are making excellent Programs are making excellent

progressprogress

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What is “experiential What is “experiential learning?”learning?”

learning through reflection on doing, learning through reflection on doing, which is often contrasted with rote or which is often contrasted with rote or didacticdidactic learning learning

focuses on the learning process for the focuses on the learning process for the individualindividual

make discoveries and experiment with make discoveries and experiment with knowledge firsthand, instead of hearing knowledge firsthand, instead of hearing or reading about others' experiences or reading about others' experiences

““experience” – 42 times in core program experience” – 42 times in core program requirements requirements

AN_AA_11_13_2008AN_AA_11_13_2008

What is “experiential What is “experiential learning?”learning?”

IV.A.5.a).(1)(o) IV.A.5.a).(1)(o) (o) Patients who require (o) Patients who require specialized techniques for their perioperative specialized techniques for their perioperative care. There must be significant care. There must be significant experienceexperience with a broad spectrum of airway with a broad spectrum of airway management techniques (e.g., performance management techniques (e.g., performance of fiberoptic intubation and lung isolation of fiberoptic intubation and lung isolation techniques such as double lumen techniques such as double lumen endotracheal tube placement and endotracheal tube placement and endobronchial blockers).endobronchial blockers).

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Innovative ProjectsInnovative Projects

Process has evolved; now governed by ACGME Pol & Proc 6/08

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Innovative ProposalsInnovative Proposals

Proposal ContentProposal ContentThe program director submits the proposal using the ACGME form, The program director submits the proposal using the ACGME form,

“Proposal for Program Experimentation and Innovation” to the Review “Proposal for Program Experimentation and Innovation” to the Review Committee Executive Director. The institution’s and program’s Committee Executive Director. The institution’s and program’s responsibilities are to clearly demonstrate that the project will responsibilities are to clearly demonstrate that the project will improve resident educationimprove resident education and/or and/or patient carepatient care. The proposal must . The proposal must include the following:include the following:a) description of the project,a) description of the project,b) rationale for the project,b) rationale for the project,c) method of evaluation,c) method of evaluation,d) accreditation requirements from which the program/institution will d) accreditation requirements from which the program/institution will

deviate,deviate,e) description of any new, missing or variant on-line submission of e) description of any new, missing or variant on-line submission of

information through the Accreditation Data System (ADS) that information through the Accreditation Data System (ADS) that would require Review Committee approval,would require Review Committee approval,

f) approval by the institutional GME Committeef) approval by the institutional GME Committeeg) signature of the designated institutional official.g) signature of the designated institutional official.

ACGME Pol & Proc 6/08, pp. 103-5

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Approval ProcessApproval Process Institutional (DIO)Institutional (DIO) RRC – Executive Director reviews RRC – Executive Director reviews

– screen for variance to CPRs/Instit Reqs; ACGME judges whether the screen for variance to CPRs/Instit Reqs; ACGME judges whether the proposal justifies granting a variance to the common program and/or proposal justifies granting a variance to the common program and/or institutional requirements.institutional requirements.

– ADS issues? Addressed prior to RRC reviewADS issues? Addressed prior to RRC review RRC reviewRRC review

– Formal review at regular meetings; documentation in program’s Formal review at regular meetings; documentation in program’s historyhistory

– Determine whether request justifies granting approval of the project; Determine whether request justifies granting approval of the project; – stipulate the duration of the approval, which will be no longer than stipulate the duration of the approval, which will be no longer than

the next review;the next review;– inform the program and/or institution of the form of monitoring by inform the program and/or institution of the form of monitoring by

the Review Committee;the Review Committee;– enter information regarding the approved Innovative Projects in the enter information regarding the approved Innovative Projects in the

Accreditation Data System.Accreditation Data System.

ACGME Pol & Proc 6/08, pp. 103-5

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Status Status – 14 proposals received by RRC14 proposals received by RRC

3 denied (design; program/institution status)3 denied (design; program/institution status) 1 currently undergoing ABA review1 currently undergoing ABA review 10 underway 10 underway

Themes to dateThemes to date– Supervisory ratio/transition to practiceSupervisory ratio/transition to practice– eICUeICU– Specialty tracks/combined fellowshipSpecialty tracks/combined fellowship

AN_AA_11_13_2008AN_AA_11_13_2008


International rotationsInternational rotations

ABA and RRC support programs ABA and RRC support programs integrating international rotations integrating international rotations as as standing electivesstanding electives and seek RRC and seek RRC approval rather than seeking ABA approval rather than seeking ABA approval on a case-by-case basis.approval on a case-by-case basis.

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Common CitationsCommon Citations

Core ProgramsCore Programs 7/05-9/08 7/05-9/08 Institutional supportInstitutional support

– Sponsoring Inst’n, PD support, space, call rooms, etc.Sponsoring Inst’n, PD support, space, call rooms, etc. Resident appointment issuesResident appointment issues Program personnel & resourcesProgram personnel & resources

– Qual/responsibilities of PD; of facultyQual/responsibilities of PD; of faculty The Education ProgramThe Education Program

– G&O, curriculum, procedural experience, G&O, curriculum, procedural experience, competencies, progressive responsibility, competencies, progressive responsibility, service/education, scholarly activity, supervision, service/education, scholarly activity, supervision, duty hoursduty hours

Evaluation Evaluation – residents, faculty, program, board scoresresidents, faculty, program, board scores

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Program DirectorProgram Director

Increasing quantity and quality of Increasing quantity and quality of responsibilitiesresponsibilities

RRC expects protected time for PD*RRC expects protected time for PD*– 1 day/week for fellowships, small programs1 day/week for fellowships, small programs– 2 days/week for core programs2 days/week for core programs

RRC discourages Department Chairs RRC discourages Department Chairs from serving simultaneously as Program from serving simultaneously as Program Director for the core anesthesiology Director for the core anesthesiology programprogram

*Anesthesiology RRC website - FAQs

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Other ACGME InformationOther ACGME Information

ACGME Resident SurveyACGME Resident Survey – Any report of duty hours violations Any report of duty hours violations

will be taken VERY seriouslywill be taken VERY seriously

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Fellowship programsFellowship programs– Adult CardiothoracicAdult Cardiothoracic– Pediatric AnesthesiologyPediatric Anesthesiology– Pain MedicinePain Medicine– Critical CareCritical Care

AN_AA_11_13_2008AN_AA_11_13_2008

Adult Cardiothoracic Adult Cardiothoracic AnesthesiologyAnesthesiology

Program Program requirements requirements approved approved 2/14/062/14/06

7/07-6/087/07-6/08 – – 33 programs33 programs88 positions filled88 positions filled


0

20

40

60

80

100

7/07-6/08

7/08-6/09

# progs

# fellows

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Adult Cardiothoracic Adult Cardiothoracic AnesthesiologyAnesthesiology

Clinical CurriculumClinical Curriculum– 1 mo noncardiac thoracic1 mo noncardiac thoracic

Thoracic stents under anesthesiaThoracic stents under anesthesia count (but count (but can’t be all the thoracic cases)can’t be all the thoracic cases)

– 1 mo ICU - adult CT surgery/non-surg1 mo ICU - adult CT surgery/non-surg– 2 mos electives (2 mos electives (min 2 wksmin 2 wks) or 1-2 mos ) or 1-2 mos

research research – Experience with Experience with pediatricpediatric cardiothoracic cardiothoracic

anesthesia is encouragedanesthesia is encouraged– 300 complete perioperative echo exams300 complete perioperative echo exams

at least 150 comprehensive intraoperative TEE at least 150 comprehensive intraoperative TEE examinations performed, interpreted, and examinations performed, interpreted, and reported by the fellowreported by the fellow

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Adult Cardiothoracic AnesthesiaAdult Cardiothoracic Anesthesia 7/05-9/08 7/05-9/08 Institutional supportInstitutional support


– Qual/responsibilities of PD; of facultyQual/responsibilities of PD; of faculty The Education ProgramThe Education Program


Evaluation Evaluation – residents, faculty, programresidents, faculty, program

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Pediatric AnesthesiologyPediatric Anesthesiology

7/07-6/087/07-6/08 – –

45 programs45 programs

162 positions filled162 positions filled

7/08-6/097/08-6/09 – –



0

50

100

150

200

7/07-6/08

7/08-6/09

# progs

# fellows

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Pediatric AnesthesiaPediatric Anesthesia 7/05-9/08 7/05-9/08 Institutional supportInstitutional support


– Responsibilities of PD; of facultyResponsibilities of PD; of faculty The Education ProgramThe Education Program



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Critical Care AnesthesiologyCritical Care Anesthesiology

7/07-6/087/07-6/08 – –



7/08-6/097/08-6/09 – –



0

20

40

60

80

100

7/07-6/08

7/08-6/09

# progs

# fellows

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Critical Care AnesthesiologyCritical Care Anesthesiology

Proposed new program requirementsProposed new program requirements Proposed revision 2007-8Proposed revision 2007-8 Undergoing review by ACGME Undergoing review by ACGME

Requirements Development CommitteeRequirements Development Committee Then, to be Then, to be posted for formal commentposted for formal comment Final approval expected 6/09Final approval expected 6/09 Formal rotations in pediatrics are not Formal rotations in pediatrics are not

required, but there should be education required, but there should be education about differences in approach to the about differences in approach to the critically ill adult vs. pediatric patient.critically ill adult vs. pediatric patient.

AN_AA_11_13_2008AN_AA_11_13_2008


Critical Care Critical Care 7/05-9/087/05-9/08 Institutional supportInstitutional support

– Sponsoring Inst’n, PD support, spaceSponsoring Inst’n, PD support, space Resident appointment issuesResident appointment issues Program personnel & resourcesProgram personnel & resources

– Responsibilities of PD; of faculty, resourcesResponsibilities of PD; of faculty, resources The Education ProgramThe Education Program

– G&O, curriculum, procedural experience, G&O, curriculum, procedural experience, competencies, progressive responsibility, scholarly competencies, progressive responsibility, scholarly activity, supervision, duty hoursactivity, supervision, duty hours


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Pain MedicinePain Medicine

Multidisciplinary PRs in Multidisciplinary PRs in effect effect 7/1/077/1/07



0

100

200

300

400

7/07-6/08

7/08-6/09

# progs

# fellows

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Initial Experience - Initial Experience - New Pain Program New Pain Program Requirements Requirements

Multidisciplinary Program Requirements Multidisciplinary Program Requirements 7/1/077/1/07

Anesth, Neurology, PM&R, Psychiatry Anesth, Neurology, PM&R, Psychiatry Significant challenge to incorporate all Significant challenge to incorporate all

required experiences in 12 month programrequired experiences in 12 month program Pain Advisory Committee – conducts Pain Advisory Committee – conducts

prescreenprescreen Reviews to date = significant challenges for Reviews to date = significant challenges for

some programssome programs

AN_AA_11_13_2008AN_AA_11_13_2008


Pain Medicine Pain Medicine 7/05-9/087/05-9/08 Institutional supportInstitutional support

– Sponsoring Inst’n, PD support, participating inst’n, Sponsoring Inst’n, PD support, participating inst’n, spacespace

Resident appointment issuesResident appointment issues Program personnel & resourcesProgram personnel & resources

– Responsibilities of PD; of faculty, resourcesResponsibilities of PD; of faculty, resources The Education ProgramThe Education Program



AN_AA_11_13_2008AN_AA_11_13_2008

Recommendations to avoid Recommendations to avoid citations citations

Low hanging fruit (Low hanging fruit (avoiding common avoiding common citationscitations))

Conduct annual program review & create Conduct annual program review & create written action planwritten action plan

Evaluations - residents (360*), faculty, programEvaluations - residents (360*), faculty, program Internal review - midpoint of accreditation cycleInternal review - midpoint of accreditation cycle Program letters of agreementProgram letters of agreement G&O and outcome measures – by rotation and G&O and outcome measures – by rotation and

by training levelby training level Competency-based languageCompetency-based language Education – sleep and fatigue – faculty, too!Education – sleep and fatigue – faculty, too!

AN_AA_11_13_2008AN_AA_11_13_2008

Learning Portfolio ProgramLearning Portfolio Program

Individual learning plans, self-reflection, Individual learning plans, self-reflection, tracking tracking

ACGME pilot programACGME pilot program Electronic portfoliosElectronic portfolios Hardcopy portfoliosHardcopy portfolios

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Further SuggestionsFurther Suggestions

Bookmark Anesthesiology RRC site (Bookmark Anesthesiology RRC site (www.acgme.orgwww.acgme.org))

Update and save on your desktop:Update and save on your desktop:– Program requirementsProgram requirements– Program information form (PIF)Program information form (PIF)– Other items useful to your programOther items useful to your program

Contacts for questions/suggestionsContacts for questions/suggestions– Core programs - Missy Fleming PhD (Core programs - Missy Fleming PhD (

[email protected]@acgme.org) ) – Subspecialties - Linda Thorsen (Subspecialties - Linda Thorsen (

[email protected]@acgme.org))

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What else?What else?

Your questions …Your questions …

Thank you!Thank you!

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Theoretical Competency Report Card Theoretical Competency Report Card Summary, Program XSummary, Program XAll Residents, All LevelsAll Residents, All Levels

0

10

20

30

40

50

60

70

80

90

100P-1

P-2P-3

P-4

P-5

P-6

PTC-1

PTC-2

PTC-3

PTC-4

PTC-5

PTC-6

C-1

C-2

C-3

C-4C-5

C-6MK-1

MK-2MK-3

MK-4

MK-5

MK-6

PBLI-1

PBLI-2

PBLI-3

PBLI-4

PBLI-5

PBLI-6

SBP-1

SBP-2

SBP-3

SBP-4SBP-5

SBP-6

National % at orabove milestone

ProfessionalismProfessionalism

Patient CarePatient Care

CommunicationsCommunicationsMedical Medical KnowledgeKnowledge

Systems BasedSystems BasedPracticePractice

PracticePracticeBasedBasedLearningLearningAnd And ImprovementImprovement

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0

10

20

30

40

50

60

70

80

90

100P-1

P-2P-3

P-4

P-5

P-6

PTC-1

PTC-2

PTC-3

PTC-4

PTC-5

PTC-6

C-1

C-2

C-3

C-4C-5

C-6MK-1

MK-2MK-3

MK-4

MK-5

MK-6

PBLI-1

PBLI-2

PBLI-3

PBLI-4

PBLI-5

PBLI-6

SBP-1

SBP-2

SBP-3

SBP-4SBP-5

SBP-6

National % at orabove milestone

2 SD or more belowNational Mean %






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0

10

20

30

40

50

60

70

80

90

100P-1

P-2P-3

P-4

P-5

P-6

PTC-1

PTC-2

PTC-3

PTC-4

PTC-5

PTC-6

C-1

C-2

C-3

C-4C-5

C-6MK-1

MK-2MK-3

MK-4

MK-5

MK-6

PBLI-1

PBLI-2

PBLI-3

PBLI-4

PBLI-5

PBLI-6

SBP-1

SBP-2

SBP-3

SBP-4SBP-5

SBP-6

Program % at orabove milestone

National % at orabove milestone2 SD or more belowNational Mean %






AN_AA_11_13_2008AN_AA_11_13_2008

2008 saaa presentation, anesthesiology rrc update by lois - acgme

Health & Medicine

month rotations

residents residents

month intervals1

month intervalstaken

months of pm

months of ccm

core programscore programs

positions filled131