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ACGME AccreditationACGME Accreditation

New Program Coordinator RetreatNew Program Coordinator RetreatOctober 3, 2011October 3, 2011

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GoalsGoals

Accreditation cycle: overview Office files: managing paperwork Annual accreditation to-dos ACGME rules and program specifics ADS to-dos Program changes Accreditation cycle: details Computer files Resources

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Accreditation Cycle: Accreditation Cycle: MultiMulti--year Spanyear Span

Site VisitSite Visit PIF Preparation

InternalReview

Accreditation Letter in ADS

Program Responseto the RRC

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Internal vs. ExternalInternal vs. External

Internal [check] GMEC & IRC Internal Review (IR) Program Director

Questionnaire (PDQ) Internal Review Report –

recommendations Program Response to IRC

External [test] RRC Site Visit (SV) Program Information

Form (PIF) Accreditation Letter –

citations Program Response to RRC

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Office FilesOffice Files

Trainee Files (contracts!)Trainee Files (contracts!) Evaluations (final evaluations!)Evaluations (final evaluations!) Annual Program Review (documentation!)Annual Program Review (documentation!) Affiliation AgreementsAffiliation Agreements Duty HoursDuty Hours Procedure and/or Case LogsProcedure and/or Case Logs

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Annual Accreditation IssuesAnnual Accreditation IssuesPlace on your CalendarPlace on your Calendar

Trainee Eligibility Requirements USMLE policy Contracts

Program Letters of Agreement Summative Evaluations Annual Program Review meeting and

documentation

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What are the Rules?What are the Rules?

RRC Requirements

Specialty PIF

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Program Requirements & Common Program Program Requirements & Common Program RequirementsRequirements

Scope and duration of training Participating sites Trainee eligibility criteria ACGME competencies Scholarly activities Trainee formative evaluation Trainee summative evaluation Faculty evaluation Program evaluation & improvement And many more…

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ADS LoginADS Login

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““Update Program InfoUpdate Program Info””Program Accreditation PageProgram Accreditation Page

View Program informationView Program information DIO, PD, Department Chair, CoordinatorDIO, PD, Department Chair, Coordinator Dates: original accreditation, accreditation effective Dates: original accreditation, accreditation effective

date, last site visit date, next site visit datedate, last site visit date, next site visit date Length of training, number of years of prior or Length of training, number of years of prior or

additional GME training, additional research yearsadditional GME training, additional research years Approved trainee complement & filled positionsApproved trainee complement & filled positions Participating sites & purpose of experienceParticipating sites & purpose of experience Resident rosterResident roster

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Annual ADS toAnnual ADS to--dosdos

Annual Update (JulyAnnual Update (July--August)August) ““Update Program InformationUpdate Program Information”” ““Update Resident InformationUpdate Resident Information””

If your trainees start training offIf your trainees start training off--cycle, you may need to cycle, you may need to update this information throughout the yearupdate this information throughout the year

Resident Survey (JanuaryResident Survey (January--June)June)

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““Update Program InfoUpdate Program Info”” contcont’’dd……

View program information

Update contact information Program Director Program Coordinator

Add/delete participating sites after GMEC approval

Update faculty/CVs

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““Update Resident InfoUpdate Resident Info””

Also make sure to enter accurate DOB

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““Resident/Fellow SurveyResident/Fellow Survey””

• Quality Assurance Checkpoint• Resource for PIF Preparation

• Aggregate Report• National Data

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Program ChangesProgram Changes

GMEC reviews and approves prior to submission to the RRC/ACGME:

all applications for new programs and subspecialties (PEC: including NON-ACGME) applications for new accreditation (PEC) changes in resident complement (BWHEC/ECOTE; PEC, if hospital funding is sought) major changes in program structure or length of training (BWHEC/ECOTE) additions or deletions of participating institutions used in a program (BWHEC/ECOTE) appointment of new program director (BWHEC/ECOTE) progress reports requested by any Review Committee (BWHEC/ECOTE) requests for increases or any change in resident duty hours (BWHEC/ECOTE) requests for "inactive status" or to reactivate a program (BWHEC/ECOTE) voluntary withdrawals of ACGME-accredited programs (BWHEC/ECOTE) responses to all proposed adverse actions (BWHEC/ECOTE) requests for an appeal of an adverse action (BWHEC/ECOTE) appeal presentations to a Board of Appeal or the ACGME (BWHEC/ECOTE)

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In ADS: In ADS: ““Request ChangesRequest Changes””

GMEC approval must be obtained prior to submitting any program changes to the RRC

Documents must be submitted at least 3 weeks before the GMEC meeting

GMEC staff BWH – Irina Knyshevski MGH – Georgi Bland

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Accreditation Cycle: detailsAccreditation Cycle: details

Where in the accreditation cycle Where in the accreditation cycle are you?are you?

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Accreditation Cycle: Accreditation Cycle: MultiMulti--year Spanyear Span

Site VisitSite Visit PIF Preparation

InternalReview

Accreditation Letter in ADS

Program Responseto the RRC

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““PIF PreparationPIF Preparation””

Common PIF Print/Preview PIF Specialty Specific PIF PIF must be submitted to the GME Office

2 weeks prior to mailing to the site visitor

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Faculty RosterFaculty Roster

Allows you to copy faculty details and CVs from other programs within the

Sponsoring Institution

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““Site Visit ResultsSite Visit Results””

Notification Letters Respond to Citations

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6 months before an RRC site visit6 months before an RRC site visit

Review: ACGME Resident Survey Annual program review Internal Review and your response to the recommendations Accreditation letter with citations and your response to the RRC

Determine your weak points

Do any of your action plans need to be re-evaluated?

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6 months before an Internal Review6 months before an Internal Review

Review: Curriculum; goals and objectives ACGME Resident Survey Annual program review Internal Review and your response to the recommendations Accreditation letter with citations and your response to the RRC

Do any of your RRC citations and Internal Review recommendations still need to be addressed?

Do any of your action plans need to be re-evaluated?

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Computer FilesComputer Files

Accreditation Folder Prior Program Information Form (PIF) Accreditation Letter RRC Correspondence Program Response to the RRC Internal Reviews Program Response to Internal Reviews ACGME Resident Surveys Minutes from the Annual Program Review Resources: Program Requirements, Common Program

Requirements, ACGME Newsletters, etc.

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RESOURCESRESOURCES

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ACGME Resources: ACGME Resources: ““Tools/ReferenceTools/Reference””

ADS Video Tutorials Duty Hours FAQ Competency/Assessment Glossary Optional Resident Upload Instructions

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GME Resources on the WebsiteGME Resources on the Website

Site Visit Preparation documentsSite Visit Preparation documents Responding to the RRC Responding to the RRC Affiliation Agreement formsAffiliation Agreement forms Trainee ContractsTrainee Contracts PoliciesPolicies

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Other GME ResourcesOther GME Resources

PORT Core Curriculum Chief Resident Course Fellow Retreat Orientation

Centers Of Expertise New Innovations

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GME Directors & APECS staffGME Directors & APECS staff

Dr. Dempsey SpringfieldUrology

Dr. Dempsey SpringfieldThoracic Surgery

Dr. Dempsey SpringfieldSurgery

Dr. Eric NadelRadiology

Dr. Dempsey SpringfieldRadiation Oncology

Dr. John CoPsychiatry

Dr. Dempsey SpringfieldPlastic Surgery

Dr. Eric NadelPhysiatry

Dr. Eric NadelPediatrics

Dr. John CoPathology

Dr. Eric NadelOrthopedics

Dr. John CoOB-GYN

Dr. Dempsey SpringfieldNuclear Medicine

Dr. Eric NadelNeurology

Dr. Dempsey SpringfieldNeurosurgery

Dr. John CoInternal Medicine

Dr. John CoEmergency Medicine

Dr. John CoDermatology

Dr. Dempsey SpringfieldAnesthesiology

Associate DirectorDEPARTMENT

Georgi Bland. Irina Knyshevski

Partners Education Committee

Cheryl Reif NRMP Residency Match

Anne Rigg New Innovations

Georgi BlandMGH Education Committee (ECOTE)

Irina Knyshevski BWH Education Committee (BWHEC)

Georgi Bland. Irina Knyshevski

Duty Hours

Cheryl ReifInternal Reviews

Georgi Bland. Irina Knyshevski

ACGME accreditation

Contacts for APECS questions regarding:

Accreditation, Program, and Education Committee Support

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Lessons Learned and Action ItemsLessons Learned and Action Items

Review Program Requirements Calendar reminders for annual activities Office files Computer files Where in the accreditation cycle are you?