ACGME Next Accreditation System (NAS) Site Visit

A Coordinator Perspective

Donna Guinto, Thomas Jefferson University Hospital, Philadelphia, PA Lauren Hook, Einstein Healthcare Network, Philadelphia, PA

DISCLOSURE

• No conflicts or interest to report

OBJECTIVES

• Describe the updated processes of an ACGME Site Visit

• Review the logistics and preparation needed for a successful Site Visit

WHEN YOU HEAR THE WORDS

“SITE VISIT”

OLD ACCREDITATION SYSTEM NEW (NEXT) ACCREDITATION SYSTEM

Notification Letter—Ingrid Philibert - 4 months before visit

Notification Letter—Ingrid Philibert - 2 months before visit

Contact the Site visitor - 2 months before visit

Wait for the site visitor to contact you - They set the schedule for the day

No Survey Data Resident + Core Faculty survey data reviewed during PD meeting

Prepare and mail the PIF No PIF to prepare! - Annual update is the PIF

Site Visitor(s) meets with peer selected residents

Site Visitor(s) meets with all residents - in our experience

Tour of Hospital No Tour - CLER responsibility

No feedback Feedback about the visit at the end

Old Accreditation Site Visit vs

NAS Site Visit

The Next Accreditation System (NAS)

NAS

Annual Program

Data

Aggregate Board Pass

Rate

Resident Clinical

Experience

Resident and

Faculty Survey

CLER—every 18 months

• No More PIFS! • Internal Reviews—not required • 10 year self-study • NAS is a continuous accreditation

model:

Site Visit Schedule

• 7AM – 1PM

• Introductory meeting with PD/PC—Includes document review (1 hour)

• Meeting with residents—schedule TBD by field staff. Usually by PGY Level (2 hours)

• Meeting with DIO/Chair ( ½ hour)

• Faculty Interviews (1 hour)

• PD/APD/PC Feedback Meeting ( 1 hour)

*breaks throughout the day

• **Quality Improvement Projects** • Faculty & Resident Surveys • Resident Education – specifically conference structure • Preliminary Residents – same opportunities as categorical • Scholarly Activity Data • Clinical Competency Committee Minutes • PEC Minutes • Faculty Qualifications (board certification and recertification)

**PLEASE NOTE THE REVIEWER SOMETIMES WILL HAVE AN OLD ADS REPORT

• Effective hand-offs • ABS Passage Rate • Attrition

WHAT ARE REVIEWERS LOOKING FOR

SPONSORING AND PARTICIPATING INSITUTION: 1. Current Program Letters of Agreement (PLA) RESIDENT APPOINTMENT 2. Files of current/fellows and most recent program graduates 3. If applicable, files of current residents who have transferred into the Program

including documentation of previous experiences and competency-based performance evaluations

4. If applicable, files of residents who have transferred out of this program into another program.

DOCUMENTS FOR REVIEW BY THE SITE VISITORS

EDUCATIONAL PROGRAM: 5. Overall Educational Goals for the program.

6. Competency based goals and objectives for each assignment at each

educational level

7. Didactic and Conference Schedule for each year of training.

EVALUATION: 8. Evaluations of residents/fellows at the completion of each assignment

9. Evaluations showing use of multiple evaluators

10.Documentation of Residents’ semi-annual evaluations of performance

with feedback

11.Final (summative) evaluation of residents, documenting performance during the final period of education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision.

Evaluations (continued): 12.Completed annual written confidential evaluations of faculty by the

residents

13.Documentation of program evaluation and written improvement plan

14. Documentation of duty hours for residents in this program

15. Written description of Clinical Competency Committee (CCC) including structure, membership, semi-annual resident evaluation process, semi-annual reporting of resident Milestones evaluation to ACGME and protocols for the CCC advising the program director regarding resident progress including promotion, remediation and dismissal.

16.Written description of the Program Evaluation Committee (PEC) including structure, membership, evaluation and tracking protocols, development of the written annual Program Evaluation and protocols for the development and monitoring of improvement action plans resulting form the Annual Program Evaluation. In addition, copies of the last three (3) PEC meeting minutes should be available for review.

Duty Hours and the Learning Environment: 17.Policy for supervision of residents (addressing progressive responsibilities

of patient care, and faculty responsibility for supervision) including protocols defining common circumstances requiring faculty involvement.

18.Program policies and procedures for residents duty hours and work environment including moonlighting policy.

19.Sample documents for episodes when residents remain on duty beyond scheduled hours

17.Sample documents offering evidence of resident participation in Quality

Improvement and Safety Projects.

UNDER THE MICROSCOPE

• Quality Improvement • residents must have projects

• Summative Evaluations • “the resident has demonstrated

sufficient competence to enter practice without direct supervision”

• Yearly Didactic Schedule • proof of faculty participation • documentation of 75% resident

attendance • faculty led Grand Rounds

• Semi Annual PD Meetings • documented in file

• Program Letter Of Agreement • goals and objectives must be

included • identify the faculty responsible for

residents

• Supervision Policy • addressing progressive

responsibilities for patient care • faculty responsibility for

supervision (including protocols defining circumstances requiring faculty involvement)

• Web Ads Block Schedule • # months at outside institutions • % outpatient for each rotation • % research for each rotation • name of the rotation needs to

clearly indicate the nature of the rotation • I.e. – if “white” is vascular

surgery then block should say vascular!

ADS UPDATED

REVIEWED FOR ACCURACY

NO ISSUES WITH BOARD SCORES

65% PASSAGE RATE

RESIDENT SURVEY

70% COMPLETE

FACULTY SURVEY

60% COMPLETE

CONTINUED ACCREDITATION

BEST CASE SCENARIO