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© 2018 Lehigh Valley Health Network

Graduate Medical Education

AY18 Annual Institutional Review

Tom Whalen, MD, MD, MMM, CPE, FACS, FAAP, FACHE, Executive Vice-President & Chief Medical Officer, ACGME DIO)

Maggie Hadinger, EdD, Director of Medical EducationOn behalf of LVHN’s Graduate Medical Education Committee (GMEC)

AIR Presented/Disseminated To:

▪ Graduate Medical Education Committee (Nov 2018)▪ LVHN Department of Education (Nov 2018)▪ LVHN Medical Executive Committee (Jan 2019)▪ LVHN Board of Trustees (Feb 2019)

LVHN Graduate Medical Education Committee (GMEC)

▪ GMEC governed by ACGME requirements and LVHN GME Responsibilities Policy

▪ Responsible for oversight of all GME programs▪ Chaired by GME Director/DIO▪ Comprised of all Program Directors; attended by PDs, Program

Coordinators▪ Voting members include: All PDs, CMO/DIO, QI/Pt Safety, Medical

Informatics, Diversity Liaison▪ Meets monthly, except June▪ All documentation (agendas, minutes, documents for review) posted

on GMEC SharePoint site

GME Policies Reviewed in AY18

▪ Faculty Evaluation of Residents▪ GMEC Responsibilities▪ Institutional Agreements▪ Internal Review▪ International Rotations▪ Invasive Procedure Performance by Residents▪ Moonlighting and Other Professional Activities Outside the Program▪ Resident Meals▪ Resident Visas – Protocol and Options

LVHN GME/UME Updates

▪ Expansion of students to new LVHN sites▪ Development of LVH-Pocono as a PCOM Core Clinical

Campus ▪ Exploration of expansion of GME to new sites

11 LVHN ResidenciesFor Academic Year 2017-2018

Actual enrollment as of June 1, 2018

▪ Dermatology 6▪ Dental Medicine 7▪ Emergency Medicine 56▪ Family Medicine 18▪ General Surgery 27

▪ Internal Medicine 49▪ Neurology 4▪ Obstetrics/Gynecology 24▪ Pediatrics 18▪ Plastic Surgery 6▪ Transitional Year 15

9 LVHN FellowshipsFor Academic Year 2017 - 2018

Actual enrollment as of June 1, 2018

▪ Cardiovascular Disease 15▪ Colon and Rectal Surgery 2▪ Gastroenterology 4▪ Hematology Oncology 5▪ Hospice and Palliative Medicine 2

▪ Nephrology 4▪ Rheumatology 1▪ Sports Medicine 2▪ Surgical Critical Care 1

LVHN – Sponsoring Institution

▪ LVHN continues to be approved as an ACGME Sponsoring Institution, effective 1/24/2018.

Status Effective Date ACGME (self-study)

ACGME Prior Site

Visit

ACGME Next Site

Visit (appx.)

CLER Site Visit

Osteopathic Site Visit

Date# Citations

LVHN Sponsoring Institution

Continued Accreditation

1/24/2018 10/1/2025 8/9/2011 4/1/2027 9/25/2018 N/A 0

Program Accreditation Status Summary

Accredited ProgramProgram Length Status Effective

DateACGME

(self-study)

ACGME Prior Site

Visit

ACGME Next Site

Visit (appx.)


Date

# Citations

APR Date

Cardiovascular Disease 3 Continued Accreditation

1/19/2018 10/31/2015 1/29/2010 9/11/2018 N/A 0 3/15/2018

Colon/Rectal Surgery 1 Continued Accreditation with Warning

1/12/2018 3/1/2020 5/24/2012 9/1/2021 N/A 1 3/13/2018

Dental 1 Approved Without Reporting Requirements

11/30/2012 N/A N/A 11/2019 (CODA)

N/A 0 4/11/2018

Dermatology 3 Continued accreditation

1/5/2018 1/1/2028 9/27/2017 7/1/2029 N/A 0 3/23/2018

Emergency Medicine 4 Continued Accreditation

1/8/2018 2/1/2022 8/10/2011 8/1/2023 N/A 0 2/1/2018

Endocrinology, Diabetes, and Metabolism

2 Initial Accreditation

7/1/2016 N/A N/A 4/1/2019 N/A 0 N/A


DateACGME

(self-study)

ACGME Prior Site

Visit

ACGME Next Site

Visit (appx.)


Date

# Citations

APR Date

Family Medicine 3 Continued Accreditation with Warning

4/26/2018 10/31/2018 3/21/2018 4/1/2020 7/1/2017 5 2/14/2018

Gastroenterology 3 Initial Accreditation

7/1/2016 N/A N/A 9/12/2018 N/A 0 2/15/2018

Hematology/Oncology 3 Continued Accreditation

1/19/2018 N/A 7/22/2015 9/11/2018 N/A 0 3/13/2018

Hospice/Palliative Medicine

1 Continued Accreditation

1/19/2018 10/1/2015 2/19/2014 9/11/2018 N/A 0 3/19/2018

Internal Medicine 3 Continued Accreditation

1/19/2018 10/31/2015 7/24/2001 9/11/2018 N/A 0 2/7/2018

Medical Toxicology (Emergency Medicine)

2 Initial Accreditation

4/6/2017 N/A N/A 7/1/2019 N/A 0 N/A



DateACGME

(self-study)

ACGME Prior Site

Visit

ACGME Next Site

Visit (appx.)


Date

# Citations

APR Date

Nephrology 2 Continued Accreditation

1/19/2018 N/A 7/21/2015 9/11/2018 N/A 0 2/15/2018

Neurology 3 Continued Accreditation

1/25/2018 4/1/2027 12/9/2016 10/1/2028 N/A 0 3/29/2018

Obstetrics/Gynecology 4 Continued Accreditation

2/1/2018 12/1/2021 4/12/2011 6/1/2023 N/A 0 2/16/2018

Osteopathic Internship/ Medicine

1 Continuing Approval

4/21/2017 N/A N/A N/A 4/7/2017 0 2/7/2018

Pediatrics 3 Continued Accreditation

4/19/2018 7/1/2024 11/13/2017 1/1/2026 N/A 2 2/21/2018

Plastic Surgery 3 Voluntary Withdrawal

1/21/2016 10/1/2019 3/20/2008 N/A N/A 0 3/12/2018

Plastic Surgery Integrated

6 Continued Accreditation

1/25/2018 10/1/2019 9/17/2013 4/1/2021 N/A 0 3/12/2018



Date

ACGME (self-

study)

ACGME Prior Site

Visit

ACGME Next Site

Visit (appx.)


Date

# Citations

Prior APR Date

Psychiatry 4 Initial Accreditation 7/1/2017 N/A 11/15/2017 2/1/2020 N/A 2 N/A

Pulmonary Disease and Critical Care Medicine

3 Initial Accreditation 7/1/2017 N/A N/A 4/1/2020 N/A 0 N/A

Rheumatology 2 Initial Accreditation 4/8/2016 N/A 3/20/2018 N/A N/A 0 4/5/2018

Sports Medicine 1 Continued Accreditation

1/31/2018 10/31/2018

5/17/2016 4/1/2020 N/A 0 3/21/2018

Surgery 5 Continued Accreditation

1/18/2018 1/1/2021 5/23/2012 5/1/2023 N/A 0 3/13/2018

Surgical Critical Care 1 Continued Accreditation

1/18/2018 11/1/2021 5/25/2012 5/1/2023 N/A 0 3/13/2018

Transitional Year 1 Continued Accreditation

12/11/2017 5/31/2018 3/21/2008 11/1/2019 N/A 0 2/7/2018


LVHN Other Training Programs

▪ Pharmacy 1▪ Clinical Pastoral Care* 4▪ Administrative 2

OverviewAY2014 AY2015 AY2016 AY2017 AY2018

Residents/fellows 254 250 255 262 262Visiting residents 85 85 70 67 67Total accredited medical/dental residency programs

17 17 19 20 22

ACGME programs 14 15 16 16 18

AOA programs 4 4 4 4 4

Dually accredited programs 2 2 2 2 2

Re-accredited programs 4 3 15 16 22

New program(s) applied for 1 2 3 2 2

Medical/dental graduates a 102 105 90 92 94

Applicant and Match DataAY 14 AY 15 AY 16 AY 17 AY 18

U.S. medical & dental school applicants 2,718 2,504 2,957 3,969 4,331

Applicant interviews conducted 954 972 1,088 1,165 1,203

Match positions availablea 86 95 101 105 106

% matched from allopathic accredited medical schools 35% 42% 55% 40% 35%

% matched from osteopathic medical schools 43% 40% 38% 42% 45%

% matched from international medical schools 22% 18% 16% 18% 15%

% matched from PA medical schools 37% 35% 27% 36% 35%

AY15-19 Number of ACGME/AOA/CODA Actual and Approved Graduate Trainee Positions

250247

255

262

276

243

256

268

283281

AY 15 AY 16 AY 17 AY 18 AY 19

Actual Approved

GME Program Growth

▪ New programs with trainees beginning in AY18:• Rheumatology Fellowship (with fellows beginning in AY18)

▪ New programs approved in AY18:• Psychiatry Residency (with residents beginning in AY20)• Pulmonary Critical Care Fellowship (with fellows beginning in AY20)

▪ New programs with trainees beginning in AY19:• Medical Toxicology Fellowship (with fellows beginning in AY19)• Endocrinology Fellowship (with fellows beginning in AY19)

▪ Programs under consideration/being proposed in AY19:• Neurovascular Medicine• Geriatric Medicine

Annual Program Reviews (APR)

▪ APRs conducted January-June 2018▪ All programs reviewed by DIO/GME Director

1. Meeting with trainees only, by program2. Meeting with program leadership

▪ Additional materials reviewed:• Past year’s APR report• Themes from meetings with trainees• ACGME and LVHN faculty/resident surveys• ACGME program accreditation documentation • Additional relevant documents

▪ APR summary presented by DIO to GMEC (Oct 2018)

APR Template

▪ Standard template of questions posed to trainees follow ACGME competencies▪ Standard template of questions posed to program

leadership include:•What is your program’s greatest strength?•What is the greatest challenge your program faces?•What assistance could you most benefit from?

AY18 APR Findings

▪ Strengths• Faculty, faculty, faculty• Research opportunities• Innovations

▪ Challenges• Faculty development and feedback• Service/scheduling constraints• Faculty pressures/RVU focus• Research support• Recruitment/Match

▪ Assistance/support needed• Advocacy• Coordination of communications• CE programming• Faculty development• Wellbeing/wellness resources• Academic support• Marketing• GMEC as venue for sharing best

practices

ACGME CLER

▪ 1st visit occurred 2014▪ 2nd visit occurred 2016▪ 3rd visit completed Sept 2018▪ Multiple initiatives underway to address CLER 3.0 priorities

• Inclusion of Pt Safety/Quality, Diversity liaisons on GMEC (AY18/19)• Resident/faculty training on Title IX (AY18/19)• Network-wide resident & student QI awards initiated (AY18)• Roll-out of AMA GME Competency Curriculum & Wellness Survey (AY19)• Requirement of IHI module completion (AY19)• Enhanced collaboration with Patient Safety (AY18)

How do graduate trainees learn about LVHN residency/fellowship programs?

ERAS23%

LVHN Physician4%

LVHN Employee0%

LVHN Resident12%

LVHN Resident Alum5%

Program Director3%

Dean0%

Medical School CORE Rotation6%

Medical School Elective Rotation16%

Friend/Family Member17%

Other13%

Faculty Evaluation CompletionProgram % Core faculty completion within 30 days

Cardiovascular Disease 72%Colon/Rectal Surgery 71%Dental 78%Dermatology 100%Emergency Medicine 100%Family Medicine 100%Gastroenterology 95%General Surgery 53%Hematology/Oncology 88%Hospice/Palliative Medicine 79%Internal Medicine 100%Nephrology 100%Neurology 47%Obstetrics/Gynecology 75%Pediatrics 100%Plastic Surgery 71%Sports Medicine 100%Surgical Critical Care 0%Transitional Year 100%

ACGME Duty Hours Violations SummaryProgram 80 HR Call Days Off Night

Float24+ Short

Break Cardiovascular Disease a 0 0 1 0 0 0Dermatology 0 0 0 0 0 0Emergency Medicine b 0 0 7 0 0 4Family Medicine 0 0 0 0 0 0Gastroenterology c 0 0 0 0 0 2Hematology/Oncology 0 0 0 0 0 0Hospice/Palliative Medicine 0 0 0 0 0 0Internal Medicine 2 0 1 0 0 0Nephrology 0 0 0 0 0 0Neurology 0 0 1 0 7 2Obstetrics/Gynecology d 5 0 9 0 4 6Pediatrics e 0 0 1 0 6 12Primary Care Sports Medicine 0 0 0 0 0 0Surgical Colon/Rectal f 1 0 1 0 0 0Surgical General Surgery g 2 0 10 0 1 1Surgical Plastic Surgery 0 0 0 0 0 0Surgical Critical Care 0 0 0 0 0 0Transitional Year 1 0 0 0 0 0

Trainee Involvement in Quality/Patient Safety

Program

% of residents

completing case review

Nature of Case Review

% of residents

completing a QI project

Documentation Method

(A3, ppt, paper)

IHI modules required by program?

Cardiovascular Disease 15 M&M, RCAs, Chart reviews

5 (all 15 have project) paper/presentation No

Dental Medicine 1 Dental Chart Review 1 with faculty NoDermatology 6 Grand Rounds 4 paper yesEmergency Medicine 13 M&M, Chart Review 13 paper Yes

Family Medicine 18 Chronic pt chart review 6 complete -12 in progress PPT Yes

Gastroenterology 4 GR/MM 0 NA NoHematology/ Oncology 5 GR, M&M 2 paper NoHospice/Palliative Medicine 0 N/A 2 paper/data Yes

Internal Medicine 33 CPC, CCU, GR 49paper, ppt, poster, data

rpt No

Trainee Involvement in Quality/Patient Safety

Nephrology 4 GR MM Poster 4 No

Neurology 4 M&M, RCA0 (all 4 have a project not

yet complete) Poster, ppt No

Obstetrics/Gynecology 1 Peer Review & M&M 0 PPT No

Pediatrics 12 M&Ms; RCAs 12Clinical

pathways Yes

Rheumatology 3 M&M, chart reviews in progresspaper, data Yes

Sports Medicine 0 NA 0 NA NoSurgery, Colon Rectal 2 M&M 0 NA NoSurgery, General 15 M&M in progress YesSurgery, Plastic 3 M&M not sure YesSurgical Critical Care 1 M&M not sure NoTransitional Year 15 0 ppt. No

Program

% of residents

completing case review

Nature of Case Review% of residents

completing a QI project

Documentation Method

(A3, ppt, paper)

IHI modules required by program?

Trainee Scholarly Work

Program

# Peer Reviewed Abstracts/Posters/ Oral

Presentations# Peer Reviewed

Manuscripts PublishedCardiovascular Disease 11 12Dental 14 1Dermatology 6 6Emergency Medicine* 17 10Family Medicine 18 0Gastroenterology 11 1Hematology/Oncology 2 1Hospice Palliative Medicine 0 0Internal Medicine 41 2

*Additionally, Emergency Medicine residents were awarded 2 grants in AY18.


Nephrology 4 0Neurology 4 0OB/GYN 8 1Pediatrics 8 0Rheumatology 3 0Sports Medicine 2 0Surgery, Colon/Rectal 0 0Surgery, General 3 2Surgery, Plastics 8 0Surgical Critical Care 1 0Transitional Year 5 0TOTALS 149 36

Program

# Peer Reviewed Abstracts/Posters/ Oral

Presentations# Peer Reviewed

Manuscripts Published

*Additionally, one Pediatric resident authored a book chapter and one Pediatric resident was awarded a CATCH grant.


▪ In AY18, 107 resident/fellow records were added to LVHN’s Scholarly Works online repository

▪ 107 works = 467+ downloads, across 132+ countries▪ Top 5 downloads in AY18 (20+ downloads/each):

• Sarcoidosis, the Great Imitator: An Unusual Finding on Bone Marrow Pathology• Analysis of Endoscopic Simulators for Assessment of Surgical Skills of OBGYN

Residents• A Rare Presentation of HSV Type 2 Hepatitis• Central Hypoventilation: A Rare Complication of Wallenberg Syndrome• Economic Impact of Pharmacist Participation in the Neurocritical Care Unit

Residency Graduation, Fellowship, and Board Passage Rates

Residency ProgramTotal # of graduates

# of graduates who stayed at

LVHN

# of graduates progressing to

LVHN residency/fellowship

# of graduates

progressing to outside residency/ fellowship

Board passage rate (5 year rolling

average)Dental 7 0 N/A N/ADermatology 2 0 0 N/A 100%Emergency Medicine 13 3 3

ABEM 97%; ABOEN 100%

Family Medicine 6 5 0ABFM 90%;

AOBFP 100%

General Surgery 7 3 3 70%Internal Medicine 15 2 2 97%Obstetrics/Gynecology 6 1 0 87%Pediatricsa 6 3 0 65% Plastic Surgery 1 0 0 100%Transitional Year 15 0 5* 10 N/A

Fellowship Graduation, Fellowship, and Board Passage Rates

Fellowship ProgramTotal # of graduates

# of graduates who stayed at LVHN

# of graduates progressing to

Fellowships

Board passage rate (5 year rolling average)

Cardiovascular Disease 5 1 3 100%Colon Rectal 2 0 0 60%

Hematology/Oncology 2 0 0 100%

Hospice/Palliative Medicine 2 0 0 87.5%Nephrology 2 0 0 100%

Primary Sports Medicine 2 0 0 100%

Surgical Critical Care 1 0 0 100%

AY18 Graduation Data

▪ 78 medical/dental residency + 16 fellowship graduates▪ 18 stayed at LVHN for employment/appt to Medical Staff▪ 13 continued to residency/fellowship with LVHN▪ 17 continued to residency/fellowship elsewhere

▪ 33% graduates stayed on at LVHN for further training or employment/appointment▪ 19% stayed on for employment/appointment

Graduate Trainees > LVHN Employment

■ In AY18, 25 DDS/DMD/DO/MDs who completed training at LVHN were appointed to LVHN’s Medical Staff, representing 16% of total new appointments

First SELECT Alum/LVHN Resident Graduate Joins Medical Staff

USF undergrad/Tampa native SELECT Medical StudentLVHN Family Medicine Resident LVHN Family Physician

Yasir Abunamous, MD

ACGME Trainee Survey

20 programs surveyedn = 248 = 98% response rate

ACGME Faculty Survey

n = 187 = 86% response rate

Trainee Wellbeing

Trainee Wellbeing

20 programs surveyedn = 248 = 98% response rate

Faculty Wellbeing

Faculty Wellbeing

n = 187 = 86% response rate

Next Steps for AY19

▪ AMA Wellbeing/Burnout Survey – fall 2018/2019▪ Response to CLER site visit – fall 2018▪ Beginning in 2019, GMEC will monitor program-specific

action plans▪ Exploration of GME expansion at northern sites

Thank you

Contact Information:

[email protected][email protected]

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