Program Director’s Guide to Common Program Requirements Cuc Mai MD GME Director of Faculty Development November 2011 Goals & Objectives Improve in-depth understanding of ACGME common program requirements Correlate ACGME common program requirements to the program information form (PIF) Correlate ACGME common program requirements to the resident survey Why is this important? Compliance with requirements = Accreditation Common Program Requirements Speciality Specific Requirement Program Information Form (PIF) Site Visitor’s Report Resident Survey Results Monitoring Committee of ACGME board Board Scores Resources www.acgme.org Step 1 Step 2 Step 3 More fun reading !!! When you need clarification… If unclear directive, see FAQs or speciality specific RRC guidelines 3 types of requirements “Must”: no exceptions “Should”: almost a must; need to have a strong educational rationale for not doing “Suggested”: is not required and not citable ACGME Common Program Requirements Outline I. Institutions II. Program Personnel and Resources III. Resident Appointments IV. Education Programs V. Evaluation VI. Resident Duty Hours VII. Innovative Projects I. Institutions I.A. Sponsoring Institution I.B. Participating Sites I. A. Sponsoring Institution Must assume responsibility for the program and must ensure that the PD has sufficient protected time and financial support Internal Review: formal mid-cycle review conducted by the GMEC. Reviewer group must include at least one faculty member and one resident from sponsoring institution not from program being reviewed. I.B. Participating Sites A program letter of agreement (PLA) must exist between the program and each participating site providing a required assignment. Document needs to be renewed at least every 5 years. Additions or deletions need to be update from the ACGME Accreditation Data Systems (ADS) See handout. I.B. Participating Sites PLA Identify faculty who assumes education and supervisory responsibility for residents Specify faculty responsibilities for teaching, supervision, and formal evaluation of residents Specify the duration and content of the education experience State the policies and procedures that will govern resident education during that assignment II. Program Personnel & Resources II. A. Program Director II. B. Faculty II. C. Other Program Personnel II. D. Resources II. E. Medical Information Access II. A. Program Director Qualifications expertise acceptable to Review committee, Board Certification, and Current Medical licensure and Staff appointment Provide each resident with documented semiannual evaluation of performance with feedback Evaluate program faculty and approve the continued participation of program faculty based on evaluation II. A. Program Director Comply with sponsoring institution’s written policies and procedures Review with DIO before submitting ACGME information or requests for the following Changes in resident complement Major changes in program structure or length of training Progress reports requested by the Review committee Responses to proposed adverse actions Requests for increases or change to resident duty hours Voluntary withdrawal of ACGME accredited programs Requests for appeal of an adverse action Proposals to ACGME for approval of innovative educational approaches Correspondence about program citations II. B. Faculty Must be a sufficient number of faculty with documented qualifications to instruct and supervise all residents at that location. Establish and maintain an environment of inquiry and scholarship with an active research component Must regularly participate in organized clinical discussions, rounds, journal clubs, and conferences. Demonstrate scholarship Encourage and support residents in scholarly activities Accreditation Data System (ADS) III. Resident Appointments III. A. Eligibility Criteria III. B. Number of Residents III. C. Resident Transfers III. D. Appointment of Fellows and Other Learners III. B. Number of Residents Increasing number of residents require PRIOR residency review committee and DIO approval Request for change should be documented in ADS IV. Educational Programs IV. A. 5. ACGME Core Competencies IV. B. Residents’ Scholarly Activities IV. Educational Program Goals for the program must be distributed to residents and faculty annually Competency based goals and objectives for each assignment at each educational level must be distributed to residents and faculty annually. These should be reviewed by residents at the start of each rotation Regularly scheduled didactic sessions Delineation of resident responsibilities for patient care, progressive responsibility for patient management, and supervision of residents over the continuum of the program IV. Educational Program Resident Survey Questions: Has your program provided you with goals and objectives for each rotation and major assignment in either a hard copy or electronic form? Has your program provided you with its general goals and objectives in either a hard copy or electronic form? IV. Educational Program Resident Survey: How sufficient is the supervision you receive from faculty and staff in your program? How often do your faculty and staff provide an appropriate level of supervision for residents? How often has your clinical education been compromised by excessive service obligations? IV. A. 5. ACGME competencies Patient Care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based practice IV. A. 5. ACGME competencies ACGME Outcomes Project Minimal Threshold model Competency Based model IV. A. 5. ACGME competencies Patient Care Provision of learning experiences can be documented through rotation schedules, written goals and objectives, and resident files. Completed procedure/case logs IV. A. 5. ACGME competencies Medical Knowledge Documentation by written didactic curriculum, lecture schedule, reading assignments IV. A. 5. ACGME competencies Practice Based Learning and Improvement Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, to improve patient care based on constant self evaluation and life-long learning Identify strengths, deficiencies, and limits in one’s knowledge and expertise Set Learning and improvement goals Identify and perform appropriate learning activities Analyze practice using quality improvement methods and implement changes with the goal of practice improvement Locate, appraise, and assimilate evidence Use information technology to optimize learning Participate in the education of patients, families, students, residents, and other health professionals IV. A. Practice based learning improvement PIF question Describe one learning activity in which residents engage to identify strengths, deficiencies, and limits in their knowledge and expertise; set learning and improvement goals; identify and perform appropriate learning activities to achieve self identified goals. IV. A. Practice based learning improvement PIF question Describe one example of a learning activity in which residents engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients’ health problems. The description should include a) locating information b) using information technology c) appraising information d) assimilating evidence information 3) applying information to patient care IV. A. Practice based learning improvement PIF question Give one example and the outcome of a planned quality improvement activity or project in which at least one resident participated in the past year that required the resident to demonstrate an ability to analyze, improve, and change practice or patient care. Describe planning, implementation, evaluation, and provisions of faculty support and supervision that guided this process. IV. A. Practice based learning improvement PIF question Describe how residents: A) develop teaching skills necessary to educate patients, families, students, and other residents B) Teach patients, families, and others C) Receive and incorporate formative evaluation feedback into daily practice. IV. A. Interpersonal and Communication Skills Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. IV. A. Interpersonal and Communication Skills PIF question Describe one learning activity in which residents develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with physicians, other health professionals, and health related agencies. IV. A. Interpersonal and Communication Skills PIF question Describe one learning activity in which residents develop their skills and habits to work effectively as a member or leader of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities. IV. A. Interpersonal and Communication Skills PIF question Explain (a) how the completion of comprehensive, timely, and legible medical records is monitored and evaluated, and (b) the mechanism for providing residents feedback on their ability to competently maintain medical records. IV. A. Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. IV. A. Professionalism PIF question Describe at least one learning activity, other than lecture, by which residents develop a commitment to carrying out professional responsibilities and an adherence to ethical principles. How does the program promote professional behavior by the residents and faculty? How are lapses in these behaviors addressed? IV. A. Professionalism Resident Survey: To what extent does your program provide an environment where residents/fellows can raise problems or concerns without fear of intimidation or fear of retaliation? IV. A. Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. IV. A. Systems based Practice PIF question: Describe the learning activity through which residents achieve competence in the elements of systems-based practice; work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost-containment and risk-benefit analysis in patient care; advocate for quality patient care and optimal patient care systems; and work in interprofessional teams to enhance patient safety and care quality. IV. A. Systems based Practice PIF question: Describe an activity that fulfills the requirement for experiential learning in identifying system errors. Important elements include faculty guidance and active engagement by residents with written goals and objectives; resident assessment; and aggregated resident outcomes. IV. B. Residents’ Scholarly Activities Curriculum MUST advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. Should participate in scholarly activity Sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities. IV. B. Residents’ Scholarly Activities Resident Survey: Does your program offer you the opportunity to participate in research or scholarly activities? V. Evaluation V. A. Resident V. B. Faculty V. C. Program V. A. Resident Evaluation Faculty must evaluate resident performance in a timely manner and document evaluation at completion of the assignment. Evaluations must be accessible for review Program Provide objective assessments of all ACGME competencies Use multiple evaluators Document progressive resident performance improvement appropriate to educational level Provide each resident with documented semiannual evaluation of performance with feedback V. A. Resident Evaluation Resident Survey: Overall, how satisfied are you with the written or electronic feedback you receive after you complete a rotation or major assignment? If you want to review feedback on your performance, are you able to access your evaluations? V. B. Faculty Evaluation Must provide faculty with evaluation ANNUALLY MUST include annual written confidential resident evaluations SHOULD include a review of faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities. V.B. Faculty Evaluations PIF question: Describe the system used by the residents to provide annual confidential written evaluations of the teaching faculty Describe the program’s system for evaluating and providing feedback to the teaching faculty V.B. Faculty Evaluations Resident Survey: Do you have the opportunity to evaluate faculty members at lease once a year? How satisfied are you that your program treats your evaluations of faculty members confidentially? V. C. Program Evaluation MUST document formal, systematic evaluation of curriculum ANNUALLY MUST monitor and track Resident performance Faculty Development Graduate Performance Program Quality: assessed by residents in writing annually and this must be used to improve program. SHOULD document action plan if deficiencies found. V. C. Program Evaluation PIF question: Describe the approach used for program evaluation. Describe one example of how the program used the aggregated results of residents’ performance and/or other program evaluation results to improve the program V. C. Program Evaluation PIF question: Describe the improvement efforts currently undertaken in the program based on feedback from the ACGME resident survey. What improvements, if any, has the program undertaken to address potential issues identified by the most recent ACGME resident survey summary report? Review your survey summary. Board Pass Rates for past three years V. C. Program Evaluation Resident Survey: Do you have the opportunity to evaluate your overall program at least once a year? How satisfied are you that your program treats your evaluations of the program confidentially? How satisfied are you with the way your program uses the evaluations that residents/fellows provide to improve the program? VI. Resident Duty Hours in the Learning and Work Environment VI. A. Professionalism, Personal Responsibility, and Patient Safety VI. B. Transitions of Care VI. C. Alertness Management & Fatigue Mitigation VI. D. Supervision of Residents VI. E. Clinical Responsibilities VI. F. Teamwork VI. G. Resident Duty Hours VI. Resident Duty Hours in the Learning and Work Environment From: www.acgme.org VI. Resident Duty Hours in the Learning & Working Environment Must educate residents & faculty concerning the professional responsibilities of the physician to appear for duty rested and fit Must be committed to and responsible for patient safety and resident well being in a supportive educational environment VI. Resident Duty Hours in the Learning & Working Environment Must ensure a culture of professionalism that supports patient safety and personal responsibility. Must demonstrate an understanding and acceptance of their personal role in the following: Assurance of their fitness for duty Recognition of impairment, including illness and fatigue, in themselves and in their peers Attention to lifelong learning Monitoring of their patient care performance improvement indicators Honest and accurate reporting of duty hours, patient outcomes, and clinical experience data VI. B. Transitions of Care Must design clinical assignments to minimize the number of transitions of patient care. Must ensure and monitor effective, structured handover processes to facilitate both continuity of care and patient safety. Must ensure that residents are competent in communicating with team members in the hand-over process Must ensure the availability of schedules that inform all members physicians responsible for patient’s care VI. C. Alertness Management/Fatigue Mitigation Must educate faculty members and residents to recognize the signs of fatigue and sleep deprivation Educate all faculty members and residents in alertness management and fatigue mitigation processes Adopt fatigue mitigation processes Must have a process to ensure continuity in the event resident is unable to perform Must have adequate sleep facilities and/or safe transportation options for residents who may be too fatigued VI. D. Supervision of Residents Each patient must have an identifiable attending who is ultimately responsible for patient care. Must demonstrate appropriate level (graded) of supervision in place for residents and must use appropriate classification of supervision. Direct: supervisor is physically present with patient and resident Indirect: a) direct supervision immediately available b) with direct supervision available Oversight: supervisor is available to provide review of encounter after care is delivered VI. G. Resident Duty Hours Maximum Hours per week is 80, averaged over a 4 week period, inclusive of all in-house call and moonlighting. Moonlighting must not interfere with educational program and PGY-1 not permitted to moonlight. Must have minimum of one day free of duty every week, when averaged over 4 weeks. No at home call on these days. VI. Resident Duty Hours PGY-2 residents and above Must be scheduled for in-house call no more frequently than every third night, averaged over a 4 week period. May be schedule to a maximum of 24 hours of continuous duty. Strategic napping especially after 16 hours of continuous duty and between the hours of 10 pm and 8 am is strongly suggested. Time for transitions of care must be no longer than an additional four hours. Must not have additional clinical responsibilities after 24 hours of continuous in-house duty VI. Resident Duty Hours PGY 1 residents must not exceed 16 hours per duty period length. Should have 10 hours Must have 8 hours free of between duty periods VI. Resident Duty Hours Resident Survey: How often did you break the rule that duty hours must be limited to 80 hours per week, averaged over a fourweek period, inclusive of all in-house call activities? How often did you break the rule that residents/fellows must be scheduled for a minimum of 1 day in 7 free from all residency related duties, averaged over a 4week period? How often did you break the rule that there should be a 10-hour time period provided between all daily duty periods and after in house call? VI. Resident Duty Hours Residents, on their own initiative, may remain beyond their duty to continue to provide care for single patient if severely ill, academic importance, humanistic attention. Resident must document reasons for maintaining care and submit documentation to program director. Program director must review each submission and track both individual and program wide episodes of additional duty Conclusions It is important that GME faculty have an in-depth understanding of common program requirements. PIFs and Resident survey questions correspond directly to these requirements. It is important that GME faculty are aware of additional resources to review.