Residency Review Committee 101 What is the Residency Review Committee? Felicia Davis
Residency Review Committee 101 Felicia Davis Senior Accreditation Administrator Review Committee for Internal Medicine What is the Residency Review Committee? A group of volunteer internal medicine specialists and subspecialists operating under delegated authority from the ACGME board of directors. Their charge: • Set accreditation standards • Provide peer evaluation of residency and subspecialty programs • Confer an accreditation status on those programs that meet the standards 1 Overview • Starting the site visit and review process • Preparation for the Site Visit - the PIF • The Site Visit • The results and all that comes after Acronyms for the Internal Medicine Review Process ADS Accreditation Data System DIO Designated Institutional Official RQ and RS Resident Questionnaire and Resident Survey PIF Program Information Form CAAR Computer Assisted Accreditation Report 2 Computer-Assisted Accreditation Report (CAAR) What is CAAR ? • Data Entry Software • Core IM programs only • Program Information Forms • Extractable data file How Does the Site Visit Process Begin? Initiated by e-mail to program director and DIO Followed by hard-copy letter with RQ materials Identifies due dates 90 days to complete PIF 60 days to complete RQ Provides instruction as to where to access the CAAR software and the PIF in ADS Describes the resident questionnaire process 3 What is the PIF? A paper document that the RC uses to gather a comprehensive description of programs and their compliance with program standards Collects data regarding all components of your program Is your opportunity to present your program and its structure to the RC A Few Pointers on PIF Preparation Start Early! Know your program Prior citations and efforts to address Issues from the last institutional review that affect your program (read LOR) Current rotations and their role in the total educational program Faculty strengths/contributions to program 4 A Few Pointers on PIF Preparation (cont) • Check spelling and proof carefully for content • Fix internal inconsistencies in the PIF • Have PD, faculty, chief residents, other staff to review and suggest edits Resident Survey vs Resident Questionnaire ACGME Resident Survey All ACGME accredited programs regardless of specialty must participate Administered every other year to programs with 4 or more residents/fellows Programs must achieve 70% compliance Core IM resident questionnaire merged with survey beginning 2007 IM Subspecialty Resident Questionnaire Mailed to programs based upon number of residents identified in ADS Asked to administer questionnaire at the time of PIF preparation only. Peer-selected resident returns in ACGME-Business Reply envelope 30 days from the due date of PIF 5 Checklist for Return of Accreditation Materials 9 Program information Forms 9Original and two copies with attachments 9Must be signed off on by the DIO and Core PD 9Returned by deadline date (90 days) 9 CAAR Data File (Core only) 9 Questionnaires mailed by designated date (60 days) Site Visit Announcement • 110-120 days before the visit, email communication will be sent to the Program Director, announcing the site visit date, site visitor assigned and their contact information. • A copy of this communication will also be sent to the DIO. • A hard copy letter of the full announcement will arrive via US MAIL. 6 Requests for Changes in the SV Date Contact: Jim Cichon, Associate Director Penny Iverson Lawrence, Administrator within 14 days of date of email at: 312-755-5015 or [email protected] 312-755-5014 or [email protected] Please do not contact the Site Visitor, RRC staff, or an RRC chair What Happens on the Visit Day? The Site Visitor will… --Explain the Survey process to PD, Residents, & Others --Clarify, confirm, verify, and sometimes help correct PIF - it needs to be accurate! --Meet with: Program Director, Residents, Faculty, Administrators -- At times: Tour areas of the facilities 7 Professionalism: Yours ¾Continuously demonstrated Shows on the day of the visit ¾PIF accurately reflects the program No embellishing - site visitors can tell ¾Don’t ask, “How did we do?” Site visitor cannot answer, he/she is not the decision-maker ¾Don’t grill residents after the visit Professionalism: Ours ¾ ACGME Expectations for the Site Visit ¾Conducted in accord with established policies ¾Provide accurate, meaningful data ¾Verify/clarify information in the PIF ¾Address all relevant aspects of the program ¾Contain no recommendation for RRC action ¾Are educational and non-adversarial ¾Inform RRC accreditation decisions 8 Timeline Overview 1 - 4 weeks after the site visit * Site visit report is completed 2 - 6 months after the site visit * Program is reviewed * RRC-IM meets every January, May and September for program reviews What Happens Next? •Program is assigned to a reviewer •RC staff prepares program materials for assigned review by 1- 2 members of the RC •The reviewer: * Evaluates all the information available on the programs assigned *Submits their recommendation and a written evaluation listing areas of non-compliance with the program requirements 9 Program Review at RC Meeting •Presents each program to the entire RC and defends recommendations •Recommendation and any opposing recommendations are subjected to a vote •Decisions based upon committee consensus and may not agree with recommendation of reviewer •The majority decision of the entire RC establishes the accreditation decision. RC Actions Actions open to the RC for core IM programs Accredited > Initial > Continued Accreditation > Probation Non-Accredited > Withhold > Withdraw 10 RC Actions Actions open to the RC for subspecialties Accredited + Accreditation (initial) + Continued Accreditation + Continued Accreditation with Administrative Warning Non-Accredited + Withhold + Withdraw How Do I Find Out the Decision? Preliminary e-mail within 1 week of the meeting E-mail within 60 days of the meeting that Notification letter has been posted in ADS 11 Notification Letter The Residency Review Committee, functioning in accordance with the policies and procedures of the Accreditation Council for Graduate Medical Education (ACGME), has reviewed the information submitted regarding the following residency program: (SPECIALTY) Program University Program University Medical Center Regional Medical Center Chicago, IL Program 1400000123 Notification Letter Status: Continued Accreditation Length of Training: 3 Maximum Number of Residents: 54 Effective Date: 1/27/2005 Approximate Date of Next Survey: 06/2009 FS Cycle Length: 4.0 Year (s) Progress Report Due Date: 8/1/2005 Approximate Date for Internal Review: 07/2007 12 Notification Letter AREAS NOT IN SUBSTANTIAL COMPLIANCE (CITATIONS) The Review Committee commended the program for its demonstrated substantial compliance with the ACGME’s Requirements for Graduate Medical Education. However, the Committee cited the following areas as not in compliance: Citation #1 Residents do not receive formal feedback concerning their performance in continuity clinic. The record of evaluation should document that residents were evaluated in writing and their performance in continuity clinic reviewed with them verbally on at least a semiannual basis(VII.A.1.b)(8). Citation #2 What Do I Do Between Site Visits? 13 l rna Inte w ie Rev im er rts t In p o Re Review Announcement PIF Preparation (RQ) ADS Outcomes Project Program Requirements No tific a Let tion ter RRC Meeting Site Visit RRC Reviewer Assignment Ongoing Process •Start early!!!!!!!! •Begin with notification letter •Know the players in the world of GME: ACGME, ABIM, CMS, FSMB, NBME, ECFMG •Know how the ACGME/RC functions •Be familiar with your accreditation timeline 14 Know the Program Requirements Common PRs/Specialty Specific PRs Program Requirements are Complex Demonstrated Knowledge of PRs + Suggest changes in program to PD + Review changes for consistency with PRs Documentation and Record Keeping Get Organized Gather Data Ahead of Time + + + + + Faculty Credentials Research Bibliographies Hospital Statistics Conference Schedules BE PERSISTENT with Evaluations and Procedure Documentation 15 Keep Current ACGME Website • What’s New – ACGME • RC Webpage • Newsletters • Look for new program requirements Use Your Resources Utilize ACGME/RC staff Develop Network – You are NOT Alone + At your Institution + Nationally *APDIM (www.im.org) 16 Questions 17
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