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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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)
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Questions
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