What do I need to know about the 10-Year Accreditation Site Visit? by Lynne Meyer, PhD, MPH University of Florida College of Medicine Graduate Medical Education Office March 2018 Session Objectives
Discuss the Self-Study process and components as preparation for 10-year Accreditation Site Visit Compare and contrast Clinical Competency Committees (CCC) and Program Evaluation Committees (PEC) Identify key elements of an annual program evaluation (APE) Discuss Program Improvement Projects (PIP) using Action Plans (AP) Discuss what is required for the 10-Year Site Visit SELF-STUDY Discuss the Self-Study process and components as preparation for 10-year
Accreditation Site Visit Self-Study: Why? The Focus is on Drivers of Change for Improvement In the past, citations from the RRC were used as drivers of change With Self-Studies, programs use internal drivers for change http://www.acgme.org/What-We-Do/Accreditation/Self-Study Self-Study: Who?
PEC or Self-Study Group -- The ACGME wants to see high resident/fellow involvement in the improvement process Everyone should be on the same page, aware of priorities, and where you are heading as a program Self-Study: Key Questions Is the learning environment effective? How do you know? Have you achieved your desired educational outcomes?
How do you know? Have you done your SWOT? -- analysis of strengths, weaknesses, and plans for improvement (continuous quality improvement) Each program (core and subs) must complete its own self-study. Q: What is the timing between the Self-Study and the 10-Year Site Visit?
A: 12-18 months (realistically, at least 24 months) For at least one annual program evaluation (APE) prior to the 10-year site visit For time to make improvements Note: For the 10-year accreditation site visit, the ACGME will not ask programs to provide any information on areas identified during the SelfStudy that have not yet resulted in improvements Self-Study: Tips for Large Programs
Consider sub-groups performing a mini-self-study on a specific topic and bring information back to the larger group Self-Study: Components Vision & Mission PECs Annual Program Evaluations (APE) Must include items under Program Evaluation and Improvement Program Requirements section Program Aims/Goals (reviewed annually) & SWOT Analysis
Items/areas needing improvement are linked to action plans and tracked year to year Need to describe how the 3-5 issues focused on were prioritized Summary Statement that addresses taking the program to the next level Statement of what was learned during the Self-Study process Self-Study: Vision Vision and plans for next 5 years (250 words)
Vision Example: To be the leading ________residency program in the Southeast United States among the nations leading public university programs. Plans (including Mission) answer the following questions: What does the next level look like? How do we get there (and when do we expect to get there?) What help, resources, etc. are needed?
Self-Study: Mission Mission one sentence that describes plan to achieve vision Example Through commitment to education, scholarship and safe, high quality patient care, we will improve the health and well-being of Gainesville, FL and referral area patients and their families by producing physicians who continue to learn and/or lead in whatever setting they choose for their career. (distinctive competence) (what) (for whom) (how)
One Minute Activity Load your programs website Do you have vision and mission statements? Current? Revisions needed? Tips: If you dont have these statements, consider asking someone with strategic planning expertise to assist you in the process. Honor everyones perspectives including nursing, medical education, research, residents/fellows at all levels
of training, etc. [keep it loaded, we are going to refer to your site again] 10-Year Site Visit Preparation: Mission/Vision Program leaders expectations for the program ASK: Do we have a vision and mission? Can the PD recite the vision and mission? Can the APDs/Chair recite it?
Are we confident our trainees can recite it? UF COM Mission Who can state our College of Medicines Mission? Institutional leaders expectations for the program Q: How do your program mission/vision/aims/goals relate to the UF College of Medicines Mission and Goals? http://med.ufl.edu/about/deans-welcome/missions-of-the-college/
One Minute Activity Load your programs website If you have vision and mission statements on your web site -- How well do they relate to the College of Medicines mission statement? Self-Study: Components Program Description -Concise description (250 words) Does your programs description on your
website align with your vision? When is the last time your web site was updated? Your web site is the first thing 10-Year site visitors review Self-Study: Components
Program Aims/Goals What does the program strive to produce [for what kinds of settings and roles]? (150 words) How does our program differentiate itself from other programs in the same specialty/subspecialty What are you good at, what is your brand? What is your ideal program? Does every stakeholder agree?
about your Programs Goals/Aims How do your goals align with your vision and mission? Are your program goals SMART? What outcomes do you have to indicate success of your goals? How do your program goals
align with the institutional goals? Do you need to revise your program goals? A goal properly set is halfway reached Abraham Lincoln Sample Aims/Goals by Common Attributes
Competence/Preparation for Practice in the Chosen Clinical Specialty: Train surgeons of outstanding ability and judgment who will be leaders in their areas of interest, and in the setting of their choice Resident/Graduate Traits: Develop mindfulness, curiosity, patient advocacy, and a commitment to life-long learning, while being adaptable to future changes in the healthcare system Attributes of Individuals Recruited: Recruit diverse candidates with an emphasis on giving opportunities to students who have a track record of overcoming barriers, and the potential to excel in terms of physician competencies, advocacy and leadership Service to the Local or Other Specific Communities: Serve our surrounding community in a
culturally competent manner, the program aims to recruit residents who reflect the diversity of the population it serves, OR, 70% of our graduates will remain in Florida Specific Academic Practice/Research/Leadership Roles: Train the next generation of leaders in academic pulmonary and critical care medicine Attributes of the Program and Its Learning Environment: Provide a culture that is supportive, respectful, and compassionate towards trainees, patients and colleagues Three Minute Activity Load your programs website and discuss them with a person or two sitting by you. What are ways you can measure your programs aims/goals?
Do they need revision? How can you track the data? Are aims/goals related to your vision and mission? OR How would you evaluate/measure/revise (if needed) these program aims/goals?
Educate residents to be excellent practitioners of medically directed anesthesiology in an anesthesia care team model Train individuals for expertise in population health and care of the medically underserved Produce excellent, independent practitioners who will be leaders in academic medicine Train residents to enter primary care practice Self-Study: Components Activities/Projects Activities that further the aims/goals of the program Listing of actions or projects aligned with
aims/goals (250 words) Review your programs action plans -Which ones relate to your programs aims/goals? 10-Year Site Visit Preparation: Mission/ Vision ASK: What are our program Aims/Goals? Who all knows the program Aims/Goals? What Program Improvement Projects (PIPs) relate to the program Aims/Goals?
What was the outcome of the PIPs, what PIPs are in process, what PIPs are being planned? Reminder: For the 10-year accreditation site visit, the ACGME will not ask programs to provide any information on areas identified during the Self-Study that have not yet resulted in improvements Self-Study: Components SWOT analysis Opportunities (250 words) Threats (250 words)
Suggest an anonymous survey using Qualtrics or similar to ask housestaff & faculty to list at least top three items for each category (S W O T), collate, then review Significant changes over past 5 years (250 words) looking backwards and where youve come to this point.
Self-Study: Process Self-Study Process Description (300 words) Who is involved? How was data was analyzed? How were conclusions reached? How were improvement areas prioritized? e.g.- Categorize SWOT items Important-Immediate attention
Important-Can do later Important Cant do anything about it SWOT Fishbone Will it close an existing performance gap? Effort/Impact Grid Choose 3-5 areas for prioritization Self-Study: Core Program Role If core program what was role with
subspecialty programs? (150 words) Self-Study: Learning What did you learn (200 words) Self-Study: Looking Backwards and Forwards A five-year look back at changes in the program, and a five-year look forward
Review of program revisions and achievements (APE documentation) Defining the five-year strategic plan The approach to the self-study and who was involved Review of the conduct of the selfstudy Self-Study: Looking Forward The answer to the question what will take this
program to the next level? What does the next level look like? How do we get there (and when do we expect to get there?) What help, resources, etc. are needed? Focus will be on long-term and sustainability Self-Study: Executive Summary Develop a Concise Self-Study Document
In addition to the detailed self-study document(s), also develop an executive summary version to be used for: Further program improvement Checking for progress during next APE prior to 10-year site visit Documentation for programs 10-year site visit Point of comparison for after the 10-year site visit CCC & PEC Compare and contrast Clinical Competency Committees (CCC) and Program
Evaluation Committees (PEC) ACGME Q: What is the fundamental difference between the PEC and CCC? A: The CCC assesses each resident/fellow individually and provides recommendations to the program director
and the PEC evaluates the program using multiple data sources including, but not limited to aggregate resident/fellow performance data Program Evaluation Committee Role: To assess the quality of the program Aggregate and analyze data Prioritize, plan, develop, implement, and evaluate programs educational activities Review and make recommendations for revision of competency-based curriculum goals and
objectives Address areas of non-compliance with ACGME standards Review the program at least annually using evaluation of faculty, residents, and other All PEC members (including residents/fellows) should be familiar with the following ACGME documents: Program Requirements, FAQs, and other Documents and Resources found on the RRC website Milestones The Milestones Guidebook (Version 2016)
Milestones Guidebook for Residents and Fellows (June 2017) Clinical Competency Committee Role: To assess the clinical competency of the fellow Review all fellow evaluations semi-annually Prepare and ensure reporting of Milestones to ACGME semi-annually Advise the PD regarding promotion, remediation or dismissal of trainees All CCC members should be familiar with the following ACGME documents: Clinical Competency Committees: A Guidebook for Programs (2nd Edition)
The Milestones Guidebook (Version 2016) CCCs may need to meet more often to review specific residents/fellows in trouble ACGME Q: How many competencies are there? Q: List them Patient Care and Procedural
Skills A: Six Practicebased Learning and Improvement Medical Knowledge
Developing Competence as a Physician Systemsbased Practice Professionalism Interpersonal &
Communication Skills Q: What is the difference between a subcompetency and a milestone? Q: What is the difference between a subcompetency and a milestone?
Q: What is the difference between a subcompetency and a milestone? APE Identify key elements of an annual program evaluation (APE) APE: Template in New Innovations
The PEC is responsible for the APE PEC Aggregates and Analyzes Data Review data from various sources (see example sources below) Identify common themes PEC Prioritizes Program Improvement Projects Determine 3-5 key strategic program improvement areas to help you reach your next level
Link these improvement areas to program aims/goals What measurements will demonstrate success? Determine what can reasonably be accomplished in 12-18 (and 24 or even 36) months PIPs and APs Discuss Program Improvement Projects (PIP) using Action Plans (AP) PEC Develops Action Plans (AP) for Program Improvement Projects (PIP)
Assemble teams of residents, faculty and staff to take ownership of action items to reach next level goals Use a PDSA model for program improvements Measure your change How do you know youve been successful? Plan Do Some PIPs may require more than one AP Some PIPs may require a Plan B Act
Study Complete the PDSA cycle A: adopt, adapt, or abandon change decision is very important Sample Action Plan (AP) in New Innovations In New Innovations: All action plans, prioritized or not, need to go into New Innovations Action Plan module (this makes it
easy for your PEC to generate reports) All action plans must be linked to a citation or concern All Citations or Concerns must have an identified Source (RRC, PEC-internally identified, or GMEC--IPRC) You can have one concern with several action plans, or one action plan may be linked to more than one concern Be sure to document outcomes for
APs Action Plans for. ACGME Citations & Concerns Program Aims (connected to your program mission and vision) If you have NOT achieved your program aims, you need action plans to help you achieve your programs next level Issues related to PECs annual program evaluation including ACGME survey results
Issues identified by the Institutional Program Review Committee (IPRC) 10-Year Site Visit Discuss what is required for the 10-Year Site Visit 10-Year Site Visit: What do Site Visitors Review prior to the visit?
Your web site Letters of Notification ACGME resident and faculty surveys ADS data Submitted Self-Study documents
Eight Steps to Prepare for the 10-Year Accreditation Site Visit https:// www.acgme.org/What-We-Do/Accreditation/Site-Visit/Eight-Steps-to-Pr epare-for-the-10-Year-Accreditation-Site-Visit 1. Review PIP data identified and worked on during Self-Study (SS) A single years Annual Program Evaluation For tracking improvements longitudinally across multiple Annual Program Evaluations
2. Discuss SS Improvements with Stakeholders 3. Reassess Program Aims/Goals and SWOT analysis 4. Discuss Program Aims, Achieved Improvements, and SWOT assessment with Stakeholders Eight Steps to Prepare for the 10-Year Accreditation Site Visit 5. Complete and Submit Summary of Achievements Summary of Achievements Template Self-Study Summary Update
6. Update ADS 7. Summary of Achievements, Self-Study Summary Update submitted via ADS 12 days prior to site visit Eight Steps to Prepare for the 10-Year Accreditation Site Visit 8. Set and Confirm Site Visit Logistics Site Visit Document
List (Review this document sooner than later) Where are the documents I need? https://www.acgme.org/What-We-Do/Accreditation/Self-Study Summary: Process Overview with Timing
Summary: 10-Year Site Visit Logistics From Dr. Nascas CEO Address at the 2018 ACGME Annual Educational Conference, March 2, 2018 Questions?
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