Accreditation Council for Graduate Medical Education · I-6 Core Surgery PR IntC1c)(2) •Core...

Accreditation Council for Graduate Medical Education

ACGME UPDATES

Thoracic Surgery Residency Administrators/Coordinators

Section

Los Angeles, CA

January 27, 2012

Peggy Simpson, EdD Executive Director

Thoracic Surgery RRC

Disclosures

• Financial

• None

• Fiduciary

• Full-time employee of ACGME

• AND…..

Outline

• Next Accreditation System

• Operative Log System

• RRC Updates

© 2012 Accreditation Council for Graduate Medical Education (ACGME)

Next Accreditation System


• Goals

• Program activities

• Overview of accreditation in NAS

• Timeline for transition

• CLER visits

Next Accreditation System Goals

• Reduce the burden of accreditation

• Free good programs to innovate

• Assist poor programs to improve

• Realize the promise of Outcomes

• Provide public accountability for outcomes


Conceptual change from…

The Current Accreditation System

Rules

Corresponding Questions

“Correct or Incorrect”

Answer

Citations and Accreditation

Decision

Rules

Corresponding Questions

“Correct or Incorrect”

Answer

Citation and Accreditation

Decision

© 2012 Accreditation Council for

Graduate Medical Education (ACGME)

To...

The Next Accreditation System


Continuous

Observations

Potential

Problems

Diagnose

the Problem

(if there is one)

Ensure Program

Fixes the Problem Promote

Innovation


• Goals




• CLER visits

NAS-Annual Inputs

RRC

Board Pass Rate

Case Logs/Clinical

Experience

ADS Annual Update

Resident

Survey

Core Faculty Survey

Milestone

Semi Annual

Reporting

Trended Performance Indicators

Annual ADS Update

Program Attrition – Changes in PD/Core Faculty/Residents

Program Characteristics – Structure and Resources

Scholarly Activity – Faculty and Residents

Board Pass Rate – Rolling Rates

Resident Survey – Common and Specialty Elements

Clinical Experience – Case Logs or other

Semi-Annual Resident Evaluation and Feedback

Milestones

Faculty Survey – Core Faculty

Ten year self-study


Most already in place


• No PIF’s

• No site visits (as we know them)

• Focused site visits for “issues”

• Self-study visits every ten years


Internal Reviews

• Currently required at mid-cycle

• In NAS, NO requirement for routine IRs

• GMEC must demonstrate program oversight

• Annual Program Reviews

• Special Review for programs when warranted


NOTE: New Institutional Requirements available for comment on 11/19/2012

Streamlined ADS Annual Update

• 33 questions removed

• 14 questions simplified

• Very few essay questions

• Self-reported board pass rate removed

• Faculty CVs removed

• 11 MCQ or Y/N questions added


Current PIF Faculty CV


Scholarly Activity Template


Faculty Scholarly Activity

Enter

Pub Med ID #’s

© 2012 Accreditation Council for Graduate

Medical Education (ACGME)


Enter a number




Answer

Yes or No




• For each core faculty member enter:

–x Pub Med ID’s

–Four numbers

–Answer two Y/N questions

• For each resident with scholarly activity enter:

–x Pub Med ID’s

–Two numbers

–Answer two Y/N question


NAS: Program Activities

2014-2015 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun




Case Logs Yr 0 Yr 1





ADS Update Yr 1

Case Logs Yr 0 Yr 1





Resident Survey Yr 1

ADS Update Yr 1

Case Logs Yr 0 Yr 1





Faculty Survey Yr 1


ADS Update Yr 1

Case Logs Yr 0 Yr 1





Milestones Yr 0 Yr 1 Yr 1

Faculty Survey Yr 1


ADS Update Yr 1

Case Logs Yr 0 Yr 1




• Goals




• CLER visits

Conceptual Model of Standards Implementation

Across the Continuum of Programs in a Specialty

STANDARDS

Outcomes

Core Process

Detail Process


Continued

Accreditation

Outcomes

Core Process

Detail Process



STANDARDS

Outcomes

Core Process

Detail Process

Application

for

New Program

Outcomes

Core Process

Detail Process

Initial

Accreditation

Outcomes

Core Process

Detail Process


Continued

Accreditation

Outcomes

Core Process

Detail Process



STANDARDS

Outcomes

Core Process

Detail Process

Application

for

New Program

Outcomes

Core Process

Detail Process


Withhold Accreditation



STANDARDS

Outcomes

Core Process

Detail Process

Accreditation

With

Warning

Outcomes

Core Process

Detail Process

Continued

Accreditation

Outcomes

Core Process

Detail Process




STANDARDS

Outcomes

Core Process

Detail Process

Probationary

Accreditation

Outcomes

Core Process

Detail Process

Continued

Accreditation

Outcomes

Core Process

Detail Process




STANDARDS

Outcomes

Core Process

Detail Process

Outcomes

Core Process

Detail Process


Continued

Accreditation

Outcomes

Core Process

Detail Process

Withdrawal of Accreditation

Accreditation

with Warning

Probationary

Accreditation



STANDARDS

Outcomes

Core Process

Detail Process

© 2012 Accreditation Council for

Graduate Medical Education (ACGME)

Continued

Accreditation

Withdrawal of Accreditation

Accreditation

with Warning

Probationary

Accreditation

2-4% 10-15% 75-80%

<1%

Application

for

New Program


• Goals




• CLER visits

NAS Timeline

Phase I specialties • Neurological Surgery

• Orthopedic Surgery

• Urology

• Diagnostic Radiology

• Emergency Medicine

• Internal Medicine

• Pediatrics

• Subspecialties of all above

© 2012 Accreditation Council for Graduate Medical Education (ACGME) JGME 2012; 4:399

NAS Timeline: Phase 2 Specialties

• Spring 2013:

• Programs with > 2 year cycles are moved into NAS

• July 1, 2013 – June 30, 2014

• Programs report annual data

• Spring 2014

• Identify and train CCCs

• July 2014: Go live


http://www.acgme-nas.org/assets/pdf/KeyDatesPhase1Specialties.pdf


• Goals




• CLER visits

CLER Visits

Clinical

Learning

Environment

Review


JGME 2012; 4:396-8

CLER Visits: Six Areas of Focus

• Patient Safety

• Quality Improvement

• Transitions in Care

• Supervision

• DH Oversight / Fatigue Management

• Professionalism

© 2012 Accreditation Council for Graduate Medical Education (ACGME) JGME 2012; 4:396-8

CLER Visits: Context

• Resources

• Faculty

• Residents

• Measures

• Improvement


CLER Visits: Structure

• NOT yet fully established

• But will include:

• Meetings:

• C suite

• Quality / Safety Officers

• Program Directors

• Faculty

• Residents

• “Walk Arounds”


CLER Visits: Report Content


CLER Program

• Five pilot visits

• Beta testing began September

• Institutions to be visited q 18 months

• 1st round: Formative feedback

• Thereafter, used in accreditation


What’s Next

• 9 programs have “beta” tested PS milestones already (THANK YOU)

• Request for volunteers for 2nd MS Beta Test

• Look for information on ACGME Monthly “Webinars” • General Information

• Specialty Specific Webinars

• Announced in ACGME e-Communications

• Look for announcements in ACGME e-Communication

• Registration required

• Will be recorded for future use

What’s Next (cont.)

• Check NAS “Microsite” on ACGME

website often:

• http://www.acgme-nas.org/

http://www.acgme-nas.org/




NAS in a Nutshell

• Continuous Accreditation Model

• Based on review of annually submitted data

• SVs replaced by 10-year Self-Study Visit

• Program Requirements revised every 10 yrs.

• Program Requirements organized by:

• Outcomes

• Core Processes

• Detailed Processes


Based on review of annually

submitted data

• SVs replaced by 10-year Self-Study Visit

• Standards revised every 10 years

• Standards organized by:

• Outcomes

• Core Processes

• Detailed Processes

Summary: NAS

• Focus on outcomes

• Reduce burden

• Allow programs to innovate


Operative Log System

ACGME Case Logs-Key Points

• Case log system required for al I-6 programs on July 1, 2012 for entering residents

• Case log system required for all other TS residents on July 1, 2013

• Set up is required for:

• Sites

• Physicians

• Rotations

• Mentoring Reports Available

RRC Updates

Program Data

Total # Accredited Programs 95

TS Independent # Core 66

TS Integrated # Core 18

Congenital

Cardiac

Surgery

# Sub 11

2012-13 RRC Citation Data

Top Five Citation Categories

Duty Hours

Goals and Objectives

Responsibility of PD and Faculty

Evaluation

Performance on Board Exams

TS FAQ

I-6 Core Surgery PR IntC1c)(2)

• Core surgical education includes no more than six months of adult and congenital heart surgery, general TS, & cardiothoracic ICU.

• 24-36 months should include:

• general surgery,

• cardiac surgery,

• thoracic surgery,

• congenital cardiac surgery,

• cardiothoracic surgery critical care,

• urology,

• gynecology,

• neurological surgery,

• plastic surgery,

• burn surgery,

• trauma,

• vascular surgery,

• surgical critical care,

• pediatric surgery,

• abdominal & alimentary tract surgery,

• basic & advanced laparoscopic skills,

• head &neck & endocrine surgery,

• surgical oncology,

• transplantation.

2014 Meeting Dates

• Meeting: January 10-11, 2014

• Agenda Closing: November 15, 2013

• Meeting: July 11-12, 2014

• Agenda Closing May 1, 2014

TS RRC ACGME Contacts

• Peggy Simpson, EdD-Executive Director

• Cathy Ruiz, MA-Sr. Accreditation Administrator

• Allean Morrow-Young-Accreditation Assistant

QUESTIONS????????????????

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