Urology RRC: Policies, Processes and Inner Workings

Transcription

1 Urology RRC: Policies, Processes and Inner Workings Kathleen Quinn-Leering, PhD Executive Director, Review Committee for Urology 2018 SAU Program Directors, Coordinators & Academicians Meeting February 8, 2018

2 Disclosure Fiduciary Full-time employee of ACGME Financial None

3 Topics Annual Program Review Self-Study and 10 Year Site Visits ACGME and RRC News Tips and Reminders Questions

4 Annual Program Review

5 Accreditation Process Continued Accreditation Following Year & Subsequent Yrs Continued Accreditation Application for ACGME Accreditation Initial Accreditation (1-2 yrs) Site Visit Initial Accreditation with Warning (1 yr) Site Visit Site Visit Continued Accreditation with Warning Probationary Accreditation (2 yrs max) Withdrawal of Accreditation

6 Programs that have achieved Continued Accreditation Continued Accreditation RRC Annual Review RRC Annual Review RRC Annual Review RRC Annual Review RRC Annual Review RRC Annual Review RRC Annual Review Program Selfstudy & RRC Annual Review RRC Annual Review 10 Year Site Visit

7 RRC Annual Review Clinical Case log Board Pass Rate Attrition Faculty Survey Program Change Resident Survey RRC Annual Review Scholarly Activity

8 RRC Annual Review The RRC Executive Committee examines Programs with statuses of Continued Accreditation with Warning or Probation Programs with existing citations Programs that do not meet one or more of the RRC s established thresholds for data collected

9 On the flip side... Which programs does the RRC Executive Committee NOT examine? Programs that have all of the following: Continued Accreditation No current citations Meet/exceed all of the RRC s established thresholds

10 RRC REVIEW Most programs are substantially compliant with requirements or have no significant issues placed on a special agenda Remaining programs: Each program assigned to two RRC members for in-depth review Program discussed at an RRC meeting to render an accreditation decision Programs notified of new accreditation status right after meeting ( ) and letter with details sent within 60 days

11 When does the RRC request clarifying information or a site visit? When additional information is needed to render an accreditation decision.

12 Self-Study and 10 Year Site Visit

13 Schedule for Urology Programs Self-studies scheduled from Year Site Visits Have started Will likely take place ~ 2 years after self-study

14 Self-Study Program notified to begin Self-Study 6-7 months before summary due Dates in ADS Core residency and fellowship(s) undergo process together once fellowship has achieved Continued Accreditation

15 Self-Study Program conducts comprehensive evaluation of program Program completes & upload a Self-Study Summary Summary does not include agreed upon action items

16 See acgme.org for Self-Study resources

17 10 Year Site Visit Once Site Visit is announced, program: Updates information in ADS as needed Completes self-study related documents and upload in ADS Gathers documents for Site Visitor to review (e.g., training files, goals & objectives, policies)

18 10 Year Site Visit Site Visitor will: Review compliance through meetings & documents review Review the self-study process RRC will assess compliance with requirements & render accreditation decision Department of Field Activities will share feedback on selfstudy process

19 Could there be changes by the time your program is notified of a self-study or 10 year site visit? YES there may be changes as more data and feedback is gathered on the self-study and 10 year site visit process.

20 In sum... Once a program achieves continued accreditation, the RRC will review the program each academic year The review may be: An annual review of program data (and may involve site visits, there may clarifying information or a site visit) OR A 10 Year Site Visit review Keep in mind, due to the challenges of scheduling occasionally be programs that receive two accreditation decisions in one year.

21 ACGME and RRC News

22 Common Program Requirements Revised Section VI: The Learning and Working Environment Went into effect on July 1, 2017 Proposed Sections I-V: Posted for Review and Comment Please take time to review and give feedback positive or negative

23 Milestones Milestones 2.0 has started Goal: Easier to understand & implement Urology will be a later participant Urology Milestones Working Group will: Focus on Medical Knowledge and Patient Care/Procedural Skills Review other four harmonized competency areas Input from programs will be sought

24 Physician Well-being Resources on acgme.org What We Do>Initiatives>Physician Well-Being Resources include: Physician suicide prevention video Webinar Worksheets to help get started Literature review MORE TO COME

25 More online ACGME resources to come!

26 Independent Subspecialties The RRC will consider exceptions to the requirement that fellowships be residency-dependent (i.e., linked to a core program) Reviewed by the RRC on a program-by-program basis

27 Tips and Reminders

28 Why does ADS* matter? *Accreditation Data System

29 Does your program: Have qualified faculty? Have residents who meet eligibility requirements? Provide adequate procedural experience? Provide residents and faculty with timely feedback? Have an appropriate service to education balance? Teach residents about quality improvement? Prepare residents to pass the board exams?

30 Citation Responses Clear Succinct Accurate Updated

31 Major Changes Not just for major changes! Use this area to directly to communicate to the RRC Outline how program is addressing ANY area of concern (e.g., Area for Improvement or AFI, recent survey results, faculty attrition)

32 Faculty Roster: Certification ABU Certified = ABMS AOBS Certified = AOA Use Maintenance of Certification (MOC) or Original/Recertified consistently Over 10 years old? Cannot be Original... Use Time Unlimited, Lapsed or Re-certified

33 Faculty Roster Certification cont d If faculty member is not board certified (and not in the process), can ask RC to consider qualifications Letter from program director and Designated Institutional Official (DIO) to RC with faculty CV (send to jcampbell@acgme.org) If faculty member has a subspecialty Include both specialty and subspecialty in ADS Specialty listed first

34 Faculty Information Use ADS instructions

35 Let s chat about block diagrams... Strongly recommend following the instructions in ADS

36 Block Diagram It is a block diagram, not the residents /fellows schedules Use the same site numbers as on the Site Tab in ADS Site information on Site Tab must be consistent with block diagram Rotation name = educational experience (e.g., Urodynamics, Pediatric Urology) Include notes at bottom for site number/names, abbreviations, vacation and any other helpful information

37 Remember... Should be easy for someone not at your institution to understand the block diagram Tip: If the block diagram is very colorful... it s not a block diagram!

38 Complement Increase Requests

39 Complement Increase Requests Temporary increase requests < 90 days: educational rationale Temporary increase 90 days and Permanent increase requests: educational rationale, proposed block diagram and institutional procedural data

40 Complement Increase Requests Educational rationale should clearly outline educational reason for request RRC will look at institutional data and case log reports to see if adequate procedural volume Proposed block diagram for each year of increase

41 Complement Request Reminders Requests are required for increase in a given year even if the program will not exceed total complement Temporary are reviewed by RRC Executive Committee and turn around is typically under 3 weeks Permanent are reviewed by full RRC pay attention to agenda closing date

42 Core vs. Detail vs. Outcome Requirements

43 Definitions CORE: Statement that defines structure, resources, or process elements essential to the program. DETAIL: Statement that describes a way to achieve compliance with core requirement. OUTCOME: Statement that specifies attributes residents will achieve.

44 Why is this important? Programs that are substantially compliant with program requirements (i.e., have Continued Accreditation) are allowed to innovate in how meet Core Requirements Programs with Continued Accreditation Do not need to comply with Detail Requirements as long as meet Core Cannot receive a citation for non-compliance with Detail Requirement

45 Annual ACGME Activities Beginning of Academic Year: Update ADS for new academic year Ensure graduate case logs are complete before archive November-December: Milestones evaluations of residents/fellows January-April: ACGME Resident and Faculty Surveys End of academic year: Ensure ADS is accurate for current academic year before archived Milestones evaluations of residents/fellows

46 Upcoming RRC Meetings April 12-13, 2018 (Agenda closes February 5, 2018) August 24, 2018 (Agenda closes June 22, 2018) January 17-18, 2019 (Agenda closes November 15, 2018) April 29-30, 2019 (Agenda closes February 10, 2019) August 23, 2019 (Agenda closes June 21, 2019)

47 Have a question? acgme.org Specialties Urology

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49 THANK YOU!