RRC Ne w s. Co l o n a n d Re c t a l Su r g e r y

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1 RRC Ne w s Co l o n a n d Re c t a l Su r g e r y Accreditation Council for Graduate Medical Education April 2012 Department of Accreditation Services Reorganizes Review Committee Members Effective January 1, 2012, the Department of Accreditation Services was Patrice Blair, MPH, Ex-Officio reorganized into four sections (hospital-based, institutional, medical, and Eric J. Do z o i s, MD Karen M. Hardiman, MD, PhD, surgical), each to be led by a newly hired senior vice president. All senior Resident Bruce A. Or k i n, MD, Vi c e Chair vice presidents are now in place and hard at work. They are: Senior Vice David Schoetz, MD, Ex-Officio President, Hospital-Based Accreditation Louis J. Ling, MD; Senior Vice Anthony Senagore, MD President, Institutional Accreditation Kevin B. Weiss, MD, MPH; Senior Michael J. Stamos, MD Vice President, Medical Accreditation Mary Lieh-Lai, MD; and Senior Vice President, Surgical Accreditation John R. Potts III, MD. Er i c G. We i s s, MD, Ch a i r Charles B. Whitlow, MD Review Committee Staff Pamela L. Derstine, PhD, MHPE Executive Director p d e r s t i n e@a c g m e.o r g Susan Mansker Associate Executive Director s m a n s k e r@a c g m e.o r g Jennifer Luna Accreditation Administrator j l u n a@a c g m e.o r g Deidre Williams Accreditation Assistant dwilliams@a c g m e.o r g ACGME 515 North State Street Suite 2000 Chicago, Illinois w w w.a c g m e.o r g John R. Potts III, MD leads the surgical section, which consists of the following specialties: colon and rectal surgery, neurological surgery, obstetrics and gynecology, ophthalmology, orthopaedic surgery, otolaryngology, surgery, thoracic surgery, and urology. Prior to joining the ACGME, Dr. Potts was assistant dean for graduate medical education, vice chairman for education, and professor of surgery at the University of Texas Health Sciences Center. Dr. Potts brings a wealth of knowledge and experience to the ACGME, including 21 years as a program director, 19 years as chair of the UTHSC GMEC, and two years as a designated institutional official (DIO). We look forward to working with him as we move towards the next accreditation system. Meet Your New ACGME Team With the reorganization of the department, the Review Committee assignments for most executive directors also were reorganized so that the specialties assigned to each executive director fell into just one of the four sections. Former Executive Director Louise King and her team are now working with the Review Committees for Allergy and Immunology, Neurology, and Psychiatry. Pamela Derstine, PhD, MHPE is the new executive director for the Review Committee for Colon and Rectal Surgery, as well as for the Review Committees for Neurological Surgery, Orthopaedic Surgery, and Otolaryngology. The new team supporting these committees includes Susan Mansker, Jennifer Luna, and Deidre Williams. We all look forward to working with the colon and rectal surgery community! (see staff photo on p.2) Meeting and Agenda Closing Dates Meeting: September 21, 2012 Agenda: August 10, 2012 Meeting: March 21, 2013 Agenda Closing: February 7, 2013 Meeting: September 19, 2013 Agenda Closing: August 8, 2013 No t i f i c a t i o n De a d l i n e s 5 Da y s Af t e r Me e t i n g: notification of review status/ 60 Da y s Af t e r Me e t i n g: cycle length automatically sent to program director and DIO. alert sent stating that Letter of Notification is posted in ADS. *Until the official letter is posted in ADS, Review Co m m i t t e e s t a f f m e m b e r s a r e u n a b l e/n o t p e r m i t t e d t o d i s c u s s t h e Co m m i t t e e s a c t i o n o r s p e c i f i c d e t a i l s o f the areas of non-compliance.*

2 Deidre Susan Pam Jennifer Recent Review Committee Activity Recent actions of the Review Committee as well as accreditation data for programs are summarized in the tables that follow. ACCREDITATION STATUS DECISIONS NUMBER March 2012 Continued Accreditation 8 Probation 1 Proposed Withhold 1 NON-STATUS DECISIONS NUMBER Reviewed 2 Resident Complement Approve 1 Deny 1 Reviewed 0 Progress Report Requested 3 Case Log Report Reviewed 3 Requested 11 RRC News for Colon and Rectal Surgery 2 April 2012

3 Review Committee Announcements and Reminders Updates to the ACGME Case Log System for Colon and Rectal Surgery are complete. All programs should regularly monitor residents case logs, and in particular the resident index Case Log Report for each on-duty resident, to ensure timely progress towards achieving the required minimum case numbers in all index case categories. The Review Committee will review the program and resident Case Log Reports in the ACGME Accreditation Data System (ADS) for all program graduates at every fall meeting. Requests for a temporary increase in resident complement for periods of less than three months do not need Review Committee approval. However, programs must still inform the Committee via ADS of any temporary complement change. An educational rationale (remediation, medical leave, off-cycle start date) must be provided with these notifications and requests. Participating site changes (additions, deletions) submitted via ADS and approved by a program s DIO will be reviewed as they are received. Residents must not rotate to a proposed participating site until Review Committee approval for that site is obtained. RRC News for Colon and Rectal Surgery 3 April 2012

4 Colon and Rectal Surgery Milestones The Milestone Project is intended to provide a structured approach to facilitate development of specialty-specific milestones (measurable, developmental benchmarks for competency-based outcomes) and a set of common evaluation tools that all accredited programs in the specialty will use. The planned evaluation/reporting structure will incorporate these tools into an online system used by program directors to assess resident outcomes. The current accreditation system will be replaced, in part, by program reports to the Review Committee containing de-identified data aggregated at the program level and compared to national standards for program performance in the specialty. Such program-level outcome data will be regularly reviewed by the Review Committee as part of the next accreditation system (see following article). Development of specialty-specific milestones requires the assembly of two groups: a Working Group of educators and leaders drawn from the Review Committee (including the resident member and the Committee s executive director), the American Board of Colon and Rectal Surgery (ABCRS), the Association of Program Directors for Colon and Rectal Surgery (APDCRS), and other related organizations; and an Advisory Group of specialty leaders who will assist with establishing support for the milestones and providing feedback to the Working Group. The 9- member Working Group, chaired by Charles Whitlow, MD, had its first meeting in July 2011 and has completed drafts for the patient care and medical knowledge milestones. A second meeting is planned for May A final draft of milestones for all six competency domains should be completed by December The draft will be beta tested during 2013 with full implementation scheduled to begin in July ACGME Announces Next Accreditation System On February 22, 2012, the ACGME announced its next accreditation system in a special report published in The New England Journal of Medicine. The new process, which will be fully implemented by 2014, is an outcomes-based system through which will be measured and evaluated tomorrow s doctors competency in performing the essential tasks necessary for clinical practice in the 21st century. In conjunction with this announcement, the ACGME has launched a microsite, where detail updates and presentations will be posted regularly, explaining in greater depth the philosophy of the next accreditation system, and demonstrating how the rollout of next accreditation system will reduce administrative burden, facilitate innovation, improve patient safety, and enhance quality of patient care. For more information, please visit our new microsite, FOCUS ON ACGME POLICY AND PROCEDURES: SECTION 6.50 MONITORING COMMITTEE The Monitoring Committee is a standing committee of the ACGME Board of Directors, comprised of Board members appointed by the Chair of the Board. It evaluates each Review Committee at least once every five years, functioning very much like the GMEC does with respect to residency and fellowship programs in an institution. It is charged with: evaluating the performance of Review Committees; monitoring, advising, and making recommendations to the ACGME regarding Review Committee activities and delegation of accreditation authority; and accruing knowledge about improving accreditation practices. When preparing for a review by the Monitoring Committee, the Review Committee must complete an extensive Monitoring Committee Report Form, as well as provide all Committee meeting minutes, current program information forms (PIFs) and Site Visitor Report Forms, past Monitoring Committee reports, past Review Committee newsletters, and statistical data on accreditation activities. The Monitoring Committee Report Form covers: basic information and history about the specialty and past accreditation activities of the Review Committee; extensive information related to Review Committee functions, such as member appointments, accreditation procedures, revision of Program Requirements, and use of data for accreditation decisions, including data related to competency-based outcomes; and procedures and outcomes related to Review Committee self-evaluation and improvement activities. The Monitoring Committee reviews the materials and then meets with the Review Committee chair and executive director to discuss and clarify the information. At the conclusion of this interview, the Monitoring Committee reconvenes in an executive session to finalize its recommendations. These are provided to the Review Committee in a written report that includes a recommendation for a period of delegated authority to the Review Committee (up to five years) and may identify areas of concern (much like citations) that must be addressed in a progress report to be reviewed by the Monitoring Committee prior to the next scheduled Monitoring Committee review. RRC News for Colon and Rectal Surgery 4 April 2012

5 The Review Committee for Colon and Rectal Surgery was reviewed by the Monitoring Committee in September 2010 and was awarded a five-year period of delegated authority by the ACGME Board of Directors. ACGME BOARD RESOLUTION ON PROFESSIONALISM At its meeting of February 7, 2012, the ACGME Board of Directors unanimously adopted the following resolution: WHEREAS, the ACGME Board of Directors expects the highest degree of professional behavior to be modeled by Residency Program Directors and Faculty, and; WHEREAS, the ACGME Board of Directors has endorsed standards of Resident professionalism in the core competencies for more than 10 years, and therefore; WHEREAS, the ACGME Board of Directors reaffirms its expectation that Designated Institutional Officials, Program Directors, Faculty, and Residents must demonstrate the core elements of professional behavior in all aspects of their clinical and educational activities; RESOLVED, that it directs the ACGME to review its standards, and recommends any modifications of these standards and their enforcement required to assure that these expectations are met. Progress Reports to the Review Committee The Review Committee continues to remind program directors that progress reports should only be submitted for review upon request, as noted specifically in the accreditation notification letter. The Committee will not review unsolicited progress reports. Such reports will be administratively acknowledged with no further action. It is also important to note that the Review Committee does not rescind (remove) citations from a program s history upon review of a (requested) progress report. A progress report should update the Committee on how the program is addressing those areas identified for comment in the Committee s request for the report. Citations can only be identified as corrected at the time of a full program review when they are thoroughly evaluated through the site visit and review of accreditation materials. The Resident Review The latest issue of Resident Review, the ACGME s online newsletter for residents, is always available on the ACGME website. The newsletter features articles on ACGME programs of interest to residents, resident opinion pieces, a question of the month provided by the ACGME Office of Resident Services, and resident human interest stories. The latest issue can be viewed here. Please forward the link to his newsletter to residents in your program or institution. Article ideas and comments are welcome. Please send ideas or suggestions to Marsha Miller, associate vice president of resident services, mmiller@acgme. org. Save the Date 2013 ACGME Annual Educational Conference February 28-March 3, 2013 Walt Disney World Swan and Dolphin Orlando, Florida **more information to follow** RRC Ne w s p r o v i d e s t i m e l y a n d c u r r e n t Re v i e w Co m m i t t e e u p d a t e s, a s w e l l a s g e n e r a l ACGME i n f o r m a t i o n a n d e x p l a n a t i o n s o f i t s s y s t e m s, p o l i c i e s, a n d p r o c e d u r e s. It a l s o s e r v e s a s a v e h i c l e f o r communication between the Review Committee and its constituents. Pl e a s e c o n t a c t t h e Ed i t o r w i t h s u g g e s t i o n s o r c o m m e n t s a b o u t t h i s n e w s l e t t e r: m s c h w a b@a c g m e.o r g. Ne w s l e t t e r s a r e t y p i c a l l y a v a i l a b l e f o l l o w i n g a Re v i e w Co m m i t t e e meeting, between once and three times per year. RRC News for Colon and Rectal Surgery 5 April 2012