2/10/2016. Session Goals. Big Picture. Using The ACGME Program Self-Study as a Catalyst for Program Improvement

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1 Using The ACGME Program Self-Study as a Catalyst for Program Improvement Heidi Kromrei, PhD Assistant Vice President, Academic Affairs Associate Designated Institutional Official Detroit Medical Center Education and Research Michigan State University Statewide Campus System GME eforum Webinar Series February 10, 2016 Session Goals 1. Identify Data Sources used by ACGME Residency Review Committees to Evaluate Residency Programs 2. Understand ACGME Annual Program Evaluation (APE) Requirements and their role in the Self-Study Process 3. Align ACGME Annual Update, APE and Self-Study efforts to Improve Residency Program Performance Big Picture 1

2 Pre-Next Accreditation System: 5-Year Biopsy Next Accreditation System (NAS): Annual Exams NAS: Continuous Evaluation and Improvement Source ACGME 2

3 ACGME 10 Year Self-Study Model APE is important!! ACGME 10 Year Self-Study Model ACGME RRCs Evaluate Programs Annually!! ACGME 10 Year Self-Study Model 3

4 Residency Review Committee Annual Review Data RRC will evaluate this data every year. Will you? The Details: ACGME Annual Update The Details: ACGME Annual Update 4

5 July 2015 ACGME e-news ACGME Annual Update Errors Data Reviewed Annually by RRC: Resident/Faculty Surveys 5

6 Data Reviewed Annually by RRC: Resident Survey Data Reviewed Annually by the RRC: Milestone Evaluations Data Reviewed Annually by the RRC: Milestone Evaluations 6

7 Data Reviewed Annually by the RRC: Case Log Reports Data Reviewed Annually by the RRC: Scholarly Activity Scholarly Activity It s Important! Source: ACGME 7

8 How is Faculty Scholarly Activity Measured? Participation in Professional Activities/Committees Publications Presentations Chapters/Textbooks Grant Leadership Leadership or Peer-Reviewed Role Teaching Formal Courses The Details: Annual Program Evaluation The Details: Annual Program Evaluation 8

9 APE: Identify, Collect, & Analyze Data RRC will evaluate this data every year. Be sure to include it in your APE SWOT Analysis SWOT Analysis Definitions: S: Strengths: Factors likely to have a positive effect on (or be an enabler to) achieving the program s objectives W: (Formerly Known as Weaknesses): Opportunities to improve program performance in areas with noted deficits O: Opportunities: External factors that are likely to have a positive effect on achieving or exceeding the program s objectives, or goals not previously considered T: Threats: External factors and conditions that are likely to have a negative effect on achieving the program s objectives, or making the objective unachievable Conduct SWOT Analyses Strengths of the Program What should definitely be continued? Weaknesses of the Program What aspects of the program should be improved? Prioritized by relevance to program aims, importance to stakeholders, compliance with ACGME requirements Opportunities in the Program Environment What are opportunities that favor the program? New areas for the curriculum? Changes to enhance program performance? Threats in the Program Environment What are the threats to the program? Factors that threaten program success and sustainability Local or national 9

10 Document Findings: The APE Report Program Director s Report Program Aims Resident Performance SWOT Analysis Graduate Performance SWOT Analysis Faculty Development Performance SWOT Analysis Program Quality Performance SWOT Analysis Action Plan for Program Improvement Document Findings: The APE Action Plan for Program Improvement DMC APE Action Plan for Program Performance Improvement Template 10

11 Communicate APE Findings 1. Prepare Final APE Report 2. Submit for Faculty Approval 3. Share with Residents 4. Submit to GMEC 5. Track and provide quarterly progress report to all stakeholders ACGME Self Study Replaces to 5-Year Biopsy method with systematic self-assessment Longitudinal Evaluation Must use successive APE results ACGME defines Eight Steps ACGME Self Study: Eight Steps 1. Assemble the Self-Study Group 2. Engage Program Leaders/Constituents in Discussion of Program Aims 3. Examine Opportunities and Threats 4. Aggregate & Analyze Data to Generate a Longitudinal Assessment of Program s Improvement 5. Obtain Stakeholder Input 6. Interpret the Data and Aggregate the Self-Study Findings 7. Discuss the Findings with Stakeholders 8. Develop Succinct Self-Study Document for Use in Continued Improvement/10 Year Site Visit 11

12 Back to the Big Picture Annual Update, APE & Self-Study Alignment 1. Conduct, document, and Report APE 2. Regularly evaluate the same data sources used by RRC 3. Develop action items (ACGME recommends 3-5 per year)aligned with outcomes reviewed by RRC (e.g. citations, survey deficits, procedural volume, etc.) as well as resident recommendations 4. Don t forget to focus on STRENGTHS as well as deficits 5. Evaluate your program performance in the context of your selfdefined Program Aims 6. Use the ACGME Annual Update Major Changes Section to inform the RRC of your program improvements 7. Update and consult program/institutional stakeholders regularly Final Thoughts Program Aims Annual Program Evaluation ACGME Annual Update Self-Study 10 Year Site Visit 12

13 Questions? References ACGME Slide Presentations for Faculty Development. Accessed online on January 29, 2015 at: caleducation/slidepresentationsforfacultydevelopment.aspx The Self-Study and 10-Year Site Visit: Clarifying the Timeline and Action Steps. Accessed online on April 27, 2015 at: ebinarselfstudy pdf ACGME Eight Steps for Conducting the ACGME Program Self- Study. Accessed online on April 27, 2015 at: nalaccreditation/self-study.aspx 13

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