ACGME RESIDENCY INTERNAL PROGRAM REVIEW CHILDREN'S HOSPITAL, INC 1 The Accreditation Council for Graduate Medical Education (ACGME) requires Children's Hospital, Inc. (Children s) to review of all residency programs approximately midway through their accreditation period. This tool is utilized by the Graduate Medical Education Committee (GMEC) to partially fulfill this requirement. Additional information may be requested by the GMEC as necessary. I. COMPLIANCE WITH ACGME & CHILDREN S INSTITUTIONAL POLICIES A. Previous ACGME Citations and Concerns 1. Date of last Residency Review Committee (RRC) accreditation survey and any citations or concerns. 2. Please describe specific actions taken to address each previous citation or concern identified in the previous ACGME letter of accreditation. Include any Progress Reports which have been submitted to the RRC. 3. Please describe actions taken to address issues identified in previous Internal Program Review. B. Financial Support & Benefits for Residents 1. Please identify the salary for each level of resident. PGY-1 PGY-4 PGY-2 PGY-5 PGY-3 Other (specify) 2. Residents are required to sign a Children s resident contract. Please attach a copy of the contract used and verify that all residents have the appropriate contract. C. Supervision and Working Environment 1. Please describe your mechanism to assure adequate supervision of residents, including nights, weekends, and in community-based activities. 2. Please describe how you give residents progressively more independence during their training while maintaining necessary and appropriate supervision. 3. Have any institutional or other factors inappropriately shifted the balance of resident activities from education to service? Please describe. D. Duty Hours 1. Please attach the program-specific policy on resident duty hours. Provide copies of the schedules, including in-house, home, and moonlighting assignments.
2. How does the Program document compliance with the duty hours policies and ACGME guidelines. 2 3. Do the residents moonlight? Yes No. If yes, please describe your policy and verify that the Program Director or designee approves in writing each moonlighting experience. 4. How are residents educated to recognize signs of fatigue and stress in themselves and others? E. Ancillary Support Please check if residents have had any problems with the following areas that have adversely influenced their educational experience. Call rooms Food services Lab services Radiology services Pathology services Pharmacy services Respiratory care services Other (please specify) Please explain any checks. IV services Phlebotomy services Transportation Library Medical records Nursing services OT/PT services Safety & security F. Counseling and Support Services 1. Are the residents and Program Director familiar with available counseling and support services? Do they know whom to contact to obtain services? 2. Please identify any barriers you believe influence residents utilization of counseling and support services. G. Do any of your residents spend time at another institution? Yes No If yes, written program letters of agreement (memoranda of understanding) with each institution must be in place (overall GME Affiliation Agreement is not sufficient). This agreement must specify how this educational experience complies with the Program s requirements. Please identify each institution and attach the agreement.
3 II. EDUCATION PROGRAM The educational content of the residency program is driven by two, complimentary sets of standards: (1) general competencies that apply to every ACGME accredited program and (2) program specific standards are defined in the Program Requirements specified by each RRC. A. Program Design Please attach a copy of written curriculum, including the program s educational goals and objectives. This curriculum must address the specific knowledge, skills, attitudes, and educational experiences required for the residents to achieve competence in the 6 areas as well as the RRC Program Requirements. B. Attach a typical block rotation schedule for the residents (see PIF for required format) C. Available Resources Are there adequate educational and financial resources available to meet the program s goals and objectives? If not, please identify deficiencies. SIX GENERAL COMPETENCIES Programs are required to design the educational program to teach and evaluate each of the 6 general competencies. A single, global rating scale is not sufficient evaluation. For each of the competencies below, please describe the teaching and assessment process in the program. Attach any evaluation tools used. 1. Medical Knowledge List the conference, didactic lectures and other educational experiences which facilitate residents gaining core medical knowledge identified by the RRC In-training exams? Other knowledge tests? 2. Patient Care Experiences Number & types of patients seen (refer to PIF & RRC requirements) Compassionate, appropriate, & effective treatment of health problems & promotion of health Procedure log? Tools and processes to verify competency 3. Interpersonal & Communication Skills
4 Skills in exchanging information, teaching, and communicating with patients, families, and the other members of the health care team Rating scales? Direct observation which is documented in resident file? Patient feedback? 360 o feedback? 4. Professionalism Ethical issues and challenges specific to your specialty Residents abilities to sensitively and compassionately interact with patients and families of diverse backgrounds Rating scales? Direct observation which is documented in resident file? Patient feedback? 360 o feedback? 5. Practice-based Learning Performance improvement process, including participation in hospital-wide initiatives such as COE or medication safety, M&M conferences, department or section PI projects, etc Lectures or presentations EBM project List residents who are members of a PI team or who have participated in a PI initiative Feedback from team members or faculty evaluation Documentation of project they produced 6. Systems-based Practice Activities which enable residents demonstrate awareness of, and responsiveness to, the larger context and system of health care. Describe how residents learn to effectively call upon system resources to provide care that is of optimal value. Participation in discharge planning or case conferences (document) Feedback from faculty, case managers, or other members of interdisciplinary team RESIDENT & PROGRAM EVALUATION A. Residents must receive written, semi-annual evaluations by the Program Director or designee with input from the teaching faculty. Please verify that all residents have these in their files.
B. Residents must have a final, written evaluation in their file. Please document compliance. 5 C. Please attach samples of any tools which residents use to evaluate (1) faculty, (2) rotation(s), and (3) overall program (as distinct from evaluation of individual faculty or rotations). Specifically describe how the residents and faculty measure the program s effectiveness in meeting its written goals and objectives as defined above. D. Please describe how you evaluate the quality of the residency program. Check all that apply and include additional comments as appropriate. Please attach any reports or minutes which document this process. Resident evaluations Faculty review(dates) External, peer review Other (please specify) In-training exams Board exams Professional standards Annual meeting with faculty and residents E. Please identify changes in the program since the last RRC review. F. Please attach all of the program s annual reports since the last RRC review. G. Please provide evidence of the process to link educational outcomes (vis-à-vis 6 competencies) as well as other measures with program improvement. What changes have been made as a result of evidence gathered from educational outcomes? What evidence do you have that the program is effective in meeting its objectives? H. Please identify any trends in resident evaluations that require the attention of the GMEC. For fellowship programs in particular, please discuss the availability and satisfaction with the research activities of the program. I. Please identify the current positions of the alumni for the last 3 years. For large programs with numerous residents, please pick a random sample of three residents from each year. J. Please identify any concerns current residents have about the program, including the relevance of any issues identified through the annual on-line survey of residents conducted by the GMEC.
III. PROGRAM ADMINISTRATION & PERSONNEL A. List the Program Director and the date of appointment to the position. If there has been a change in the Program Director since the last RRC visit, has ACGME been notified? 6 Yes No. If no, please contact the GME Office immediately. B. Are all faculty required by the RRC available for resident teaching? If not, please explain how residents acquire this training? C. Does the faculty have regular meetings? weekly monthly other (specify) D. Please identify any concerns that the teaching staff has expressed since the last report concerning the quality of the residency program. E. Resident Selection Do you ever accept residents outside the match? Yes No If yes, please explain. F. Resident Dismissal Have any residents been dismissed from the program or not had their contracts renewed since the last RRC visit? If yes, please describe the circumstances and how the residents rights were protected. REQUIRED ATTACHMENTS: 1. Program-specific policy on duty hours, including process to document compliance 2. Program goals and objectives 3. Block rotation schedule 4. Sample contract 5. Tools to teach and assess ACGME Competencies 6. Copy of last letter from ACGME 7. Clinical log or equivalent 8. Tool(s) for resident to evaluate faculty and/or program 9. Tool(s) for faculty to evaluate residents 10. Teaching staff and appointment date 11. Complete listing of those interviewed during the internal review (to include program director, program faculty and residents)
REVIEW COORDINATION TEAM GUIDELINES 7 Thank you for agreeing to serve as an internal review coordination team member for the graduate medical education (GME) program at Children's. The coordination team consists of a physician faculty member, a resident, and an educational administrator who have been appointed by the GME Committee (GMEC). The GMEC has developed these guidelines to facilitate your completion of this task. Your responsibility in conducting this review is to help the Program Director continuously improve the program by asking the hard, but necessary, questions. It is certainly better for you to identify a problem, and therefore give the Program Director an opportunity to address it, than to have an issue arise during the site survey. If you have questions or need assistance, please contact the GME Office at 722-4905. I. PROCESS A. Send attached questionnaire to the Program Director and explain the purpose, your role, and offer your assistance in completion. A sample letter is attached for your consideration B. Faculty members in the section/department must be interviewed. Interview section/department faculty to get their perspective on key information. Generally all members of the review coordination team participate in this interview, which is best conducted with several faculty members. See attached sample questions. C. Residents must be interviewed. Interview residents who are in process or have completed the program. In large programs, a sample of residents may be interviewed. Resident interviews are done by the resident member of the review coordination team. No faculty or administrators can be present. See attached sample questions. D. Prepare the draft summary report. Submit it, along with the completed questionnaire, to the GME Office. See attached template. II. PARTING TIPS A. IF IT IS NOT DOCUMENTED IT DOES NOT EXIST. B. Our purpose is to improve the quality of our graduate medical education programs, not to see how many problems we can find. However, it is always better for us to find and address issues rather than have the site surveyor find them for us.
8 (date) Program Director Dear : The Accreditation Council for Graduate Medical Education requires that institutions regularly review "all residency training programs in relation to their compliance with institutional policies and the requirements of the relevant ACGME review committee." In order to facilitate this process, the Graduate Medical Education Committee (GMEC) of Children's has developed a three-step process. 1. Completion of attached questionnaire which contains all required ACGME information. This questionnaire should be completed mid-term in your approved accreditation period. For example, if you were approved for 6 years at your last year, this questionnaire needs to be completed 3 years from that most recent site survey. 2. Review of questionnaire, along with interviews from faculty and residents, by the designated review coordination team member 3. Review of program evaluation report by the GME Committee 4. Preparation of final internal review summary by GME office. We have been selected by the GMEC to coordinate the review of your program. The ACGME Residency Program Evaluation questionnaire is attached. Please complete the information by (give 3 weeks). During that time I will be contacting faculty and residents from your area to get information as well. The GME Office is available to assist in compiling certain information. Please feel free to call them or myself for assistance. Sincerely, List 3 members of the review coordination team