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ACGME AccreditationACGME Accreditation
New Program Coordinator RetreatNew Program Coordinator RetreatOctober 3, 2011October 3, 2011
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GoalsGoals
Accreditation cycle: overview Office files: managing paperwork Annual accreditation to-dos ACGME rules and program specifics ADS to-dos Program changes Accreditation cycle: details Computer files Resources
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Accreditation Cycle: Accreditation Cycle: MultiMulti--year Spanyear Span
Site VisitSite Visit PIF Preparation
InternalReview
Accreditation Letter in ADS
Program Responseto the RRC
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Internal vs. ExternalInternal vs. External
Internal [check] GMEC & IRC Internal Review (IR) Program Director
Questionnaire (PDQ) Internal Review Report –
recommendations Program Response to IRC
External [test] RRC Site Visit (SV) Program Information
Form (PIF) Accreditation Letter –
citations Program Response to RRC
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Office FilesOffice Files
Trainee Files (contracts!)Trainee Files (contracts!) Evaluations (final evaluations!)Evaluations (final evaluations!) Annual Program Review (documentation!)Annual Program Review (documentation!) Affiliation AgreementsAffiliation Agreements Duty HoursDuty Hours Procedure and/or Case LogsProcedure and/or Case Logs
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Annual Accreditation IssuesAnnual Accreditation IssuesPlace on your CalendarPlace on your Calendar
Trainee Eligibility Requirements USMLE policy Contracts
Program Letters of Agreement Summative Evaluations Annual Program Review meeting and
documentation
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What are the Rules?What are the Rules?
RRC Requirements
Specialty PIF
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Program Requirements & Common Program Program Requirements & Common Program RequirementsRequirements
Scope and duration of training Participating sites Trainee eligibility criteria ACGME competencies Scholarly activities Trainee formative evaluation Trainee summative evaluation Faculty evaluation Program evaluation & improvement And many more…
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ADS LoginADS Login
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““Update Program InfoUpdate Program Info””Program Accreditation PageProgram Accreditation Page
View Program informationView Program information DIO, PD, Department Chair, CoordinatorDIO, PD, Department Chair, Coordinator Dates: original accreditation, accreditation effective Dates: original accreditation, accreditation effective
date, last site visit date, next site visit datedate, last site visit date, next site visit date Length of training, number of years of prior or Length of training, number of years of prior or
additional GME training, additional research yearsadditional GME training, additional research years Approved trainee complement & filled positionsApproved trainee complement & filled positions Participating sites & purpose of experienceParticipating sites & purpose of experience Resident rosterResident roster
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Annual ADS toAnnual ADS to--dosdos
Annual Update (JulyAnnual Update (July--August)August) ““Update Program InformationUpdate Program Information”” ““Update Resident InformationUpdate Resident Information””
If your trainees start training offIf your trainees start training off--cycle, you may need to cycle, you may need to update this information throughout the yearupdate this information throughout the year
Resident Survey (JanuaryResident Survey (January--June)June)
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““Update Program InfoUpdate Program Info”” contcont’’dd……
View program information
Update contact information Program Director Program Coordinator
Add/delete participating sites after GMEC approval
Update faculty/CVs
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““Update Resident InfoUpdate Resident Info””
Also make sure to enter accurate DOB
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““Resident/Fellow SurveyResident/Fellow Survey””
• Quality Assurance Checkpoint• Resource for PIF Preparation
• Aggregate Report• National Data
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Program ChangesProgram Changes
GMEC reviews and approves prior to submission to the RRC/ACGME:
all applications for new programs and subspecialties (PEC: including NON-ACGME) applications for new accreditation (PEC) changes in resident complement (BWHEC/ECOTE; PEC, if hospital funding is sought) major changes in program structure or length of training (BWHEC/ECOTE) additions or deletions of participating institutions used in a program (BWHEC/ECOTE) appointment of new program director (BWHEC/ECOTE) progress reports requested by any Review Committee (BWHEC/ECOTE) requests for increases or any change in resident duty hours (BWHEC/ECOTE) requests for "inactive status" or to reactivate a program (BWHEC/ECOTE) voluntary withdrawals of ACGME-accredited programs (BWHEC/ECOTE) responses to all proposed adverse actions (BWHEC/ECOTE) requests for an appeal of an adverse action (BWHEC/ECOTE) appeal presentations to a Board of Appeal or the ACGME (BWHEC/ECOTE)
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In ADS: In ADS: ““Request ChangesRequest Changes””
GMEC approval must be obtained prior to submitting any program changes to the RRC
Documents must be submitted at least 3 weeks before the GMEC meeting
GMEC staff BWH – Irina Knyshevski MGH – Georgi Bland
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Accreditation Cycle: detailsAccreditation Cycle: details
Where in the accreditation cycle Where in the accreditation cycle are you?are you?
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Accreditation Cycle: Accreditation Cycle: MultiMulti--year Spanyear Span
Site VisitSite Visit PIF Preparation
InternalReview
Accreditation Letter in ADS
Program Responseto the RRC
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““PIF PreparationPIF Preparation””
Common PIF Print/Preview PIF Specialty Specific PIF PIF must be submitted to the GME Office
2 weeks prior to mailing to the site visitor
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Faculty RosterFaculty Roster
Allows you to copy faculty details and CVs from other programs within the
Sponsoring Institution
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““Site Visit ResultsSite Visit Results””
Notification Letters Respond to Citations
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6 months before an RRC site visit6 months before an RRC site visit
Review: ACGME Resident Survey Annual program review Internal Review and your response to the recommendations Accreditation letter with citations and your response to the RRC
Determine your weak points
Do any of your action plans need to be re-evaluated?
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6 months before an Internal Review6 months before an Internal Review
Review: Curriculum; goals and objectives ACGME Resident Survey Annual program review Internal Review and your response to the recommendations Accreditation letter with citations and your response to the RRC
Do any of your RRC citations and Internal Review recommendations still need to be addressed?
Do any of your action plans need to be re-evaluated?
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Computer FilesComputer Files
Accreditation Folder Prior Program Information Form (PIF) Accreditation Letter RRC Correspondence Program Response to the RRC Internal Reviews Program Response to Internal Reviews ACGME Resident Surveys Minutes from the Annual Program Review Resources: Program Requirements, Common Program
Requirements, ACGME Newsletters, etc.
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RESOURCESRESOURCES
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ACGME Resources: ACGME Resources: ““Tools/ReferenceTools/Reference””
ADS Video Tutorials Duty Hours FAQ Competency/Assessment Glossary Optional Resident Upload Instructions
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GME Resources on the WebsiteGME Resources on the Website
Site Visit Preparation documentsSite Visit Preparation documents Responding to the RRC Responding to the RRC Affiliation Agreement formsAffiliation Agreement forms Trainee ContractsTrainee Contracts PoliciesPolicies
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Other GME ResourcesOther GME Resources
PORT Core Curriculum Chief Resident Course Fellow Retreat Orientation
Centers Of Expertise New Innovations
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GME Directors & APECS staffGME Directors & APECS staff
Dr. Dempsey SpringfieldUrology
Dr. Dempsey SpringfieldThoracic Surgery
Dr. Dempsey SpringfieldSurgery
Dr. Eric NadelRadiology
Dr. Dempsey SpringfieldRadiation Oncology
Dr. John CoPsychiatry
Dr. Dempsey SpringfieldPlastic Surgery
Dr. Eric NadelPhysiatry
Dr. Eric NadelPediatrics
Dr. John CoPathology
Dr. Eric NadelOrthopedics
Dr. John CoOB-GYN
Dr. Dempsey SpringfieldNuclear Medicine
Dr. Eric NadelNeurology
Dr. Dempsey SpringfieldNeurosurgery
Dr. John CoInternal Medicine
Dr. John CoEmergency Medicine
Dr. John CoDermatology
Dr. Dempsey SpringfieldAnesthesiology
Associate DirectorDEPARTMENT
Georgi Bland. Irina Knyshevski
Partners Education Committee
Cheryl Reif NRMP Residency Match
Anne Rigg New Innovations
Georgi BlandMGH Education Committee (ECOTE)
Irina Knyshevski BWH Education Committee (BWHEC)
Georgi Bland. Irina Knyshevski
Duty Hours
Cheryl ReifInternal Reviews
Georgi Bland. Irina Knyshevski
ACGME accreditation
Contacts for APECS questions regarding:
Accreditation, Program, and Education Committee Support
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Lessons Learned and Action ItemsLessons Learned and Action Items
Review Program Requirements Calendar reminders for annual activities Office files Computer files Where in the accreditation cycle are you?