Applying for ACGME Accreditation: Obstetrics & Gynecology

Transcription

1 Applying for ACGME Accreditation: Obstetrics & Gynecology Mary C. Ciotti, MD RC Chair Mary Joyce Turner, RHIA, MJ Executive Director ACGME Webinar May 20, 2015 Updated: September 2015

2 Disclosures Fiduciary Turner (Full-time employee of ACGME) Financial None

3 Discussion Topics Review Committee Members and Staff Accreditation Statistics Pre-Accreditation Status Program Requirements Eligibility Curriculum Case Logs

4 Important Reminder: VIEW! The Transition to ACGME Accreditation: An Overview for AOA Programs John R. Potts, III, MD, FACS Senior Vice President, Surgical Accreditation ACGME Webinar originating from the offices of the ACGME Chicago 1 April 2015

5 Review Committee Members and Staff

6 Department of Accreditation Services (DAS) Sections Hospital-Based Accreditation Medical Accreditation Surgical Accreditation Osteopathic Accreditation Louis Ling, MD Mary Lieh-Lai, MD John Potts, MD Lorenzo Pence, DO Anesthesiology Allergy and Immunology Colon & Rectal Surgery Osteopathic Recognition Diagnostic Radiology Dermatology Neurological Surgery Osteopathic Neuromusculoskeletal medicine Emergency Medicine Family Medicine Obstetrics & Gynecology Medical Genetics Internal Medicine Ophthalmology Nuclear Medicine Neurology Orthopaedic Surgery Pathology Pediatrics Otolaryngology Preventive Medicine PM&R Plastic Surgery Radiation Oncology Psychiatry Surgery Transitional Year Thoracic Surgery Urology

7 All volunteers Review Committee Number of members from 7-20 Physician nominees from: American Medical Association ABMS specialty board American Osteopathic Association Specialty academy/college At least one resident member per RC At least one public member per RC

8 Committee Composition Mary C. Ciotti, MD University of Southern California- Chair Jessica L. Bienstock, MD, MPH- John Hopkins University-Vice Chair Karen E. Adams, MD - Oregon Health and Science University AnnaMarie Connolly, MD -University of North Carolina at Chapel Hill Amber Crowder, MD - Tripler Army Medical Center-Resident Member Gary Frishman, MD - Women & Infants Hospital

9 Committee Composition Robert V. Higgins, MD - Carolinas Medical Center Kimberly S. Kenton, MD - Northwestern University Lee A. Learman, MD, PhD - Indiana University School of Medicine Robert S. Schenken, MD - UTHS Center at San Antonio School Patrice M. Weiss, MD - Carilion Roanoke Memorial Hospital Larry C. Gilstrap, III, MD ABOG Ex-Officio Hal C. Lawrence, MD -ACOG Ex-Officio

10 New Committee Members (7/15) Anita Blanchard, MD University of Chicago Rajiv B. Gala, MD - Ochsner Medical Center Alice Reeves Goepfert, MD University of Alabama Birmingham Gavin F. Jacobson, MD - Kaiser Permanente San Francisco David Jaspan, DO - Albert Einstein Medical Center

11 Turner Team RCs for Ophthalmology, Obstetrics and Gynecology, Urology, and Council of Review Committee Chairs (CRCC) ACGME Staff Mary Joyce Turner, RHIA, MJ Executive Director Jenny Campbell, MA Senior Accreditation Administrator Jordan Elvord Accreditation Administrator Mary Joyce Turner, RHIA, MJ

12 Review Committee Functions

13 Review Committee Functions Review programs and institutions Determine accreditation status* Propose program/institutional requirements *Authority for accreditation actions delegated by ACGME Board of Directors

14 OBG Review Committee Meet 2-3 x per year Review all programs Determine Accreditation status Specialty Specific Program Requirements Set minimums Milestones FAQ s

15 Program Requirements and Common Program Requirements

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18 CPRs Specialty Specific Req.

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20 New OBG requirements Final approval- 9/14 Implementation 7/15 Evaluated/Measured 7/16 Overall few changes more clarification

21 Common Program Requirements Specialty- specific Requirements

22 Common Program Requirements Specialty specific Requirements

23 Terminology Must: A term used to identify a requirement which is mandatory or done without fail. This term indicates an absolute requirement. Shall :(See "Must.") Should: A term used to designate requirements that are so important that their absence must be justified. A program or institution may be cited for failing to comply with a requirement that includes the term should. ACGME Glossary of Terms June 28, Accreditation Council for for Graduate Medical Education (ACGME)

24 PD Qualifications current certification in the specialty by the American Board of Obstetrics and Gynecology (ABOG), or specialty qualifications that are acceptable to the Review Committee; (Core) current medical licensure and appropriate medical staff appointment; and, (Core) a minimum five years of clinical experience in obstetrics or gynecology after completion of a residency in obstetrics and gynecology. (Core)

25 Program Director The sponsoring institution and the program must ensure that the program director has sufficient protected time and financial support for his or her educational and administrative responsibilities to the program. (Core) I.A.1. The program director must dedicate no less than of his or her professional effort to the and activities of the Obstetrics and Gynecology educational program and receive institutional support for this time. (Core) I.A.2. The program director must not be required to generate clinical or other income to finance this administrative time. (Core)

26 Program Coordinator I.A.3. At a minimum, a full-time program coordinator is required for all programs, and should receive full financial support from the institution. (Detail)

27 Program Director There must be a single program director with authority and accountability for the operation of the program. The sponsoring institution s GMEC must approve a change in program director. (Core) The program director should continue in his or her position for a length of time adequate to maintain continuity of leadership and program stability. (Detail) Note: As part of the MOU the RC will consider co-program directors.

28 CPR II.A.4. (2011) PD Responsibilities The program director must administer and maintain an educational environment conducive to educating the residents Oversee didactic and clinical education in all sites Approve local site director each site Approve selection of program faculty Evaluate program faculty Monitor resident supervision

29 PD Responsibilities CPR II.A.4.h) (2011) Ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and implemented by the sponsoring institution

30 Resident Complement There should be at least three approved categorical positions per PGY level. (Detail) All requests for a change in resident complement must demonstrate adequate resources to support the number of resident positions requested must demonstrate that the change will not adversely impact the education of residents currently in the program. based not only on the availability of an adequate patient population but also on adequate resources for supervision, education, and evaluation. (Core)

31 The Faculty must The physician faculty must have current certification in the specialty by the American Board of Obstetrics and Gynecology (ABOG), or possess qualifications judged acceptable to the Review Committee. The physician faculty must possess current medical licensure and appropriate medical staff appointment. (Core) As part of the MOU the RC will accept AOA certified physicians as Core faculty in Type 1 programs (those that were AOA approved and had matriculated residents as of July 1, 2015.

32 The Faculty must: Devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities; and to demonstrate a strong interest in the education of residents; Maintain an educational environment conducive to educating residents in each of the ACGME competency areas; and, (Core) The faculty must establish and maintain an environment of inquiry and scholarship with an active research component

33 Faculty Responsibilities CPR II.B.5 (2011) The faculty must regularly participate in: Organized clinical discussions Rounds Journal clubs Conferences 2014 Accreditation Council for Graduate Medical Education

34 Subspecialty educator The Subspecialty Faculty Educator should be: currently certified in the subspecialty by ABOG, or possess qualifications that are acceptable to the Review Committee; and, accountable to the program director for coordination of the residents educational experiences in order to accomplish the goals and objectives in the subspecialty. (Detail)

35 Faculty supervision- OBG The physician faculty must be immediately available to a resident if clinical activity is taking place in the operating rooms and/or labor and delivery areas; and, If the program director judges that the size and nature of the patient population does not require a 24-hour on-site presence of residents or physician faculty members, this situation must be carefully defined, and must receive prior approval from the Review Committee. (Core) The physician faculty should be within easy walking distance of patient care units. (Detail)

36 Curriculum CPR IV.A. (2011) Curriculum must contain: Overall educational goals for program Goals and objectives Competency based Each assignment Each level Distributed to faculty annually 2014 Accreditation Council for Graduate Medical Education

37 Curriculum CPR IV.A.4. (2011) Curriculum must contain: Delineation of resident responsibilities for: Patient care Progressive responsibility for pt management Supervision of residents 2014 Accreditation Council for Graduate Medical Education

38 Regularly scheduled didactic sessions These sessions should consist of patient rounds, case conferences, simulation training, journal clubs, and protected time for educational activities covering all aspects of obstetrics and gynecology, including basic sciences pertinent to the specialty. (Detail) Interdisciplinary sessions should occur and include health care providers from appropriate specialties. (Detail)

39 Competency- Knowledge Must develop and ultimately demonstrate knowledge of the core and subspecialty content of obstetrics and gynecology, and topics related to women s health care appropriate for the unsupervised practice of obstetrics and gynecology. (Outcome)

40 Patient Care Must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice. (Outcome) Must develop and ultimately demonstrate proficiency in obstetric and gynecologic procedures essential for specialty board certification. (Outcome)

41 PBLI Incorporate formative evaluation feedback into daily practice; (Outcome) locate, appraise, and assimilate evidence from scientific studies related to their patients health problems; (Outcome) use information technology to optimize learning; and,(outcome) participate in the education of patients, families, students, residents and other health professionals.

42 System Based Practice Work effectively health care settings Coordinate patient care Incorporate considerations of cost awareness Work in inter-professional teams to enhance patient safety and improve patient care quality; Identify system errors and implementing potential systems solutions. (Outcome)

43 Chief Resident Experience Within the final 24 months of education, residents must serve at least 12 months as a chief resident. Should be structured to prepare the resident for an independent practice of obstetrics and gynecology. With appropriate supervision, should promote a high level of responsibility and independence, and should include development of technical competence and proficiency in the management of patients with complex gynecological conditions, management of complicated pregnancies, and the performance of advanced procedures. (Detail)

44 Continuity Care-Ambulatory Resident experience in the provision of ambulatory care must be structured to include a minimum of 120 distinct half-day sessions over the course of the program. (Core) Ambulatory care experiences must include longitudinal care for a group of patients whose obstetric, gynecologic, or primary care is the primary responsibility of the residents. (Core)

45 Ambulatory Care Evaluation of performance data for the resident s patients relating to problem orientated and preventative health care; (Core) Faculty member guidance for developing an action plan to improve patient care outcomes based on performance data, and evaluation of this plan at least twice per year; (Core) Resident participation in coordination of care within and across hospital-based and outpatient health care settings; and, (Core) availability to participate in the management of their continuity patients between outpatient visits. (Core) There must be systems of care to provide coverage of urgent problems when a resident is not readily available. (Core)

46 Continuity -Perioperative The opportunity to demonstrate proficiency in peri- operative management must be included in the residents clinical experience. (Core) The program must ensure that residents' clinical experience emphasizes appropriate involvement in the process that leads to selection of the surgical or therapeutic option, the pre-operative assessment, and the post-operative care of the patients for whom they share surgical responsibility. (Core)

47 Family Planning Programs must provide training or access to training in the provision of abortions, and this must be part of the planned curriculum. (Core) Residents who have a religious or moral objection may opt-out, and must not be required to participate in training in or performing induced abortions. (Core) Residents must have experience in managing complications of abortions and training in all forms of contraception, including reversible methods and sterilization. (Outcome)

48 Residents Scholarly Activities IV.B.1. The curriculum must advance residents knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. (Core) IV.B.2. Residents should participate in scholarly activity. (Core) IV.B.3. The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly

49 Resident Evaluation CPR V.A.1. (2011) Resident Evaluation - Formative Faculty must evaluate timely after each rotation Assess all 6 ACGME competencies Must use multiple evaluators Be accessible to residents Timely 2014 Accreditation Council for Graduate Medical Education

50 Board Pass Rate At least 80 percent of the program s graduates from the preceding three-year period must have taken the ABOG written certification examination. (Outcome) At least 80 percent of a program s graduates from the preceding three-year period who take the ABOG written certification exam for the first time must pass. (Outcome) Incorporation of the AOA certification exam into the requirement will occur in the future.

51 Eligibility

52 Eligibility Requirements

53 Eligibility Requirements in Effect on June 30, 2013 Int.C.1. The prerequisite for admission to a urology residency program is a minimum of one year of an Accreditation Council for Graduate Medical Education (ACGME)-accredited surgery program. Based on educational objectives, two years of general surgery is an alternative format. During these one or two years, residents must spend a minimum of three months in general surgery as well as a minimum of three months in the core surgical rotations of critical care, vascular surgery, or trauma. Additional clinical assignments, not including dedicated research time, must enhance the resident education and prepare residents for the practice of urology. The educational program for the general surgery period is developed by the program director of the respective surgery residency program with the input and approval of the respective urology program director. Eligibility Requirements Common Program Requirements are in BOLD Obstetrics & Gynecology Eligibility Requirements Effective July 1, 2014-June 30, 2016 Int.C.1. The prerequisite for admission to a urology residency program is a minimum of one year of an Accreditation Council for Graduate Medical Education (ACGME)-accredited surgery program. (Core)* Eligibility Requirements Effective July 1, 2016 Int.C.1.a) Based on educational objectives, two years of III.A.1.a) All prerequisite post-graduate clinical education general surgery is an alternative format. During these one required for initial entry or transfer into ACGME-accredited or two years, residents must spend a minimum of three residency programs must be completed in ACGME- accredited months in general surgery as well as a minimum of three residency programs, or in Royal College of Physicians and months in the core surgical rotations of critical care, Surgeons of Canada (RCPSC)-accredited or College of Family vascular surgery, or trauma. Additional clinical Physicians of Canada (CFPC)- accredited residency programs assignments must enhance the resident education and located in Canada. Residency programs must receive verification of each applicant s level of competency in the prepare residents for the practice of urology. If there is required clinical field using ACGME or CanMEDS Milestones only a single year of general surgery, dedicated research assessments from the prior training program. (Core) time during that period is not allowed. The educational program for the general surgery period is developed by III.A.1.a).(1) The prerequisite for admission to a urology residency program is a minimum of one year of education in an ACGMEaccredited surgery program or an RCPSC-accredited surgery the program director of the respective surgery residency program with the input and approval of the respective program located in Canada. (Core) urology program director. (Detail) III.A.1.a).(1).(a) Based on educational objectives, two years of III.A. Eligibility Criteria general surgery is an alternative format. During these one or two The program director must comply with the criteria for years, residents must spend a minimum of three months in general resident eligibility as specified in the Institutional III.A. Eligibility Criteria surgery as well as a minimum of three months in the core surgical rotations of critical care, vascular surgery, or trauma. Additional Requirements. The program director must comply with the criteria for clinical assignments must enhance the resident education and prepare residents for the practice of urology. If there is only a single resident eligibility as specified in the Institutional Requirements. (Core) III.A. Eligibility Criteria The program director must comply with the criteria for resident eligibility as specified in the Institutional Requirements. (Core) III.A.1.Eligibility Requirements Residency Programs year of general surgery, dedicated research time during that period is not allowed. The educational program for the general surgery period is developed by the program director of the respective surgery residency program with the input and approval of the respective urology program director. (Detail) A physician who has completed a residency program that was not accredited by ACGME, RCPSC, or CFPC may enter an ACGME-accredited residency program in the same specialty at the PGY-1 level and, at the discretion of the program director at the ACGME-accredited program may be advanced to the PGY-2 level based on ACGME Milestones assessments at the ACGMEaccredited program. This provision applies only to entry into residency in those specialties for which an initial clinical year is not required for entry. (Core) A Review Committee may grant the exception to the eligibility requirements specified in Section III.A.2.b) for residency programs that require completion of a prerequisite residency program prior to admission. (Core) Review Committees will grant no other exceptions to these eligibility requirements for residency education. (Core)

54 The Application (Specialty Specific)

55 Updated Specialty-specific Application will be posted in June 2015

56 Sponsoring Institution/ Program Director Section

57 Sponsoring Institution List at least one other relevant ACGME-accredited programs (i.e., Family Medicine, Internal Medicine, Pediatrics, or Surgery) that are also sponsored by the sponsoring institution. [PR I.A.4.] Name of Specialty Program Name

58 Program Director Will the program director dedicate no less than 20 hours per week of his or her professional effort to the administrative and educational activities of the Obstetrics and Gynecology educational program and receive full institutional support for this time? [PR I.A.1.] Describe the program director s educational and administrative leadership experience that ensures that she or he has the requisite expertise to hold the position of residency program director. (List at least five but no more than ten examples in the last five years) [PR II.A.3.a] Describe the program director s clinical leadership experience within the specialty that ensures that she or he has the requisite expertise to hold the position of residency program director? (List at least three but no more than five examples in the last five years) [PR II.A.3.a]

59 Clinical Volume Obstetrics Profile of Program Site #1 Site #2 Site #3 Site #4 Site #5 Total Spontaneous deliveries # # # # # # Cesarean deliveries # # # # # # Operative vaginal deliveries # # # # # # Obstetric ultrasound # # # # # # Percent of obstetric patients available for resident education #% #% #% #% #% #% Gynecology Profile of Program Site #1 Site #2 Site #3 Site #4 Site #5 Total Abdominal hysterectomy # # # # # # Vaginal hysterectomy # # # # # # Laparoscopic hysterectomy - all types, including robotic # # # # # # Surgery for urinary incontinence (vaginal or abdominal) and reconstructive # # # # # # pelvic procedures Number of operative laparoscopic procedures # # # # # # Cystoscopy # # # # # # Operative hysteroscopy # # # # # # Abortion # # # # # # Transvaginal ultrasound # # # # # # Surgery for Invasive Cancer # # # # # #

60 Continuity Clinic a) Continuity Clinic Data (Do not include sessions that are obstetric only) Planned number of weeks of clinic per year per resident Planned number of halfday sessions per resident per week Estimated average number of patients seen per resident per session PGY I # # # PGY II # # # PGY III # # # PGY IV # # #

61 Family Planning Will the program provide training in the provision of abortions as part of the planned curriculum? [PR IV.A.6.d).(1)] YES NO (please explain) Briefly describe how residents will have experience in managing complications of abortions and training in all forms of contraception, including reversible methods and sterilization. [PR IV.A.6.d).(3)] (Limit response to 400 words)

62 PROCEDURAL DATA Perform and/or Manage Do Not Perform or Assist but Learn the Principles of Assist Obstetrics Obstetric Procedures Vaginal delivery Forceps assisted delivery Vacuum assisted delivery Vaginal breech delivery 3 rd degree laceration repair 4 th degree laceration repair Cesarean delivery Cesarean hysterectomy

63 Minimum Thresholds

64 Block Schedule Uploaded by program as PDF Instructions and formats detailed in ADS Essential elements (more on this later): PGY Clinical site Rotation name (Specific) % outpatient time % research time Important for RC to understand program

65 Block Diagram Instructions Include the participating site in which a rotation takes place, as well as the name of the rotation. If the name of the rotation does not clearly indicate the nature of the rotation, then clarifying information should be provided as a footnote to the block diagram or elsewhere in the document. Group the rotations by site. The site numbers listed in the Accreditation Data System (ADS) should be used to create the block diagram. When elective time is shown in the block diagram, the choice of elective rotations available for residents should be listed below the diagram. Elective rotations do not require a participating site. For each rotation, the percentage of time the resident spends in outpatient activities should be noted. The percentage of time devoted to structured research on a clinical rotation should be noted. If a block is purely research, it should be labeled as such, and should not be associated with a participating site.

66 Examples of Accurate/Complete Block Diagrams

67 Accreditation Statistics

68 Accreditation Statistics Number of Accredited Programs Core 244 FPMRS 46 Number of Approved Residents/Fellows Core 5184 FPMRS 136

69 Accreditation Status CORE- 244 FPMRS- 46 Initial Accreditation 3 41 Initial Accreditation with Warning 1 0 Continued Accreditation Continued Accreditation with Warning Continued Accreditation without Outcomes Probation 2 0 Applications 3 2

70 Core OBGYN Applications by Academic Year (AY) AY Total # of New Program Applications Reviewed by the RC Total # of Applications where Accreditation was Withheld (April)

71 Important Reminder: VIEW! The Transition to ACGME Accreditation: An Overview for AOA Programs John R. Potts, III, MD, FACS Senior Vice President, Surgical Accreditation ACGME Webinar originating from the offices of the ACGME Chicago 1 April 2015

72 THANK YOU