New Expectations for Single Program and Small Institutions: Accreditation and CLER

Transcription

1 Accreditation Council for Graduate Medical Education SES 003 ACGME Annual Education Conference February 27, 2015 New Expectations for Single Program and Small Institutions: Accreditation and CLER Baretta R. Casey, MD,MPH Regional Vice President, CLER Site Visit Program, Small Institutions Patricia M. Surdyk, PhD Executive Director (retired), Institutional Review Committee

2 SES003 New Expectations for Small Institutions: Accreditation and CLER Disclosures Baretta R. Casey, MD,MPH has no conflict of interest to report Patricia M. Surdyk, PhD has recently retired as Executive Director of the Institutional Review Committee and remains employed by the ACGME via contract as special advisor to Kevin B. Weiss, MD, Senior Vice President, Institutional Section

3 Learning Objectives Examine the rationale for separate institutional accreditation review for single-program institutions Examine the specific areas of the Institutional Requirements that have been revised to address the unique characteristics of single-program sponsoring institutions Review the CLER program process as it will be applied to small sponsoring institutions

4 Single Program Sponsoring Institutions (SPSIs) ACCREDITATION

5 Institutional Accreditation The intent of institutional accreditation for all SIs is to differentiate between program and institutional expectations in four areas: Structure for institutional oversight Institutional resources Resident/fellow learning and working environment Institutional GME policies & procedures

6 Why Now? Revised ACGME Policies & Procedures (2014) assign Institutional Review Committee (IRC) responsibility for all sponsoring institutions (SIs). IRC assures single standard of excellence for all SIs. Institutional Requirements represent core components for an SI tested over time since IRC was awarded delegated authority for institutional accreditation in 2005.

7 Specialty No. of Progs. Specialty Family Medicine 130 Complex General Surgery Oncology 1 Orthopedic Sports Medicine 31 Dermatopathology 1 Internal Medicine 27 Emergency Medicine 1 Forensic Pathology 17 Foot and Ankle Surgery 1 Procedural Dermatology 12 Hand Surgery 1 Preventive Medicine 12 Medical Genetics 1 Psychiatry 10 Neurotology 1 Transitional Year 5 Ophthalmology 1 Blood Banking/Transfusion Med 4 Pathology 1 Surgery 3 Pediatric Radiology 1 Colon & Rectal Surgery 2 Radiation Oncology 1 Pediatrics 2 Physical Medicine & Rehab 2 Diagnostic Radiology 2 Pediatric Orthopedics 2 Orthopedic Spine Surgery 2 No. of Progs.

8 Review Process All Institutional Requirements have always applied and will continue to do so for all SIs without waiver. Specialty-specific Review Committee evaluation of five Common PIF questions has been eliminated. Institutional commitment Program evaluation Resident/fellow eligibility and selection Resident/fellow support Grievance procedure available to residents/fellows

9 Revised Definitions for Accreditation A single-program sponsoring institution (SPSI) sponsors ONLY ONE ACGMEaccredited program with a unique ACGME-assigned program number. A multiple-program institution (MPSI) sponsors MORE THAN ONE ACGMEaccredited program, each with a unique ACGME-assigned program number.

10 Revised Definitions: Examples Guiding principle: the number of programs, not the size, is what matters. SPSI: only an Internal Medicine program, even with 100 residents MPSI: an Internal Medicine program that adds a Cardiovascular Disease program

11 ACGME Institutional Requirements ACGME approved: June 9, 2013; Effective: July 1, 2013 for new sponsoring institutions making new applications and July 1, 2014 for existing sponsoring institutions (including both multiple- and singleprogram sponsors); revisions effective July 1, 2015 for single-program sponsors

12 Institutional Requirements: Content I. Structure for Educational Oversight II. III. Institutional Resources Resident/Fellow Learning and Working Environment IV. Institutional GME Policies & Procedures

13 Institutional Responsibility/Authority One Sponsoring Institution has ultimate authority and responsibility for its ACGME-accredited programs DIO in collaboration with GMEC have authority and responsibility for oversight and administration of the Clinical Learning Environment

14 Oversight and Administration (I.B.4.a) 1. Accreditation status 2. Quality of all learning and working environments 3. Quality of educational experiences 4. Annual Programs Evaluation (APE) activities 5. Processes related to reductions and closures

15 Review and Approval (I.B.4.b) 13 Responsibilities GME policies Stipends/benefits New applications Changes in complement Program structure or duration of education Additions/deletions New PD(s) Progress reports CLER responses* Duty hour exceptions Voluntary withdrawal of accreditation Requests for appeal of adverse action Appeal presentations *Responses to CLER reports are not required.

16 AIR: Oversight of Institutional Accreditation (I.B.5) AIR is a core and associated with identified performance indicators that are detail requirements Results of institutional self-study (Detail) Results of ACGME surveys (Detail) Notification of programs accreditation statuses and self-study visits (Detail) Remember that detail requirements represent minimum performance indicators

17 AIR: Oversight of Institutional Accreditation (I.B.5) AIR is a core and associated with identified performance indicators that are detail requirements Results of institutional self-study (Detail) Results of ACGME surveys (Detail) Notification of programs accreditation statuses and self-study visits (Detail) Remember that detail requirements represent minimum performance indicators

18 Evidence of AIR Oversight (I.B.5) AIR must have monitoring procedures for action plans (Core) Monitoring should be documented in the GME minutes Written executive summary of AIR submitted to governing body each year (Core)

19 GMEC Special Review: Oversight of Program Accreditation (I.B.6) The Special Review process identifies the need for improvement by: Developing a protocol that identifies underperformance (Core) Generating a report that identifies improvement goals, corrective actions, and the process for GMEC monitoring of outcomes. (Core)

20 Focused Revisions to Requirements Accreditation GMEC composition Resident forum

22 Accreditation, I.A.9 When a Sponsoring Institution s or participating site s license is denied, suspended, or revoked, or when a Sponsoring Institution or participating site is required to curtail activities, or is otherwise restricted, the Sponsoring Institution must notify and provide a plan for its response to the IRC within 30 days of such loss or restriction. Based on the particular circumstances, the IRC may request that the ACGME invoke its Procedure for Alleged Egregious or Catastrophic Events policy. (Core)

24 GMEC Composition I.B.1.b) I.B.1.b).(1) I.B.1.b).(2) I.B.1.b).(3) A Sponsoring Institution with one program must have a GMEC that includes at least the following voting members: the DIO; (Core) the program director when the program director is not the DIO; (Core) a minimum of two peer-selected residents/fellows from its ACGME-accredited program or the only resident/fellow if the program includes only one resident/fellow; (Core)

25 GMEC Composition (cont d) I.B.1.b).(4) I.B.1.b).(5) the individual or designee responsible for monitoring quality improvement or patient safety if this individual is not the DIO or program director; and, (Core) one or more individuals from a different department than that of the program specialty (and other than the quality improvement or patient safety member), within or from outside the Sponsoring Institution, at least one of whom is actively involved in graduate medical education. (Core)

27 Operations No application required No extra fees involved for institutional accreditation Scheduling of self-study and the 10-year institutional accreditation visit eventually synchronized with program self-study visit wherever feasible (Note: Institutional self-study and 10-year accreditation visits will begin in 2017.)

28 Small Sponsoring Institutions THE CLINICAL LEARNING ENVIRONMENT REVIEW (CLER)

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30 The Building Blocks or Components of The New Accreditation System 10 year Accreditation Visit 10 year Self-Study prn Site Visits (Program or Institution) Continuous RRC and IRC Oversight and Accreditation Clinical Learning Environment Review CLER Visits

31 CLER Focus Areas Supervision Patient Safety Healthcare Quality Professionalism Healthcare Disparities Duty Hours Fatigue Management Transitions of Care

32 CLER Program 5 key questions for each site visit Who and what form the hospital/medical center s infrastructure designed to address the six focus areas? How integrated is the GME leadership and faculty in hospital/medical center efforts across the six focus areas? How engaged are the residents and fellows? How does the hospital/medical center determine the success of its efforts to integrate GME into the six focus areas? What are the areas the hospital/medical center has identified for improvement?

33 CLER visits Short notice (2 & ½ weeks) Visits occur at clinical learning environments of ACGME accredited sponsoring institutions

34 CLER Evaluation Process Oral Report: end of visit Written Report: 4-6 weeks after Optional response to report National aggregated deidentified data for comparison In Development for Multi-programs

35 CLER Pathways to Excellence Rapidly advance the national conversation regarding the clinical learning environment s impact on resident and fellow training while being focused on improving the safety and quality of care that patients receive

36 Program Staff Robin Wagner, RN, MHSA VP CLER Program Regional Vice Presidents Baretta R. Casey, MD, MPH Robin Newton, MD Carl Patow, MD CLER site visitor staff Administrative Staff Anne Down Betsy Kimball Nancy Koh

37 Clinical Learning Environment Review (CLER) Program Multi-Program Institution +/- 290 institutions 3 or more core programs Usually includes fellowships Protocol 1 near completion Small Program Institution +/- 450 institutions 2 or less core programs Could include fellowships Protocol 1 in development Additional programs onboarding under single accreditation system

38 All Small Programs Approximate numbers No. of Progs. Size per number of residents No. of Progs. Two person visit ~25% Single core program ~230 One or two person visit ~50% Two cores, no subspecialty (ies) ~60 One person visit ~25% Single subspecialty program ~58 Programs with 10 residents or less ~75 Core(s) and subspecialty(ies) programs ~125

39 CLER Site Visits Small/single program sponsoring institutions (approx. 450) In development Collecting input from key stakeholders (DIO/PD focus groups, interviews) Adapting the protocol to a range of sizes and environments Planned pilot testing in summer, full rollout later in 2015

40 CLER Small Institution Site Visit Program Development Possible visits to ambulatory and hospital sites affiliated with sponsoring institution Formative visit-used solely for feedback, learning, and establishment of baseline information Exception: potentially egregious situations

41 CLER Small Program Development 1 Regional Vice President Recruiting additional filed staff Approximately 10 field staff (majority parttime)

42 Unique Environment Issues Two day visits or less More than one protocol: -one for programs based in hospital/medical center with ambulatory experiences -one for programs that are solely ambulatory based

43 Protocol Development Visit process will have a qualitative and quantitative assessment and variable use of the Audience Response System The leadership team may vary as to whether the program is hospital-based vs clinic-based The site visit will include resident/fellow, faculty members and program director(s)

44 Unique Considerations of Small programs Small number of faculty members, many may be volunteer/part-time faculty Potential degree of burden on the practice for the visit Potential geography concerns related to distance between the hospital/clinic Difficulty ensuring confidentially or anonymity

45 Thank You