Preparing for Internal Reviews and Site Visits Robert J. Nolan, MD

Preparing for Internal Reviews and Site Preparing for Internal Reviews and Site VisitsVisits

Robert J. Nolan, MD

Preliminary ConsiderationsPreliminary Considerations

Check the ACGME Website for PIF revisions on a routine basis

PIFs now have two sections – the “Common PIF” (Part I) and the “Specialty Specific PIF” (Part 2)

Preparing for an internal review ideally should be identical to preparing for a site visit – but your GME office consists of friends…your RRC, not.

Preliminary ConsiderationsPreliminary Considerations

Create a PIF team Program Director Relevant Faculty Program Coordinator Trainees Hospital/Clinic Data Folk

Program DirectorProgram Director

“The program director must …prepare and submit all information required and requested by the ACGME, including but not limited to the program information forms and annual program resident updates to the ADS, and ensure that the information submitted is accurate and complete.” (CR II.A.4.f)

Create a Time LineCreate a Time Line

The Internal Review Process begins your Site Visit PIF preparation process (With a 1 or 2 year cycle, the LON starts the process)

Address previous citations and current compliance issues

Review Curriculum and Evaluation Processes

Review Data Collection processes


Patient Volume Data, Procedure Numbers, etc. come from a consistent base year – most recent academic year or the most recent calendar year

Example: Site Visit – August 2010, base year will be 2009-2010 or calendar year 2009. So…accurate data collection systems need to be in place by the end of 2009!


For site visits in the November/December 2010, the data year should probably be the 2009 – 2010 academic year rather than calendar year 2009 – otherwise the PD may have some explaining to do (“My Hospital/Clinic’s IT system is really third-rate” is an excuse, not an explanation)


Compliance is judged at the time of the site visit, but…

It is helpful to have annual reviews of program effectiveness (ARPE), ARPE action plans, evaluation systems, quality improvement projects, ILPs, portfolios, competency didactics in place for more than a couple days – word might not get around!

Writing the PIF – Writing the PIF – Practical GuidancePractical Guidance

Read the PIF instructions Follow the instructions Avoid internal inconsistencies Typos and poor grammar are signs of

sloppy work, so… Consider composing in Word and “cutting

and pasting” … the PIF doesn’t have spellcheck

Numerical DataNumerical Data

The current resident list must be accurate Past resident list must be accurate – this

may not be a trivial task if both the program director and program coordinator are new since the last site visit

The past resident lists (graduating residents) must be consistent with lists of residents taking the board examination

Numerical data – cont’dNumerical data – cont’d

In Part I – each resident must be accounted for. Residents starting = Residents finishing (3 or 4 or 5 years later) – Residents leaving during the program + Residents transferring into that class

All graduating residents either have taken the board or have not; those who have, either have passed (1st attempt) or not

CVs - BibliographiesCVs - Bibliographies

Ideally one person should be responsible constructing the Part I CVs and Bibliographies based on CVs provided by the faculty

Follow the instructions – time limits, # of citations, etc.

Use the same citation style for each CV Use the same formatting and font on each CV

– (a plain font: Arial, Tahoma, etc.)

Reacting to “The Letter”Reacting to “The Letter” 12 weeks to the site visit 12 weeks to the site visit

View site visit preparation as “party View site visit preparation as “party preparation”preparation” An Opportunity to celebrate your program’s An Opportunity to celebrate your program’s

success and compliance with the ACGME success and compliance with the ACGME Program Requirements!Program Requirements!

Establish a timelineEstablish a timeline

TimelineTimelineWorking backwards, set dates for:Working backwards, set dates for:

– The site visit – that date is set for you!The site visit – that date is set for you!– The final briefing of all site visit participantsThe final briefing of all site visit participants– Final prep work on program documentationFinal prep work on program documentation– Mailing the finished PIFMailing the finished PIF– Communicating with the site visitorCommunicating with the site visitor– Completing each major section of the PIFCompleting each major section of the PIF– Collecting the relevant site visit documentsCollecting the relevant site visit documents– Arranging for a mock site visitArranging for a mock site visit– Finalizing the schedule of eventsFinalizing the schedule of events– Identifying your team to plan and implement the site visitIdentifying your team to plan and implement the site visit

11 weeks to the site visit11 weeks to the site visit

The Program Director meets with Key The Program Director meets with Key Faculty, Program Coordinator, and other Faculty, Program Coordinator, and other Administrative Staff to discuss the Administrative Staff to discuss the accreditation processaccreditation process

The Program Director decides what to The Program Director decides what to delegate and sets clear timelinesdelegate and sets clear timelines


Continue organizing documentsContinue organizing documents Final polishing of the PIF – e.g., adding Final polishing of the PIF – e.g., adding

patient or procedure data from most recent patient or procedure data from most recent calendar or academic year – this part calendar or academic year – this part shouldn’t be hard as you have been working shouldn’t be hard as you have been working on the PIF on and off for months/years, as on the PIF on and off for months/years, as you have known the approximate date of the you have known the approximate date of the site visit for yearssite visit for years


Faculty preparation in groups or individually – Faculty preparation in groups or individually – remember the program gets to select the remember the program gets to select the faculty for the site visit faculty for the site visit !!!!!!

Resident preparation – the residents for the Resident preparation – the residents for the site visit are peer selected – “coaching” vs. site visit are peer selected – “coaching” vs. preparation; i.e., briefingpreparation; i.e., briefing

All residents need some preparation – All residents need some preparation – remember the site visitor may encounter the remember the site visitor may encounter the “unselected” on his/her tour“unselected” on his/her tour

8 weeks to the site visit – cont’d8 weeks to the site visit – cont’d

Chairman Briefing!Chairman Briefing! Adjust resident call schedules – no Adjust resident call schedules – no

participating resident should be post-call!participating resident should be post-call! Finalize PIF – internal consistency, all Finalize PIF – internal consistency, all

blanks filled, format, font, spell check, blanks filled, format, font, spell check, proper English proper English

7 to 8 weeks prior to site visit – PIF to GME 7 to 8 weeks prior to site visit – PIF to GME office for initial review (Drs. Nolan and Peel)office for initial review (Drs. Nolan and Peel)


Incorporate revisions of GME office into PIFIncorporate revisions of GME office into PIF Contact the site visitor (per his/her Contact the site visitor (per his/her

instructions) to confirm the day’s agendainstructions) to confirm the day’s agenda– Keep in mind that the agenda is the site Keep in mind that the agenda is the site

visitor’s, not yours!visitor’s, not yours!– Inquire about any special dietary restrictionsInquire about any special dietary restrictions– Ask if s/he wants advice on hotels, etcAsk if s/he wants advice on hotels, etc– Ask if s/he will want to tour the program’s Ask if s/he will want to tour the program’s

facilitiesfacilities

6 weeks to the site visit – cont’d6 weeks to the site visit – cont’d

Designate a meeting room for the site visitDesignate a meeting room for the site visit– plenty of space, quiet, comfortable chairs, no plenty of space, quiet, comfortable chairs, no

distractionsdistractions

Confirm lunch plansConfirm lunch plans

5 weeks to the site visit5 weeks to the site visit Have DIO read and sign the PIFHave DIO read and sign the PIF

– Give the DIO at least 10 business days to Give the DIO at least 10 business days to read and comment on the PIFread and comment on the PIF

– Modify PIF with DIO suggestionsModify PIF with DIO suggestions

3 -4 weeks to the site visit3 -4 weeks to the site visit Mail the PIF to the site visitor (per his/her Mail the PIF to the site visitor (per his/her

instructions!)instructions!)– Send the requested number of copiesSend the requested number of copies– Don’t staple if instructions specify not to stapleDon’t staple if instructions specify not to staple– Bind with a rubber band if so instructedBind with a rubber band if so instructed– Send only the requested number of attachmentsSend only the requested number of attachments– Include a cover letter confirming the agenda and contact Include a cover letter confirming the agenda and contact

numbersnumbers

Send the PIF on Time!Send the PIF on Time!

1 – 2 weeks before the site visit1 – 2 weeks before the site visit

PD to reread his/her PIFPD to reread his/her PIF PD should know your PIF coldPD should know your PIF cold PC: have all potential documents PC: have all potential documents

ready– portfolios, files, policies, didactic ready– portfolios, files, policies, didactic schedules, documentations of schedules, documentations of conference attendance, patient logs, conference attendance, patient logs, etc. – per your site visitor’s instructions etc. – per your site visitor’s instructions and your RRC’s requirementsand your RRC’s requirements

1 – 2 weeks before the site visit1 – 2 weeks before the site visit• Consider creation of binders for Consider creation of binders for

required supporting documents with required supporting documents with clear (large font) binder labelsclear (large font) binder labels

• Consider creation of binders for special Consider creation of binders for special supplementary materials – material supplementary materials – material that support your responses to PIF that support your responses to PIF questions or address anomalies in your questions or address anomalies in your programprogram

1 – 2 weeks before the site visit1 – 2 weeks before the site visit• Consider a “re-inoculation” briefing of Consider a “re-inoculation” briefing of

participating faculty and residentsparticipating faculty and residents

• Have participants read the relevant Have participants read the relevant portions of the PIF?portions of the PIF?

• Consider a re-brief your chairman!Consider a re-brief your chairman!

The day before the site visitThe day before the site visit PD to review his/her PIF - againPD to review his/her PIF - again PD/PC to personally remind all PD/PC to personally remind all

participants to arrive 30 minutes early – participants to arrive 30 minutes early – do do not rely on email reminders!not rely on email reminders!

Set up SV room – all documents/binders Set up SV room – all documents/binders should be in the room should be in the room the day before the day before the the SV beginsSV begins

The day before the site visitThe day before the site visit Create “tent cards” for all participants Create “tent cards” for all participants

(some visitors may not want these) – (some visitors may not want these) – some visitors just want resident’s PGY some visitors just want resident’s PGY level on the tent card, not their name; for level on the tent card, not their name; for faculty: name and role in program (i.e., faculty: name and role in program (i.e., continuity clinic supervisor, director of continuity clinic supervisor, director of L&D, chief of Hospitalist’ Group, etc.)L&D, chief of Hospitalist’ Group, etc.)

The Day of the Site VisitThe Day of the Site Visit

Meet the site visitor at a pre-arranged place – Meet the site visitor at a pre-arranged place – do do not allow the site visitor to wander around lost! not allow the site visitor to wander around lost! (Corollary – do not let the visitor out of your (Corollary – do not let the visitor out of your sight!)sight!)

Call all participants one hour before their meeting Call all participants one hour before their meeting with the site visitor – with the site visitor – do not rely on email or text do not rely on email or text mail reminders!mail reminders!

The Day of the Site VisitThe Day of the Site Visit

Collect all pagers, cell phones, blackberries, other Collect all pagers, cell phones, blackberries, other electronic bric-a-brac, and visible Pharma stuff (from electronic bric-a-brac, and visible Pharma stuff (from residents, faculty and yes, Chairman)at the SV room residents, faculty and yes, Chairman)at the SV room door!door!

PD should PD should discretelydiscretely debrief participants as they leave debrief participants as they leave – consider having a debriefing room prepared (out of – consider having a debriefing room prepared (out of the direct sight of the visitor)the direct sight of the visitor)

PD should rapidly prepare to address any unexpected PD should rapidly prepare to address any unexpected lines of questioning raised with the faculty and lines of questioning raised with the faculty and residents in the PD’s closing session with the visitorresidents in the PD’s closing session with the visitor

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Preparing for Internal Reviews and Site Visits Robert J. Nolan, MD