Program Evaluation Committees (PEC), Annual Evaluations, and the 10 year Self Study and Visit in the Next Accreditation System Cuc Mai MD FACP August 2014

Program Evaluation Committees (PEC), Annual Evaluations, and

the 10 year Self Study and Visit in the Next Accreditation System

Cuc Mai MD FACPAugust 2014

Disclaimers

• No part of my salary is supported by ACGME.• I am only a messenger and also a program

director.• Information may change in the Next Best

Accreditation System.

Goals and Objectives

• Review the goals of the accreditation process in the Next Accreditation System for Maintenance of Accreditation

• Define current description of the Annual Program Evaluation, the 10 year self study, and 10 year self study visit

• Define the requirements for the Program Evaluation Committee

• Describe some actions programs should consider for the 10 year self study

The Old Days…

• Internal Reviews• Program Information Form• Duration between Site Visits based on Results

of Accreditation Visit

Maintenance of Accreditation in the Next Accreditation System

Self-Studyvisit

Ongoing Improvement

AE

Self-Study

Yr 0 Yr 1 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7 Yr 8 Yr 9 Yr 10Yr 2

AE AE AE AE AE AE AE AE AE

Annual Program Evaluation (PR-V.C.) Resident performance Faculty development Graduate performance Program quality Documented improvement plan

AE: Annual Program Evaluation

Focused assessments possible at any time based on data from AE.Full site visit at any time if data from AE eggregious.

© 2013 Accreditation Council for Graduate Medical Education Information Current as of December 2, 2013

Aims of the Next Accreditation System

Enhance the ability of the peer-review system to prepare physicians for practice in the 21st Century

To accelerate the movement of the ACGME toward accreditation on the basis of educational outcomes

Reduce the burden associated with the current structure and process-based approach

10 Self-Study and Self-Study Visit

Self-Study Conducted by the

program Annual Program

Evaluation Review of program

goals and improvement efforts

Self-Study Visit Conducted by ACGME

Field Staff members

© 2013 Accreditation Council for Graduate Medical Education Information Current as of December 2, 2013

Annual Data Review ElementsPolicy 17.61 Review of Annual Data

Continuous Data Collection/Review ADS Annual Update Resident Survey Faculty Survey Milestone data Certification examination performance Case Log data/Clinical experience Hospital accreditation data Faculty member and resident scholarly activity and

productivity Other: ACGME complaints, Institutional Quality Metrics

The Next Accreditation System

ContinuousObservations

Identify Opportunities for Improvement

Program MakesImprovement(s)

AssessProgramImprovement(s)

PromoteInnovation

Next Accreditation System: Ten-Year Self-Study and Self-Study Visit

Self-Studyvisit

Ongoing Improvement

AE




Objectives of the Ten Year Self-Study Visit

• A comprehensive review of the program– Using the Annual Program Evaluation and 10 year

self study– Information on how the program creates an

effective learning and working environment– How this leads to desired educational outcomes

Objectives of the Ten Year Self Study Visit

• Judge program success at Continuous Quality Improvement

• Learn future goals of program• Will verify compliance with CORE

requirements• Core and subspecialty programs will be

reviewed together


Ongoing Improvement

AE

Self-Study




Objectives of the 10 year Self Study

• Conducted one year before self study visit• Assess ongoing compliance and improvement in all

dimensions, specifically on outcomes• Consider program aims and

strengths/weakness/opportunities/threats (SWOT) of program

• Uses annual program evaluations and ACGME data to review program improvement activities, successes achieved, and areas still in need of improvement


Self-Studyvisit

Ongoing Improvement

AE

Self-Study





Annual Program Evaluation

• Annual but may be more frequent• Done by Program Evaluation Committee• Document Review of Program Outcomes from

Annual Data• Document Review of Program Achievement of

Aims, Program Strengths, Program Threats, and Program Opportunities

• Develop Continuous Program Improvement Projects and Track/Document Follow-up

Maintenance of Accreditation in the Next Accreditation System

Self-Studyvisit

Ongoing Improvement

AE

Self-Study





Focused assessments possible at any time based on data from AE.Full site visit at any time if data from AE eggregious.

Program Considerations for the 10 Year Self Study Visit

• How are you and your subspecialty programs working together?

Program Considerations for the 10 year Self Study

• Do you have defined program aims?• Have you ever analyzed your program with a

SWOT analysis?

Program Considerations for the Annual Evaluation?

• Do you have a Program Evaluation Committee and policy?

• Are you reviewing all the Program Outcomes evaluated by the ACGME and looking for areas of program improvements?

• Do you create, follow through on, and document program improvement projects?

The Next Accreditation System

ContinuousObservations

Identify Opportunities for Improvement

Program MakesImprovement(s)

AssessProgramImprovement(s)

PromoteInnovation

ACGME Webinars and Other Resources ACGME webinars are available at: http://

www.acgme.org/acgmeweb/tabid/431/ProgramandInstitutionalAccreditation/NextAccreditationSystem/Webinars.aspx CLER Overview of Next Accreditation System Milestones, Evaluation, CCCs Specialty-Specific Webinars (Phase I) Phase I Coordinator Webinars (surgical and non-surgical) Specialty-specific Webinars (Phase II): Nov 2013-Dec 2013

Slide presentations for distribution to the GME community: NAS, CCC, Milestones, Annual Program Evaluation/PEC, Updates on Policy– December 2013

Upcoming Specialty-specific Webinars (Phase II): Jan 2014-May 2014 CLER Self-Study (what programs do) Self-Study Visit (what ACGME site visitors do)

http://www.acgme.org/acgmeweb/tabid/431/ProgramandInstitutionalAccreditation/NextAccreditationSystem/Webinars.aspx



Documents

Program Evaluation Committees (PEC), Annual Evaluations, and the 10 year Self Study and Visit in the Next Accreditation System Cuc Mai MD FACP August 2014