MSU KCMS Department of Emergency Medicine

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Emergency Medicine Residency
     Coordinators Forum
  Las Vegas, March 4, 2006
  David T. Overton MD, MBA, FACEP
    Residency Review Committee
         Emergency Medicine

   The “PIF”:
     “Program Information Forms”

     IE, the residency application

   “PIF-Manship”:
      A somewhat facetious term coined by
       RRC members to describe:
   The art and science of skillfully and adroitly
    filling out the PIF
   Usually termed “Poor PIF-manship”:
      Sloppy, inconsistent or inaccurate

      A PD that is new, green, naïve or cocky

      Not knowing how to play the game

      Not knowing the rules, requirements and
         guidelines, to avoid citations (or worse)
But what about our actual
program, not just this paperwork?
   Like it or not, the PIF is the main reflection of
    the program
   The RRC reviewers are allowed to base
    decision on ONLY 3 things
      PIF

      Site Visitor’s Report

      Residents’ Survey

   The PIF is the most important one
   Even individual knowledge of the program
    can’t be used
Overview of Talk:

 Specific examples of common PIF and
  accreditation problems
 Suggestions on how to avoid them
 Time at the end for questions & (I hope)
Common Problem - Inconsistency

 A PIF that is internally inconsistent
    A number or concept in one area of
     the PIF is different than that in
    So, which one do we believe?

 Commonly happens when you use the
  last PIF as the basis for your next Site
   How to avoid:
     Make sure there’s not a new version of the PIF

     They change every 4-5 years

        Often very minimal changes, and very
         easy to miss
        Find them on the ACGME web page

     Proofread multiple, multiple times, by multiple
     Attention to detail
Advice – Be as clear as possible

 Don’t assume that the reviewer
  understands your setting
    There’s lots of different settings out
 Avoid “don’t ask – don’t tell”
 When in doubt, explain
 Makes it much easier for your reviewer
  to tell what’s going on
Be as clear as possible…

 Remember - the RRC members are
  volunteers who have a lot of paperwork
  to review for each meeting
 It’s in your best interest for your
  reviewer to be in a good mood when
  he/she is done reviewing your PIF!!
 So, make it easy for them!
Be responsive to citations /

 Even if you don’t agree
 Don’t argue, evade or be sarcastic
   “If only the reviewer had read page

    561…he would know the answer…”
   Even if it’s true, or you think the
    requirement is stupid
Know the RRC’s “Guidelines”

 Many still don’t know what these are
 These are a separate set of “guidelines”
  (ie, rules), different from the P.R.
 These are an RRC-EM invention to:
    “open the black box”

    Be more nimble and responsive
Philosophical aside…

   A quandary for the RRC:
     To be specific or flexible??

     Default for most RRC members would
      be to be flexible
     But, when we are specific, it’s nice to

      let you know what the rules are
     This is where the Guidelines come in
Back to the Guidelines

 The RRC can change the Guidelines on
  the fly
    The P.R. (and PIF) take a long time to
     get changed
 Most citations these days are based on
  the Guidelines!
    So, you need to know them!
Where are the Guidelines?

 On the Web, of course
   “Residency Review Committees”

   “Emergency Medicine”

   “Emergency Medicine Guidelines”

 The Guidelines currently cover…
   Core faculty protected time
   Program Director protected time
   Core faculty scholarly requirements
   Program scholarly requirements
   Required ABEM pass rates
   ED faculty staffing levels
   ABEM status for EM faculty
   Procedure & resuscitation # requirements
Core Faculty Protected Time

 Defined inversely – the maximum
  allowed clinical hours for core faculty
 28 hours per week, maximum
    (No minimum, as long as it’s >0)

 Or, 1344 hours per year
    Allows for 4 weeks of vacation

 Common Citation!
Be sure the PIF’s consistent

   This data is entered in two places on
    the PIF:
   Section 6.C of the PIF: OK
Hours per Week Spent in:   Institution 1   Institution 2   Institution 3   Institution 4

Clinical Supervision       27

Administration             5

Research                   10

Didactics/Teaching         10
   Not OK – a citation (is >28)
Hours per Week Spent in:   Institution 1   Institution 2   Institution 3   Institution 4

Clinical Supervision       29

Administration             5

Research                   10

Didactics/Teaching         10
   Not OK – A citation (30 > 28)
Hours per Week Spent in:   Institution 1   Institution 2   Institution 3   Institution 4

Clinical Supervision       15              15

Administration             5

Research                   10

Didactics/Teaching         10
  PIF Section 6.E. (this is OK - < 28)
Summary of Core Faculty

                                                                               Teaching    P         National/
                                           Clinical                                            Non
                     Board    Faculty                 Administra-   Research        /      e         Regional     Editorial
             Res.                          Super-                                               -
Name   Pos            Cert.   Years in                   tion       (Hrs/Wee   Didactics   e         Presentati   Review
             Trng.                         vision                                              Pee
                     (Year)     EM                    (Hrs/Week)       k)      (Hrs/Wee    r           ons (5     Services
                                         (Hrs/Week)                                             r
                                                                                   k)                   Yrs)

  PIF Section 6.E. (Not OK-a citation)
Summary of Core Faculty

                                                                               Teaching    P         National/
                                           Clinical                                            Non
                     Board    Faculty                 Administra-   Research        /      e         Regional     Editorial
             Res.                          Super-                                               -
Name   Pos            Cert.   Years in                   tion       (Hrs/Wee   Didactics   e         Presentati   Review
             Trng.                         vision                                              Pee
                     (Year)     EM                    (Hrs/Week)       k)      (Hrs/Wee    r           ons (5     Services
                                         (Hrs/Week)                                             r
                                                                                   k)                   Yrs)

Program Director Protected Time

 A maximum of 20 clinical hours per
   Or, 960 per year (4 weeks vacation)

 Uncommon citation
ABEM Pass Rates
   Why?
     The ACGME wanted it

     Is very outcomes-oriented

     We have always looked at ABEM
      pass rates, and occasionally cited
     But now, we’ve openly established a

      specific threshold (ie, opened the
      black box)
ABEM Performance

 5-year moving average
 >70% pass Writtens on 1st attempt
 >80% pass Orals on 1st attempt
 Take trends into account

   Rarely cited – most programs do fine
Faculty ED Staffing Levels

 Need to have enough supervising
  faculty in the ED
 Guideline established in collaboration
  with CORD
 Must be <4.5 pt / faculty hour
 How do we (you) calculate?
A. Patient Population Statistics
   If more than 4 Emergency Departments are used, copy this page, renumber the institutions and insert.

For the most recent 12-month period                        From:                             To:

                                                            Institution 1
                            Statistics                                      Institution 2     Institution 3   Institution 4
a.                Total ED Patients*                       53,678
b.                % of ED pediatric patients**

c.                % of ED adult patients

* Include only patients evaluated and treated in the ED.
** Ages 0 - 18 Years.

            Total # of annual patients
   PIF Section 7.B.4.

4. How many EM faculty hours of on-line supervision per day are provided in the
area?                                                                             48
5. Does this coverage change on weekends?                      YES (X ) NO ( )
   If YES, please specify.

   There are 40 hours of facutly coverage per day on weekends, because volumes are less

                    Total # of annual faculty hours
Faculty ED Coverage

 So: Each week there is:
    48 x 5 = 240,   40 x 2 + 80
    So, there’s 320 total hours per week

 320 x 52 = 16,640 hours per year
 53,678 ÷ 16,640 = 3.22 pts/faculty hour
 Run your own numbers to make sure
Faculty ED Coverage

 Not a common citation
 But, the RRC will consider extenuating
    So, if your number is too high, explain

     it in your PIF:
        “Note – 13% of our ED patients are
         seen by PA’s”
Qualifications for EM Faculty
   “All emergency medicine faculty supervising
    emergency medicine residents on emergency
    medicine rotations must be board certified by the
    American Board of Emergency Medicine, or have
    appropriate educational qualifications in emergency
    medicine. Examples of educational qualifications
    acceptable to the RRC include:

       Certification by the American Osteopathic Board
        of Emergency Medicine
       Certification by a subspecialty board sponsored or
        cosponsored by the American Board of
        Emergency Medicine
       Recent residency or fellowship graduates actively
        working toward certification by the above boards”
Qualifications of Faculty

 So, all your EM docs HAVE to be
  boarded if they’re going to supervise
  EM residents
    Peds + Peds EM is OK

    Peds alone is not!

 New grads “actively” working toward…?
“But what about our guy who….?”

   Everyone thinks they have somebody who
    should be a special exception (I doubt it)
   Common citation
   If you have somebody, they can work in the
    ED, but NOT supervise EM residents
      They can supervise rotators, students, etc.,

        but not EMR’s
      They can lecture, run U/S, whatever
Procedure / Resuscitation #’s

 The RRC Guidelines have specific
  thresholds for certain procedures and
  resuscitations (that are DIRECTED by
 Note - These can include simulations
 These are probably the most common
  citation these days!!
   These are AVERAGES for your graduating residents
   Can count both procedures “on patients” and “in the
      Means in animal labs, simulations, procedures
       done on each other, etc, etc
      On the PIF, “on patients” & “in lab” listed
       separately – so you must track separately
      Rarely done procedures (crics, DPL’s,
       pericardiocentesis, etc) – ALL can be in lab
      Others, it’s subjective
Procedure Guidelines:
Ultrasound                     40
Cardiac pacing                  6
Cardioversion/Defibrillation   10
CVP access                     20
Chest tube                     10
Conscious sedation             15
Cricothyrotomy                  3
Dislocation reduction          10
Intubation                     35
Lumbar Puncture                15
Pericardiocentesis              3
Peritoneal lavage               3
Vaginal delivery               10
Resuscitation Guidelines:
 Adult medical resuscitations       45
 Adult trauma resuscitations        35
 Pediatric medical resuscitations   15
 Pediatric trauma resuscitations    10
How about thoracotomy?

 It’s still listed on the PIF
 But, the required number is ZERO
    (The Committee decided this after the
     PIF went to press)
 Essentially, it isn’t required
 But, you still need to teach it
    “But, our residents just don’t document all
    the stuff they do – they don’t have the
   That argument won’t work!!
   PR.V.E.9.a).
      “Programs must maintain a record of all
       major resuscitations and procedures
       performed by each resident.”
   Common Citation (and a pet peeve of mine)
   The Program MUST have an accurate
    procedure / resuscitation documentation
Procedure Documentation
 The RRC-EM doesn’t mandate what
  system you use (at least for now)
 As long as it’s accurate and real
 Must be “verifiable”
    Do not use estimates, guesstamites,
     wild hunches or anything else
    (Only new applications can use
Procedural Documentation
   Lots of options:
      Check book systems

      Palm / PDA based systems

      Web based systems

      Paper logs

      Hospital / Billing databases?

         (I’ve never seen one of these work)
My advice?
   K.I.S.S.
   Must be as fast, easy and flexible as possible
   Enable the residents to easily comply
   Web-based? Check to see how long it takes
    to log a procedure
   I use a dumb, simple paper pocket log:
      Works great

      Takes them maybe 5 seconds to log a
More advice…
   Make it clear to the residents that you’re
    serious about this
   Include in performance evaluations
   Log ONLY the stuff you must (K.I.S.S.)
      Note-lacerations aren’t tracked anymore

   Track it and provide them peer comparison
   Get faculty buy-in, so the faculty can remind
    and harass them
More Advice - Manage your
Procedure / Resuscitation Data
   Example:
     It’s March, and you’re due for a SV in

     You look at the UTD current

      procedural & resuscitation total for
      your current PGY-3 class
     And you find…
Managing your Procedures

 You see that the average per resident is
    Chest tubes – 7

    But the Guideline mandates a
     minimum of 10
 You WILL be cited for this unless you
  do something quick!
So – Fix it!
   Hold a procedure lab for the PGY-3’s
   Use pigs, dogs, simulators, whatever
   One anesthetized dog = as many as a dozen
    chest tubes
   Each resident does at least three tubes
      They religiously enter them in their logs as
       “in the lab”
   Average numbers go from 7 to 10
   Problem solved!
Managing your numbers
   Can do similar “catch up” plans for virtually all
    procedures and resuscitations
      Even resuscitations can be simulated in
       the lab
   Only possible if you have a reliable, UTD
    documentation system
   This can virtually eliminate the chance of a
    common citation
   And is good education
Faculty Scholarly Activity

 Another VERY common citation
 Guidelines have two separate rules:
   One for individual core faculty

           Commonly cited
       Another for the collective program as
        a whole
           Rarely cited
Individual Core Faculty
 “80% of the designated core faculty
  members must demonstrate at least
  one piece of scholarship per year…”
    Note – 80% threshold just recently
     established by the RRC (used to be
 Here “Scholarship” is defined very
Individual Core Faculty Scholarly
Productivity – from the PIF:
 “Insert (P.R. III.D) a list of scholarly
 activities over the past five years
 including: peer review articles, textbook
 chapters, other non-peer reviewed
 publications, abstracts, visiting
 professorships, scientific presentations
 at national meetings, and editorial
 review services to professional
 publications or organizations”
Quote from the PIF – List:
   “Peer-reviewed Articles or case reports accepted or
    published within the past 5 years
   Non-Peer reviewed articles, case reports or book
    chapters accepted or published within past 5 years
   Invited presentations at regional or national meetings,
    visiting professor presentations, etc.
      Do not list presentations within one’s own
   Editorial board service, reviewer for peer-reviewed
    journals, peer reviewer for academic or grant-
    awarding organizations”
Individual Scholarly Productivity

 So, LOTS of things are counted here
 80% of core faculty members must have
  at least one qualifying project each year
 So, for a five year cycle, 80% of core
  faculty need five “points”
Advice – Leverage what you
already do:
   Make sure abstracts are presented at multiple
    venues (each one counts)
      Local, regional, national, international

      Make sure it’s legal for the meeting

   Make sure everything gets published
      <50% of research presented as abstracts
       ever gets published
      Remember-anything can get published if
       you try hard enough!
Advice - Leveraging

   Get multiple core faculty on each project
     No, not academic fraud

     Just plan ahead, so that “weak”
      faculty get involved with new projects
      from the beginning, and get their
      names on them (and deserve to)
Share the wealth

 Senior faculty are commonly
  approached to do book chapters,
  multicenter projects, etc, etc
    We often aren’t interested

 Don’t turn them down – pass them on to
  your junior people (either junior faculty
  or residents)
“So, it sounds like we can get away with a
bunch of book chapters and letters to the

 NO!
 There still must be a nucleus of real
  research in the program
 This leads to the next Guideline….
Collective Program Scholarly

 “The program as a whole must demonstrate
 significant contributions to the specialty of
 Emergency Medicine. On average, these
 collective contributions should equal or
 exceed the total achieved if 20% of the core
 faculty were to publish one original, scientific
 peer-reviewed publication each year”
Collective Program Scholarly
 Confusing wording (blame me)
 Over a 5 year cycle, if you have 8 core
  faculty, you need 8 “real” research
 To prevent programs from just doing
  weenie stuff
 Actually, this is rarely cited, except for
  brand new programs
Conference Attendance
   Not a frequent citation, but an important one
   Some confusion by some:
      “The program should ensure that residents are
       relieved of clinical duties to attend the planned
       educational experiences. Although release from
       some off-service rotations may not be possible,
       the program should require that residents
       participate, on average, in at least 70% of the
       planned emergency medicine educational
       experiences offered (excluding vacations).
       Attendance should be monitored and
Conference Attendance
   Note – the ONLY thing excluded from the
    denominator is vacation!!
      Not trauma, not ICU, not some
       international rotation, etc., etc.
      All these “exceptions” must fit within the
   So, if you have some rotations where they
    simply can’t attend, they will need to hit
    almost 100% on the ones where they can!
Conference Attendance

 The RRC will also calculate the
  attendance listed on the 8 weeks of
  conference on the PIF
 So, even if you claim that they attend
  82%, if the attendance for the 8 sample
  weeks is 65%, you’ll likely still be cited
    So, choose the 8 weeks wisely
Conference Attendance

 Also, that’s 70% of your planned
  conferences, NOT necessarily 70% of 5
  hours a week
 So, if you chose to average 8 hours of
  planned conference a week, they need
  to attend 70% of 8 hours (not 5)
Conference Attendance
   Remember, the RRC will consider things other than
    traditional didactic lectures as part of the 5 hours:

       “They may include but are not limited to problem-
        based learning, evidence-based learning,
        laboratories, and computer-based instruction, as
        well as joint conferences cosponsored with other
        disciplines. The Committee will consider the use of
        alternative methods of education, such as
        interactive teleconferencing, with appropriate
        educational justification”
On-line ACGME Resident Survey

 Not really part of the PIF, but it’s
  reviewed at the same time
 Done every 3 years for every program
  (yearly for the Pilot Project)
 Very controversial
 Not our idea…
    Remember, everybody’s got a boss!
On-line ACGME Resident Survey

 Residents complete on-line, completely
 Program gets results on-line
 The SV and the RRC get the results at
  your next SV and Review
    The SV will probe any problem areas

 The RRC will cite any areas greater
  than a minimum threshold
On-line ACGME Resident Survey

   Many confusing questions – residents often
    forget or don’t understand
   Programs are advised to “manage” the
    survey, just like everything else
   Need to prep your residents ahead of time
   No, you’re not telling them what to answer,
    you’re educating them about the survey
Survey – remind them that…

 you gave a fatigue lecture last year
 PGY-1’s WILL have two performance
  evaluations each year
 their evaluations are confidential
 they got a written statement of
  educational goals
 their performance evals are accessible
Remind them that…
   you gave a lecture on patient safety
   they have opportunities to participate in
    scholarly activity
   what research resources they have
   what you’re done on the competencies
   how often they evaluate the program in
   how often the PD meets (or will meet) with
In Summary:
   Avoid inconsistency
   Be as clear as possible
   Be responsive
   Know the Guidelines:
     Protected time

     Scholarly activity

     ABEM pass rates

     ED faculty staffing levels

     Faculty ABEM status

     Procedure & resuscitation #’s
In Summary:

 Have a good procedural documentation
 Manage your procedural numbers
 Leverage your scholarly activity
 Be serious about conference
  attendance (both residents and faculty)
 Manage the On-line ACGME Survey

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