Site Visit Manual and Workbook for Osteopathic

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					          SITE VISIT MANUAL AND WORKBOOK
                         FOR
  OSTEOPATHIC NEUROMUSCULOSKELETAL MEDICINE AND
OSTEOPATHIC MANIPULATIVE MEDICINE RESIDENCY TRAINING
                      PROGRAMS:

   “PLUS ONE” NEUROMUSCULOSKELETAL MEDICINE AND
                    OSTEOPATHIC
                MANIPULATIVE MEDICINE




              American Osteopathic Association
                         and the
              American Academy of Osteopathy



                                                 Effective 11/2008
                                                   SITE VISIT MANUAL

INTRODUCTION
This manual has been developed by the American Academy of Osteopathy (AAO) and the
Postdoctoral Standards and Evaluation Committee (PS&E). The PS&E is responsible for developing and maintaining
residency training standards as well as making recommendations to the American Osteopathic Association (AOA)
Program and Trainee Review Council (PTRC) on whether training programs meet the established standards for program
approval. Residency training standards for all Neuromuscular Medicine and Osteopathic Manipulative Medicine
specialties (NMM/OMM) are posted on the AOA’s fast-finder website: https://www.do-
online.org/pdf/acc_postdocfastfinder or the specialty web-site: https://www.do-
online.org/index.cfm?PageID=acc_postdocstdspeclist


This manual is designed to:
      • Describe the process for assessing the compliance of osteopathic NMM/OMM residencies with the
      AOA/AAO standards
      • Clarify the expectations of the AAO regarding the responsibilities of site visitors, program directors, directors
      of medical education, and the training institution
      • Enhance the reliability, consistency, and validity of the decisions regarding the compliance of training programs
      • Assist the program director to describe how the program complies with the residency training standards
      • Prepare the program director, director of medical education, and institution for a site visit

Questions? Contact the AAO at (317) 879-1881 or visit the AAO web site:
www.academyofosteopathy.org

AAO Mission Statement:
The mission of the American Academy of Osteopathy is to teach, advocate, and research the science, art and philosophy
of osteopathic medicine, emphasizing the integration of osteopathic principles, practice and manipulative treatment in
patient care.

AOA RESIDENCY PROGRAM APPROVAL

Recognition
The AOA is the only organization recognized by federal and state authorities to establish and maintain standards for
osteopathic postdoctoral medical education. The AOA has assigned this responsibility to the AAO and the AOA
Council on Postdoctoral Training (COPT), a component of the AOA Bureau of Osteopathic Education.

Benefits of AOA and AAO Program Approval
Approval by the AAO and AOA assures that an Osteopathic Neuromusculoskeletal and Manipulative Medicine
residency program has demonstrated sufficient evidence of the capability to successfully educate osteopathic physicians,
and that the program should continue to do so in the future.

The AAO PS&E serves as an advisory body to the AOA’s Program and Trainee Review Council (PTRC) for the
approval of individual resident training and of training programs. The PS&E's primary functions are to develop and
maintain residency training standards and to assure that residency programs and individual physicians seeking AOA
approval comply with the training standards. Program approval signifies that the residency program meets or exceeds
the AOA residency training standards.

Successful completion of a residency training program approved by the AAO and AOA is a prerequisite for a physician
to be certified by the AOA through the American Osteopathic Board of Neuromusculoskeletal Medicine (AOBNMM).
   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
                                                                 Page 1
Approval Process
Prerequisites for AOA program approval and the process of approval for new programs are explained in the residency
training standards. In summary, the institution obtains application materials from the Department of Education,
Division of Postdoctoral Training, Inspection Services of the AOA. The institution must submit a new program
application along with a program description, information on scope, volume and variety of patients, the qualifications of
the program director and faculty, copies of affiliation agreements, and fees. This information is reviewed by the AOA
staff and forwarded to the AAO PS&E.

The AAO PS&E may decide to take action on a request based on the information provided, or may require additional
materials prior to consideration of a new program. The PS&E meets four to six times per year to consider such
requests.

The AAO PS&E reviews the application. The Committee makes a recommendation regarding program approval to the
AOA’s PTRC. Recommendations for denial are accompanied by an explanation of program deficiencies that are cross-
referenced to the residency training standards.

All new programs must be re-visited within one (1) year of residents enrolling in the residency program. If no resident is
recruited within three (3) years, the program lapses and must begin the approval process as a new program.

Procedures for continuing approval of established programs are described in the residency training standards. When a
residency program is due for a site visit, the AAO assigns site visitors to visit specific programs. The AAO informs the
AOA of the selected site visitor. The AOA confirms the name of the site visitor with the program director and director
of medical education (DME).

The site visitor arranges a visitation date with the program director, conducts the site visit to validate compliance with
the training standards, and submits a completed site visit workbook and narrative with appropriate documentation, to
the AAO PS&E for review. The AAO PS&E makes a recommendation to the PTRC.


Criteria for Continuing Approval PS&E Recommendations
AAO PS&E recommendations for continuing program approval always specify the number of years before another site
visit is necessary. Excellent programs may be approved by the PTRC for up to five (5) years before the next site visit.
Programs that meet most standards but have some deficiencies or appear to be in transition are recommended for
approval with a re-visit within two (2) to five (5) years.

The PS&E adheres to the following criteria for continuing approval recommendations to the AOA:

Approval with re-evaluation in five (5) years:
The program is exemplary and has no deficiencies; the program meets or exceeds all AOA/AAO standards.

Approval with re-evaluation in four (4) years:
The program is exemplary with no more than minor deficiencies.

Approval with re-evaluation in three (3) years:
The program is good with minor deficiencies and no more than one major deficiency.

Approval with re-evaluation in two (2) years:
The program is weak, however, with remediation the program could become a good program.
NOTE: The two-year recommendation is to be used for programs which have correctable deficiencies or in a transition
which may affect the quality of training, but require an early re-visit to evaluate the correction of deficiencies.

Approval with re-evaluation in one (1) year:
The program has major deficiencies and is recommended for probationary status.
A program with major deficiencies fails to address one or more of the following standards:
1. Qualified active program director and sufficient faculty who teach, evaluate, and support the program.
2. Institution’s support to run the program effectively.
3. An effective planned curriculum that covers the scope of the specialty.
4. An effective and comprehensive evaluation system for the residents and the faculty.
5. An internal evaluation system for the program that focuses on improvement.
6. A good balance of service and education – i.e. good education and good clinical experience.
7. Evidence of osteopathic application.

Deficiencies considered minor are administrative in nature and unrelated to the basic structure and quality of the
training.

NOTE: In deliberation of deficiencies, the PS&E will determine the significance of deficiencies in relation to the
program.

One-Year Approval/Denial of Program Approval Recommendation
Programs that meet most standards but are not in compliance with one (1) or more major standard may be approved
with a re-visit within one (1) year, with a requirement that the program immediately correct any deficiencies. Such
programs are informed of the specific deficiencies, referenced to the specific residency training standards. Any
established residency program which has received AOA approval for one (1) year because of deficiencies will not be
permitted to contract with a new resident until such time as the program receives AOA approval of two (2) or more
years although such programs may continue to contract with residents already in training. After appropriate review and
recommendation from a specialty college, the PTRC may waive this requirement. All one (1) year continuing program
approvals shall be considered probationary status, unless deemed otherwise by the PS&E. Furthermore, failure to
correct deficiencies will result in denial of program approval. Institutions that are unable to correct deficiencies may
choose to voluntarily terminate their programs.

If programs are recommended for denial of continuing approval or for approval with a re-visit within one (1) year, the
program may appeal the decision by entering the AOA PTRC appeal process.



SITE VISITORS

Eligibility and Selection of the Site Visitor
A potential site visitor must be a member of the PS&E and will volunteer or be assigned by the chair of the PS&E to be
the site visitor for a particular program. To be eligible for consideration by the PS&E, the potential site visitor should be:
        • AOBNMM (or its equivalent) Certified
        • A member of the AAO and AOA
        • Have at least two (2) years of clinical practice experience with a focus on Neuromusculoskeletal Medicine and
        Osteopathic Manipulative Medicine
        • Experienced in the training of NMM/OMM residents in an AOA-approved residency program

In an effort to reduce the cost of a site visit, a site visitor may be asked to conduct two (2) or three (3) site visits in the
same geographic area, to avoid additional airfare. However, cost considerations are secondary to those of specialty
expertise and conflict of interest. NOTE: Any qualified site visitor may inspect any NMM/OMM residency program.

Efforts are made to avoid a conflict of interest in assignment of site visitors. Site visitors may not practice in the same
geographic area as the program being inspected. Site visitors also should not agree to visit a program for which they
have a personal conflict of interest – for example, if the program director is a relative; if the site visitor’s
employment/staff privileges were ever terminated by the institution being inspected; if the site visitor is a candidate for
employment/staff privileges at the institution or if there are any other personal or professional relationships, either
positive or negative, which might influence or might appear to influence the site visitor’s judgment regarding the
program. It also is preferable that site visitors not visit programs at institutions where they trained or practiced. If the
potential site visitor or program being visited has questions about a possible conflict of interest, he or she should contact
the AOA or the AAO for clarification regarding the site visit assignment.

   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
Site Visitor Responsibilities
The site visitor’s primary responsibility is to confirm the training program’s adherence to the AOA/AAO training
standards and to collect supporting data for the PS&E to review and evaluate.

The site visitor is representing both the AOA and the AAO. The site visitor must remain professional and objective at
all times. The site visitor is acting as an advocate for educational improvement. Derogatory comments are unacceptable
and will not be tolerated. The site visitor also should avoid social activities with institution representatives that might be
perceived as creating a conflict of interest (i.e. - accepting expensive dinners or entertainment).

While the AAO welcomes suggestions for improvement of standards and site visit procedures from all members of the
profession, the site visit is not an appropriate time to voice objections to AOA or AAO policy or procedures. During a
site visit, site visitors are expected to be supportive of the AOA, the AAO, the standards developed by these
professional organizations, and site visit procedures.

Site visitors must assist in defusing any hostility towards the site visit process and work in a collegial, fair and impartial
manner. This is particularly important for assignments with programs that have been cited for previous deficiencies, or
that feel they were unfairly treated in the past. The site visitor must maintain and communicate the need for adherence
to educational standards, and exhibit behavior which is beyond reproach and fully professional.


PREPARING FOR THE SITE VISIT

Responsibilities of the Site Visitor Prior to the Visit
After a site visitor has agreed to conduct the site visit, the AAO confirms the site visit in writing to the site visitor with
copies to the AOA and the program director. The AOA staff sends a letter to the site visitor and to the residency
program director at the institution to confirm the name of the site visitor, the due date for completion of the site visit,
and preparations to be completed in advance of the site visit. The letter to the site visitor should include the AOA travel
policies that must be followed by the site visitor in order to be reimbursed for their site visit expenses. The AOA
forwards copies of all correspondence to the AAO, DME, and OPTI administrative staff. The letter from the AOA to
the residency program director should instruct the residency program director of the materials to be available at the time
of the visit.

The program director is required to send one (1) copy of the following materials to the AOA approximately 30 days
prior to the site visit. The AOA will forward the same Information to the site visitor no less than 2 weeks prior to the
site visit. (It Is advisable, but not required for the program director to send one copy of the following Items directly to
the site Inspector 30 days prior to the site visit.)

       •A current program description (includes mission statement, goals and objectives, curriculum, summary of
       academic and clinical experience, resident-patient care responsibilities, rules and regulations)
       •Departmental segregated totals of patient scope and volume for the last full year (NOTE: The patient load of
       the residency program must be sufficient to train a minimum of three (3) residents)
       •Current curriculum vitae of the program director
       •A list of department members and their current certification status
       •Current affiliation agreements for all outside rotations
       •Completed standards worksheet (Part C of this workbook) by the institution/training program
       (NOTE: All deficiencies must be explained.)

If the site visitor has not received the required materials listed above at least two (2) weeks before the date of the site
visit, this may be interpreted as non-compliance with the standards and may jeopardize the approval status of the
program.

As soon as the site visitor receives a formal confirmation letter from the AOA, the site visitor should contact the
program director to arrange a specific date for the visit. The site visit should be conducted on a week day, which is not a
holiday, on a date when the institution’s DME and program faculty will be available to meet with the site visitor, and
when the program residents are on-site and available for interview. Other schedules (such as a weekend day) may be
negotiated if mutually agreeable to the site visitor and program director, if necessary personnel are available. The site
visitor must inform the AOA or AAO of the date of the site visit.
NOTE: The program director is responsible for arranging a date suitable for the DME and faculty. The site visit must
be completed within a 30-day time frame before or after the due date identified by the AOA in the confirmation letter.

In preliminary telephone conversations with the program director, the following should be discussed:

       •Specific date of the site visit

       •Expected arrival time of the site visitor

       •Materials to be sent in advance, including a map to the institution and name and phone number of a local hotel
       and airport, if necessary

       •Characteristics of the room in which the site visitor will be working (a board room or private conference room is
       most desirable), the room should be able to accommodate all required materials and allow privacy for interviews

       •Materials to be available at the institution at the time of the site visit (see Appendix, Part B)

       •The agenda for the site visit (see page 9)

       •Specific individuals whom the site visitor wishes to interview, including the DME, administration, and residents

       •Individuals to be available for the final meeting, including the DME and program director

The site visitor must be completely familiar with the site visit manual and completed workbook prior to the
site visit. The site visitor must read the workbook completed by the program director as well as any supplemental
documents. The site visitor also should read the site visit materials provided by the AOA, including the report of the
last site visit of the program. If the site visitor has other reasonable requests for materials or if there appear to be
inconsistencies or inaccuracies in the submitted materials, the site visitor should ask the residency program director to
send corrected or additional documentation.

Travel Arrangements
The site visitor should carefully follow the AOA policies regarding reimbursement, which accompany the AOA letter
confirming the appointment as site visitor for a particular program. (These policies are subject to change, and
therefore not included in this manual.) If the AOA does not provide a copy of the travel policies, the policies should
be requested from the AOA Division of Postdoctoral Training Inspection Services.

Questions about travel expenses should be directed to the AOA at (800) 621-1773.

Policies

Timeline for Site Visits
Written correspondence from the AOA will notify both the site visitor and the program director of the timeline for the
site visit. This correspondence will state the due date for the site visit. A copy of the correspondence also will be
forwarded to the DME of the institution. NOTE: Inspections should be arranged four months prior to the due date
determined by the AOA. Inspections must occur within a 30-day timeframe before or after the AOA due date.

If the site visit is not performed within the time frame for completion of the site visit because of an unreasonable
deferral by the program director, the AAO staff will notify the program director in writing that the PS&E may take
action to administratively withdraw the program’s approval at the next scheduled PS&E meeting for failure to follow the
policies and procedures of the PS&E and AOA. This correspondence will be copied to the DME and OPTI.

Administrative Withdrawal of Accreditation for Non-compliance with Approval Actions and
Procedures


   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
A program director may be deemed to have withdrawn from the voluntary process of approval and the PS&E may take
appropriate action to withdraw approval if a program director does not comply with the following actions and
procedures:

      To adequately prepare for or undergo a site visit as required within the required time period
      To follow policies, procedures or recommendations for corrective actions(s) associated with an approval action
      To supply the PS&E with requested information

Administrative withdrawal of approval for non-compliance with approval actions and procedures is not subject to the
AAO/AOA appeals process.


COLLECTING INFORMATION DURING THE SITE VISIT

Site Visit Agenda
The site visitor and the program director should confirm the specific agenda of a site visit in advance. Generally, the
visit should be designed to collect the most information possible in the time available, with minimum disruption to the
day-to-day activities of the institution being visited. The following general schedule may be helpful in planning the
agenda (although this schedule may be altered, including expansion to two (2) days, if necessary).

SAMPLE AGENDA
Activities for each time period are discussed in detail in the sections below.

8:00 a.m. Site visitor arrives; preliminary meeting with program director

8:30 a.m. Review with the program director to be sure all required documents are available/selection of charts to be
pulled

8:40 a.m. Review standards worksheet (Part C of the workbook) completed by the program with the program director

8:50 a.m. Review affiliation agreements and discuss out-rotation scheduling with the program director

8:55 a.m. Review written curriculum and discuss how it is implemented with the program director

9:00 a.m. Review resident logs, with identification of charts needed from medical records and records of adherence to
duty work hour requirements

10:00 a.m. Review of clinical, educational, and departmental facilities

11:00 a.m. Start chart review, examine scientific papers, review other documents provided or requested

Noon: Working lunch/interviews with residents

1:30 p.m. Interviews with department faculty, DME, institution administration

2:30 p.m. Complete chart review, complete site visitor’s workbook (complete Parts A and B, and verify Part C); meet
again with program director if necessary

4:30 p.m. Conduct final meeting. RECOMMENDATIONS ARE NOT TO BE DISCUSSED AT THE FINAL
MEETING. NO EXIT INTERVIEW IS ALLOWED.
PRELIMINARY MEETING WITH PROGRAM DIRECTOR (8:00 – 8:30 A.M.)

Review of Day’s Schedule.
The first item of business should be clarification regarding the day’s schedule, and when individuals will be interviewed.
(If residents are on out-rotations, the site visitor may obtain telephone numbers so that telephone interviews can be
arranged). The site visitor should be flexible regarding reasonable changes in the scheduling of agenda items, while
continuing to insure that adequate time is available with the necessary individuals to obtain needed information. The site
visitor also should know whom to contact for additional information, if needed during the day (i.e., the telephone
number for the program director’s secretary, who would know how to respond to any requests).

Review of Final Meeting.
The site visitor also should clarify expectations regarding the final meeting to be sure that the program director
understands the format of that meeting and knows whom to have in attendance.

Overview Discussion of the Residency Program.
Finally, the site visitor should ask the program director to provide an overview of the residency program – its history,
current status, administrative support, out-rotations, affiliation agreements, curriculum, and what the director regards as
the program’s strengths and weaknesses.

REVIEW OF DOCUMENTS (8:30 – 10:00 a.m.)
At the beginning of the visit, the site visitor should verify that all requested documents are available. (Detailed review of the
content is done later in the day.) When the site visit was scheduled, the AOA advised the program director that the following
documents were to be available in the room at the time of the site visit. (For a new program, the list must be modified,
i.e., expect a list of proposed lectures rather than lectures given.)

If any documents are missing, request them so they will be available for review. Documents include:

1. Resident logs, annual reports, and scientific papers for each resident for their current and previous year(s).

2. Department/division minutes for the current and previous year.

3. Current department/division rules and regulations.

4. List of lectures for current and previous year.

5. Journal Club minutes for current and previous year(s).

6. Evaluations of each resident for all rotations for current and previous year.

7. List of journals and books available in the hospital library and/or via online services in this specialty.

8. Each resident’s evaluations of the program since last inspection.

9. Completed standards worksheet (see Appendix, Part C).

10. Current resident manual, including resident dismissal/grievance process, and resident duty hour policies and
procedures.

11. Current program description (includes a mission statement, goals and objectives, curriculum, summary of academic
and clinical experience, resident-patient care responsibilities, rules and regulations).

12. Current CVs of program director and department members participating in the training program.

   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
13. Current affiliation agreements for all out-rotations.

14. Program segregated totals for the last year or last complete training year.

15. Resident duty work hour logs for the last 12 months.

16. Current contracts for each resident.

17. Documentation attesting to each resident’s professional qualifications to include:

     Official graduation transcript from the college of osteopathic medicine;
     Certificate and letter of recommendation from the DME of the internship program of graduation;
     Current licensure as a physician in the state where the training program and clinical training site(s) are located;
       and,
     Membership in the AOA and AAO.

Explanation of Documents
Meeting minutes and or log are reviewed primarily to assess resident participation in these activities. Review of
minutes should document participation by residents in all professional staff activities involving patient care.

Affiliation agreements are required by the AOA for all out-rotations. The documents are reviewed to determine if
they are current and to ensure adherence to the standards and program curriculum.

Lecture schedules are reviewed to assess the adequacy of the didactic program. Lecture topics should encompass the
entire gamut of NMM/OMM over the years of the program. Faculty of the institution, outside consultants, and
residents, should conduct teaching.

Evaluations of resident performance are reviewed to monitor the timeliness and quality of feedback given to
residents. These evaluations, in combination with the resident logs, provide information regarding the nature of clinical
rotations, particularly for out-rotations that may be a critical part of the resident’s experience.

Resident evaluations of their rotations should be reviewed before the interviews with residents, so that the site visitor
can discuss with residents whether the issues they raised in their evaluations were adequately resolved by the program
director and program administration.

Resident contracts are reviewed to ensure that the number of contracts do not exceed the number of AOA-approved
resident positions.

Segregated totals are reviewed to determine if the program provides adequate scope and volume in the patient
diagnoses and procedures afforded to the residents.

Resident duty work hour logs are reviewed to ensure compliance with AOA standards.

Selection of Charts from Medical Records
During most program site visits, the next item is selection of charts to be pulled by medical records, so that these charts
will be available for review later that morning. Charts from the acute care hospital setting as well as the ambulatory
continuity clinic setting should be reviewed. Resident logs are reviewed to evaluate the volume and mix of patients
being seen and the resident’s level of participation. The site reviewer at his or her discretion may request additional
charts. All patient identifiable information must remain at the training site.

During the review and evaluation of health care facilities’ postdoctoral training programs, health care facilities may
disclose or otherwise provide to the site visitor certain Protected Health Information (“PHI”) as defined in 45 C.F.R.
164.501, that may be subject to protection under the Health Insurance Portability and Accountability Act of 1996
(“HIPAA”) and/or regulations promulgated hereunder. AOA has entered into business associate agreements with the
healthcare facilities to which it provides review and evaluations of postdoctoral training programs and the terms of such
business associate agreements require AOA and AAO to ensure that any site visitor that receives, uses, or has access to
such health care facility’s PHI, comply with the same restrictions, conditions and requirements regarding the use and/or
disclosure of PHI and safeguards for PHI that apply to AOA/the AAO, and/or are required by law.
In addition, the AAO has entered into a business associate agreement with the AOA that requires that site visitors shall
not remove or take any PHI from the healthcare facilities that the site visitor reviews and evaluates for AOA and AAO.

REVIEW OF CLINICAL, EDUCATIONAL, & DEPARTMENTAL FACILITIES
(10:00 – 11:00 a.m.)

The library is a critical area, which should contain adequate facilities and references to allow independent learning. Note
the availability of audio-visual resources and computer access to the internet for residents. The site visitor has the
responsibility for determining if the resources are current and adequate in number to fully train residents. The site
visitor must also determine if the resources are available to residents a reasonable number of hours each day and that
adequate access to references is provided for the residents' use.

CHART REVIEW (11:00 a.m. – 12:00 noon)
The major purpose of the chart review is to evaluate whether residents are getting progressive responsibility consistent
with the level of training as well as a wide variety of diagnoses in both the hospital and ambulatory settings. Chart
review also assesses resident involvement in the management of cases. AOA standards require that residents be given
progressively increasing responsibility for patient care. All patient identifiable information must remain at the
training site.

The site reviewer is to give a narrative assessment of the program. The narrative must include an assessment of the
charts reviewed addressing the following chart review elements:

       1. Number of records reviewed
       2. Categories
       3. Completeness – (H and P’s, consults discharge summaries, progress notes)
       4. Evidence of resident participation
       5. Diagnosis, appropriate management
       6. Evidence of osteopathic principles and application

INTERVIEWS WITH RESIDENTS (12:00 noon - 1:30 p.m.)
If possible, all residents in the program should be interviewed either in person or by telephone, rather than allowing the
program director to select only a small proportion to meet with the site visitor. Residents may be interviewed either as a
group or one-to-one. The residents should be advised that the site visitor is seeking information for program approval
and program improvement, and that while the general results of the interview will be included as part of the report, the
identity of any individual resident will not be revealed. Interviews with residents should focus on two (2) major issues:

       1. The degree to which the program teaches, rather than just using residents for clinical service; and,

       2. The extent to which residents are actually allowed appropriate, progressive, and increasing responsibility, rather
       than only being allowed to watch or assist.

The interviews also should serve to verify the written information provided, or “fill the gaps” in the documentation.
Interviews should solicit resident reactions to learning activities. Specific questions to consider include:

       1. What is the balance between education and service?

       2. Is there a current written curriculum for the residency training program? Does it fulfill or follow the AAO
       requirements?

       3. Do you have adequate time to study?

       4. What are your rotations like?

       5. Are there areas where you should have rotations n particular disciplines but don’t?


   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
        6. What is your relationship with the DME office?

        7. Do you get enough feedback on your performance?

                What is the time frame for evaluations?
                How often are you evaluated?
                Are strengths and weaknesses identified? Are the evaluations constructive?
                Do you receive suggestions for improvement? Is remediation offered?
                Is the in-service exam important to you? Is the in-service exam used effectively?

        8. What is the didactic program like?

              Are lectures given as scheduled?
              What are the department/committee meetings like? Are they good learning experiences?

        9. Are residents working on scientific research papers, and do they understand the AOA/AAO requirements for
        the paper?

        10. Does the program adhere to AOA resident work hour limits?

        11. Have the residents read the AOA code of ethics?


INTERVIEWS WITH DEPARTMENT FACULTY, DME, INSTITUTION
ADMINISTRATION
(1:30 - 2:30 p.m.)

Interviews with department faculty and hospital administration also focus on the relationship between education and
service, and the extent to which residents are given progressive responsibility consistent with their level of training. The
site visitor should ask about work time/time off for residents; moonlighting; time and funding for lecture; philosophy
regarding out-rotations; the selection process (specifically, determine whether procedures followed match written selection policies); and
how the program handles weak residents, the kinds of remediation used, and how dismissals of residents are handled
(whether faculty are aware of written policies, and whether these policies are followed).

Questions to learn more about the quality of the faculty are:

        1. How is faculty recruitment and selection performed?

        2. Have any faculty been successfully recruited to the program since the last AOA approval?

        3. What are the desired qualifications of potential faculty?

        4. What are expectations for new faculty and continuing expectations of senior faculty? How are they evaluated?

        5. Do you have a formal program for faculty development?

              Are time and funds provided for faculty development training opportunities?
              Has the program offered you an opportunity to develop teaching skills?

        6. Describe the relationship between the training institution’s administration and the program.

        7. Is there an internal evaluation of the residency program to determine if the program is meeting stated goals?
COMPLETION OF SITE VISIT REPORTS (2:30 – 4:30 p.m.)
During the site visit, the site visitor will collect all necessary information and complete Parts A and B and verify part C
of the Site Visit Workbook (see Appendix). The Site Visit Workbook helps summarize data the site visitor has obtained
from charts, audits, review of documents, and interviews with all parties, and other information collected during the site
visit. The Site Visit Workbook should be completed before the final meeting. Non-compliance with a standard must be
supported with a written explanation of the deficiency.

At the end of the visit, the site visitor will meet with departmental faculty, DME, and institutional administration in a
final meeting. Within two (2) weeks of the site visit, the site visitor is required to forward the completed Site Visit
Workbook and required documents (see Appendix, Part A) to the AOA. The completed Site Visit Workbook submitted
to the AOA by the site reviewer must include the program director’s assessment as well as the site reviewer’s assessment
(see Appendix, Part C).

FINAL MEETING (4:30 p.m.)
A final meeting will be held as an opportunity for the site visitor to thank the participants involved in the site visit. The
program director and director of medical education are expected to attend this session, and they determine whom else
they wish to invite to the final meeting. Other program faculty and the chief executive officer or other hospital
administrators, and residents may participate.

Prior to departure, the site visitor should confirm that the program has provided the information necessary for the
review. The site visitor must not make recommendations for improvements. If it becomes apparent from the site
visit that the program director is in need of program development assistance, the AAO PS&E will determine the course
of action.

REPORTING FINDINGS OF THE SITE VISIT

Submitting the Site Visit Report
The completed workbook, required documents (see Appendix, Part A), and a written summary narrative must be
submitted to the AOA within two (2) weeks of the site visit. The site visitor must not delay the report to wait for receipt
of additional information from the institution. The site visit is completed when the visitor leaves the institution, and the
report must be based on the information available at that time. Any further information provided by the institution goes
directly to the AAO and AOA, not to the site visitor. NOTE: One complete workbook must be submitted to the AOA
by the site reviewer that includes the program director’s assessment and the site reviewer’s assessment of the program.

The written summary narrative completed by the site visitor should be an overall assessment of the residency
program. It must include:
     The date of the visit
     Names of participants
     Program strengths
     Program weaknesses and deficiencies
     Assessment of charts reviewed addressing the following chart review elements:
                       • Number of records reviewed
                       • Categories
                       • Completeness
                       • Evidence of resident participation
                       • Diagnosis, appropriate management
                       • Evidence of osteopathic principles and application
     How the program develops and evaluates resident core competencies in the following areas:
                       • Osteopathic principles and practices
                       • Patient care
                       • Medical knowledge
                       • Practice-based learning and improvement
                       • Interpersonal and communication skills
                       • Professionalism and systems-based practice
   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
 Verify documentation of internal review activities and noted in report
 Work hour compliance must be noted and discussed




                                            APPENDIX




                           Site Visit Workbook for
                      Neuromusculoskeletal Medicine
                       And Osteopathic Manipulative
                    Medicine Residency Training Programs
                               (NMM/OMM)
                                           American Osteopathic Association
                                       and the American Academy of Osteopathy


Introduction and Instructions
The Site Visit Workbook for NMM/OMM Residency Training Programs is designed to assess compliance with
the AOA/AAO Basic Standards for Residency Training. The program director is required to complete Part C: Standards
Worksheet with appropriate documentation (see Part A) and send one copy to the AOA and one copy to the site visitor
approximately 30 days prior to the inspection date. During the site visit, the site visitor verifies the program’s adherence
to the standards by reviewing the program director’s completion of Part C and the appropriate documentation. In
addition, the site visitor must complete Parts A and B of the workbook and submit the appropriate documentation to
the American Osteopathic Association at least two weeks after the site visit date.

This workbook includes the following forms:

Part A: Program Identification Data
Part B: Required Documents Checklist and Signature Sheet
Part C: Standards Worksheet
Questions about this workbook or reports should be forwarded to:

American Academy of Osteopathy
Chair of Postdoctoral Standards and Evaluation Committee
3500 DePauw Blvd., Suite 1080
Indianapolis, Indiana 46268
Phone: (317) 879-1881

and

American Osteopathic Association
Division of Postdoctoral Training, Inspection Services
142 East Ontario Street
Chicago, Illinois 60611
Phone: (800) 621-1773




   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
Part A: Program Identification Data
(The site visitor is required to complete all information below.)


Date of Current Site Visit:


Training Site/Base Institution:


City/State:


OPTI Name/Affiliation:


Name of Residency Training Program:


Name of designated Program Director:


Name of Director of Medical Education:


Number of participating trainers in the department:


Number of these trainers who are ABONMM (or equivalent) Board certified:


Total number of AOA-approved resident positions for this program:


Actual number of residents in training, by year:


OGME 2 _            _ OGME 3 _             _ OGME 4 _          _


Date of last site visit: _       _______


Deficiencies cited at last site visit:
The following materials must be submitted by the site visitor to the AOA to be forwarded to the AAO PS&E within
two weeks of the site visit.

     Departmental segregated totals

     Program description (includes a mission statement, goals and objectives, curriculum, summary of academic
      and clinical experience, resident-patient care responsibilities, rules and regulations.)

     Current affiliation agreements for all outside rotations

     Curriculum vitae of the program director

     List of departmental faculty with current certification status

     Completed Site Visit Workbook (Part C)

     Summary narrative




_       _______________________________
Site Visitor’s Name (print)


_       _______________________________                                                           _      ______
Site Visitor’s Signature                                                                                Date




   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
Part B: Required Documents Checklist and Signature Sheet
(To indicate compliance with the site review process, the site visitor is required to read and sign Part B.)

Institution:


Program Specialty:
This checklist serves as confirmation that the following documents were provided by the training site during the site visit
to support specific standards of the AOA/AAO Basic Standards for Residency Training In Neuromusculoskeletal Medicine:
Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Residency (NMM/OMM)




  YES/NO                                                  DOCUMENTS

   Yes
                  Resident logs, annual reports, and scientific papers for each resident for the current and
   No             previous years.

   Yes
                  Department minutes for current and previous years.
   No
   Yes
                  List of lectures presented to residents for the current and previous year.
   No
   Yes
                  Journal Club minutes for the current and previous year.
   No

   Yes            Evaluations of each resident for base institution and outside rotations for the current and
                  previous year.
   No
   Yes
                  Resident evaluations of the program.
   No

   Yes
                  Program segregated totals for the last complete training year.
   No
   Yes
                  Current department/division rules and regulations.
   No
   Yes
                  List of journals and books available in the hospital library and/or via online services for this
   No             specialty.

   Yes
                  Current resident manual, including resident dismissal/grievance process and work hour policy.
   No


   Yes
                  Duty work hours for each resident for the last 12 months.
   No
   Yes
                   Current program description (includes a mission statement, goals and objectives, curriculum,
   No              summary of academic and clinical experience, resident-patient care responsibilities, rules and
                   regulations).
   Yes
                   Current CVs of department members participating in the training program.
   No
   Yes
                   Current affiliation agreements for all rotations.
   No
   Yes
                   Current resident contracts for all residents.
   No
   Yes
                   Documentation attesting to each resident’s professional qualifications to include:
   No              -Official graduation transcript from the college of osteopathic medicine;
                   -Certificate and letter of recommendation from the DME of the internship program of
                   graduation;
                   -Current licensure as a physician in the state where the training program and clinical training
                   site(s) are located; and,
                   -Membership in the AOA and AAO

   Yes
                   Documentation attesting to the occurrence of the mid-term Internal audit with list of
   No              participants and date of audit. (Outcomes of the audit should not be released to the residency
                   program Inspector.)



NOTE: ALL PATIENT IDENTIFIABLE INFORMATION MUST REMAIN AT THE
TRAINING SITE.
Within two weeks of the site review, the program is encouraged to submit a report to the AAO and the AOA
Department of Education addressing the program’s correction of any noted deficiencies. Duplicate copies of this report
should be submitted to the American Academy of Osteopathy, 3500 DePauw Blvd., Suite 1080, Indianapolis, Indiana
46268, and to the American Osteopathic Association Department of Education, Program and Trainee Review Council
(PTRC), 142 East Ontario Street, Chicago, Illinois 60611.

The findings of the site visit represent the site visitor’s best judgment and are to assess the program’s compliance with
the residency training standards. The PS&E will make a recommendation to the AOA PTRC for continuing approval or
denial based upon the site visit report. The recommendation does not become final until reviewed and acted upon by
the AOA PTRC.



_       ________________________________
Site Visitor’s Name (print)


_       ________________________________                                                            _       ______
Site Visitor’s Signature                                                                                   Date




   Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                        “Plus One” NMM/OMM
                                                     Revised 6/2008, Effective 7/2008
                                        Part C: Standards Worksheet
                                                       Instructions
The Standards Worksheet is used to assess a program’s compliance with the AOA/AAO Basic
Standards for Residency Training in Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine. Program directors are
required to complete a self-assessment of program compliance with the standards and submit the self-assessment to the
site visitor approximately 30 days prior to the site visit date. During the site visit, the site visitor must validate program
compliance with each standard by checking “Yes” or “No”. Program directors and site visitors indicating non-
compliance must provide written comments in the section provided next to the standard explaining how/why the
program is not in compliance with the standard. An additional sheet may be attached if necessary for the explanation.
The completed workbook forwarded to the AAO must include both the program director’s assessment of compliance
and the site reviewer’s validation of compliance of the program.

Within two weeks of the site review, the program is encouraged to submit a report to the AAO and the AOA
Department of Education addressing the program’s correction of any noted deficiencies. Duplicate copies of this report
should be submitted to the American Academy of Osteopathy, 3500 DePauw Blvd., Suite 1080, Indianapolis, IN 46268,
and to the American Osteopathic Association Department of Education, Program and Trainee Review Council (PTRC),
142 East Ontario Street, Chicago, Illinois 60611. If the report is received prior to the meeting of the PS&E, the
corrections will be considered in the review when the site visitor’s report is reviewed.



Training Institution:

City: _       ________________________              State: _       __________

OPTI Affiliation:




_     _______________________________
Program Director’s Name (print)

_     _______________________________                                                    _       __________
Program Director’s Signature                                                             Completion Date of
                                                                                           Self-assessment


_       _______________________________
Site Visitor’s Name (print)

_       _______________________________                                                 _     __________
Site Visitor’s Signature                                                                Date of Site Review
                 STANDARD                                     PROGRAM COMPLIANCE                                         SITE VISITOR
                                                                 AND COMMENTS                                          VALIDATION AND
                                                                                                                          COMMENTS


PART ONE: Introduction


Article III –
Institutional Requirements


A. Be approved by the AOA for a residency in                Compliance:        Yes         No                  Compliance:         Yes       No
Neuromusculoskeletal Medicine and Osteopathic
Manipulative Medicine, an institution must meet             Documentation:           Yes        No             Commendation:           Yes        No
all the requirements as formulated in the Residency
Training Requirements of the American Osteopathic
Association.


B. Must provide sufficient patient load to                  Compliance:        Yes         No                  Compliance:         Yes       No
properly train a minimum of three (3) residents in
NMM/OMM. The available patients must                        Documentation:           Yes        No             Commendation:           Yes        No
provide a broad spectrum of problems, as defined
in this document, for the adequate training of
students.



C. Shall maintain an adequate library containing,           Compliance:        Yes         No                  Compliance:         Yes       No
or providing appropriate electronic access to,
carefully selected texts, the latest editions of            Documentation:           Yes        No             Commendation:           Yes        No
medical journals and other publications pertaining
to NMM/OMM and Osteopathic Medicine.



The Library shall be in the charge of a qualified           Compliance:        Yes         No                  Compliance:         Yes       No
person who shall act as custodian of its contents
and arrange for the proper cataloging and                   Documentation:           Yes        No             Commendation:           Yes        No
indexing that will facilitate investigative work by
the resident. Electronic retrieval of information
from medical databases must be available.

D. Shall have the following equipment:
   1. Treatment table(s) appropriate for                    Compliance:        Yes         No                  Compliance:         Yes       No
      osteopathic manipulative treatment.
   2. Diagnostic equipment necessary for                    Documentation:           Yes        No             Commendation:           Yes        No
      differential diagnosis.
   3. Access to physical therapy equipment
      during that portion of the program
      addressing physical medicine and
      rehabilitation activities and integration into
      a treatment program.

              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
E. Must provide an opportunity for exposure in        Compliance:      Yes         No        Compliance:      Yes         No
a supervised ambulatory site for continuity of care
training that will suit the needs of the program.     Documentation:         Yes        No   Commendation:      Yes            No
Institutional clinics, outpatient department of
offices may be used.




F. Will provide adequate space for a residency        Compliance:      Yes         No        Compliance:      Yes         No
study area.
                                                      Documentation:         Yes        No   Documentation:         Yes        No




G. Will provide qualified physicians in the various   Compliance:      Yes         No        Compliance:      Yes         No
disciplines to supervise resident training.
                                                      Documentation:         Yes        No   Documentation:         Yes        No
The program director will be responsible for the
approval of residents’ teaching contracts




H. Must provide a written policy and                  Compliance:      Yes         No        Compliance:      Yes         No
procedures, for the selection of residents, which
shall be included in the institutional training       Documentation:         Yes        No   Documentation:         Yes        No
protocol for NMM/OMM.




I. Shall execute a contract with each resident in     Compliance:      Yes         No        Compliance:      Yes         No
accordance with the Residency Training Requirements
of the AOA.                                           Documentation:         Yes        No   Documentation:         Yes        No




J. Shall award the resident an appropriate            Compliance:      Yes         No        Compliance:      Yes         No
completion certificate. The certificate shall
confirm the fulfillment of the program                Documentation:         Yes        No   Documentation:         Yes        No
requirements, starting and ending dates of the
program and the name(s) of the training
institution(s) and the program director(s).
K. Sponsoring institutions must be affiliated with          Compliance:        Yes         No                  Compliance:         Yes         No
an Osteopathic Postdoctoral Training Institute
(OPTI). For specific details of OPTI standards,             Documentation:           Yes        No             Documentation:            Yes        No
refer to the AOA document Program to Accredit
Osteopathic Postdoctoral Training Institutions.




L. Any additional institutions participating in the         Compliance:        Yes         No                  Compliance:         Yes         No
training of residents must have an affiliation
agreement with the sponsoring institution.                  Documentation:           Yes        No             Documentation:            Yes        No




M. The sponsoring institution shall provide the             Compliance:        Yes         No                  Compliance:         Yes         No
necessary resources for residents to attend the
annual convocation of the AAO and take the                  Documentation:           Yes        No             Documentation:            Yes        No
annual resident in-service examination given in
conjunction with this meeting.




              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
ARTICLE IV –
PROGRAM REQUIREMENTS


A. The training program shall commence only           Compliance:      Yes         No        Compliance:      Yes         No
after it has received the recommendation of the
AOA Council on Postdoctoral Training (COPT)           Documentation:         Yes        No   Documentation:         Yes        No
and the approval of the AOA Board of Trustee.




B. The “plus-one” residency training program in       Compliance:      Yes         No        Compliance:      Yes         No
NMM/OMM shall be one (1) year in duration.
                                                      Documentation:         Yes        No   Documentation:         Yes        No




C. Core Competencies                                  Compliance:      Yes         No        Compliance:      Yes         No

The following core competencies shall be required     Documentation:         Yes        No   Documentation:         Yes        No
of all residents to successfully complete a
residency in NMM/OMM.

The following core competencies shall be
integrated into the training and evaluation process
for each resident. Each program shall be
responsible for implementation and
documentation.

The competency based evaluation document shall
be the instrument used by all programs to
document achievement of these core
competencies.
 C.1. Osteopathic Philosophy and OMM
 C.2. Medical Knowledge
 C.3. Patient Care
 C.4. Interpersonal & Communication Skills
 C.5. Professionalism
 C.6. Practice-Based Learning and Improvement
 C.7. Systems-Based Practice

*Site Inspectors must include discussion of core
competency activities and evaluation of residents
in narrative report. (April 2008 COPT Newsletter)


D. The resident’s training program shall              Compliance:      Yes         No        Compliance:      Yes         No
commence following a review of the previously
completed AOA approved residency training             Documentation:         Yes        No   Documentation:         Yes        No
program.
E. The training program shall provide an                    Compliance:        Yes         No                  Compliance:         Yes         No
organized formal training program for the
development of highly skilled physicians capable            Documentation:           Yes        No             Documentation:            Yes        No
of supplying the needs for teaching in the basic
concepts of osteopathic philosophy; physicians
capable of integrating these concepts through
teaching and practice into the hospital and clinical
training of students and provide sufficient number
of these physicians to assure the availability of this
type of service.


F. There shall exist in every residency program in Compliance:                 Yes         No                  Compliance:         Yes         No
NMM/OMM a required and structured
curriculum, which incorporates the educational              Documentation:           Yes        No             Documentation:            Yes        No
objectives listed in Article IV, Section F. Each
phase of the curriculum shall be properly allocated
as to time, either longitudinally or as an intensive
experience of shorter duration.

The core curriculum is required but each
individual institution may meet the requirements
in ways that utilize the relative strengths of that
institution. Each program’s structure should
allow exposure to all areas of outpatient and
inpatient NMM/OMM. In addition, each
program is to define those areas of instruction
that are unique to that specific program.


G. Training in the different types of manipulative          Compliance:        Yes         No                  Compliance:         Yes         No
care and their indications, contraindications and
appropriateness in patient care including all               Documentation:           Yes        No             Documentation:            Yes        No
myofascial, soft tissue, direct and indirect
techniques currently taught in osteopathic colleges
will be provided.



H. Emphasis on the importance of preventive                 Compliance:        Yes         No                  Compliance:         Yes         No
medicine in total health care.
                                                            Documentation:           Yes        No             Documentation:            Yes        No


I. Methods for the proper recording of all                  Compliance:        Yes         No                  Compliance:         Yes         No
osteopathic diagnosis and treatment in all patient
records, consultation and reports in such a                 Documentation:           Yes        No             Documentation:            Yes        No
manner that these documents reflect the
osteopathic approach, treatment and effect.




J. Training in research design, especially in an            Compliance:        Yes         No                  Compliance:         Yes         No
osteopathic manipulative medical setting.
                                                            Documentation:           Yes        No             Documentation:            Yes        No


              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
K. Study and application of educational              Compliance:      Yes         No        Compliance:      Yes         No
principles.
                                                     Documentation:         Yes        No   Documentation:         Yes        No




L. Exposure to past and current medical literature   Compliance:      Yes         No        Compliance:      Yes         No
as well as specified reading list.
                                                     Documentation:         Yes        No   Documentation:         Yes        No




M. Educational programs intended to enhance          Compliance:      Yes         No        Compliance:      Yes         No
the resident’s understanding of practice
management, health care delivery systems, and        Documentation:         Yes        No   Documentation:         Yes        No
continuing medical education.




N. The program may offer quality outside             Compliance:      Yes         No        Compliance:      Yes         No
rotations that meet standards formulated in the
Residency Training Requirements of the American      Documentation:         Yes        No   Documentation:         Yes        No
Osteopathic Association.

Such rotations shall be arranged as needed to meet
the other goals and requirements of the residency
program and/or provide the breadth of patient
exposure required in this program.

Up to four (4) months of the program may be
spent in outside rotations, but the continuity of
the resident’s outpatient clinic experience should
be maintained within reason.
O. CORE CURRICULUM


O. 1. General Information

The resident should spend time in a variety of              Compliance:        Yes         No                  Compliance:         Yes         No
clinical and academic settings.
                                                            Documentation:           Yes        No             Documentation:            Yes        No
The resident’s performance in primary specialty
areas will be evaluated by both the primary or
specialty physician and the specialist in
NMM/OMM.

The curriculum is designed as a general guide to
concepts and skills that should be acquired while
in residency. The curriculum assumes a one (1)
year intensive program, which presumes
successful prior completion of an AOA approved
internship and residency program.

The following subjects must be included in every
residency program. The mode of implementation
is left to the individual program.


O. 2. CONTINUITY OF CARE
CLINICS

Should constitute the majority of outpatient                Compliance:        Yes         No                  Compliance:         Yes         No
training. The patient base should provide a
population with diversity of age and pathology.             Documentation:           Yes        No             Documentation:            Yes        No
The longitudinal care provided should address the
physiological, emotional, cultural, economic,
psychological, and environmental factors as they
relate to the disease process.

Each resident should have a dedicated panel of              Compliance:        Yes         No                  Compliance:         Yes         No
patients for whom, with appropriate supervision,
they are the principal care provider.                       Documentation:           Yes        No             Documentation:            Yes        No

The scope and variety of patients should be
adequate to support the educational objectives of
the NMM/OMM residency program.

The resident should spend an average of three (3)
half-days per week in the continuity clinic setting
over the course of the training period.

While the quality and diversity of the patients is
more important than the numbers themselves, it is
recommended that the resident provide care for at
least 120 individual patients and see
approximately 360-400 patient visits in the
continuity clinic through the course of their
training.
              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
O. 3. HOSPITAL CARE

Inpatient care must be incorporated into the           Compliance:      Yes         No        Compliance:      Yes         No
residency training program. Residents must
participate at the level of NMM/OMM specialist         Documentation:         Yes        No   Documentation:         Yes        No
consultant.




Appropriate follow-up hospital care should be          Compliance:      Yes         No        Compliance:      Yes         No
given to those patients on whom consultations are
performed.                                             Documentation:         Yes        No   Documentation:         Yes        No




Inpatient osteopathic care must be given under         Compliance:      Yes         No        Compliance:      Yes         No
the supervision of a physician board certified by
the American Osteopathic Board of                      Documentation:         Yes        No   Documentation:         Yes        No
Neuromusculoskeletal Medicine (AOBNMM) or
its precedents.




There must be direct interaction with the              Compliance:      Yes         No        Compliance:      Yes         No
attending physician who is providing primary care
to the patient, and supervised discussion of the       Documentation:         Yes        No   Documentation:         Yes        No
physical exam, differential diagnosis, and medical
or surgical management of the patient.




Consultation and inpatient care should be              Compliance:      Yes         No        Compliance:      Yes         No
performed on patients with a broad variety of
diagnoses compatible with the educational              Documentation:         Yes        No   Documentation:         Yes        No
objectives of the program.




The OMT provided must be designed to produce           Compliance:      Yes         No        Compliance:      Yes         No
a physiological change in the patient that will
impact the course of the illness. It is insufficient   Documentation:         Yes        No   Documentation:         Yes        No
to treat only the musculoskeletal complaints in
medically ill patients.
Consultation and inpatient care should be                   Compliance:        Yes         No                  Compliance:         Yes         No
performed on patients with a broad variety of
diagnoses compatible with the educational                   Documentation:           Yes        No             Documentation:            Yes        No
objectives of the program.

The OMT provided must be designed to produce
a physiological change in the patient that will
impact the course of the illness. It is insufficient
to treat only the musculoskeletal complaints in
medically ill patients.

The resident should participate in all phases of the
consultation, including patient evaluation,
management including the delivery of OMT and
writing of the consultation and follow-up notes.




O. 4. ACADEMIC TRAINING


Residents must receive education in both lecturing          Compliance:        Yes         No                  Compliance:         Yes         No
and hands-on training. This training may occur at
osteopathic colleges in undergraduate OPP and               Documentation:           Yes        No             Documentation:            Yes        No
OMM departments, or in OPTIs training
osteopathic interns, residents, and medical
students.

Ideally, this aspect of training will include teaching
experience in both large and small group settings.




O. 5. OSTEOPATHIC PHILOSOPHY



The resident in NMM/OMM must study                          Compliance:        Yes         No                  Compliance:         Yes         No
osteopathic philosophy in depth.
                                                            Documentation:           Yes        No             Documentation:            Yes        No
Although this may be accomplished by reading
assignment, it is best done with the incorporation
of group discussion on a regular basis.

A minimum of one text by A.T. Still must be read
during the residency period.




              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
O. 6. BEHAVIORAL SCIENCE

Is best learned in the longitudinal care setting      Compliance:      Yes         No        Compliance:      Yes         No
utilizing didactic and clinical methods.
                                                      Documentation:         Yes        No   Documentation:         Yes        No
The continuity of care center should serve as the
site for this training.

Learning medical community resources available
and developing appropriate referral skills should
be part of this aspect of the residents training.

The behavioral science component of the
curriculum should include the promotion of the
physician’s well being and prevention of
impairment.
O. 7. GERIATRICS

This aspect of the residents training should be met   Compliance:      Yes         No        Compliance:      Yes         No
by the diversity of patients in the ambulatory and
inpatient components of training.                     Documentation:         Yes        No   Documentation:         Yes        No




O. 8. INTERNAL MEDICINE

This aspect of the residents training should be       Compliance:      Yes         No        Compliance:      Yes         No
both didactic and clinical, and involve training
from both specialists in NMM/OMM and                  Documentation:         Yes        No   Documentation:         Yes        No
Osteopathic Internists and Generalists.




It should occur in both the inpatient and             Compliance:      Yes         No        Compliance:      Yes         No
outpatient settings.
                                                      Documentation:         Yes        No   Documentation:         Yes        No




Over the course of training, the resident should      Compliance:      Yes         No        Compliance:      Yes         No
evaluate and treat a minimum of approximately
fifty (50) patients with a broad variety of the       Documentation:         Yes        No   Documentation:         Yes        No
diagnoses.

The quality and diversity of cases is more
important than the number itself.
This requirement may be met through both the                Compliance:        Yes         No                  Compliance:         Yes         No
continuity clinic and hospital care portions of the
program.                                                    Documentation:           Yes        No             Documentation:            Yes        No




If insufficient volume or depth is produced                 Compliance:        Yes         No                  Compliance:         Yes         No
through these avenues, a minimum of one (1)
month of intensive rotation on internal medicine            Documentation:           Yes        No             Documentation:            Yes        No
services must be done.




The rotation may be in general medicine or one or           Compliance:        Yes         No                  Compliance:         Yes         No
more of the subspecialties, however the minimum
osteopathic manipulative treatment requirement              Documentation:           Yes        No             Documentation:            Yes        No
still exits. Therefore, it is unacceptable for the
resident to rotate solely as an intern or medical
resident.

A specialist in NMM/OMM must supervise the
osteopathic structural evaluation and manipulative
treatment.

There must also be direct interaction with the
internist or sub-specialist providing medical care
to the patient, and supervised discussion of the
physical exam, differential diagnosis, and medical
management of the patient.


Both the specialist or sub-specialist in internal           Compliance:        Yes         No                  Compliance:         Yes         No
medicine physician and the specialist in
NMM/OMM may evaluate the resident’s                         Documentation:           Yes        No             Documentation:            Yes        No
performance in internal medicine.




The manipulative treatment plan must address the            Compliance:        Yes         No                  Compliance:         Yes         No
pathophysiology of the disease process. It is
insufficient to treat only the musculoskeletal              Documentation:           Yes        No             Documentation:            Yes        No
complaints of patients with medical problems.




              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
O. 9. SURGERY
This aspect of the residents training should be         Compliance:      Yes         No        Compliance:      Yes         No
both didactic and clinical, and involve training by
both specialists in NMM/OMM and Surgery.                Documentation:         Yes        No   Documentation:         Yes        No



This training should occur in both the inpatient        Compliance:      Yes         No        Compliance:      Yes         No
and outpatient settings.
                                                        Documentation:         Yes        No   Documentation:         Yes        No


Over the course of training, the resident should        Compliance:      Yes         No        Compliance:      Yes         No
evaluate and treat a minimum of approximately
fifty (50) patients with a broad variety of             Documentation:         Yes        No   Documentation:         Yes        No
diagnoses.

The quality and diversity of cases is more
important than the number itself.


This requirement can be met through the                 Compliance:      Yes         No        Compliance:      Yes         No
continental clinic and hospital care portions of the
program. If insufficient volume is produced             Documentation:         Yes        No   Documentation:         Yes        No
through these avenues, a minimum of one (1)
month of intensive rotation on surgical services
must be done.




The rotations may be on general surgery or one or       Compliance:      Yes         No        Compliance:      Yes         No
more sub-specialties, however the minimum
osteopathic manipulative treatment requirement          Documentation:         Yes        No   Documentation:         Yes        No
still exists.

Therefore, it is unacceptable to rotate the resident
through surgical services solely as a surgical intern
or resident. A specialist in NMM/OMM must
supervise the osteopathic structural evaluation and
manipulative treatment.

There must also be direct interaction with the
attending providing primary and/or surgical care
to the patient, and supervised discussion of the
physical exam, differential diagnosis, and
medical/surgical management of the patient.

Both the surgical specialist or sub-specialist
physician and the specialist in NMM/OMM may
evaluate the resident’s performance in surgery.

The manipulative treatment plan must address the
pathophysiology of the disease process. It is
insufficient to treat only the musculoskeletal
complaints of patients with surgical problems.
O. 10. PEDIATRICS

This aspect of the residents’ training should be            Compliance:        Yes         No                  Compliance:         Yes         No
both didactic and clinical, and must include
training by specialists in NMM/OMM as well as               Documentation:           Yes        No             Documentation:            Yes        No
pediatrics or family practice.

This training should occur in both inpatient and
outpatient settings.


Over the course of the training, the resident               Compliance:        Yes         No                  Compliance:         Yes         No
should evaluate and treat a minimum of
approximately fifty (50) patients with a broad              Documentation:           Yes        No             Documentation:            Yes        No
variety of the diagnoses.

The quality and diversity of cases is more
important than the number itself.


This requirement can be met through both the                Compliance:        Yes         No                  Compliance:         Yes         No
continuity clinic and hospital care portions of the
program.                                                    Documentation:           Yes        No             Documentation:            Yes        No

If insufficient volume is produced through these
avenues, a minimum of one (1) month of
intensive rotation in pediatrics must be done.

It is unacceptable to rotate the resident solely as a
pediatric intern or resident. The Osteopathic
evaluation and manipulative treatment must be
supervised by a specialist in NMM/OMM.

There must be direct interaction with the pediatric
or family practice attending providing the medical
care to the patient, and supervised discussion of
the physical exam, differential diagnosis and
medical management of the patient.


The resident’s performance will be evaluated by             Compliance:        Yes         No                  Compliance:         Yes         No
both the pediatric or primary care physician and
the specialist in NMM/OMM.                                  Documentation:           Yes        No             Documentation:            Yes        No




O.11.
OBSTETRICS/GYNECOLOGY
This aspect of the residents training should be             Compliance:        Yes         No                  Compliance:         Yes         No
both didactic and clinical, and must involve
training by specialists in NMM/OMM and                      Documentation:           Yes        No             Documentation:            Yes        No
Ob/Gyn or Family Practice.

              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
The training should occur in both the inpatient      Compliance:      Yes         No        Compliance:      Yes         No
and outpatient setting.
                                                     Documentation:         Yes        No   Documentation:         Yes        No




Over the course of training, the resident should     Compliance:      Yes         No        Compliance:      Yes         No
evaluate and treat a minimum of approximately
fifty (50) patients with a broad variety of          Documentation:         Yes        No   Documentation:         Yes        No
diagnoses.

The quality and diversity of cases is more
important than the number itself.




If insufficient volume or depth is produced          Compliance:      Yes         No        Compliance:      Yes         No
through these avenues, a minimum of one (1)
month of intensive rotations in Ob/Gyn must be       Documentation:         Yes        No   Documentation:         Yes        No
done.

The minimum osteopathic treatment requirement
persists in this situation, and it is therefore
unacceptable to rotate the resident through the
service solely as an Ob/Gyn intern or resident.




A specialist in NMM/OMM must supervise the           Compliance:      Yes         No        Compliance:      Yes         No
osteopathic structural evaluation and manipulative
treatment.                                           Documentation:         Yes        No   Documentation:         Yes        No

There must also be direct interaction with the
attending providing the Ob/Gyn care to the
patient, and supervised discussion of the physical
exam, differential diagnosis, and Ob/Gyn care of
the patient.




Both the primary care or Ob/Gyn physician and        Compliance:      Yes         No        Compliance:      Yes         No
the specialist in NMM/OMM may evaluate the
resident’s performance.                              Documentation:         Yes        No   Documentation:         Yes        No

The manipulative treatment must address the
pathophysiology of the disease process. It is
insufficient to treat only the musculoskeletal
complaints in the Ob/Gyn patient.
O. 12.
NEUROMUSCULOSKELETAL
MEDICINE


This section will include divisions of:                     Compliance:        Yes         No                  Compliance:         Yes         No

       -Neurology                                           Documentation:           Yes        No             Documentation:            Yes        No
       -Rheumatology
       -Orthopedics
       -Occupational Medicine
       -Radiology
       -Anesthesiology
       -Rehabilitation medicine (PMR)

to cover the diversity of diagnoses needed to meet
this requirement.


Over the course of training, the resident should            Compliance:        Yes         No                  Compliance:         Yes         No
evaluate and treat a minimum of approximately
one hundred (100) patients with a broad variety of          Documentation:           Yes        No             Documentation:            Yes        No
diseases.

The quality and diversity of cases is more
important than the number itself.

This requirement can be met through the
continuity clinic and hospital care portions of the
program.


If insufficient volume is met through these                 Compliance:        Yes         No                  Compliance:         Yes         No
avenues, a minimum of two (2) months of
intensive rotations must be done.                           Documentation:           Yes        No             Documentation:            Yes        No




              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
ARTICLE V –
QUALIFICATION AND
RESPONSIBILITIES OF THE
PROGRAM DIRECTOR


    A. Qualifications:                                Compliance:      Yes         No        Compliance:      Yes         No
         1.    Must be certified by the American
              Osteopathic Board of                    Documentation:         Yes        No   Documentation:         Yes        No
              Neuromusculoskeletal Medicine
              (AOBNMM) in
              Neuromusculoskeletal Medicine and
              Osteopathic Manipulative Medicine
              (NMM/OMM), or hold certification
              under the precedent board, the
              American Osteopathic Board of
              Special Proficiency in Osteopathic
              Manipulative Medicine
              (AOBSPOMM).

         2.   Must meet the standards of the
              position as formulated in the AOA
              Basic Documents for Postdoctoral
              Training.

         3.    Be licensed to practice medicine in
              the state where the sponsoring
              training institution is located.

    B. Responsibilities      - the program
        director shall:                               Compliance:      Yes         No        Compliance:      Yes         No

1. Be responsible for the educational program and     Documentation:         Yes        No   Documentation:         Yes        No
shall ensure that all program requirements are met.




2. Arrange for residency training within the          Compliance:      Yes         No        Compliance:      Yes         No
institution in cooperation with allied departments.
                                                      Documentation:         Yes        No   Documentation:         Yes        No




3. Arrange affiliations and/or outside rotations      Compliance:      Yes         No        Compliance:      Yes         No
necessary to meet the program objectives.
                                                      Documentation:         Yes        No   Documentation:         Yes        No
4. Prepare required materials for inspection in             Compliance:        Yes         No                  Compliance:         Yes         No
cooperation with the AOA Division of
Postdoctoral Training.                                      Documentation:           Yes        No             Documentation:            Yes        No




5. Define his/her authority in directing the                Compliance:        Yes         No                  Compliance:         Yes         No
residency training program in the program
documents of the institution conducting the                 Documentation:           Yes        No             Documentation:            Yes        No
program.




6. Provide the resident with all documents                  Compliance:        Yes         No                  Compliance:         Yes         No
pertaining to the program, including requirements
for satisfactory completion of the program.                 Documentation:           Yes        No             Documentation:            Yes        No




7. Submit quarterly reports to the director of              Compliance:        Yes         No                  Compliance:         Yes         No
medical education (DME) of the institution.
                                                            Documentation:           Yes        No             Documentation:            Yes        No
Submit Annual reports to the AAO’s PS&E
committee.




8. Encourage the resident to apply for certification        Compliance:        Yes         No                  Compliance:         Yes         No
in Neuromusculoskeletal Medicine and
Osteopathic Manipulative Medicine by the                    Documentation:           Yes        No             Documentation:            Yes        No
AOBNMM.




              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
ARTICLE VI –
RESIDENT REQUIREMENTS


A. The applicant will:                               Compliance:      Yes         No        Compliance:      Yes         No

1. Be a graduate of a college of osteopathic         Documentation:         Yes        No   Documentation:         Yes        No
medicine accredited by the AOA.




2. Successfully complete a one (1) year internship   Compliance:      Yes         No        Compliance:      Yes         No
approved by the AOA.
                                                     Documentation:         Yes        No   Documentation:         Yes        No




3. Successfully complete an AOA approved             Compliance:      Yes         No        Compliance:      Yes         No
residency program in another specialty.
                                                     Documentation:         Yes        No   Documentation:         Yes        No




4. Be and remain a member in good standing of        Compliance:      Yes         No        Compliance:      Yes         No
the AOA.
                                                     Documentation:         Yes        No   Documentation:         Yes        No




5. Be and remain a member in good standing of        Compliance:      Yes         No        Compliance:      Yes         No
the AAO.
                                                     Documentation:         Yes        No   Documentation:         Yes        No




6. Be appropriately licensed in the state in which   Compliance:      Yes         No        Compliance:      Yes         No
the training is conducted.
                                                     Documentation:         Yes        No   Documentation:         Yes        No
7. Show evidence of conformity to the Code of               Compliance:        Yes         No                  Compliance:         Yes         No
Ethics of the AOA.
                                                            Documentation:           Yes        No             Documentation:            Yes        No


B. During the residency training program, the               Compliance:        Yes         No                  Compliance:         Yes         No
resident must:
                                                            Documentation:           Yes        No             Documentation:            Yes        No
1. Submit an annual report to the Postdoctoral
Standards and Evaluation Committee of the
AAO.


2. Prepare a minimum of one paper which is                  Compliance:        Yes         No                  Compliance:         Yes         No
suitable for publication or in lieu of such a paper,
he/she may participate in the writing efforts               Documentation:           Yes        No             Documentation:            Yes        No
related to a study (clinical or basic research) from
which a report or paper suitable for publication
would evolve.


3. Attend the appropriate staff, departmental and           Compliance:        Yes         No                  Compliance:         Yes         No
hospital meetings per institutional policy.
                                                            Documentation:           Yes        No             Documentation:            Yes        No




4. Participate annually in a minimum of twenty              Compliance:        Yes         No                  Compliance:         Yes         No
(20) hours of educational programs or seminars
sponsored or approved by the AAO.                           Documentation:           Yes        No             Documentation:            Yes        No



5. Must attend the annual AAO convocation and               Compliance:        Yes         No                  Compliance:         Yes         No
sit for the annual residency in-service training
examination (written and practical), given at the           Documentation:           Yes        No             Documentation:            Yes        No
AAO convocation.

If the resident is unable to attend convocation, the
program director must approve the absence and
document on the resident’s annual report the
reason for the absence. In such a case, the
resident will sit for the written portion of the in-
service training exam and be proctored at the
sponsoring institution.

Every attempt should be made to have the
resident take the exam at the same time is being
given at convocation.

For each resident unable to sit for the annual
exam at convocation, the exam document must be
requested from the AAO by the program director,
in writing, no later than 2 weeks prior to the
examination time.

              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008
6. Maintain appropriate procedure logs. Since      Compliance:      Yes         No        Compliance:      Yes         No
osteopathic manipulative treatment (OMT) is
considered a procedure, these should include all   Documentation:         Yes        No   Documentation:         Yes        No
patient interactions in which OMT is performed.




7. Adhere to the AOA’s policies on trainee duty    Compliance:      Yes         No        Compliance:      Yes         No
hours and moonlighting as detailed in Appendix B
of this document.                                  Documentation:         Yes        No   Documentation:         Yes        No
           APPENDIX A:
     MODEL HOSPITAL POLICY ON
     ACADEMIC AND DISCIPLINARY
            DISMISSAL


The hospital and department must have clearly              Compliance:        Yes         No                  Compliance:         Yes         No
defined procedures for academic and disciplinary
action.                                                    Documentation:           Yes        No             Documentation:            Yes        No




*Site Inspectors, in the event that this situation         Compliance:        Yes         No                  Compliance:         Yes         No
applies during an inspection, please refer to
Appendix A to evaluate due process was upheld as           Documentation:           Yes        No             Documentation:            Yes        No
outlined by the AOA.




             Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                  “Plus One” NMM/OMM
                                                               Revised 6/2008, Effective 7/2008
         APPENDIX B:
        AOA POLICY ON
    POSTDOCTORAL TRAINING


There is documented proof that the residents have      Compliance:      Yes         No        Compliance:      Yes         No
read and understand the AOA work hour
restrictions as listed in Appendix B.                  Documentation:         Yes        No   Documentation:         Yes        No




Residents are aware of the anonymous reporting         Compliance:      Yes         No        Compliance:      Yes         No
method via do-online for program and/or
resident policy infractions.                           Documentation:         Yes        No   Documentation:         Yes        No

*Work hour compliance must be noted and
discussed in the inspection report. (April 2008
COPT Newsletter)

Moonlighting Policy for Trainees

The DME and medical education committee shall          Compliance:      Yes         No        Compliance:      Yes         No
establish a written policy to monitor duty hours
and moonlighting compliance.                           Documentation:         Yes        No   Documentation:         Yes        No




The institutional duty hours policy, including         Compliance:      Yes         No        Compliance:      Yes         No
moonlighting policies, must be published in the
institutional house staff manual.                      Documentation:         Yes        No   Documentation:         Yes        No




All residents must sign an attestation of receipt of   Compliance:      Yes         No        Compliance:      Yes         No
the duty hours and moonlighting policies, and the
policy must be available during on-site program        Documentation:         Yes        No   Documentation:         Yes        No
reviews.
The OGME committee shall be responsible for                 Compliance:        Yes         No                  Compliance:         Yes         No
monitoring full compliance with the AOA and
institutional policies and the process established          Documentation:           Yes        No             Documentation:            Yes        No
by the medical education department.

This monitoring shall be done at least quarterly
and recorded in the OGME committee minutes
for review at the time of on-site visits.


AOA program on-site reviews will evaluate policy            Compliance:        Yes         No                  Compliance:         Yes         No
compliance by interviews with
inters/residents/fellows, interviews of DME,                Documentation:           Yes        No             Documentation:            Yes        No
program director, faculty and review of
educational call schedules and GME committee
minutes.




Each training institution shall be responsible for          Compliance:        Yes         No                  Compliance:         Yes         No
reporting results of duty hours and the monitoring
of violations to its OPTI OGME committee upon               Documentation:           Yes        No             Documentation:            Yes        No
request.




Residents are aware of the three option levels of           Compliance:        Yes         No                  Compliance:         Yes         No
reporting of noncompliant duty hour scheduling
for review without reprisal.                                Documentation:           Yes        No             Documentation:            Yes        No




              Site Visit Manual and Workbook for Osteopathic Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Training Programs:
                                                                   “Plus One” NMM/OMM
                                                                Revised 6/2008, Effective 7/2008

				
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