Surgery - ACGME

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					RRC News

Accreditation Council for Graduate Medical Education                                                           august 2010
Review Committee membeRs                                         Accreditation Decisions
TimoThy R. BilliaR, mD                                        June 24-25, 2010 Meeting of the
PaTRice G. BlaiR, mPh, ex-officio                             Review Committee for Surgery
PaRis D. BuTleR, mD, ResiDenT                                           SURGERY
G. PaTRick claGeTT, mD                            Continued Accreditation                                          21
RonalD l. Dalman, mD                              Confirmed Probation                                               3
PeTeR J. faBRi, mD                                Proposed Probation                                                1
linDa m. haRRis, mD                               Other Administrative Decisions                                   21
James c. heBeRT, mD                                      VASCULAR SURGERY—INDEPENDENT
GeoRGe W. holcomB iii, mD                         Continued Accreditation                                          11
fRank R. leWis, mD, ex-officio                    Deferred Accreditation                                            1
maRk a. malanGoni, mD, Vice chaiR                 Proposed Probation                                                1
J. PaTRick o’leaRy, mD                            Other Administrative Decisions                                    1
maRshall Z. schWaRTZ, mD
                                                           VASCULAR SURGERY—INTEGRATED
chaRles W. Van Way iii, mD
                                                  Initial Accreditation                                              1
maRc k. Wallack, mD                               Continued Accreditation                                            2
Thomas V. Whalen, mD, chaiR                       Other Administrative Decisions                                     1
                                                                 PEDIATRIC SURGERY
                                                  Continued Accreditation                                            5
RRC staff                                         Proposed Withhold Accreditation                                    2
PeGGy simPson, eDD
execuTiVe DiRecToR                                            SURGICAL CRITICAL CARE
312.755.5499                                      Continued Accreditation                                          12
                                                  Proposed Withhold Accreditation                                   1

caThy RuiZ, ma
senioR accReDiTaTion aDminisTRaToR                                               MEEtiNG ANd AGENdA CloSiNG dAtES
                                                                         MEEtiNG:                           oCtobEr 28-30, 2010
                                      New Vice Chair Begins              AGENdA CloSiNG:                       AuGuSt 19, 2010
allean moRRoW-younG                   Term                               MEEtiNG:                           FEbruAry 24-25, 2011
accReDiTaTion assisTanT                                                  AGENdA CloSiNG:                      dECEMbEr 16, 2010
                                      Mark Malangoni, MD, began
                                      a two-year term as vice chair MEEtiNG:                                     JuNE 23-24, 2011
                                      of the Committee on July 1, AGENdA CloSiNG:                                  April 14, 2011
                                      2010.                         MEEtiNG:                                  NovEMbEr 3-4, 2011
                                                                         AGENdA CloSiNG:                        AuGuSt 25, 2011
             ACGME                    The Committee is most
       515 North StAtE StrEEt         grateful to J. Patrick O’Leary,               NotiFiCAtioN dEAdliNES
            SuitE 2000                MD for his leadership as        5 Days afteR meeting:
       ChiCAGo, illiNoiS 60654
                                      vice chair from July 1, 2008                     E-MAil NotiFiCAtioN oF rEviEw StAtuS/
                                      through June 30, 2010.                             CyClE lENGth AutoMAtiCAlly SENt to
                                                                                                       proGrAM dirECtor ANd    dio.
                                                                         60 Days afteR meeting:
                                                                                         E-MAil AlErt SENt StAtiNG thAt lEttEr
RRc neWs PRoViDes ReVieW commiTTee                                                           oF NotiFiCAtioN iS poStEd iN AdS.
anD acGme uPDaTes. Please
conTacT The eDiToR WiTh quesTions
                                                                         *unTil The official leTTeR is PosTeD in aDs, ReVieW
                                                                         commiTTee sTaff memBeRs aRe unaBle/noT PeRmiTTeD To Discuss
oR commenTs aBouT This neWsleTTeR:
                                                                         The commiTTee’s acTion oR sPecific DeTails of The aReas of
mschWaB@acGme.oRG.                                                       non-comPliance.*
Review Committee Membership Changes                             Introducing: GME Focus
The Review Committee welcomed its new resident                  The ACGME is proud to announce the official launch
member, Paris Butler, MD, on July 1, 2010.                      of GME Focus, a comprehensive, online collection
                                                                providing an overview of the current literature in
The Committee congratulates Adeline Deladisma, MD
                                                                graduate medical education. Modeled after similar
for her three years of service, and also thanks her
                                                                resource systems provided in the field of clinical
program director for his support of her Review
                                                                medicine, GME Focus scans the medical and medical
Committee activities!
                                                                education literature and provides summaries of, and
                                                                commentary on, articles relevant to program directors,
                                                                designated institutional officials (DIOs), faculty,
Site Visit Evaluations                                          residents and others with interest in graduate medical
After the conclusion of an accreditation site visit for         education, and makes it available in an easily-
programs or sponsoring institutions, the ACGME site             accessible location open to the public.
visitor completes his or her report and submits it to the
ACGME’s Department of Field Activities (DFA). The               Constant advances in medicine and education result
report is logged, and then, along with the program              in a broad range of new articles on graduate medical
information form (PIF) sent by the program or                   education every month. Time constraints and the
institution, transmitted to the Review Committee team           distribution of articles across many journals can
for assignment to reviewers.                                    present challenges to individuals attempting to keep
                                                                current and develop a broad understanding of new
Once the Site Visit Report has been received and                literature. In response to this reality, the ACGME
logged into the DFA database, the system that                   created GME Focus to assist program directors, DIOs
manages site visit scheduling generates an e-mail to            and others to remain up-to-date about new
the program director, indicating that s/he has an               information on topics such as educational research
opportunity to complete an evaluation of the site               and innovation, policy discussions, and practical
visitor’s knowledge, preparation, interpersonal                 articles for adoption or adaptation in the local setting.
conduct and other relevant elements of the visit.
The evaluation is completed online, and programs                ACGME staff searches the literature and asks key
are provided with instructions for how to access and            experts in the field to provide summaries of articles
complete it. The form is made available to program              identified as pertinent to the audience. The experts
directors only after the Site Visit Report has been filed       also comment on the relevance and implications of
and cannot be altered. One of the reasons for this is           the work to program directors and other leaders in
to ensure that programs may candidly comment on                 GME. These summaries and commentaries are
all aspects of their site visit, without concerns that          aggregated on the GME Focus Web page, which can
this may influence the Site Visit Report or the Review          be accessed via the “Bulletin & Lit Reviews” option
Committee’s subsequent review. Completed site visit             from the menu items on the ACGME website
evaluations are aggregated; members of the field staff          (, or via this direct link.
periodically are provided with an aggregate report that
                                                                The goal of producing this resource is to provide a
compares their performance to that of their 30
                                                                timely and concise review of the graduate medical
                                                                education literature for busy professionals. The digest
The e-mail notice asking for a program’s evaluation of          is arranged by topic (in categories such as
the site visit may arrive up to several weeks following         Accreditation, Duty Hours, Innovation, Patient Safety,
the actual site visit. Consequently, program directors          Quality Improvement, Supervision, and more) as well
may not recognize or appreciate that the e-mail                 as by specialty. The aim is to make the current
received is soliciting their comments on both their site        literature as simple to access as possible. To ensure
visit and the performance of their assigned field               the most current information is presented, new articles
representative. However, this feedback is extremely             will be added to GME Focus approximately every 60
valuable to the ACGME and the members of the field              days, and existing content will be moved to an
staff in improving the site visit process. The ACGME            accessible archive after a year. This will keep GME
relies on programs’ honest responses, and strongly              Focus live, active, and evolving.
encourages program directors to look for these
                                                                Questions regarding GME Focus, or interest in
messages, and to take advantage of this opportunity
                                                                volunteering to review and summarize articles, should
to provide input on the accreditation process.
                                                                be directed to Cynthia Taradejna:

rrC NEwS For SurGEry                                        2                                                 AuGuSt 2010
Resident Survey Results and the                                Requests for Voluntary Withdrawal Must be
Accreditation Process                                          Submitted through ADS
A common topic facing Review Committees across                 ACGME policy permits a program or sponsoring
specialties deals with the disposition of the Resident         institution to request voluntary withdrawal of
Survey and how the results in particular may impact a          accreditation when a decision has been made by that
program’s accreditation status. This is an area of high        program or institution to discontinue participation in
importance to all specialties, and as such, is covered         ACGME accreditation. Requests for voluntary
specifically in the ACGME’s Common Program                     withdrawal of accreditation must be submitted
Requirements, which can be reviewed online at                  using the Accreditation Data System (ADS). Review                 Committee staff will not accept letters requesting this
RequirementsDutyHours0707.pdf. There are                       action sent directly to them. The program
numerous reasons to utilize and value residents’               director initiates the request within ADS by answering
input, and the ACGME and its Review Committees                 a series of questions, including: the proposed
take their engaged participation in this annual survey         effective date which should coincide with the end of
very seriously. The following is a very general                the current academic year; the reason for program
overview addressing some of the more common                    closure; and a plan to place all active residents in
questions handled by both Review Committees and                other programs. Once submitted, ADS automatically
their staff at the ACGME.                                      generates an e-mail to the DIO requesting approval.
                                                               Once the DIO approves the request, ADS notifies the
The most recent Resident Survey results are an
                                                               Review Committee staff. After a staff member
important factor in program accreditation reviews.
                                                               processes the request, the program director and DIO
Once the ACGME site visitor assigned to review your
                                                               receive official notification, and the accreditation
program receives your completed PIF, he/she can
                                                               status is changed to voluntary withdrawal.
view the (most recent) resident survey results in order
to prepare for the on-site survey. Any areas                   DIO approval of this request for voluntary withdrawal
highlighted as noncompliant are specifically                   of the program or sponsoring institution finalizes the
addressed by the site visitor. If the site visitor             request, which means the program:
determines validation for a pre-identified area of                 1. may not accept new residents/fellows
concern, the Review Committee will cite that as an                 2. may not request “reversal” of the action
area of noncompliance with the ACGME standards in                      (regardless of the proposed effective date)
your Letter of Notification following the formal review.
                                                               The program or institution may seek accreditation at
If the site visitor cannot verify a potential area of
                                                               a future date by undergoing the application process
noncompliance per the survey results, the Review
                                                               pursuant to ACGME policy. See “How to Apply for
Committee will look closely, and while a formal citation
                                                               Accreditation in Seven Easy Steps” on the Program
may not be given, the Committee may still provide
                                                               Director & Program Coordinator area of the ACGME
a comment to the program that this is an area to be
                                                               website for an overview.
Programs should also be aware that survey results
contribute to national annual compliance data. Among           New Format for Citations
other important benefits of collecting such data,              “Citations” – areas of non-compliance that a Review
thresholds for noncompliance are established based             Committee identified during its review of a program –
on this data.                                                  have a new format. Citations now have the following
                                                               five components:
Programs across specialties that are identified as
having a series of noncompliant responses (either                (1) Citation Heading – summary of issue
annually or in consecutive program reviews) may be                   being cited
required to submit a duty hour or progress report to
                                                                 (2) Program Requirement
the Review Committee for Surgery. Should a program
                                                                 (3) Program Requirement Reference
be asked to submit a follow-up report on the basis of
the Resident Survey results (either in conjunction with          (4) Citation
a full survey, or upon annual review), the program               (5) PIF, Site Visitor Report, or Board
director should contact the Review Committee staff at            Reference (if proposed adverse action)
the ACGME directly with questions or concerns about
how to reply to these requests. Contact information            (continued on p.4)
can be found on p.1 of this newsletter.
rrC NEwS For SurGEry                                       3                                               AuGuSt 2010
Here is an example of the new citation format using a            automatically generates a welcome letter to the new
Common Program Requirement:                                      program director, with copies sent to the DIO and
                                                                 program coordinator. The welcome letter provides
  Faculty/Qualifications/Specialty Certification                 useful information about the ACGME website, as
  Common Program Requirement: II.B.2.                            noted below, and refers the new program director to
  The physician faculty must have current                        the ACGME Virtual Handbook. The welcome letter
  certification in the specialty by the American                 also informs the new program director that the DIO
  Board of Surgery, or possess qualifications                    and Graduate Medical Education Committee of the
  acceptable to the Review Committee.                            sponsoring institution and the specialty-specific
  The information provided was incomplete.                       program directors’ association are other important
                                                                 resources, and encourages the new program directors
  No information was provided for two of the
                                                                 to contact these groups for more information.
  ten physician faculty listed.
  Program Information Form pp. 2,8                               Some Review Committees approve new program
                                                                 director appointments; in such cases, the Committee
                                                                 reviews the information at its next meeting, and the
                                                                 Committee’s Executive Director provides a final letter
Resident Complement Change Requests                              of approval to the program director, sending a copy to
All resident complement change request must be                   the DIO.
requested through the Accreditation Data System
(ADS). The Review Committee for Surgery                          Other useful resources and information include:
approves resident complement changes by total,                   •	   The Review Committee Web page contains
by PGY level, and by type of position. Both                           periodic updates from the Review Committee,
temporary and permanent requests must receive                         FAQs, staff members’ contact information by
prior approval. Staff members are available to                        subject, program requirements, PIFs, and a
answer any questions about this process. Contact                      Program Directors’ Guide to the Common
information can be found on p.1 of this newsletter.                   Program Requirements.
                                                                 •	   The Program Directors & Coordinators link
                                                                      contains information about Case Logs, Resident
Progress Reports to the Review Committee
                                                                      Duty Hours, the Resident Survey, and policies.
The Review Committee for Surgery continues to
remind program directors that progress reports should            •	   The ACGME Manual of Policies and Procedures,
only be submitted for review upon request, as noted                   Section II, Accreditation Policies and Procedures,
specifically in the accreditation notification letter. The            contains a complete explanation of accreditation
Committee will not review unsolicited progress                        statuses awarded to programs and the policies to
reports. Such reports will be administratively                        which program directors must adhere.
acknowledged with no further action. It is also                  •	   In the About ACGME-->Staff Listing-->Staff listing
important to note that the Review Committee does not                  by Department link, you’ll find an overview of the
rescind (remove) citations from a program’s history                   four departments within the ACGME, including the
upon review of a (requested) progress report. A                       Department of Accreditation Committees—which
progress report should update the Committee on how                    houses all Review Committee staff—and the
the program is addressing those areas identified for                  phone and e-mail contact details for all ACGME
comment in the Committee’s request for the report.                    staff.
Citations can only be identified as corrected at the
time of a full program review when they are                      •	   The Key	to	the	Standard	Notification	Letter
thoroughly evaluated through the site visit and review                provides explanations for the common sections of
of accreditation materials.                                           accreditation letters.
                                                                 •	   The Outcome Project Web page provides
                                                                      comprehensive information about the general
Useful Resources for New Program Directors                            competencies.
Institutional Requirement III.B.10.e specifies that the          •    Please Note: You will need an ID and password
Graduate Medical Education Committee (GMEC)                           to access ADS and Resident Case Log System (if
approves a new program director prior to his/her                      applicable).
confirmation with the ACGME. Once approved, the
program director’s name is entered into ADS, which
rrC NEwS For SurGEry                                         4                                                AuGuSt 2010
Useful ACGME Online Resources
•   How to Apply for Accreditation in Seven Easy
    Steps:                Save the Date:
                                                               2011 ACGME Annual
•   Virtual Program Director Handbook: www.acgme.
                                                              Educational Conference
•   ACGME Data Book:
    dataBook/dat_index.asp                                 Gaylord Opryland Resort Hotel
•   Frequency of Accreditation Statuses by Specialty          and Convention Center
    and Average Cycle Length by Accreditation Status           Nashville, Tennessee
    and by Specialty:                    March 3-6, 2011
•   Resident Survey National Data Report - available
    in ADS for Program Directors:                          **more information to follow**
      1. Log into ADS
      2. Click “Resident/Fellow Survey”
      3. Click “National Data”
      4. DIOs select “Reporting Tools”
      5. Click “Resident Survey National Data
•   Resident Survey Institutional Data Report –
    available in ADS for DIOs for each sponsoring
    institution’s programs:
      1. Log into ADS
      2. Select “Reporting Tools”
      3. Click “Institution Level Resident Survey
•   ACGME Outcome Project—“Educating
    Physicians for the 21st Century”—Faculty
    Development Resources for Competency-based
    Education – a series of five PowerPoint
    presentations with facilitator’s manuals: www.

rrC NEwS For SurGEry                                   5                                AuGuSt 2010