Accreditation Council for Graduate Medical Education RRC-EM: EMS Fellowship ACGME Accreditation NAEMSP ® EMS Fellowship Forum January 2014 Tucson, AZ Wallace

Accreditation Council for Graduate Medical Education

RRC-EM: EMS Fellowship ACGME Accreditation

NAEMSP® EMS Fellowship Forum

January 2014 Tucson, AZ

Wallace Carter, MD Chair, Residency Review Committee for Emergency Medicine

Louis Ling, MDSenior Vice-President, Hospital Based Accreditation

© 2012 Accreditation Council for Graduate Medical Education (ACGME)

Disclosure

Carter:

New York Presbyterian

Columbia University and Weill Cornell

Ling:

Hennepin County Medical Center

University of Minnesota

Textbooks: Rosen, Harwood-Nuss


Learning Objectives

• Next Accreditation System (NAS)• Quick Review• Update and New Developments

• EMS Specific Information• Introduction to Self-Study Visits

NAS

The Next Accreditation System:

A quick review


What is the NAS and when does it start?

• The Next Accreditation System began July 1, 2013 for all core EM and EM subspecialty programs

• NAS Strategic Plan:• Foster innovation and improvement in the learning

environment• Increase the accreditation emphasis on educational

outcomes• Increase efficiency and reduce burden in accreditation• Improve communication and collaboration with key

internal and external stakeholders


The Building Blocks ofThe Next Accreditation System

CLER VisitsCLER Visits

Continuous RRC Oversight and Accreditation

Sponsor Oversight

Continuous RRC Oversight and Accreditation

Sponsor Oversight

Institutional ReviewInstitutional Review

prn Site Visits (Program or Institution)

prn Site Visits (Program or Institution)

SelfStudySelf

Study


NAS

• Instead of biopsies, annual data collection• Trends in key performance measurements• Milestones, Residents, fellows and faculty survey• Scholarly activity template• Operative & case log data• Board pass rates

• Scheduled accreditation visits every 10 years• Focused site visits if annual data trends suggest

problems• PIF replaced by self-study


NAS and ADS Annual Updates

• Each year, programs data will be required to entered in ADS such as:• Faculty information• Fellow information• Block diagrams/curricular information• Scholarly activity information• Participating site information• Responses to previous citations• Duty Hour, Patient Safety and Learning Environment

information• Evaluation information• Reporting of major changes in the program


All 9,022 ACGME Accredited Residency and Fellowship Programs*

January 1, 2013

@ 2013 Accreditation Council for Graduate Medical Education (ACGME)

* Excludes programs with Initial Accreditation


All 9,022 ACGME Accredited Residency and Fellowship Programs*

January 1, 2013

@ 2013 Accreditation Council for Graduate Medical Education (ACGME)

95.7%95.7%

4%4%

0.3%, n=270.3%, n=27

* Excludes programs with Initial Accreditation


NAS

• Ongoing data collection and trend analysis• Enhance oversight to ensure high quality

education and a safe and effective learning environment

• High-quality programs will be freed to innovate – detailed process standards• Programs with continued accreditation in good

standing will not have to demonstrate compliance with the “detail” program requirements as written, but are allowed to innovate


What are core, detail and outcome program requirements?

• Core Requirements: Statements that define structure, resource, or process elements essential to every graduate medical educational program.

• Detail Requirements: Statements that describe a specific structure, resource, or process, for achieving compliance with a Core Requirement. Programs in substantial compliance with the Outcome Requirements may utilize alternative or innovative approaches to meet Core Requirements.

• Outcome Requirements: Statements that specify expected measurable or observable attributes (knowledge, abilities, skills, or attitudes) of residents or fellows at key stages of their graduate medical education.


What are core, detail and outcome program requirements?

• II.A.2. Qualifications of the program director must include:

• II.A.2.b) current certification in the subspecialty by the American Board of Emergency Medicine, or specialty qualifications that are acceptable to the Review Committee; and, (Core)

• II.A.2.d) at least three years’ experience as a core physician faculty member in an ACGME-accredited emergency medicine program or emergency medical services program; (Detail)

• IV.A.2.a).(2).(b).(i) participation in a mass casualty/disaster triage at an actual event or drill; (Outcome)


Do I have to adhere to the “detail” program requirements?

• Programs that have initial accreditation or are in trouble must demonstrate compliance with all “detail” program requirements as written.

• Programs that have continued accreditation will be allowed to “innovate” on those program requirements that are identified as “detail”.


Trended Data Elements

Annual ADS Update Program Attrition – Changes in PD/Core Faculty/Residents Program Characteristics – Structure and Resources Scholarly Activity

Board Pass Rate – Rolling Rates Resident Survey – Common and Specialty Elements Clinical Experience – Case Logs or other Faculty Survey – Core Faculty Semi-Annual Resident Evaluation and Feedback

Milestones

Annual Sponsor Site Visit (CLER)

Annual evaluation of program outcome data (modified from TJN)

Applications for New Programs

Initial Accreditation

Applications for New Programs

Initial Accreditation

STANDARDSSTANDARDSStructureStructureCore ProcessCore ProcessDetail ProcessDetail ProcessOutcomesOutcomes

STANDARDSSTANDARDSStructureStructureCore ProcessCore ProcessDetail ProcessDetail ProcessOutcomesOutcomes

ContinuedAccreditationContinuedAccreditation

Accreditation with WarningAccreditation with Warning

StructureStructureCore ProcessCore Process

Detailed ProcessDetailed ProcessOutcomesOutcomes





Adverse Adverse ActionsActions

Adverse Adverse ActionsActions


Initial Accreditation (IA) Fellowships

• Fellowship applications are reviewed without a site visit. Within 2 years of granting IA, a site visit will be scheduled

• RRC options when reviewing application• Initial Accreditation• Withhold

• RRC options following IA site visit• Continued Accreditation• Initial Accreditation with Warning – 1 year only• Withdrawal


Site Visits

• Focused: isolated concern about data elements • Full: for IA or general concern about program, more

than one isolated issue

• No PIF to prepare• Issues will be known for focus• 30 day notice• Teams for larger than 4 residents/fellows

• Self-studies after 2015


Adverse Actions: What has changed

• No proposed adverse actions• Adverse accreditation status can only be

conferred following a site visit• Programs with adverse accreditation status

cannot request an increase in resident complement

• Probation cannot exceed 2 consecutive annual reviews


Adverse Actions: What hasn’t changed

• A program on Withdrawal can complete the current academic year• With RRC approval can complete 1 more year

• No new residents can be appointed• If program re-applies within 2 years, they must

address previous citations• A site visit is needed for all applications following a

withdrawal


Relationship of Core and Subs

Fellowships must have a relationship with a core residency program

•Self-study visits of core and associated fellowships will occur at the same time•Adverse action in core results in the same status for their associated fellowships

• Withdrawal of core means withdrawal of all associated fellowships

•New fellowships can only be granted IA status if core status is Continued Accreditation

• NO attached programs can be on Probation or in appeal


NAS

Building the case for milestones………

Defer to Laura Edgar, EdD

Accreditation Council for Graduate Medical Education

RRC-EM: EMS Fellowship ACGME Accreditation

NAEMSP® EMS Fellowship Forum

January 2014 Tucson, AZ

Wallace Carter, MD Chair, Residency Review Committee for Emergency Medicine

Louis Ling, MDSenior Vice-President, Hospital Based Accreditation


New Application Process as of July 1, 2013

• All new program applications must be initiated in ADS by the DIO of your institution



• The program director must complete 2 parts• Part 1 – Complete the ADS electronic portion initiated

by the DIO• Part 2 – Download and complete the new application

specialty specific Word document from the website and upload into ADS

• The completed application is submitted electronically in ADS



• The new application specialty specific Word document can be found on the ACGME EM Web page: http://www.acgme.org/acgmeweb/tabid/131/ProgramandInstitutionalAccreditation/Hospital-BasedSpecialties/EmergencyMedicine.aspx

http://www.acgme.org/acgmeweb/tabid/131/ProgramandInstitutionalAccreditation/Hospital-BasedSpecialties/EmergencyMedicine.aspx

http://www.acgme.org/acgmeweb/tabid/131/ProgramandInstitutionalAccreditation/Hospital-BasedSpecialties/EmergencyMedicine.aspx


Information: RC-EM Web Page Recommended Links

• Program Requirements: Currently In Effect• New Applications – Word documents• FAQs• Common Resources:

• ACGME Glossary of Terms• Apply for Accreditation in Eight Easy Steps• Program Director Guide to Common Program

Requirements• Program Directors’ Virtual Handbook


Faculty Roster

• When completing the faculty roster in ADS, enter core EMS faculty that have at least 5 hours per week and any other non-EMS physicians who provide at least 10 hours per week


Faculty Qualifications

• If faculty members are ABOEM boarded and obtain the specialty certificate in EMS from the ABOEM, does the RC view this as being “acceptable”?

• A CAQ in EMS by the ABOEM is viewed as being acceptable


For Requested Positions, can I ask for a range, e.g. 1-2?

• The RC-EM does not accept ranges of positions, only a specific number, so instead of requesting 1-2 position, you should request 2 positions (you are not required to fill all positions).

• You need to demonstrate in your application that you have enough resources to support the number of fellows requested. (e.g. you would need to have enough opportunity to have each fellow lead a disaster drill if that is part of your program so you provide the same experience for both fellows.)


How do I know if I need a PLA?

• Here is an FAQ regarding Master Affiliation Agreements and PLAs. There is a PLA template at the end of the document/site: http://www.acgme.org/acgmeweb/Portals/0/PDFs/FAQ/ab_FAQAgreement.pdf

• Program letters of agreement originate at the program (instead of the institutional) level and are required for each participating site providing a required assignment.

• Program letters of agreement are required between the residency program and all sites to which residents rotate for required education or assignments.

http://www.acgme.org/acgmeweb/Portals/0/PDFs/FAQ/ab_FAQAgreement.pdf




How do I know if I need a PLA?

However, if the two sites operate essentially as one entity, that is, they are governed by one governing body (e.g. Board of Directors) neither a master affiliation agreement nor a program letter of agreement would be necessary. Program letters of agreement are not necessary if the following on-campus or off-campus site is under the governance of the sponsoring institution or is an office of a physician who is a member of the sponsoring institution’s teaching faculty/medical staff: nursing and assisted-living homes; hospice facilities; faculty patient care offices; private physicians’ offices (volunteer faculty); ambulatory surgical centers; diagnostic centers, e.g. imaging, laboratory, etc.; treatment centers, e.g. dialysis, rehabilitation, chemotherapy, etc.; other similar sites.


New EMS FAQ for PLAs

Question

When is it necessary for a program to obtain a Program Letter of Agreement (PLA) with an EMS agency? [Program Requirement I.B.1]


New EMS FAQ for PLAs

Answer:There must be a program letter of agreement (PLA) between the program and each participating site providing a required assignment. A fellow may interact with a number of EMS agencies in different capacities.

The Review Committee guidelines on PLAs specify:•A PLA is required for any EMS agencies with which the fellow provides in person participation as part of the required curriculum•If the sponsoring institution owns the company, no PLA is needed.•If the participating site is an independent company, a PLA is still needed for liability reasons even if the program director or a faculty member of the EMS program is the medical director (and is signing the document on behalf of the program and on behalf of the participating site) at the participating site/independent company.


Medical School Letter of Understanding

I.B.6. The program must be affiliated with a medical school.I.B.6.a) The program must have a written letter of understanding which documents the duties and responsibilities of both the medical school and the program.This is similar to an affiliation agreement.

May state that the program will be compliant with the regulations and rules of the institution in matters related to the functioning of the program and that the institution will provide appropriate oversight to assure compliance with accreditation standards as well as hospital and state rules, regulations and laws

See the following web page for more information:

https://www.acgme.org/acgmeweb/Portals/0/PDFs/FAQ/ab_FAQAgreement.pdf

https://www.acgme.org/acgmeweb/Portals/0/PDFs/FAQ/ab_FAQAgreement.pdf

Information: Application Deadline

• Applications received by April 28th, 2014 will be reviewed at the June 23-24, 2014 RC Meeting


Information: Application Review Process

• Completed application and all attachments uploaded in ADS

• No site visit required• Application reviewed based upon

program requirements at an upcoming RC meeting.• In 2014 RC meets February and June • Programs are not reviewed by RC

members in same state or with a conflict of interest


Information: Application Review Process

• Within 5 business days after the meeting, emails will be sent regarding the RC’s decision• Initial Accreditation OR Withhold

• Within 60 days after the meeting, a Letter of Notification (LON) will be available.


Initial Accreditation: EMS Effective Dates

EMS Program Requirements were approved and were given an effective date of 9/30/2012

For applications reviewed at both the February and June 2014 meetings and granted initial accreditation, programs may choose to have an effective date of either 7/1/2013 or 7/1/2014.

What about current EMS fellows?

Q) If my program is accredited at the February 2014 RC meeting and I chose an effective date of July 1, 2014, what does that mean for my current fellows scheduled to finish June 30, 2014?

• If they finish the program on or before June 30, 2014, they will not graduate from an accredited program and will be ineligible to take ABEM’s EMS CAQ exam.


EMS Applications Reviewed

• 24 applications reviewed in February 2013• 13 applications reviewed in September 2013• 6 applications scheduled for February 2014

33/37 - Total EMS applications approved to date


Top 3 Most Common EMS Citations

• Lack of PLAs• PD responsibility – Inaccurate Application Form• Scholarly Activity – Core faculty

Self Study & Program Improvement

ACGME self study visits begin 2015Fellowships will be reviewed with their core programs

Tool for program improvement

Individualized Learning Plan (ILP) on steroids


Self Study & Program Improvement

• NOT A PIF• Tool for improvement• Regular goal setting• Longer term: 3-5 years• Includes self-reflection/self-study• Consider SWOT (strengths/weaknesses/

opportunities and threats)/stakeholders• Consider program outcome trends• Don’t have to wait until ACGME

announces visit© 2012 Accreditation Council for Graduate Medical Education (ACGME)


Questions??

Documents

Accreditation Council for Graduate Medical Education RRC-EM: EMS Fellowship ACGME Accreditation NAEMSP ® EMS Fellowship Forum January 2014 Tucson, AZ Wallace