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Using The ACGME Program Self-Study as a Catalyst for Program Improvement
Heidi Kromrei, PhDAssistant Vice President, Academic AffairsAssociate Designated Institutional Official
Detroit Medical Center Education and Research
Michigan State University Statewide Campus System GME eForum Webinar Series
February 10, 2016
Session Goals
1. Identify Data Sources used by ACGME Residency Review Committees to Evaluate Residency Programs
2. Understand ACGME Annual Program Evaluation (APE) Requirements and their role in the Self-Study Process
3. Align ACGME Annual Update, APE and Self-Study efforts to Improve Residency Program Performance
Big Picture
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Pre-Next Accreditation System: 5-Year Biopsy
Next Accreditation System (NAS): Annual Exams
NAS: Continuous Evaluation and Improvement
Source ACGME Webinar @: http://acgme.org/acgmeweb/Portals/0/PFAssets/Nov4NASImpPhaseII.pdf
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ACGME 10 Year Self-Study Model
APE is important!!
ACGME 10 Year Self-Study Model
ACGME RRCs
Evaluate Programs Annually!!
ACGME 10 Year Self-Study Model
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Residency Review Committee Annual Review Data RRC will
evaluate this data every
year.
Will you?
The Details: ACGME Annual Update
The Details: ACGME Annual Update
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July 2015 ACGME e-news
ACGME Annual Update Errors
Data Reviewed Annually by RRC: Resident/Faculty Surveys
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Data Reviewed Annually by RRC: Resident Survey
Data Reviewed Annually by the RRC: Milestone Evaluations
Data Reviewed Annually by the RRC: Milestone Evaluations
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Data Reviewed Annually by the RRC: Case Log Reports
Data Reviewed Annually by the RRC: Scholarly Activity
Scholarly Activity…It’s Important!
Source: ACGME Webinar @ http://acgme.org/acgmeweb/Portals/0/PFAssets/Dec12Ophthalmology.pdf
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Participation in Professional Activities/Committees
PublicationsPresentationsChapters/TextbooksGrant LeadershipLeadership or Peer-Reviewed
RoleTeaching Formal Courses
How is Faculty Scholarly ActivityMeasured?
The Details: Annual Program Evaluation
The Details: Annual Program Evaluation
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APE: Identify, Collect, & Analyze Data
RRC will evaluate this data every
year.
Be sure to include it in your APE
SWOT Analysis
SWOT Analysis Definitions:
S: Strengths: Factors likely to have a positive effect on (or be an enabler to) achieving the program’s objectives
W: (Formerly Known as Weaknesses): Opportunities to improve program performance in areas with noted deficits
O: Opportunities: External factors that are likely to have a positive effect on achieving or exceeding the program’s objectives, or goals not previously considered
T: Threats: External factors and conditions that are likely to have a negative effect on achieving the program’s objectives, or making the objective unachievable
Conduct SWOT Analyses Strengths of the Program
What should definitely be continued?
Weaknesses of the Program
What aspects of the program should be improved?
Prioritized by relevance to program aims, importance to stakeholders, compliance with ACGME requirements
Opportunities in the Program Environment
What are opportunities that favor the program?
New areas for the curriculum?
Changes to enhance program performance?
Threats in the Program Environment
What are the threats to the program?
Factors that threaten program success and sustainability
Local or national
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Document Findings: The APE Report Program Director’s Report
Program Aims
Resident Performance SWOT Analysis
Graduate Performance SWOT Analysis
Faculty Development Performance SWOT Analysis
Program Quality Performance SWOT Analysis
Action Plan for Program Improvement
Document Findings: The APE Action Plan for Program Improvement
DMC APE Action Plan for Program Performance Improvement Template
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Communicate APE Findings
1. Prepare Final APE Report
2. Submit for Faculty Approval
3. Share with Residents
4. Submit to GMEC
5. Track and provide quarterly progress report to all stakeholders
ACGME Self Study
Replaces to “5-Year Biopsy” method with systematic self-assessment
“Longitudinal Evaluation”
Must use successive APE results
ACGME defines “Eight Steps”
ACGME Self Study: Eight Steps
1. Assemble the Self-Study Group
2. Engage Program Leaders/Constituents in Discussion of Program Aims
3. Examine Opportunities and Threats
4. Aggregate & Analyze Data to Generate a Longitudinal Assessment of Program’s Improvement
5. Obtain Stakeholder Input
6. Interpret the Data and Aggregate the Self-Study Findings
7. Discuss the Findings with Stakeholders
8. Develop Succinct Self-Study Document for Use in Continued Improvement/10 Year Site Visit
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Back to the Big Picture
Annual Update, APE & Self-Study Alignment
1. Conduct, document, and Report APE
2. Regularly evaluate the same data sources used by RRC
3. Develop action items (ACGME recommends 3-5 per year)aligned with outcomes reviewed by RRC (e.g. citations, survey deficits, procedural volume, etc.) as well as resident recommendations
4. Don’t forget to focus on STRENGTHS as well as deficits
5. Evaluate your program performance in the context of your self-defined “Program Aims”
6. Use the ACGME Annual Update “Major Changes” Section to inform the RRC of your program improvements
7. Update and consult program/institutional stakeholders regularly
Final Thoughts…
Program Aims
Annual Program
Evaluation
ACGME Annual Update
Self-Study 10 Year Site Visit
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Questions?
References
ACGME Slide Presentations for Faculty Development. Accessed online on January 29, 2015 at: http://www.acgme.org/acgmeweb/tabid/442/GraduateMedicalEducation/SlidePresentationsforFacultyDevelopment.aspx
The Self-Study and 10-Year Site Visit: Clarifying the Timeline and Action Steps. Accessed online on April 27, 2015 at: http://acgme.org/acgmeweb/Portals/0/PDFs/Webinars/DIOWebinarSelfStudy03112015.pdf
ACGME Eight Steps for Conducting the ACGME Program Self-Study. Accessed online on April 27, 2015 at: http://acgme.org/acgmeweb/tabid/473/ProgramandInstitutionalAccreditation/Self-Study.aspx