Tip of the week: Prepare for the annual program review

Residency Program Insider, June 8, 2010

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The annual review provides your program with an opportunity to sit down with residency program leadership, the key documentation, and the key evaluation outcome measures you’ve collected, reviewed, and documented.
It provides an opportunity to go beyond the RC requirements and to consider the quality of your program based on your faculty and residents’ expectations and standards of excellence.

Analyze the following three curriculum components:

  • Appropriateness of educational objectives (competency-based, for all activities and rotations, for all program years)
  • Effectiveness of teaching strategic clinical assignments, conference schedules, workshops, and simulations
  • Validity of evaluation tools

Print out the most recent requirements and compare your findings against your program requirements. Go over each requirement and make sure you’ve covered every one. Consider copying the pertinent section for each faculty member and resident who will attend the review. The Annual review itself can present a wonderful opportunity for faculty (and resident) development: to teach everyone what is expected in your specialty.

Your next step is to determine whether you have a process for verifying that your residents and faculty understand each requirement. Once you have an evaluation strategy for each requirement, you are well on your way.

If RC requirements (or your specialty certifying board) provide a specific number that residents must achieve—number of hours worked, number of procedures performed, number of weeks in rotation—make sure you can document whether your residents meet those expectations. If your program requirements include a certain number of procedures, specific weeks or months of training in a given area, content that should be included in didactics, a specified time in continuity clinic, or even the gender or ages of patients seen, make sure you have a way of documenting that your program meets these expectations. They are not suggestions; they are usually requirements. (You can find areas in which the RC uses the words “should.”)

Identify the common citations the RC has given programs in your specialty. You can frequently find this on the ACGME’s Web site or through your specialty society. This information will help you identify the requirements that programs in your specialty most often find challenging. The data will also help you pinpoint those areas that will likely be subjects of the RC’s scrutiny. Common citations will alert you to the RC’s “hot buttons.” Analyze how your own program performs on those measures.

Also consult with your GME office to find out the common citations for other programs at your institution. Although these citations may not apply to weaknesses in your program, these data will show how programs at your own institution are being judged. Determine how you would fare if evaluated rigorously in these same areas.

 This week’s tip is from Insiders’ Guide to the ACGME Site Visit, Second Edition available now for $99.

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