**3.3 About readiness assessments**

The GME office, in collaboration with the network business planning, offered a "first-cut analysis" of the business and workforce feasible of starting new and rightsizing the existing programs in the network. Readiness assessments determined how "ready" a department was to start or right-size its program, identify gaps, refine relevant/expected projections, and develop action plans including time lines (**Table 1**). After finding the leads for various departments like Accreditation/Project Management Office (PMO), Community/FQHC, Research Reimbursement, Capital/ Operational Expense, and Clinical, Physician Leads received accreditation standards and application, while GME office helped them draft a rotation schedule prior to planning meeting. The goal of the meeting was to score the department's readiness. The readiness assessment helped to structure the way we launched the change and minimize the time and resources spent on implementing the changes. Pro-forma development and workforce forecasting were also instrumental in the assessment. With the assessment, we learnt: (1) current state of department compliance, capacity, personnel, and resource, (2) what the curriculum rotation schedule could look like, and (3) the department's experience and belief in the value of the change.


*Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*


#### **Table 1.**

*Readiness assessment.*

#### **4. Program accreditation**

#### **4.1 Complete the ACGME application**

The initial accreditation process should be started early as the application process is the "final product" and many things need to be discussed, outlined, and developed before the application is submitted. The DIO must initiate the application process in ACGME's Accreditation Data System (ADS). The DIO must name the program director at this time. The program director is responsible for completing the application and submitting it through Accreditation Data System (ADS) for the DIO to approve. The program director is ultimately responsible for the application submission, but the advice and expertise of key faculty, department chair, and/or recent graduates should be utilized. It is strongly advisable to become well acquainted with the ACGME requirements and have them at hand while completing the application [21]. ACGME does have a video on "Completing an Application for ACGME Accreditation" that is a great resource, providing specific details on sections of the application [22]. The ACGME has a specific section for program directors on accreditation, which should be reviewed prior to starting the application as it provides an overview of the accreditation process [23]. If a requirement is not clear, the ACGME publishes "FAQs" that may be of assistance. *This would also be a good time to meet with your designated institutional official (DIO) to discuss any other requirements that are unclear. It is also suggested that you review other documents in the Program Resources section, which could include case log requirements, definitions, etc*.

Each specialty has a specialty-specific application form. Read each question carefully and answer only that question in the space provided. Ensure the answer is complete, detailed, and if requested, provide specific examples on how something may be handled within the specific program. Many applications ask about hospital data and resources, including the number of beds, average daily census, faculty numbers, and patient care resources. Plan to include the expected schedule for the residents. *For most applications, you will need a current copy of all core faculty's curriculum vitaes (CVs) (with an updated list of scholarly activities), Board Certification status, and most recent date of ABMS Subspecialty certification.*

Many citations occur because the application is incomplete or inaccurate, required education experiences are not demonstrated in the schedule, scholarly activity requirements for the faculty have not been met, or the minimum number of core faculty is not identified. *It is imperative when addressing the questions in the program information form (PIF), you answer completely, concisely, and above all, with complete honesty. If your program has flaws or weaknesses, as do all programs, do not exaggerate or attempt to mislead, as this will undoubtedly be picked up during the site* 

*visit leaving an irreconcilable black mark against your program.* If the program has weaknesses or flaws, it is best to concisely describe how they will be addressed and corrected with a time line. Once the application is completed, the program director submits the application to the DIO for final review and approval, after which the DIO submits to the applicable ACGME Review Committee. It is important to note that applications can only be submitted once and cannot be revised after submission. Although it seems obvious, one might be surprised by the number of applications that are submitted where directions were not followed, or the application lacked proper grammar: neatness and grammar do count. A poorly prepared application sets the stage for what could be a difficult process, as noted by John Gienapp, M.D., former executive director of the ACGME, "when a site visitor reads a poorly prepared PIF he/she comes prepared for the worst."

Once the application is completed, fellow members like faculty, residents, educators, and/or DIO should read the application and propose their suggestions and offer amendments. This is helpful to ensure that all aspects of the residency/ fellowship program have been correctly presented and the document is internally consistent. It is not uncommon to have slips and/or inconsistencies in a document that has been worked on for many months. Review should include an examination of all sections of the application for accuracy, including the faculty rosters and curriculum vitaes (CVs) [24]. Before submission, the program should find someone not familiar with the program but familiar with the ACGME policies and procedures to review the requirements and applications. This person should read both documents fully and identify areas that may need more details or that do not make sense.

After the application is submitted, program staff should interact with RC team to confirm that the application has been received. The RC team can also help with information about deadlines for forthcoming meetings. These meeting dates are posted on the ACGME website and are typically 8–10 weeks in advance of the meeting date. The goal for submission is several months prior to the site visit [24].

#### **4.2 Preparation of site visit**

This will take a year or more from finding a sponsoring institution to matching the first class of residents. In between those two bookends is the site visit from the ACGME. From our experience as newly accredited residency programs, there are pieces of the process, that on reflection, were key to our success.

Before thinking of the site visit, becoming familiar with the ACGME common program and program-specific requirements is essential. Having established, veteran program directors review the application in advance can give you the benefit of feedback and ability to troubleshoot. *Preferably, use one from your specialty to review the PIF and then one from outside the specialty for the site visit, who can challenge you on parts of the application unfamiliar to them and make you explain your rationale.* The most helpful part for our programs was the mock site-visit with other program faculty and having all parts of the application in folders with easily identified tabs so that all questions could be addressed quickly during the actual visit [21]. This gave us confidence and it showed the site visitor how much time, attention to detail, and effort went into application. Preparation began while creating all the applications and PIF and knowing the "purpose" of every rotation, every needed document [25]. *Understanding all the ACGME requirements and how your program will address them in the future is key during the site visit and having thought of contingency plans will impress the review committee with the level of preparation and thoroughness.*

*While the ACGME assigns the site visitor and outlines the agenda for the day, it is paramount to know your program inside and out, especially if those at the site visit*  *Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*


*Start early on accumulating and updating faculty CVs. You can use a well-written PIF as a model template, which paints the program in clear and concise manner and have another experienced PD's critique it along with other faculty.*

#### **Table 2.**

*Preparation of site visit timeline.*

*were not involved in PIF preparation. This starts with the being confident in the details (from the time of the visit and the locations to the program specific requirements) will ensure a less stressful environment for you and the site visitor. This includes blocking vacation time for all key personnel until the site visit is complete. Likely, your visitor will not be from your specialty and you cannot assume they are familiar with all the program specific nuances, so you need to.* Also, the core faculty being interviewed should be familiar with the PIF and the mission statement of the new program. If not then, at the minimum, they should know their expectations (core faculty, Core Competency Committee (CCC) or Program Evaluation Committee (PEC) members, and the rotation schedules).

#### **4.3 Time line**

One should think of the site visit as an open book test—good preparation should yield no surprises. Dr. Ingrid Philbert, Ph.D., MBA, Senior Vice President, Director, Field Activities for the ACGME, borrowed this analysis from the five stages of grief by Elizabeth Kubler Ross. Denial: "They not coming again, already"; Bargaining: "We can get a postponement"; Anger: "She says, we cannot get a postponement"; Depression: I will never be ready"; Acceptance: "We will be ready!"

In general, information gathering for the PIF should begin approximately 1 year before the application due date. Begin focused writing 6 months before the due date and finish the first draft 3 months prior to the due date (**Table 2**).

After the respective resident review committee (RRC) has reviewed the program, an e-mail notification of the accreditation status will be sent within 5 days. This e-mail note will not provide any details about the findings from the review, only the status. The letter of notification is sent approximately 60 days after that. This letter outlines areas not deemed to be substantially compliant by the RRC (citations), other areas in need of improvement, and actions the program is asked to take. This letter should be read carefully and discussed with faculty, residents, and department as well as institutional leadership.

## **5. Educational development**

#### **5.1 ACGME requirements**

As the new program application to the ACGME begins with the designated institutional official (DIO) by submitting a program application to the ACGME's Accreditation Data System (ADS),[24] the DIO also must select a program director (PD). PD is not only responsible for completing and verifying the accuracy of application information but also responsible for running the program successfully. The program director must be approved by the sponsoring institutions' Graduate Medical Education Committee (GMEC) as well as the RRC. The program director must be appointed for the length of the program plus 1 year. The PD must have educational and administrative expertise as well as certification in their respective specialty by the American Board of Medical Specialties. The PD must also be currently licensed and have a medical staff appointment at the sponsoring institution. Additionally, the PD must demonstrate adequate scholarly activity and be 5 years removed from residency/fellowship training or have worked as an associate program director for 3 or more years. To successfully oversee a program, the ACGME recommends at least 20% protected time for the PD. To assist the PD in running the program, each program is required to have a designated program coordinator (PC). The PC is responsible for assisting the PD in the day-to-day administration of the training program. The ACGME website precisely dictates the academic requirements while also mandating that the PD "embody personal qualities of integrity, confidence, and model outstanding professionalism, high-quality patient care, educational excellence and promote an environment where respectful discussion is welcome, with the goal of continued improvement of the educational experience." The above should be viewed as absolute requirements for a program director; however, for a PD to maximize the potential of those individuals under his or her charge, the PD must act as a disciplinarian while maintaining the confidence and respect of the trainees. To maximize trainee morale and a conducive educational environment, the PD may act as a confidant, counselor, and at times, therapist.

#### *Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*

Furthermore, it is imperative for the PD to establish good working relationships with the other program directors. Aside from providing support and advice, PDs must often work together. Because the ACGME does not permit integration with another sponsoring institution with the same specialty, programs are often required to work together to meet requirements. For instance, medical residents are required to rotate through cardiology; if a poor relationship exists between the two program directors, there is no option for the medical residents to rotate through another institution's cardiology training program.

ACGME sets standards for residency and fellowship programs that are comprised of common program requirements (CPR) that all programs regardless of specialty must meet and specialty-specific program requirements. Each program must provide program-specific details in the form of the program information form (PIF), which should be provided by the program director (PD) as they will know the program best and no one has a more significant stake in the program outcome. The PIF contains questions related to the CPR and the specialty-specific requirements and provides a clear understanding of why your program's mission and vision should exist and how it will serve the residents/fellows, hospital, and community at large.

Each program must have an accredited institution as its sponsor and designated primary training site(s). The ACGME requires accredited residency/fellowship programs to operate under the authority and control of one sponsoring institution. The sponsoring institution must comply with the ACGME institutional requirements and must ensure that all accredited programs remain in compliance with institutional-, common-, and specialty-specific program requirements as well as ACGME policies and procedures. Additionally, the sponsoring institution retains responsibility for the quality of GME, including when resident/fellow education occurs at other sites. The sponsoring institution defines and regulates compliance through affiliation agreements. Master affiliation agreements (MAAs) are the overriding agreements between the sponsoring institution and all its major participating graduate medical education sites involved in residency/fellowship education. If training was to occur at sites not governed by the sponsoring institution's primary training site's Board of Directors, a program letter of agreement (PLA) is required. In contrast to MAAs, PLAs are program-specific, originating at the program level, and offer details on faculty, supervision, assessment, educational content, size of the assignment, and policy and procedures for each essential assignment that occurs outside of an accredited program's sponsoring institution. These documents are designed to protect the program's residents/fellows by confirming a proper educational experience under sufficient supervision and must be renewed every 5 years [26].

Following initial program accreditation by the ACGME, the Residency Review Committee in your given specialty will, in subsequent years, monitor key performance measures to determine programmatic effectiveness and value. Data points are derived from the resident and faculty surveys, and board certification pass rates and performance by program graduates will determine the program accreditation status. The program must also submit every year to the ACGME program information via the Accreditation Data System (ADS). This includes reports of trainee development as measured using the specialty-specific milestones. Site review intervals will extend to 10 years if the program continues to meet performance goals. Prior to the once-a-decade site visit, it is expected that the programs will conduct, at least yearly, self-studies to consider accomplishments and opportunities for improvement [27].

The ACGME and other medical societies, especially the Association of Program Directors for the specialty, have a robust collection of resources to assist program development for everything from preparation for an ACGME initial application to

the 10-year accreditation site visit and everything in between. *One should consider attending the association of program directors meeting in your given specialty and the annual national ACGME Education Conference, usually held in the spring, join the GME committee at your institution, and call on other PDs at your institution and others in your specialty for advice* [24].

## **5.2 Creating a "successful" residency curriculum in graduate medical education**

Developing a "successful" curriculum means designing and implementing an effective program of study and discovery in a focus area. In graduate medical education, this "focus area" may represent a rotation, that is, cardiology, ambulatory rotation, critical care, etc. It may also represent an educational activity (i.e., grand rounds presentation) or research and scholarly activity (i.e., quality improvement project). A resident's skill level within this area is then evaluated within the "lens" of the core competencies as established by the ACGME. This "lens" includes the ACGME core competencies and their associated milestones [28]. The six core competencies include patient care, medical knowledge, systems-based practice, professionalism, practice-based learning and improvement, and professionalism [29].

The curriculum that you design for each of your focus areas should include the skill set needed within the "lens" of the competencies and milestones. Your "curriculum format" should include the following key areas:


For the purposes of providing a more concrete example, consider what a curriculum for a first-year internal medicine resident [30] who is about to begin a cardiology rotation would look like using this format.

#### *5.2.1 Overview*

This describes and sets the tone for your "focus area." It would provide a little background about the focus area (in this example, cardiology) and may briefly describe aspects including the subject matter and clinical interactions. It may also briefly touch on other areas including educational content and methods of teaching that you will describe more in depth later in the curriculum [29].

#### *5.2.2 Goals and objectives*

The goals and objectives of a rotation or activity need to be clearly defined within the framework of the ACGME core competencies. For example, the goals and objectives of an internal medicine resident on the cardiology rotation would be defined within the framework of the six core competencies. Each of the core competencies should be listed in the goals and objectives section and the milestones *Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*

can be further defined considering the respective competency discussed. Each core competency should be listed as a separate heading under your Goals and Objectives section. Two examples of a cardiology-focused goals and objectives under **patient care** could be:


The wording of the goals and objectives should be in the active voice. The first word of each objective should be a behavioral verb like: define, develop, review, identify, obtain, demonstrate, correlate, present, use/utilize, and/or communicate. They are dynamic words that are important when trying to convey each of your individual goals and objectives. Communicate, for example, may be the initial "buzzword" under specific goals and objectives under the section on **interpersonal and communication skills.** Look at the following examples:


*You will find as you are developing your curriculum for different focus areas that the patient care and medical knowledge competencies will vary greatly depending on your focus area.* Pulmonary and nephrology, for example, are likely to have very different goals and objective in these areas*. As you continue to develop and design curricula, you will also find that there is significant overlap in the content of the other core competencies (especially professionalism, systems-based practice and practice-based learning and improvement) and their associated milestones.*

Note that the resident must have access to the curriculum, especially the goals and objectives. Many residency programs maintain these on the residency management system, whether it is New Innovations or MedHub. Another option is to save them on a shared drive on the computer which is readily accessible. The resident should review the goals and objectives portion prior to the beginning of each rotation.

#### *5.2.3 Teaching methods*

This section defines the methods by which the residents learn the different topic areas. Common examples of teaching methods germane to most resident rotations include:

