Review Committee for Internal Medicine (RC-IM) Update 2019

Review Committee for Internal Medicine (RC-IM) Update 2019

Review Committee for Internal Medicine (RC-IM) Update 2019 APDIM Fall Meeting, Plenary, Saturday October 19, 2019 Sima S. Desai, MD Residency Program Director, Oregon Health & Science University, Chair, RC-IM Jerry Vasilias, PhD Executive Director, RC-IM #ACGME2019 Disclosures No conflicts to disclose #ACGME2019 2019 ACGME Program Requirement Revisions Update on NAS Lessons Learned from Self-Study/10-year visits Announcements Who is the RC-IM? #ACGME2019 2019 ACGME

Types of Program Requirements (PRs) Common PRs Specialty PRs #ACGME2019 2019 ACGME Summary of Recent Common PRs (CPRs) Changes Revision of Section VI The Learning and Working Environment (fka Duty Hours). New patient safety, quality improvement, and physician well-being language; eliminated the 16 hours for PGY1; all residents held to the same clinical/work hours, particularly 80 hours. Vetted in winter of 2016, approved in Feb 2017, went into effect July 1, 2017 Revision of Section I-V Most CPRs are core; mission and aims baked into CPRs; AOA certification is acceptable; new term core faculty; FTE for coordinator support; scholarship overhauled; more language on faculty development and APE; new certification exam rates.

Vetted in spring of 2018, approved June 2018, went into effect July 1, 2019 #ACGME2019 2019 ACGME As a result of new CPRs changes Resident and faculty surveys need to be updated Survey experts have been hired to revise & update. Requested input on survey items from PDs, faculty and trainees. Interest in keeping as many good items as possible to allow RCs to see trends. Will go live in early spring of 2020. #ACGME2019 2019 ACGME As a result of new CPRs changes ADS questions have changed Unfortunately, ADS was burdensome this year. You did not receive clear guidance on expectations. Challenges with who to list on the faculty roster. o Is it all or some? Its not all. It is some. Its those minimum required faculty and

anyone else who spends significant time with residents. New narrative questions were added, but not clear that o Responses do not need to be finalized during the update window, can edit later. o Responses will auto-populate for next years ADS update. o Narrative questions were removed. TY for contacting the RC staff. Offered solutions and notified ACGME leadership. Message of apology and appreciation will be coming soon from leadership. ACGME has learned that big systems changes require greater communication. Thank you for helping us learn and apologies for the burden this year. #ACGME2019 2019 ACGME Recent announcement for more CPR Changes New focused revision to CPRs related to: Supervision as it relates to telemedicine. Allowing RCs to further specify requirements regarding support for core faculty (e.g., hours or FTE). Out now for review-and-comment, through November 13, 2019 To be reviewed by ACGME BOD at February 2020 meeting, with effective date of July 1, 2020. #ACGME2019 2019 ACGME

Internal Medicine Program Requirement Revisions 1.Focused 2. Major #ACGME2019 2019 ACGME Focused Revisions to date We did focused revisions to accommodate CPRs that went into effect July 1, 2019 Edited IM PRs to remove redundancies/conflicts. Clarified RCs expectation for new CPRs by adding a few new PRs. #ACGME2019 2019 ACGME Focused Revisions Clarifications/new language for RESIDENCY PRs CPRs now refer to core faculty (physicians and non-physicians), so needed to clarify that the RC still expects a min # of core INTERNIST faculty, who must be ABIM or AOBIM certified. CPR for PD support is only 20% FTE, but IM expects 50%. APD language written so that FTE can be shared. Expectation for scholarly activity remains broad do not expect publication.

o CPRs ask RCs to look at program as a whole Vetted in winter of 2018, approved at June 2019 ACGME Board meeting, in effect now. #ACGME2019 2019 ACGME Focused Revisions Clarifications/new language for FELLOWSHIP PRs New CPRs use core facultyphysicians and non-physicians. RC not allowed to use key clinical faculty, so needed to clarify it still expects a minimum # of core subspecialty-certified physician faculty, certified by ABIM or AOBIM Re-categorized PD support 20-50% as core instead of detail CPR for fellows to practice independently in specialty does not appear in IM subs o But will be in multidisciplinary Clinical Informatics, at that communitys request Expectation for scholarly activity remains broad o No expectation for a peer-reviewed publication o 50% of graduates must have engaged in more than one SA from long list o 50% of faculty must engage annually in a variety of SA from long list Hem, onc, hem-onc, and PCCM were vetted in winter of 2018, approved at June 2019 ACGME Board meeting, in effect now. Remaining subs were vetted in fall of 2019, and will likely go to the February 2020 Board for approval. #ACGME2019

2019 ACGME Final thought on Focused Revisions So, as mentioned earlier, there are new CPR proposed revisions If approved by the Board in February, 2020 there will be another focused revision to IM PRs to re-insert hours for core internist faculty, and to clarify expectations for telemedicine. #ACGME2019 2019 ACGME Major Revision Current IM PRs in effect since 2009. RCs do major revisions every 10 years. For this major revision, ACGME asked RC to pilot scenario-planning. Intent of scenario-planning: not to predict the future and then build a master plan, but rather to ask what might future hold and identify actions today that are most likely to be valuable regardless of how the future turns out. Most Likely Future

Predictive Planning: Today Alternative Futures Scenario Planning: Master Plan Strategies Across Futures Today #ACGME2019 2019 ACGME Key insights from the scenario planning workshops Executive summary from the workshops RC held in June and September of 2017, https://www.acgme.org/Portals/0/PFAssets/ProgramResources/ IM2035ExSummary.pdf?ver=2018-08-16-133452-567 #ACGME2019 2019 ACGME

Major Revision (fall 2018) Jan 2018 RC Meeting Review Report from IM2035 Workshops + SI2025 Identify Chair of PR Writing Group + members Feb/March 2018 CEO & RC Chair at AEC and APDIM Discuss use of scenario planning for PR revision May 2018 Solicit input from PDs Make IM2035 report available to PDs Conduct Literature Review September 2018 IM2035 Writing Group Meeting #1 June 2017 IM2035 Workshop #1 IM & non-IM discuss IM in 2035 November 2018 IM2035 Writing Group Meeting #2

Sept 2017 IM2035 Workshop #2 April 2019 IM2035 Writing Group Meeting #3 RC & non-RC June/July 2019, TBD IM2035 Writing Group Meeting #4 J J A S O N 2017

D J F M A M J J 2018 A S O N

D J F M A M J J A S O N

D 2019 #ACGME2019 2019 ACGME Major Revision: September 2018 Paragraph 1 Preamble (draft) Internists are specialists who care for adult patients through comprehensive, clinical problem solving. They integrate the history, physical examination and all available data to deliver, direct and coordinate care across varied clinical settings. Internists are master diagnosticians who manage patients with undifferentiated, complex illnesses and comorbidities; promote health in communities; collaborate with colleagues; and lead, mentor and serve multidisciplinary teams. Internists integrate care across organ systems and disease processes throughout the adult lifespan. They are expert communicators, creative and adaptable to the changing needs of patients and the healthcare environment. Internists embrace lifelong learning and the privilege and responsibility of educating patients, populations, and other health professionals. The discipline is characterized by a compassionate, cognitive, scholarly, relationshiporiented approach to comprehensive patient care. #ACGME2019 2019 ACGME

Major Revision: September 2018 Paragraph 2 Preamble (draft) Successful, fulfilled internists of the future will maintain this core function and these core values. They find meaning and purpose in caring for individual patients with increased efficiency through well-functioning teams, and are equipped and trained to manage change effectively and lead those teams. They understand and manage the business of medicine to optimize cost-conscious care for their patients. They expertly applies data management science to population and patient applications and solve the clinical problems of their patients and community. They communicates fluently, and are able to educate and clearly explain complex data and concepts to all audiences, especially patients. They collaborate with patients to implement healthcare ethics in all aspects of their care. They display a high emotional intelligence in their relationships with colleagues, team members, and patients, maximizing both their own and their teams well-being. They are committed professionals who have the knowledge, skills, and attitudes to effectively use all available resources and who bring intellectual #ACGME2019 curiosity and human warmth to their patients and community. 2019 ACGME Major Revision (winter 2018/early 2019)

Jan 2018 RC Meeting Review Report from IM2035 Workshops + SI2025 Identify Chair of PR Writing Group + members Feb/March 2018 CEO & RC Chair at AEC and APDIM Discuss use of scenario planning for PR revision May 2018 Solicit input from PDs Make IM2035 report available to PDs Conduct Literature Review September 2018 IM2035 Writing Group Meeting #1 June 2017 IM2035 Workshop #1 IM & non-IM discuss IM in 2035 November 2018 IM2035 Writing Group Meeting #2 Sept 2017 IM2035 Workshop #2

April 2019 IM2035 Writing Group Meeting #3 RC & non-RC June/July 2019, TBD IM2035 Writing Group Meeting #4 J J A S O N 2017 D

J F M A M J J 2018 A S O N D

J F M A M J J A S O N D

2019 #ACGME2019 2019 ACGME Major Revision (after April 2019 meeting) Jan 2018 RC Meeting Review Report from IM2035 Workshops Feb/March 2018 CEO & RC Chair at AEC and APDIM May 2018 Solicit input from PDs September 2018 IM2035 Writing Grp (WG) Mtg #1 November 2018 IM2035 WG Mtg #2 June 2017 IM2035 Workshop #1 April 2019 IM2035 WG Mtg #3 IM & non-IM discuss IM in 2035

June 2019 Request more input Sept 2017 IM2035 Workshop #2 September 2019 IM2035 WG Mtg #4 RC & non-RC October 2019 IM2035 Stakeholders Summit J J A S O

N D 2017 J F M A M J J 2018 A S

O N D J F M A M J J A S

O N D 2019 #ACGME2019 2019 ACGME At April 2019 meeting, the IM2035 Writing Group decided 1) Input from the IM community on paradigm-shifts Within 36 months of training, how can programs provide more deliberate individualized educational experiences to residents based on competency evaluation? Should we test/study pilots using AIRE? Should program requirement revisions be done iteratively, using an evidence-based approach? For example, taking lessons learned from AIRE pilots and then editing requirements? - What are the strengths of this approach? - What are the weaknesses? - What opportunities would be gained by this? - What are the limitations of such an approach? - What could be the unintended consequences of such an approach?

#ACGME2019 2019 ACGME At April 2019 meeting, the IM2035 Writing Group decided 2) It would write a paper describing the major revision journey #ACGME2019 2019 ACGME At April 2019 meeting, the IM2035 Writing Group decided 3) Host a summit of stakeholder leaders to discuss the feedback received on paradigm-shifts and direction of major revision Summit is on October 30th Attendees include AAIM, ABIM, ACOI, ACP, and SGIM. Resident representatives. 15 attendees and 11 Writing Group members.

#ACGME2019 2019 ACGME When can you expect to see the major revision PRs? Jan 2018 RC Meeting Review Report from IM2035 Workshops + SI2025 Feb/March 2018 CEO & RC Chair at AEC and APDIM May 2018 Solicit input from PDs IM2035 Major Revision February/March 2020 September 2018 IM2035 Writing Grp (WG) Mtg #1 (we November 2018 IM2035 WG Mtg #2 June 2017 IM2035 Workshop #1

think) April 2019 IM2035 WG Mtg #3 IM & non-IM discuss IM in 2035 June 2019 Request input Sept 2017 IM2035 Workshop #2 RC & non-RC September 2019 IM2035 WG Mtg #4 October 2019 IM2035 Summit J J A

S O N D J F 2017 M A M J J 2018

A S O N D J F M A M J J

2019 A S O N D J F M A M J 2020

#ACGME2019 2019 ACGME J Final thought related to the Major Revision RC wants to acknowledge and thank the coordinators in developing consensus statement supported by AAIM for recommendation for coordinator support. Reviewed at the recent RC meeting and will be reflected in major revision. This is the current PR for coordinator support II.C.1. There must be a program coordinator. (Core) II.C.2. At a minimum, the program coordinator must be supported at 50 percent FTE (at least 20 hours per week) for administrative time. (Core) #ACGME2019 2019 ACGME Not related to revisionsDH citations *

In April Many learned that they received a citation for duty hours based on the previous years resident survey. We explained that the decision was made by the ACGME board and RCs need to follow this directive. Program directors provided feedback. Shared the feedback received and concerns with leadership. For the upcoming NAS review cycle The ACGME board is again asking RCs to cite programs identified as outliers, but the RCs will have discretion as to what, if any, further action to take depending on review of the programs other accreditation information. #ACGME2019 * Corrected slide 2019 ACGME Program Requirement Revisions Update on NAS Lessons Learned from Self-Study/10-year visits Announcements Who is the RC-IM? #ACGME2019

2019 ACGME What have we learned from the NAS? NAS = New/Now Accreditation System RC reviews every established program annually using data elements that identify outliers Resident survey, faculty survey, ABIM/AOBIM pass rate, clinical experience, scholarly activity, change w/in program, performance of subs, omission of data. If a program is flagged as outlier it will human review to determine if the flag is real #ACGME2019 (signal) or not (noise). 2019 ACGME NAS: Fewer Site Visits Pre-NAS ~25% NAS <1% % of IM programs (core and sub) with site

visits per year #ACGME2019 2019 ACGME NAS: Very few programs have citations Pre-NAS 79% NAS 5% % of IM programs (core and sub) with citations #ACGME2019 2019 ACGME NAS: Fewer citations overall Total # of citations declining by AY 2500 2111 2000 1739

1500 1714 1643 1516 1352 1051 1000 962 467 500 0 2004-05 2005-06 2006-07

#ACGME2019 2007-08 2008-09 2009-10 2010-11 2011-12 379 2012-13 2013-14 208 233 220

2014-15 2015-2016 2016-17 128 2017-18 NAS started July 1, 2013 2019 ACGME NAS: Few core programs have citations 80 70 % of programs 60 50 40 30 20 10 0

AY 2013-14 #ACGME2019 AY 2014-15 CIT AY 2015-16 CIT + AFI AY 2016-17 AFI AY 2017-18 Neither 2019 ACGME True/False: Citations and AFIs are the same thing FALSE Citations require a response in ADS, AFIs

(Areas for Improvement) do not. Citations are typically weightier than AFIs. However, if you receive an AFI, a good practice would be to write a couple of sentence in the major changes and other updates section in ADS on efforts to improve. #ACGME2019 2019 ACGME True/False: Being an outlier means getting a citation FALSE Annually, about 60% of the 2,400 IM programs (core and subs) are flagged as outliers on at least one NAS data element, but only 5% have a citation. This means that flags do not translate to citations! A flag means that a program undergoes human review to determine if the flag is real (signal) or not (noise). #ACGME2019 2019 ACGME Program Requirement Revisions Update on NAS

Lessons Learned from Self-Study/10-year visits Announcements Who is the RC-IM? #ACGME2019 2019 ACGME NAS: Review every year; site visit every decade Annual Data Submission Annual ACGME Review Annual Program Evaluation (PEC) 10 Y9 Self-Study / 10-year Site Visit Y8 Y7 Y6 Y5 Y4 Y3 Y2

Y1 #ACGME2019 2019 ACGME RCs decision about self-study report At its April 2017 meeting, the RC decided that it will not provide programs feedback on their self-study. RC will provide feedback 89% on compliance with requirements and allow the Department of Field Activities to provide the no programs feedback on the self-study. citation #ACGME2019 2019 ACGME Timing of Self-Study and 10-year Site Visits The due date for the self-study will be pushed forward. In all likelihood, up to 24 months into the future. The tentative date of the 10-year compliance visit will is also be pushed forward into the future. For more specific information on the timing of both things,

call/email the staff of the Department of Field Activities, Andrea Chow, [email protected], 312.755.5009. #ACGME2019 2019 ACGME Summary of 10-year compliance visits 220 programs All programs on Continued Accreditation. 6 years of mostly/entirely clean NAS screens. Results from 10-year compliance reviews 100% Continued Accreditation #ACGME2019 90% no no citation 90% citation 90% no

citation If cited, received 1 citation, on average 2019 ACGME Summary of citations from 10-year compliance visits First, few programs receive a citation, and, theres nothing frequent about the citations received. But, here are two infrequent citations - Inadequate evaluations systems. - Structural/resource related citations (inadequate work space/lounge; not enough ancillary support). 90% no QUESTION: Why are there fewer citations? citation ANSWER: Maybe, engaging in the self-study process 18-24 months in advance of the 10-year site visit, allows programs to start making broad improvements throughout. #ACGME2019 2019 ACGME Lessons learned from 10-year compliance visits Annual screening works - Multiple years clean NAS positive accreditation outcomes.

Most programs do not receive any citations 89%receives a single citation. - If cited, on average, program no citation #ACGME2019 2019 ACGME Program Requirement Revisions Update on NAS Lessons Learned from Self-Study/10-year visits Announcements Who is the RC-IM? #ACGME2019 2019 ACGME Hospital Closures In July, Hahnemann University Hospital announced it would close Affected approximately 550 residents/fellows - about 150 IM residents, 50 IM fellows. The staff received and processed countless complement increase requests. The number of slots made available, far exceeded the number of displaced

trainees, by almost double! Thank you for your willingness to take in the displaced residents. In August, Ohio Valley Medical Center announced it would close Affected approximately 30 residents 12 IM and 18 EM. Again, staff received and processed many requests for increases in complement and again the number of slots made available far exceeded the number of displaced trainees. Thank you again for your willingness to take in these displaced residents. #ACGME2019 2019 ACGME Congratulations! #ACGME2019 2019 ACGME Program Requirement Revisions Update on NAS Lessons Learned from Self-Study/10-year visits Announcements of Gratitude Who is the RC-IM? #ACGME2019

2019 ACGME Who is the RC-IM? #ACGME2019 2019 ACGME As of July 1, 2019: Composition of the RC-IM Ruth Campbell, MD Nephrology Amy Oxentenko, MD GI Alan Dalkin, MD Endocrinology Jill Patton, DO GIM Andrew Dentino, MD Geriatrics/HPM Kristen Patton, MD CCEP Sanjay Desai, MD PCCM David Pizzimenti, DO GIM Chair: Sima Desai, MD GIM

Donna Polk, MD Cardiology Jessica Deslauriers, MD Resident Member Samuel Snyder, DO Nephrology Oren Fix, MD Transplant Hepatology David Sweet, MD GIM Gerald Fletcher, MD Resident Member Jacqueline Stocking, RN, PhD Public Member Russ Kolarik, MD Med-Peds Sheila Tsai, MD Sleep Medicine Monica Lypson, MD GIM Vice Chair: Heather Yun, MD ID Alice Ma, MD Hematology-Oncology

Alejandro Aparicio, MD ex officio, AMA Elaine Muchmore, MD Hematology-Oncology Davoren Chick, MD ex officio, ACP Cheryl OMalley, MD GIM Furman McDonald, MD ex officio, ABIM Michael Pillinger, MD #ACGME2019 Don Nelinson, PhD ex officio, AOA Rheumatology Noobs, July 20192019 ACGME Questions? Please contact RC-IM Staff Bri Kelly [email protected] Accreditation Administrator

312.755.5052 Christine Gillard [email protected] Accreditation Administrator 312.755.7094 William Hart [email protected] Associate Executive Director 312.755.5002 Karen Lambert [email protected] Associate Executive Director 312.755.5785 Jerry Vasilias, PhD [email protected] #ACGME2019 Executive Director 312.755.7477 2019 ACGME

Thank You! #ACGME2019 2019 ACGME

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