Accreditation
A resource for medical educators - for a variety of instructors, containing everything from short didactic lectures to in-depth modules. Presentations may be used for educational events, House Officer training and for any other educational needs you may have.
Annual changes to WebADS are to be sent to the GME office. Information will be communicated about this annually. If you have questions, Email Dr. Frey
APE Data Form, PEC Minutes, Action Plans & SWOT ANALYSIS DUE AUGUST 30th
Annual Program Evaluation (APE) Program-specific statistical data from previous years has been uploaded to APE Form that will be distributed in a separate email. If you did not populate the data correctly in last years APE Form then the areas will be blank. If yours is blank, please complete. Please note:
1. Please read the directions very carefully. All information requested is for the previous AY.
2. Yellow vs White Questions – All questions in Yellow are to be completed by the Coordinator (most information uploaded from ADS). All areas in White are to be completed by the Program Director.
3. Meetings – You are to enter the date or dates that your PEC meetings were held to discuss the program and develop Action Plans. This is NOT the date where the APE is presented to the Faculty. There is a specific question on the PEC Minutes Template form for the latter.
4. Attachments – Please label all attachments by the Corresponding Attachment Letter and Name as noted in the APE Form. Save and label the file name for the APE DATA SHEET/ FORM as - APE Data Sheet (Academic Year) – Program Name
5. The completed APE Form and the Attachments must be distributed to your PEC as they will use this to review the program before the PEC meeting and discussions at the meeting will be focused on the areas that the members note are concerns.
6. The APE Form (Word Document not PDF) and Attachments must be submitted to Dr. Frey in the GME Office along with the PEC Minutes, SWOT Analysis, and Action Plans.
The ACGME Common Program Requirements, stipulate that “the educational effectiveness of a program must be evaluated at least annually in a systematic manner." This is accomplished though the Annual Program Evaluation (APE). A Program Evaluation Committee (PEC) should be created to ensure that each program has undertaken and documented a systematic review process, on at least an annual basis.
See Annual Program Evaluation Checklist
How to Complete the Annual Program Evaluation (APE)
The ACGME accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of import in graduate medical education.
The ACGME also distinctly defines important terms for graduate medical education:
For detailed ACGME program information, visit:
Formerly Resident Duty Hours
LSU School of Medicine and the ACGME are committed to addressing physician well-being for individuals, as it relates to the Clinical Learning Environment (CLE.) The creation of a learning environment with a culture of respect and accountability for physician well-being is crucial to the ability of those working in it to deliver the safest, best possible care to patients. The focus is on five key areas to support ongoing commitment to physician well-being: Resources, Education, Influence, Research, and Collaboration. Read CEO Thomas J. Nasca’s Letter to the Community.
ACGME Physician Well-Being Website
Five key areas to support ongoing commitment to physician well-being:
The ACGME’s Resident/Fellow and Faculty Surveys are an additional method used to monitor graduate medical clinical education and provide early warning of potential non-compliance with ACGME accreditation standards. All specialty and subspecialty programs (regardless of size) are required to participate in these surveys each academic year between the months of January and June.
Resident/Fellow and Faculty Surveys
Log into ACGME Surveys (for residents, fellows, and faculty members only)
Clinical Learning Environment Review
The ACGME has implemented the Clinical Learning Environment Review (CLER) program as a part of its Next Accreditation System. The CLER program is designed to provide US teaching hospitals, medical centers, health systems, and other clinical settings affiliated with ACGME-accredited institutions with periodic feedback that addresses the following six focus areas:
Health Care Quality and Disparities
The next CLER (anticipated Spring 2020) visit will take place at UMCNO.
ACGME Common Program Requirements
2019 Common Program Requirements Section VI - Implementation Dates
Selected Resources for Program Requirements
The following documents are organized by topic across all program requirements as a useful reference for determining varying expectations among specialties.
These documents will be updated periodically to reflect changes in requirements.
Evaluations are required per the ACGME Common Program Requirements (V. Evaluation). House Officers are evaluated against the ACGME Core Competencies as defined in the Common Program Requirements, and the Milestones defined by the Residency Review Committee for the respective specialty. Most evaluations should be conducted in New Innovations. A supplemental evaluation system was created for immediate feedback: Resident Evaluation Express
- Self
- Peer
- Nurse
- Patient
New Innovations has a Milestones and Portfolio feature that you should use to make this process very easy and paperless. Attached is a document from the ACGME that shows the following items that the CCC should be taking into consideration in regards to a residents performance:
- Peer Evaluations
- OSCE
- Nursing & Ancillary Personnel Evaluations
- Operative Performance Rating Scales
- Mock Orals
- ITE
- End of Rotation Evaluations
- Sim Lab
- Self-Evaluations
- Case Logs
- Student Evaluations
Clinic Work Place Evaluations
Patient/Family Evaluations
These additional resources can help programs organize for post-application activities, such as preparing for a program site visit, implementing an effective evaluation system and resident/fellow Milestones assessment, and running a Clinical Competency Committee ( CCC ).
A House Officer Portfolio is the academic and personnel record for a House Officer training at LSU School of Medicine.
The ACGME requires that all institutions which sponsor ACGME accredited GME programs have an organized process to demonstrate effective oversight through a Special Focused Program Review (SFPR) process.
Use this to complete your ACGME Self Study
The self-study is an objective, comprehensive evaluation of the residency or fellowship program, with the aim of improving it. Underlying the self-study is a longitudinal evaluation of the program and its learning environment, facilitated through sequential annual program evaluations that focus on the required components, with an emphasis on program strengths and “self-identified” areas for improvement.
To offer context for the self-study, there are two new concepts: 1) an exploration of program aims; and 2) an assessment of the program’s institutional, local and, as applicable, regional environment. Both are discussed in detail below. The focus on aims and the program’s environmental context is to enhance the relevance and usefulness of the program evaluation, and support improvement that goes beyond compliance with the requirements.
In preparation for an ACGME Site Visit, the GME office will perform a Document Review. A checklist has been created to guide you on the documents that we understand have been reviewed in previous site visits. This checklist is a working document and will be modified as updates/changes are made available. Additionally, this list should be used as a guide on an ongoing basis to house your program's files.
The Enhancing Quality Improvement for Patients (EQuIP) program at the LSU School of Medicine is an institution-wide initiative designed to engage residents and fellows in systems-based quality improvement programs at participating clinical training sites.
For more information, visit Enhancing Quality Improvement for Patients (EQuIP) or the EQuIP site.
To browse LSUSOM quality and safety projects, click the link below:
- All house officers must be familiar with Chancellor’s Memorandum-51 Policy on Weather Related Emergency Procedures for LSUHSC-New Orleans
http://www.lsuhsc.edu/administration/cm/cm-51.pdf
- All house officers who have cell phones must sign up to receive Text Messages Alerts as soon as possible:
http://www.lsuhsc.edu/alerts/TextEmailAlerts.aspx
- All house officers must monitor their LSUHSC email accounts at least daily and check for Emergency Related Updates on the LSUHSC Homepage:
The GME office will use the LSUHSC email system for all communication. The non-LSU email addresses should only be used in the event the LSUHSC system is not functioning.
The Accreditation Council on Graduate Medical Education’s (ACGME) Common Program Requirements require that residents integrate and participate in interdisciplinary clinical QI and PS programs, at their clinical sites. Further, their Clinical Learning Environment Review (CLER) visit has added a conceptual framework that includes a focus on patient safety and healthcare quality, such that residents must participate in the reporting of errors, unsafe conditions and near misses, by involvement in interprofessional teams aimed at promoting safe care and improving systems and processes that improve patient outcomes.
The EQuIP rotation provides exposure to multidimensional aspects of Quality Management and Performance Improvement. It allows exposure to the ACGME accreditation process, including the CLER site visit, residency training RRCs, program requirements and program specific milestones, the Joint Commission, the function and duties of the LSUHSC School of Medicine EQuIP office and an introduction to and participation in UMCNO Quality, Safety and Risk Management committees and practices.
Current Participating Departments:
- Pathology
- Radiology - Diagnostic
- Radiology - Interventional
- Internal Medicine
- Emergency Medicine
- Physical Medicine & Rehabilitation
View the EQuIP Rotation Calendar
Visit the EQuIP Rotation page
EQuIP Project Proposal Form 2022.pdf - Use this form to submit your QI proposal to EQuIP@lsuhsc.edu