Accreditation

Resources for Faculty Development

/wiki/spaces/MEDS/overview

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.

Click here to view MEDS

WebADS Updates

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 & Attachments

APE Data Form, PEC Minutes, Action Plans & SWOT ANALYSIS DUE AUGUST 30th

Email Dr. Frey

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)

Annual Program Evaluation Checklist

Annual Program Evaluation


Accreditation Council for Graduate Medical Education

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.

ACGME Glossary of Terms

The ACGME also distinctly defines important terms for graduate medical education:

ACGME Commonly Used Terms

For detailed ACGME program information, visit:

https://www.acgme.org/

GME Policies & Procedures
Resident Clinical Work Hours
Resident Well-Being

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:

ACGME Physician Well-Being Webinars

Campus Assistance Program

Resident/Fellow and Faculty Surveys

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)

ACGME Clinical Learning Environment Review (CLER)

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:

Patient Safety

 Key Findings

Health Care Quality and Disparities

 Key Findings

Care Transitions

 Key Findings

Supervision

 Key Findings

Wellness

 Key Findings

Professionalism

 Key Findings

The next CLER (anticipated Spring 2020) visit will take place at UMCNO.

LSUSOM House Officer Core Curriculum
Specific ACGME Program Requirements

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

Evaluation of House Officers

Evaluation of Faculty

Evaluation of Program

Milestone Reviews

360° Evaluations

    • Self
    • Peer
    • Nurse
    • Patient

Bi-Annual Resident Performance Evaluation

Summative Evaluation

Clinical Competency Committee

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 ).

Summative Evaluation

A House Officer Portfolio is the academic and personnel record for a House Officer training at LSU School of Medicine.

Special Focused Program Reviews

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.

SFPR GMEC Protocol - LSU School of Medicine-New Orleans

ACGME Program Self Study

Self Study Binder Template

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.

ACGME Site Visits
 Full Site Visits

The ACGME uses Full visits: (1) for all core program applications and applications for some subspecialty programs (the applications for other subspecialty programs and those for sponsoring institutions are generally reviewed without a site visit); (2) at the end of the two-year Initial Accreditation period, to ensure that a program or sponsoring institution with Initial Accreditation is compliant with the accreditation standards; (3) to address broad concerns identified during the review of data submitted to the ACGME annually; (4) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee; and (5) to assess overall compliance and ongoing improvement in a program or sponsoring institution during the scheduled 10-year site visit.

SAMPLE Full ACGME Site Visit Documentation

 Focused Site Visits

The ACGME uses Focused visits: (1) to conduct a timely, in-depth explorations of potential problems arising out of a Review Committee’s review of annually-submitted accreditation data; and (2) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee.

Detailed information about site visits for applications can be found in a separate set of FAQs addressing the accreditation of new programs, program mergers, and changes in sponsorship.

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. 

Document Review Checklist

EQuIP - Enhancing Quality Improvement for Patients

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:

GME Emergency Response Plan
PLEASE READ THIS ENTIRE NOTICE! The purpose of this message is to alert you to procedures surrounding weather related emergencies.
  • 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:

http://www.lsuhsc.edu/ 

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 EQuIP Rotation

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:

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


LSU GME Knowledge Base

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