Accreditation Data Collection

It is that time of year again…accreditation data collection.  There are requests that are being made of your program from the ACGME and the GME Office.  To assist in responding, the email below should provide necessary dates and information.   

  1. Evaluations - All programs should be distributing an anonymous Program Evaluation to both the Residents and Faculty to complete to get their feedback on program issues.
  2. Milestones Data – CCC Meetings to complete the End of Year Milestones data. -  Must be entered into WebADS Due June 24th
  3.  Case Log Data – Final case log data needs to be entered into WebADS.  Your 2016 Graduates’ minimums report must be uploaded into ADS before August 1st
  4. Duty Hours – All duty hours for the AY should be completed. Final reports for violations will be generated at the end of June. Due July 1st   Noncompliance will need to be addressed in New Innovations.
  5. Program Letters of Agreement – All letters must be scanned and put into New Innovations.  Due July 1st.
  6. WebADS Annual Update -  The required Annual Update timeframe is July – August.  LSU’s normally begins in August and ends early September.  As always please make sure that you enter ALL information into ADS and notify me before you hit submit so I can review the documentation. PLEASE DO NOT WAIT UNTIL THE LAST MINUTE. There are 63 programs with data that must be proofed before submission.
  7. Program Evaluation Committee (PEC) – Each program should have scheduled the final Program Evaluation Committee for this AY.  The PEC has multiple sources of data to review.  The APE Form, when completed, will assist in this committee’s meeting items.

    Please see the  Binder Collection Attachment above to help you with the documents for the PEC and APE Form completion.

  8. APE DATA FORM AND ATTACHMENTS  (see attachment above titled – APE End 2016 LSU Template)
    The fillable (Word Document) Annual Program Evaluation (APE) is attached.  Please click on it and complete.  A few things to note.
    • Please read the directions very carefully.     All information requested is for the 2015-16 AY.
    • 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.
    • 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 specific question on the PEC Minutes Template form for the latter.
    • AttachmentsPlease label all attachments by the Corresponding Attachment Letter and Name as noted in the APE Form.
      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.
    • The APE Form and Attachments must be submitted to Dr. Frey in the GME Office along with the PEC Minutes and Action Plans (see Section 9 and 10 below) by September 15th.
    • The PEC Minutes Template is under revision.  Due to the late nature of this revision, you are welcome to submit the old format for the PEC Minutes or wait for the new format.  Please let me know which one you are choosing to do.
    • PEC Minutes – PEC Committee members’ names are to be entered in the document.  Please add  names of your faculty and residents (PGY Levels) that serve on the committee.  (Please look over this document to make sure all supporting documentation was addressed). You will need to send the completed Minutes along with the APE Form, Attachments noted in APE Form, and the Action Plans Spreadsheet.
    • Required Date of Presentation of PEC Action Plans / APE to Entire Faculty -  Some subspecialties are smaller with limited faculty.  I have asked that the Core Residency Directors work with the Department Chairman and subspecialty program directors to see that the subspecialty APE’s are added to one of the upcoming Department Faculty Meetings.  Verification (minutes, email) must be available to site visitor to ensure that the PEC Findings / Action Plans were presented.
  10. ACTION PLANS TEMPLATE/Excel Spreadsheet
    • Action Plans – At the end of the PEC Review you will be required to list your programs 2016-17 Action Plans and follow up dates.  These will be tracked throughout the year.  If any Previous Years Action Plans were not successfully addressed from last year please add the updates on the spreadsheet tabs and continue to follow-up.  As well delineate how they will be measured and monitored. You should all have copies of last year’s Excel Spreadsheets of Action Items.  If you need another copy sent to you let me know.


APE FORM (including its Attachments); PEC Minutes; Action Plans; Checklist with Directors Signature - Due Date – September 15th.  –  PLEASE SUBMIT IN ONE EMAIL TITLED “PROGRAM NAME  2016 END OF YEAR DOCUMENTATION”  (ie:  Dermatology 2016 End of Year Documentation) as always if you are unable to complete by this date please let me know.  This is due after WebADS Update so most of the information will be available as you prepare for the Annual Update in WebADS.

Should revisions be necessary the GME Office will forward the documentation to the program director for corrections then resubmission.

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