Blueprint for Coordinator Success
TARGET
MONTH
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
Program Orientation
Administer processes to orient residents to hospital system(s)
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
REFERENCE SOURCES
Review department/division orientation agenda to identify speakers,
necessary handouts (goals/objectives, rotation schedules, program or
institutional policies manual etc.), required testing (drug/background check
etc), necessary training (ACLS, BLS, HIPAA compliance)
Electronic Medical Records (EMR) System
GME Track is used to collect statistical data from medical institutions for
research and educational purposes. Programs and institutions will be asked
to report data on accredited and nonaccredited programs annually.
GME Track Resident Update Opens (mid-July)
1. First-year resident data can be downloaded and imported into WebADS
or other computer tracking systems.
2. Programs can also download WebADS data and import program data into
GME Track to avoid duplicating survey information later in the academic See GME Track Website @
year.
http://www.aamc.org/programs/gmetrack/start.htm
JULY
1. The ACGME/RRC's require timely submission program data, which
includes an update of active residents, current program director/coordinator
Page 7, Section II.A 4.f (Program Director Responsibilities)
contact information, faculty CV's and case logs (as required)
ACGME Web Accreditation Data System (WebADS) Preparation
2. Programs preparing for external site reviews will need this
information for part 1 of the Common PIF.
Program Directors Guide to the Common Program
Requirements [www.ACGME.org]
3. Annually updating faculty CV's during this process saves time
during preparation for RRC site visits.
Common Program Information Form (PIF) "Physician
Faculty Roster"
4. Faculty CV's will be needed for members that devote 10 hours per
week to the educational program.
1. The collection of faculty evaluations of the resident's performance
following each educational rotation or assignment must be documented.
2. Completed evaluations must be retained in each residents file.
Begin Collection of "Formative Evaluations".
(Should be repeated monthly or following each major assignment)
Program Directors Guide to Common Program Requirements
Page 47-52, Section V.A.1 a - c.
3. Samples of competency-based evaluation tools will be needed during
future internal and external reviews.
Common Program Information Form (PIF) Questions on
Evaluations.
4. Resident files should support the programs standard practice for
collecting formative evaluations from faculty.
General Instructions for Part II, Program Specific PIF
(list of documents to have available for the site visitors ).
5. Internal/external site visitors will verify the frequency and use of
competency-based evaluation tools, as they are described in the PIF.
1
Blueprint for Coordinator Success
TARGET
MONTH
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
ERAS- opens;
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
REFERENCE SOURCES
Respond to inquiries about the program
Review Match Agreement for compliance details.
NRMP Main Match Opens (Late August/Early September)
AUGUST
End of Rotation/Assignment Formative Evaluations
1. Consider program responsibilities for Match compliance to avoid
potential Match violations.
2. Review applicant responsibilities for Match compliance.
NRMP website: www.nrmp.org
3. The ACGME Institutional requirements "strongly suggests" sponsoring
institutions and all of its programs participate in an organized matching
ACGME Institutional Requirements Section II.2b
program such as the NRMP.
(www.acgme.org)
4. NRMP Match violations are reported to the IRC, RRC, and the
applicants medical school.
5. Programs with match violations will be flagged in the NRMP system for a
specified period of time, and could have an impact on recruitment efforts for
qualified applicants.
1. The collection of faculty evaluations of the resident's performance
following each educational rotation or assignment must be documented.
2. Completed evaluations must be retained in each residents file.
3. Samples of competency-based evaluation tools will be needed during
future internal and external reviews.
4. Resident files should support the programs standard practice for
collecting formative evaluations from faculty.
Program Directors Guide to Common Program Requirements
Page 47-52, Section V.A.1 a - c.
1. Initial reporting to the ACGME on the programs' compliance with work ACGME Data collection system
hours will be part of the ACGME annual Program Update in WebADS,and https://www.acgme.org/ads/default.asp for Program Annual
downloaded in Part I of the Common PIF for external site reviews.
Update.
2. Between January and May of each year all programs will participate in
the ACGME Anonymous Resident Survey, which is used to assess
compliance with work hours and other educational components of the
training program. Site visitors will have a copy of the most recent survey
results.
Program Directors Guide to the Common Program
Requirements section II.A4j "Program Director
Responsibilities.
4. The program must develop a plan to monitor work hours with
enough frequency to document compliance.
Part II, Specialty Specific PIF List of Documents to have
available for the site visitor.
Guide to Common Program Requirements pages 61- 72 for
requirements, explanation of requirements, and Program
3. Internal and External site visitors will request to see raw duty hours Information Form PIF) questions related to work hour
data to document program compliance.
compliance.
Collect baseline Duty Hours data to monitor resident compliance with
work hour requirements.
Resident applications available in ERAS;
Electronic Residency Application Services (ERAS) developed by AAMC to
facilitate applications to residency/fellowship programs.
http://www.aamc.org/audienceeras.htm
Establish resident procedures for review and screening of application
Update recruitment letters
Prepare materials for distribution to applicants
GME Track Resident Update closes late September
SEPTEMBER
ACGME Annual Program Updates Begin (September - December
GME Track website
http://aamc.org/programs/gmetrack/start.htm
1. Complete any remaining data not previously updated in WebADS.
2. Review raw duty hour data to assure accurate reporting of duty hours.
3. Annual updates must be submitted within the timeframe outlined by the
ACGME in WebADS.
Data collection system
https://www.acgme.org/ads/default.asp
2
Blueprint for Coordinator Success
TARGET
MONTH
SEPTEMBER
CONTINUED
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
REFERENCE SOURCES
1. Quota changes must have the approval of Designated Institutional
Official (DIO).
2. It is important to ensure that the number of matched applicants through
the NRMP do not create overages in the total resident complement approved NRMP website: www.nrmp.org
by the RRC for an individual training program.
3. The program accreditation letter will outline the total number of house Guide to Common Program Requirements section
staff a program can train in a given academic year.Overages require
II.A.4n2, pg 8. (www.acgme.org)
approvals by the GMEC/DIO and the RRC for most specialties.
4. Documentation of house staff will be downloaded from WebADS for
the last 5 years in the Common PIF.
Submission of NRMP Match Quotas
End of Rotation/Assignment Formative Evaluations
See above
Prepare for Interview season
Resident Appointments:
1. Set up interview dates
2. Invitations for interviews
3. Selection committee meet to plan interviewing season
4. Remind coworkers and other hospital personnel that resident recruitment
season is beginning.
1. Program Directors Guide to the Common Program
Requirements Page 20, Section III.A-D.
Other things to consider:
Eligibility for appointment: visa issues, number of residents, resident
2. Some Specialty Specific RRC Requirements on
transfer requirements, Appointment of Fellows and Other Learners
Eligibility may also apply
OCTOBER
End of Rotation/Assignment Formative Evaluations
Complete resident application review
NOVEMBER
NOVEMBER
CONTINUED
Program Directors Guide to Common Program Requirements
Page 47-52, Section V.A.1 a - c.
Program Director Guide to the Common Requirements
section III. A-D; pg 21
Semi-Annual reviews
End of Rotation/Assignment Formative Evaluations
See above
Program Directors Guide to Common Program Requirements
Page 47-52, Section V.A.1 a - c.
Interview seasons may vary in length depending on the number of applicantsAAMC- Roadmap to Residency: From Application to the
planned for interviews, and the number of training slots a program hopes to Match and Beyond
fill.
https://services.aamc.org/publications
'Dean's Letters' released
Numerous phone calls from applicants
Work with faculty and PD in coordinating the interviews
Interviews begin
1. Formative evaluations from previous months should be used to provide
feedback to residents on their performance.
2. Semi-annual reviews should also include a review of case logs/patient
logs, if required by the RRC or Board, and a review of the residents
Program Directors Guide to Common Program Requirements
participation at required conferences within the training program.
Page 47-52, Section V.A.1 a - c.
3. Plans for remediation for academic deficiencies should be discussed at
this time for any resident of concern.
Also review programs specific requirements on resident
4. Remediation plans should include specific achievement goals, a
evaluations and feedback to determine other components
timeframe for achievement, and consequences if goals are not achieved.
required by the RRC for review during semi-annual
5. Documentation of the semi-annual review must be retained in the
evaluation of the residents performance.
residents file, and this information should be accessible by the resident upon
their request.
Part II, Specialty Specific PIF List of Documents to have
available for the site visitor.
6. This documentation will be needed for internal and external site
reviews.
See above
Program Directors Guide to Program Requirements pages 47
52.
3
Blueprint for Coordinator Success
TARGET
MONTH
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
REFERENCE SOURCES
DECEMBER
Interviews first 2-3 weeks
ACGME Anonymous Resident Surveys Begin (January - May)
JANUARY
Interview process continues
End of Rotation Evaluations
Assist PD with match list
FEBRUARY
1. The Program Director and Coordinator will be notified by the ACGME
of the timeframe of the survey.
2. The ACGME Anonymous Resident Survey will be used throughout the
accreditation cycle, and specifically during the RRC site visit to document
compliance for work hours.
3. Review the survey questions with residents to assure their
understanding/interpretation of survey questions before the survey opens.
4. Assure all contact information in WebADS is correct for all active
residents.
5. All programs must achieve 70% response rate, or the program will be
deemed noncompliant with this process.
6. Review survey results with faculty and residents to document resolution
of identified areas of noncompliance.
7. Include a discussion of the survey results in the annual program
evaluation committee meeting.
Programs with 4 or less residents will receive an aggregate
report after 3 years of data is obtained.
Review prior surveys in WebADS to document recurrent
areas of noncompliance.
schedule revisits from applicants
Follow-up letters to applicants
Obtain scores/feedback from interviewers
NRMP match quota deadline
See above
Numerous phone calls from applicants
Enter NRMP match list/Verify Match list deadlines
Notify GME of necessary changes
Report contract non-renewal decisions to GME
Process continuing residents appointments
See Resident Survey Sample ACGME website
www.acgme.org "resident survey sample".
See Institutional Requirements Section II.D4d 1 -4
Order Certificates for graduating residents
Written notification for non-renewal to residents advising of nonrenewal
and grievance process
4
Blueprint for Coordinator Success
TARGET
MONTH
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
REFERENCE SOURCES
NRMP match results - 3rd Thursday in March
Educational Commission for Foreign Medical
Graduates
MARCH
Appointment process begins for new residents
Notify GME Office of extensions of training, terminations
Review VISA requirements for IMG accepted in program
GME Office must confirm appropriate due process for grievances, if the
resident disagrees with the decision.
GME must also update employment system(s) for certificates of graduation,
salary support and other patient care access badges
See Institutional Requirements Section II.D4d 1 -4
Work with GME Office regarding packet distribution for new resident
Program Letter of Agreement (PLA) between the program and each
participating site [renewed at least every five years]
Set up Educational Committee/ Retreat/Workshop
www.ecfmg.org
See Institutional Requirements Section II.D4d 1 -4
1. Major changes to participating sites (length of the rotation) may require
GMEC/DIO and RRC Approval.
2. The addition or deletion of a participating site must be reported in
WebADS.
3. PLA's must be updated at least every 5 years, or as educational
arrangements change.
4. RRC Program Specific Requirements on additional areas to include
in PLA's will be verified during internal and external site reviews.
5. Copies of PLA's will be needed for internal and external reviews.
Evaluation: Program Evaluation and Improvement
Minutes must document:
faculty and resident/fellow participation
Review of most recent RRC letter of report/internal review report
Board performance/in-training exam performance
Review of curriculum
Confidential feedback of the program from residents and faculty
Section 1.B, pg 5-7 of the Program Directors Guide to the
Common Requirements.
Also review Program Specific Requirements for RRC
expectations for participating training sites.
Part II of the Program Specific PIF, List of Document to
Have Available for the Review #7.
V.C., pg 59 - 60 Program Directors Guide to the Common
Program Requirements
See also program specific requirements for other areas to
include in the meeting minutes.
Internal and External site reviews will require a copy of the minutes for Part II, Program Specific PIF List of Documents to have
this meeting.
Available for Site Visitor # 16
Evaluation: Faculty Evaluation/Faculty Development
Evaluate residents performance
Faculty evaluation of program
V.B., pg 57 Program Directors Guide to the Common
Program Requirements
Review curriculum
Contract non-renewal decisions
Part II of the Program Specific PIF, List of Document to
Have Available for the Review #13
5
Blueprint for Coordinator Success
TARGET
MONTH
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
REFERENCE SOURCES
Update residents files
1. Assure collection of monthly/rotation formative evaluations.
2. Documentation of semi-annual evaluation
3. Updated report of case logs/patient logs.
4. In-training exam scores, as needed.
5. Final evaluation for all graduates
Review and update residents handbook
Educational Program: Curriculum Components
IV.A. 1-4, pg 26-30 Program Directors Guide to the Common
Program Requirements
Update goals and objectives , policies and procedures and other
documents
Overall Educational goals; competency based goals and objectives for
each assignment
Program directors Guide to the Common Requirements
section IV.A.1-4, pg 25
APRIL
Update didactic programs
Didactic sessions; delineation of resident responsibilities
A copy of the overall goals, and the competency-based goals/objectives Part II of the Program Specific PIF, List of Document to
Have Available for the Review #5 and 6.
for each major assignment and PGY level will be needed for internal
IV.A.5.a-f, pg 31-47 Program Directors Guide to the
Educational Program: Curriculum Components
Common Program Requirements
ACGME Competencies
Educational Program: Residents' Scholarly Activities
Annual evaluation of program and faculty by residents
MAY
Semi-Annual reviews
IV.B., pg 48 Program Directors Guide to the Common
Program Requirements
1. Residents must be allowed, at least annually to confidentially evaluate
faculty on their teaching abilities, clinical knowledge, commitment to the
educational program, professionalism and scholarly activities.
2. The evaluation form should avoid identifying rotation names, PGY levels
or specific months to assure greater confidentiality.
II.A 4d and V.B 1-4, pg 55-56 Program Directors Guide to
3. The program director should utilize this data to determine continued
the Common Program Requirements
participation of faculty in the educational program.
4. Documentation of confidential written evaluations of the program Part II of the Program Specific PIF, List of Document to
and faculty will be required for internal and external site reviews.
Have Available for the Review #15
1. Formative evaluations from previous months should be used to provide
feedback to residents on their performance.
2. Semi-annual reviews should also include a review of case logs/patient
logs, if required by the RRC or Board, and a review of the residents
participation at required conferences within the training program.
3. Plans for remediation for academic deficiencies should be discussed at
this time for any resident of concern.
4. Remediation plans should include specific achievement goals, a
timeframe for achievement, and consequences if goals are not achieved.
5. Documentation of the semi-annual review must be retained in the
residents file, and this information should be accessible by the resident
upon their request.
6. This documentation will be needed for internal and external site
reviews.
Program Directors Guide to Common Program Requirements
Page 47-52, Section V.A.1 a - c.
Also review programs specific requirements on resident
evaluations and feedback to determine other components
required by the RRC for review during semi-annual
evaluation of the residents performance.
Part II of the Program Specific PIF, List of Document to
Have Available for the Review #8, 11 and 12.
6
Blueprint for Coordinator Success
TARGET
MONTH
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
Final Evaluations for Graduating Residents
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
The final evaluation must specifically verify that"the resident has
demonstrated sufficient competence to enter practice without direct
supervision".
REFERENCE SOURCES
Section V.A2a-b, pg 53 Program Directors Guide to the
Common Program Requirements
Part II of the Program Specific PIF, List of Document to
This statement will be verified by internal and external site visitors via Have Available for the Review # 12.
the graduate files.
Prepare annual rotation schedules
Administrative/Chief Residents should be utilized for this process.
Principles; Supervision of Residents; Fatigue; Duty Hours; On call
Resident Duty Hours in the Learning and Working Environment
Review Program Specific policies on Supervision of residents, duty
hours/work environment, moonlighting, evaluation processes.
1. ACGME Anonymous Resident survey will obtain feedback from house
staff on the program compliance.
2. The Anonymous Resident Survey will be used by the site visitor
during internal and external site reviews.
3. Items identified as noncompliant in the ACGME Anonymous
Resident Survey should be documented in the annual Educational
Program Committee meeting, and used for supporting documentation
during internal and external reviews.
4. Raw data should confirm compliance and be used for supporting
documentation for internal and external site reviews.
VI.A-G, pg. 63 -74, Program Directors Guide to the Common
Program Requirements.
WebADS Survey Results (by academic year)
Common PIF- Evaluations" will ask what improvement
efforts were undertaken by the training program as a
result of the recent resident survey. All educational and
work hour concerns should be discussed in this section.
1. These policies should be distributed to faculty and house staff.
2. copies of the policies will be needed for review during internal and
external site reviews.
Part II of the Program Specific PIF, List of Document to
Have Available for the Review #1, 2, and 3
See above
V.A.2., pg 55 Program Directors Guide to the Common
Program Requirements
See above
V.A. 1., pg 49 Program Directors Guide to the Common
Program Requirements
Process HR paperwork to terminate graduating resident
MAY
CONTINUED Plan departmental graduating residents' celebrations
Prepare documents for distribution at resident orientation
Plan departmental orientation for incoming residents
Evaluation: Resident Evaluation
Summative Evaluation (for graduating residents)
JUNE
Evaluation: Resident Evaluation
Formative Evaluations- (for continuing residents) evaluation of
resident performance during each rotation or similar educational
assignment
Coordinate election of Chief Residents with Program Director
Collect check out forms from graduating residents
forwarding addresses, pagers, keys, ID badges, et
Departmental graduation event for house staff
Review and update forms for new program yea
Note:
Information in bold applies intermittent major milestones, such as internal and external site reviews.
7
Blueprint for Coordinator Success
TARGET
MONTH
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
Thursday, September 24, 2009
PROGRAM COORDINATOR RESPONSIBILITY TIMELINE
PURPOSE AND GOALS
REFERENCE SOURCES
Other annual responsibilities to consider:
1.
2.
3.
4.
5.
6.
7.
8.
Attend regularly scheduled Educational Coordinator meetings within your institution.
Monitor the program budget and residency educational funding
Approve resident expenses
Update the American Board of Medical Specialties with enrollment and status changes for physicians. Updates due between July and September each year.
Update Alumni database
Contact/Remind Speakers for grand rounds, luncheon meetings, etc.
Monitor educational credits.
Reserve hospital or off-site location for graduation celebration. Target time between September and December.
8