The University of New Mexico
Graduate Medical Education
Program Review Committee
1 February 2007
Chair: Betty Chang, MD, Therese Bocklage, MD
Present: Chang, Quintana, Morley, Hayes, Sparkman, Bell-Pena, Olson, Saavedra, Phelan, Carmichael, Hoffman
PRC Minutes 12/07/06
The minutes of the Program Review Committee from 7 December 2006 were distributed, reviewed, and discussed by the committee.
Action: The minutes of the Program Review Committee on 7 December 2006 were accepted as presented to the committee.
ACGME Citations in Common Attachment 8 (Revised 1/25/07)
ACGME citations in common for the institution are tracked regularly on Attachment 8 of the ACGME institutional review document. The order of the citations in common has not changed. Program evaluation is the most common, and scholarly activities are the second most common. The institution has made efforts to address each citation over the past several years. A common citation, which has increased in frequency, is institutional citations such as program letters and affiliations. Particularly of concern has been the affiliation agreement with the VAMC being effective for over five years old. After a year of negotiations the VAMC affiliation agreement has been successfully updated.
Internal Review Mid Point Chart (Revised 1/25/07))
The institutional chart that provides information on the mid point for each program internal review was distributed to the committee. The information had been updated since last quarter. The goal is to conduct the program review within the calendar month in which is becomes due.
Program Reviews
Program reviews were conducted in the following programs::
Cardiovascular Disease was conducted on 12/21/06. The program had received RRC accreditation with warning with a fourteen-month cycle before the next site inspection. Representatives had met with the program shortly after the institution had received the RRC letter of accreditation. The program had taken step to address the citations at the time of the last inspection. The program was dedicated to quality education and worked well as a team. The program had addressed many of the citations through the use of New Innovations. The Department of Medicine must ensure that the program director is able to devote significant time to the administration of the program to comply with RRC standards. Goals and objectives of the program must be linked to the ACGME general competencies. A graduated level of supervision statement must be better defined. A 360- degree evaluation system was highly encouraged for the program. A survey of past graduates should be done in a manner in which they could be linked to the ACGME outcomes project.
Action: The PRC requested a follow-up action plan from the division in three months for recommendations 2, 3, 4, and 6.
Child and Adolescent Psychiatry program review on conducted on 25 January 2007. Jeanne Bereiter, MD has assumed the responsibility as Program Director. High faculty turnover had been a citation at the time of the last site inspection and remains to be problematic. The program is tracking attrition and some has been for because of internal promotions. The program is not utilizing New Innovations. New Innovations would resolve concerns about providing goals and objectives for rotations in a timely manner and resolve issues around evaluations, duty hours, and outcomes. Evaluations are not done in a timely manner. Final evaluations must incorporate the required wording regarding competency as described by the ACGME. Scholarly activities are considered low when compared to the parent program and should be improved. 360-degree evaluations would strengthen methods of assessment and should be utilized or adopted from the patent program. A survey of past graduates should be updated to provide data in addressing the outcomes project. Office space at Children’s Psychiatric Hospital is extremely limited and provides workspace issues for the trainees. The Chair of the Department of Psychiatry should address this issue.
Action: The PRC requested a follow-up on the action taken on all recommendations in three months.
Program Review Follow-Ups
A program review follow-up was due in January 2007 for Thoracic Surgery. The program was reminded of the need of an action plan to address each recommendation in December 2006.
Action: The Division of Thoracic Surgery will be reminded of the overdue action plan on the recommendations made at the time of the last program review.
Program Review Follow-Ups Pending:
No program review follow-up was due. Future program review follow-up are due in Cardiovascular Disease in April 2007, and Child and Adolescent Psychiatry on April 2007.
ACGME Letters of Accreditation
ACGME letters of accreditation were reviewed and discussed for the following departments:
Forensic Pathology (12/15/06) received continued accreditation for a period of five years. The program was commended for substantial compliance with RRC requirements and areas of strength were mentioned. Final evaluations must contain the recommended working on competency as stated by the ACGME. Faculty evaluations by fellows must be confidential. Experience must be gained in courtroom testimony. Turn around time for toxicology reports remains to be unacceptable.
Action: The committee did not feel the need for an action plan from the department was necessary due to each citation being reasonable easy to accomplish.
Pediatrics (12/27/06) received continued accreditation for a period of five years. Citations were as follows: The program review by the institution was not performed in a timely manner. Goals and objectives need to be discussed with trainees at the beginning of each rotation. Emergency experience has improved and appears to be adequate with trainees seeing sufficient patients. Continuity clinic and patient population issues appear to have been resolved. Other citations appear to have been addressed in a progress report.
Action: An action plan on the above mentioned citations would be included in the program review that will occur in April 2007.
Sport Medicine Family Medicinee (1/26/07) received an electronic communication of accreditation for a period of two years. Sport Medicine Family Medicine is a newly accredited program.
Correspondence to ACGME
The following correspondence was submitted to their RRC: Pulmonary Critical Care alleged duty hour report, action plan, and revised policy was submitted on 12/14/06, Otolaryngology requested progress report was submitted to the RRC on 12/05/06, and Geriatric Psychiatry submitted the requested RRC progress report on 1/12/07.
ACGME Correspondence
RRC provided the following correspondence to the following departments: Family Medicine Roswell (12/05/06) received permission to increase the resident complement from nine trainees to twelve trainees. Otolaryngology (1/22/07) added Presbyterian as a major participating training site. Pulmonary Critical Care (12/04/06) received an acknowledgement of the requested information that was provided to the RRC. Pulmonary Critical Care (01/09/07) received acknowledgement of the duty hour report on alleged violations that was provided. Vascular Surgery (12/14/06) program were notified of the educational format which will be expected of combined program in surgery and vascular surgery. Family Medicine (12/29/06) received notice that a core program for 1 + 2 Family Medicine programs no longer requires the CAF.
Internal Reviews Scheduled
A mid point internal review has been scheduled for the Clinical Neurophysiology fellowship on 28 February 2007. Residents who would be available to participate were asked to volunteer.
Pending Program Reviews
The following programs will need to undergo program reviews in the months indicated: Pediatrics 4/07, Pediatric Hematology/Oncology 4/07, Pediatric Pulmonary 4/07, Vascular Interventional Radiology 4/07, Infectious Disease 6/07, Gerontology 6/07, and Hematology/Oncology 6/07. Program were notified of the month in which there program review must be performed in December 2006 so that programs would have ample time to establish a date in a timely manner.
ACGME Site Inspections
The following program have been notified of pending site inspections by their RRC: Anesthesiology 5/08/07, Pediatric Anesthesiology 5/09/07, and Pain Management 5/10/07.
The next meeting is scheduled for Thursday 5 April 2007
Distribution Materials: Program Review Committee Minutes 12/07/06, IRD Attachment of Common Citations Rev 1/25/07, UNM mid point review chart Rev 1/25/07, Program Review Cardiovascular Disease (12/21/06), Cardiovascular Action Plan Task Force Report (9/18/06), Program Review Child and Adolescent Psychiatry (01/25/07), Forensic Pathology Accreditation Letter (12/15/06), Pediatric Accreditation Letter (12/27/06), Family Medicine Sport Medicine (01/26/07) Accreditation, Pulmonary Critical Care Duty Hour Response (12/14/06), Otolaryngology progress report (12/05/06), Geriatric Psychiatry progress report (12/12/07), Family Medicine Change Request (12/07/06), Otolaryngology major participating institution change (01/22/07), Pulmonary Critical Care acknowledgment of report (12/04/06), Pulmonary Critical Care acknowledgment of duty hour (12/09/06), Vascular Surgery memo (12/14/06), Family Medicine CAF change (12/29/06), Site inspections notices Anesthesiology, Pediatric Anesthesiology, and Pain Management (01/08/07).
