Document List

The Document List is located on the final page of your ACGME site visit notification letter/ACGME Dept. of Field Staff letter. You will need to upload these documents to UB BOX for the Accreditation Team to review. When all documents are ready to go, you will upload them to your site visitor's OneDrive. The site visitor will contact you shortly after you receive your initial site visit notification letter providing you with instructions on how to do this, so keep a look out for that email.

This module will walk you through preparing the following documents:

1. PLAs

2. Resident/Fellow Files

3. Goals and Objectives

4. Schedule of Didactics, Conferences, and Other Education Activities

5. Annual Confidential Evaluation of a Faculty Member by Residents/Fellows

6. Supervision Policy

7. Clinical and Educational Work Hours Policy

8. Sample documents demonstrating resident/fellow participation in patient safety and quality improvement activities

1. Program Letter of Agreement (PLA)

The purpose of a PLA is to ensure that residents/fellows are provided with an appropriate educational experience and to protect them from undue service requirements which do not enrich their education. They also ensure an understanding of common expectations, the nature of the experience, and the responsibilities of the participating site.

You will need to make sure you have ready PLAs for all of your required rotations.

They must be:

• signed -

which means you will need 3 signatures:

1. PD signature,

2. the Site Director's signature,

3. and the DIO's signature

!! Contact Mikayla Walton at mewalton@buffalo.edu for help obtaining the DIO's signature.

• current -

What is considered current?

• !! PLAs for the VAWNYHS must be renewed every 5 years. This is a federal VA requirement not found in the ACGME requirements.

• PLAs must be renewed at least every 10 years. If your PLA was signed within the past ten years, then it is considered current.

You will need to:

• Attach the Goals and Objectives to the end of PLAs

  • More on Goals and Objectives in section 3

• Make sure you have a PLA for any temporary required rotation sites

• Check to see if your PLAs match up to the sites listed in ADS

• Make sure all information about participating site information is correct and complete in ADS. For about participating sites, check here.

• Save them to UB Box for the Accreditation Team to review. For better organization, label the PLAs by the site name followed by PLA. This will make it easier for the Accreditation Team and Site Visitor to identify each PLA.

i.e. Best Self PLA

Curious to see if your PLAs are up to snuff. Check out the ACGME's suggested checklist on page 26 of the Program Director's Guide to the Common Program Requirements for Residencies and on page 24 here OR on page 26 in the Program Director's Guide to the Common Program Requirements for Fellowships and page 25 here.

2. Resident/Fellow Files

In a combined PDF, please make sure to include completed examples for the following evaluation types as:

A. Final Evaluations

• Completed final evaluation forms from program graduates for the last three years (of 2 trainees from each of the past three years)

  • You should have a total of 6 forms; 2 evaluations per year.

  • If your program graduates one trainee per year, upload that graduate's evaluations.

The form must:

• • Incorporate specialty-specific milestones

  • Incorporate specialty-specific Case Logs, if required (if not required, leave blank)

!! For graduates after 7/1/19: Verifies, verbatim, “The (resident/fellow) has demonstrated the knowledge, skills, and behaviors necessary to enter autonomous practice.”

B. Current Evaluations:

• You will need evaluations from two current resident/fellow files for each year of the educational program. Each file should contain all examples they have of the three types of evaluations listed.

  • e.g. if your program is a four-year program; you will need to provide 8 resident/fellow files; 2 trainees' files/per PGY. Each individual resident/fellow file should have a copy of a "rotation evaluation by faculty," a "semiannual evaluation," and a "multi-source evaluation."

1. Rotation evaluations by faculty

They must:

• • Be completed

2. Semiannual evaluations

They must:

• be for the current residents/fellows (1-2 trainees in each year of training)

• Include progress along specialty-specific Milestones

• Be completed

3. Multi-source evaluations

• These include evaluations from faculty, peers, patients, self, and other professional staff)

They must:

• Be for current residents/fellows (of 1-2 trainees in each year of training)

• Be completed

If applicable, prepare documentation for the following:

E. Documentation of prior training for residents/fellows who have transferred into the program in the past three years

It must include:

• A summative competency-based performance evaluation

• Milestones evaluations upon matriculation

F. Completed semi-annual evaluations of residents/fellows who have resigned OR been dismissed from the program in the past three years

!! Extra documentation - your field representative may require additional documentation. Check here to see what other resident/fellows files/forms you may want on hand during the site visit in case the site visitor asks for them.

3. Goals and Objectives

You will need to upload one example of competency-based goals and objectives.

The goals must:

• Promote progress on a trajectory to autonomous practice (including one-year fellowships)

• Describe overall outcomes of the rotation

• Include objectives for all six core competencies:

  • Patient Care and Procedural Skills

  • Medical Knowledge

  • Practice-based Learning and Improvement

  • Interpersonal and Communication Skills

  • Professionalism

  • Systems-based Practices

• Objectives must:

  • delineate expectations for resident/fellow performance at progressive points in training (at minimum: PGY1-3 for a 3-yr residency, 6-month and 12-month points for a 1-yr fellowship, etc.)

  • contain measurable verbs (e.g. describe, analyze, demonstrate, discuss, etc.) Check out the Bloom's Taxonomy of Learning objectives for helpful examples measurable verbs and examples of immeasurable verbs.

Check out these Goals and Objectives exemplars:

• Goals and Objectives Exemplar

• Short Rotation Exemplar

• Exemplar for expectations for a PGY 1 in their clinical rotation and how it should be different from a PGY 4 rotation.

4. Schedule of Didactics, Conferences, and Other Education Activities

The schedule MUST be for the current academic year, and include all of the following:

• dates

• topics

• speakers

  • the faculty member or resident/fellow who is assigned to lead or present each didactic session

• materials provided for the educational experiences provided to all residents/fellows

• PGY-level-specific educational activities/schedules

!! Didactic activities may include, but are not limited to, lectures, conferences, interdepartmental conferences, courses, labs, asynchronous learning, simulations, drills, case discussions, grand rounds, morbidity and mortality conferences, journal clubs, didactic teaching, and education in critical appraisal of medical evidence (IV.A.4.).

!! Be sure the conference schedule addresses any specialty-specific requirements for didactics.

5. Annual Confidential Evaluation of a Faculty Member by Residents/Fellows

Make sure the form is:

• for a specific faculty member

• is completed

  • The evaluation may be from individual evaluators and/or in an aggregated format.

!! Be careful! Remove any potential resident/fellow identifiers.

!! Only include one example. Do not provide the site visitor with more than what they have requested.

6. Supervision Policy

!! Be careful! The site visitor is asking for a program-specific supervision policy, so please do not upload the UB policy.

The policy must do all of the following:

• Address progressive trainee responsibility for patient care and faculty responsibility for supervision

• Include guidelines for circumstances/events requiring residents/fellows to communicate directly with faculty members

• Include the required classification levels of supervision:

  • Direct Supervision: the supervising physician is physically present with the resident during the key portions of the patient interaction. PGY-1 residents must initially be supervised directly.

  • Indirect Supervision with Direct Supervision immediately available: the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.

  • Indirect Supervision with Direct Supervision available: the supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.

  • Oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

  • !! Always check the latest common program requirements for the most up-to-date definitions for the various levels of supervision. You can access the Common Program Requirements here.

Stuck? We've got you covered. Click here for helpful examples of a well-crafted supervision policy, supervision policy must haves, and FAQs.

7. Policy for Resident/Fellow and Faculty Member Well-being

The policy must do all of the following:

• Must include a statement indicating that residents are given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours.

• Must educate faculty members and fellows in identification of the symptoms of burnout, depression, and substance use disorder, including means to assist those who experience these conditions

• Provide access to appropriate tools for self-screening

• ensure coverage and continuity of patient care in circumstances in which residents/fellows are unable to attend work, including but not limited to fatigue, illness, family emergencies, and parental leave

8. Clinical and Educational Work Hours

!! The Accreditation Team will upload data demonstrating the program’s monitoring system to UB Box. We will pull a report for the past six logging periods prior to the date of the Site Visit. This report will include your logging submission rate and logging compliance for those 6 periods.

8. Quality Improvement and Patient Safety Documents

The ACGME states all physicians share responsibility for promoting patient safety and enhancing quality of patient care. Graduate medical education must prepare residents to provide the highest level of clinical care with continuous focus on the safety, individual needs, and humanity of their patients, and requires that residents and fellows demonstrate the ability to analyze the care they provide, understand their roles within health care teams, and play an active role in system improvement processes.

The site visitor will require evidence that the program is in compliance with this expectation. It is also a great opportunity to exhibit your residents/fellows talent and hard work.

You must include:

• a list of 10 activities and opportunities in which residents/fellows participated in patient safety and interprofessional quality improvement activities (Common Program Requirement VI.A.) in the past 12 months (if applicable)

!! The site visitor may request evidence of the activities listed above such as:

• sample documents demonstrating resident/fellow participation in patient safety and quality improvement activities for the past 12 months.

It may be helpful to have some of these on hand on the day of the site visit just in case the site visit asks for them Do not offer them unless directly requested by the site visitor.

Lost? Use this exemplar here to help get you started.