Non-Standard Programs: One Institution's Approach


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Non-Standard Programs: One Institution's Approach

  1. 1. Non-Standard Programs: One Institution’s Approach W. Dennis Zerega, Ed. D. Vice President, GME Frank J. Kroboth, M D Assistant Dean, GME AHME April 15, 2009
  2. 2. Workshop Agenda <ul><li>Introduction and Overview of the Institution – University of Pittsburgh Medical Center </li></ul><ul><li>History of GME Approach to Non-Standard Programs at UPMC: Participants’ Experiences to be Shared </li></ul><ul><li>Examples of Typical Dilemmas: Participants to Adjudicate </li></ul><ul><li>Documents for Comparison and Sharing </li></ul>
  3. 3. GME at UPMCMEP W. Dennis Zerega, Ed. D.
  4. 4. Program Summary 41 OZ Programs 215 Total 2 Podiatry Programs 7 University of Pittsburgh Programs 12 Osteopathic Programs 41 SIEP Programs 2 ACGME Non-accredited 110 ACGME Accredited Programs # Programs Summary
  5. 5. ACGME Sponsoring Institutions <ul><li>Hospital # Prog. # Res/Fell </li></ul><ul><li>1. NY Presby 114 1552 </li></ul><ul><li>1. Mayo Clinic 114 1228 </li></ul><ul><li>2. UPMC 109* 1340* </li></ul><ul><li>3. Mt. Sinai 96 1445 </li></ul><ul><li>4. NY Med. Coll. 90 1350 </li></ul><ul><li>5. Emory 82 1022 </li></ul><ul><li>*includes Mercy Hospital’s (9) Prog. & 147 Res/Fell. </li></ul>
  6. 6. GME Pledges <ul><li>To continually evaluate and offer the highest quality GME residencies and fellowships that attract the best candidates possible for our programs. </li></ul><ul><li>To offer creative, engaging and state of the art training. </li></ul><ul><li>To promote diversity and respect for all human differences. </li></ul><ul><li>To provide prompt, collegial and respectful academic material by a respected and fully committed faculty. </li></ul><ul><li>To tailor training to the special needs of the residents and fellows composed of the carefully designed and published guidelines. </li></ul><ul><li>To provide residents and fellows a wide variety of information and experiences in a timely and efficient manner. </li></ul><ul><li>To interact with our residents in a respectful manner cognizant of their status as adult learners. </li></ul><ul><li>To respond in a rapid, sensitive and non-confrontational manner to requests that will enhance residents learning experiences. </li></ul><ul><li>To provide residents with an experience that will encourage them to value their residency experience throughout their careers and honor UPMC with positive comments, interest and support as they savor their experiences with us. </li></ul>
  7. 7. We Pledge <ul><li>To inspect and prepare the freshest, highest quality fish and shellfish. </li></ul><ul><li>To assure you of a clean and comfortable environment. </li></ul><ul><li>To promote diversity and respect for all human differences. </li></ul><ul><li>To provide prompt, friendly and courteous service by a knowledgeable and highly-trained staff. </li></ul><ul><li>To be sensitive to special dietary needs and provide a list of ingredients upon request. </li></ul><ul><li>To deliver all foods and beverages, prepared to guest satisfaction, in a timely and efficient manner. </li></ul><ul><li>To feature a wine list that represents the best overall value in America. </li></ul><ul><li>To respond in a rapid, sensitive and non-confrontational manner to requests that will enhance your dining experience. </li></ul><ul><li>To provide you with an experience that will encourage you to return. </li></ul>
  8. 8. GME Mission Statement We work to provide the highest quality education possible in the art and science of medicine. We direct that our patients receive the highest quality and safest care. We endeavor to select and retain the most qualified applicants. Integral to our efforts in the continuing advancement of the profession of medicine is the mission of scholarship, research, evidence based care and continual clinical innovation. We foster and require an ethical atmosphere, one of collegiality among our faculty, learners and academic leadership. The UPMCMEP insures the highest levels of professional leadership for its Graduate Medical Education Programs. We are committed to insuring that the academic infrastructure, economic supports, educational, organizational and human resources provided to our Graduate Medical Education programs will serve to provide residents with an optimal environment for them to achieve and advance in their learning and profession.
  9. 9. GME STRENGTHS <ul><li>Stable Team with a well-defined succession plan </li></ul><ul><li>Strong support from the University </li></ul><ul><ul><li>Annual Chair’s Evaluation </li></ul></ul><ul><li>New cultural imperatives </li></ul><ul><ul><li>Top Talent Program for recruitment </li></ul></ul><ul><ul><li>4.7 Year Accreditation Cycle </li></ul></ul><ul><ul><li>Those who follow GME Processes have a history of dramatic improvement </li></ul></ul><ul><li>GMEROCS </li></ul><ul><li>PSD Relationship has already shown promise </li></ul>
  10. 10. ORGANIZATIONAL CHART University of Pittsburgh Medical Center Medical Education Program (UPMCMEP) University of Pittsburgh Associate Dean & DIO Chair, GMEC UPMC Vice President, GME Office Vice Chair, GMEC GME Committee Membership Peer-Selected Residents & Fellows from Core Programs Program Directors from all Accredited Programs Hospital Leadership UPMC President, UPMC Physician Svc. Div. President, Univ. of Pittsburgh Physicians UPMCMEP Board University of Pittsburgh Medical Center (UPMC) University of Pittsburgh UPMC GME Office University of Pittsburgh Assistant Dean GME Fellowships
  11. 11. University of Pittsburgh Medical Center Medical Education Program (UPMCMEP) Organizational Chart W. Dennis Zerega, EdD Vice President, GME Vice Chair, GMEC GME Executive Committee Program Directors Department Chairs GME Committee Peer Selected Residents & Fellows from Core Programs Program Directors from all accredited programs Hospital Leadership Program Coordinators Housestaff Interns Residents Fellows Accreditation, Review & Quality Subcommittee Chief Residents Orientation Subcommittee Appeals Subcommittee Compensation & Benefits Subcommittee Program Director Development Subcommittee Resident Duty Hour Subcommittee UPMCMEP Board University of Pittsburgh University of Pittsburgh Medical Center (UPMC) Arthur S. Levine, MD Senior Vice Chancellor for the Health Sciences & Dean, School of Medicine University of Pittsburgh Marshall Webster, MD President, UPMC Physician Svc. Div. President, Univ. of Pittsburgh Physicians Frank J. Kroboth, MD Assistant Dean GME Fellowships Rita M. Patel, MD Associate Dean and DIO Chair, GMEC
  12. 12. Z Calc
  13. 13. EVOLVING ISSUES <ul><li>Flat Revenue – CAP Management </li></ul><ul><li>Increased CMS Complexity </li></ul><ul><li>Unbridled Accreditation & Certification Regulations and expense ($377K). </li></ul><ul><li>Bringing Housestaff more intimately into Patient Safety & Quality Initiatives </li></ul>
  14. 14. Gamma Mu Epsilon
  15. 15. Non- Standard Programs, UPMC Frank J. Kroboth, M.D.
  16. 16. STANDARD AND NON-STANDARD TRAINING PROGRAMS ACGME Professional Societies UPP-OZ Clinical Instructor Programs I Accredited Residencies and Fellowships Special Institutional Education Programs I ABMS Special Institutional Education Programs II UPP-OZ Clinical Instructor Programs II Mini Fellowships Post Doc Scholars
  17. 17. Non-Standard Programs 112 82 Total 55 41 OZ 57 41 SIEP Fellows Programs
  18. 18. Special Institutional Education Programs <ul><li>Anesthesiology (6): </li></ul><ul><li>Cardiothoracic </li></ul><ul><li>Hepatic </li></ul><ul><li>Neuro </li></ul><ul><li>Obstetrical </li></ul><ul><li>Orthopedic </li></ul><ul><li>Regional </li></ul><ul><li>Cardiovascular Institute (1): </li></ul><ul><li>Heart Failure/Transplant </li></ul><ul><li>Critical Care Medicine (2): </li></ul><ul><li>CCM-EM </li></ul><ul><li>Pediatric Cardiac </li></ul><ul><li>Dermatology (2): </li></ul><ul><li>Cutaneous Oncology </li></ul><ul><li>Pediatric </li></ul><ul><li>Emergency Medicine (1): </li></ul><ul><li>Mini-Fellowship </li></ul><ul><li>Family Medicine (1): </li></ul><ul><li>Faculty Development </li></ul><ul><li>Internal Medicine (5): </li></ul><ul><li>GIM </li></ul><ul><li>HIV </li></ul><ul><li>Transplant Infectious Disease </li></ul><ul><li>Pulmonary Transplant </li></ul><ul><li>Endocrinology, Diabetes and Metabolism </li></ul><ul><li>Neurology (1): </li></ul><ul><li>Interventional </li></ul><ul><li>Orthopaedic Surgery (3): </li></ul><ul><li>Foot and Ankle </li></ul><ul><li>Orthopaedic Trauma </li></ul><ul><li>Spinal Cord </li></ul><ul><li>Otolaryngology (1): </li></ul><ul><li>Pediatric </li></ul><ul><li>Pediatrics (2): </li></ul><ul><li>Research Track in Neonatal </li></ul><ul><li>Research Track in Pediatric Endocrinology </li></ul>
  19. 19. SIEP – con’t <ul><li>Pathology (1): </li></ul><ul><li>Pathology Informatics </li></ul><ul><li>Physical Medicine and Rehabilitation (1): </li></ul><ul><li>Advanced Spinal Cord Injury </li></ul><ul><li>Psychiatry (1): </li></ul><ul><li>Public Service Psychiatry </li></ul><ul><li>Radiology (1): </li></ul><ul><li>Vascular Interventional </li></ul><ul><li>Surgery (8): </li></ul><ul><li>Advanced Cardiac </li></ul><ul><li>Advanced General Thoracic </li></ul><ul><li>Breast Surgery </li></ul><ul><li>Micro-vascular Reconstructive </li></ul><ul><li>Bariatric </li></ul><ul><li>Surgical Oncology </li></ul><ul><li>Multi-Organ </li></ul><ul><li>Intestinal and Multi-Visceral </li></ul><ul><li>Women’s Health (4): </li></ul><ul><li>Reconstructive Surgery </li></ul><ul><li>Gynecologic Oncology </li></ul><ul><li>Maternal-Fetal </li></ul><ul><li>Reproductive Endocrinology </li></ul>
  20. 20. UPP-OZ Clinical Instructor Programs <ul><li>Dermatology (2): </li></ul><ul><li>Cosmetic </li></ul><ul><li>Pediatric </li></ul><ul><li>Emergency Medicine (3): </li></ul><ul><li>EMS International </li></ul><ul><li>Mini-Fellowship </li></ul><ul><li>University of Pittsburgh International </li></ul><ul><li>Internal Medicine (3): </li></ul><ul><li>Cardiac Imaging </li></ul><ul><li>GIM </li></ul><ul><li>Renal Transplant </li></ul><ul><li>Neurosurgery (1): </li></ul><ul><li>Pediatric </li></ul><ul><li>Ophthalmology (5): </li></ul><ul><li>Cornea </li></ul><ul><li>Glaucoma </li></ul><ul><li>Oculoplastic </li></ul><ul><li>Vitreo Retinal </li></ul><ul><li>Pediatric </li></ul><ul><li>Otolaryngology (5): </li></ul><ul><li>Oncologic </li></ul><ul><li>Pediatric </li></ul><ul><li>Laryngology/Voice </li></ul><ul><li>Cranial Base </li></ul><ul><li>Sinonasal </li></ul><ul><li>Pediatrics (1) </li></ul><ul><li>Academic Pediatric </li></ul>
  21. 21. OZ Programs – con’t <ul><li>Physical Medicine and Rehabilitation (1): </li></ul><ul><li>Brain Injury </li></ul><ul><li>Psychiatry (1): </li></ul><ul><li>Public Service Psychiatry </li></ul><ul><li>Radiology (4): </li></ul><ul><li>Abdominal Imaging </li></ul><ul><li>PET/CT </li></ul><ul><li>Musculoskeletal </li></ul><ul><li>Women’s Imaging </li></ul><ul><li>Surgery (12): </li></ul><ul><li>Acute Care </li></ul><ul><li>Advanced Cardiac Mini </li></ul><ul><li>Advanced Cardiac </li></ul><ul><li>Advanced General Thoracic </li></ul><ul><li>Body Contouring </li></ul><ul><li>Liver, Pancreas, Intestine </li></ul><ul><li>Micro-vascular Reconstructive </li></ul><ul><li>Bariatric </li></ul><ul><li>Pediatric Cardiothoracic </li></ul><ul><li>International </li></ul><ul><li>Plastic Surgery </li></ul><ul><li>Surgical Oncology </li></ul><ul><li>Women’s Health (3): </li></ul><ul><li>Contraceptive Research </li></ul><ul><li>Gynecologic Endoscopy </li></ul><ul><li>Reproductive Infectious Diseases </li></ul>
  22. 24. Participants’ Present Status <ul><li>Discussion </li></ul><ul><li>Policy </li></ul><ul><li>Organization and Faculty Development </li></ul><ul><li>Review and Enforcement </li></ul><ul><li>Graduation Attestation </li></ul><ul><li>Outcome Tracking </li></ul>
  23. 25. Year One <ul><li>Mandate: enroll, monitor, enhance Non-Standard Programs </li></ul><ul><li>Peer Group Survey </li></ul><ul><li>SIEP (Special Institutional Education Program) conceptualized, policy written </li></ul><ul><li>Presented to Council of Chairs </li></ul><ul><li>Enrollment Process Begun </li></ul><ul><li>SIEP Subcommittee initiated </li></ul>
  24. 26. Year Two <ul><li>Mandate: Include Attending-Level Programs </li></ul><ul><li>Working Group </li></ul><ul><li>Tracking by Fellow </li></ul><ul><li>Policy Evolved </li></ul><ul><li>Meanwhile, back in SIEP-Land: </li></ul><ul><ul><li>GME ROC’s and Duty Hours </li></ul></ul><ul><ul><li>Internal Reviews </li></ul></ul>
  25. 27. Year Three <ul><li>UPP-OZ Clinical Instructor Programs </li></ul><ul><li>Policy to Legal </li></ul><ul><ul><li>Supervision </li></ul></ul><ul><ul><li>Credentialling </li></ul></ul><ul><ul><li>Duty Hours </li></ul></ul><ul><ul><li>Policy Reviewed Again </li></ul></ul><ul><ul><li>Back to the Council of Chairs </li></ul></ul><ul><ul><li>Mini-Fellowships and Observerships </li></ul></ul>
  26. 28. Year Three <ul><li>Meanwhile, back in SIEP-Land </li></ul><ul><li>Updated Enrollment Surveys </li></ul><ul><li>Rapid Response Communiques begun </li></ul><ul><ul><ul><li>Perks and Liabilities </li></ul></ul></ul><ul><ul><ul><li>Summative Evaluation </li></ul></ul></ul>
  27. 29. Mini Fellowship <ul><li>Definition: </li></ul><ul><ul><ul><li>1-6 month duration </li></ul></ul></ul><ul><ul><ul><li>not accredited or ABMSD certified </li></ul></ul></ul><ul><ul><ul><li>may be externally supported </li></ul></ul></ul><ul><li>Questions: </li></ul><ul><ul><ul><li>CME vs. GME vs. Business </li></ul></ul></ul><ul><ul><ul><li>Selection of candidates </li></ul></ul></ul><ul><ul><ul><li>Rigor of education </li></ul></ul></ul><ul><ul><ul><li>Degree of Supervision </li></ul></ul></ul><ul><ul><ul><li>What documentation/certification </li></ul></ul></ul><ul><ul><ul><li>Process of enrollment, credentialling </li></ul></ul></ul><ul><ul><ul><li>Participants in process </li></ul></ul></ul>
  28. 30. Benefits of Mini Fellowships <ul><li>Dissemination of Specialty Knowledge and Procedures </li></ul><ul><li>Enhancement of Reputation </li></ul><ul><li>Business and Financial Gain </li></ul><ul><li>Service Needs Satisfied </li></ul>
  29. 31. Liabilities of Mini-Fellowships <ul><li>Dilution of the Primary Educational Mission </li></ul><ul><ul><ul><li>* Competition for Cases * Faculty time * Morale </li></ul></ul></ul><ul><li>Credentialling Boundaries </li></ul><ul><li>Orientation and Policy </li></ul><ul><li>Clinical Performance Issues </li></ul><ul><li>Certification Questions </li></ul>
  30. 32. Recent Mail 10 Visa, Credentialling, Licensing 2 Perks and Liabilities 8 Mixed or Transitioning Programs 4 Mini-Fellowships 10 Custom Programs 14 Classification, Enrollment, Communication Issues
  31. 33. You Make the Call, Scenario 1: The Ad Hoc Program <ul><li>“The spouse of our newest molecular biology mega-recruit is a cardiologist who needs/desires an extra year of training in transplant cardiology – We have designed a curriculum…” </li></ul>
  32. 34. Scenario 1: Issues <ul><li>Easy Case - </li></ul><ul><li>You want the spouse </li></ul><ul><li>Hard Case - </li></ul><ul><li>Cardiology doesn’t want the spouse, but CT Surgery does. </li></ul><ul><li>How to work this out or end it? </li></ul><ul><li>Who pays the slot? </li></ul>
  33. 35. Scenario 2: The For-Profit Mini <ul><li>“A small referring institution in the region has requested four-month update experiences for its three cardiologists in our busy Cardiac Pavilion and CCU…” </li></ul>
  34. 36. Scenario 2: Issues <ul><li>Regional educator </li></ul><ul><li>Protector of residencies </li></ul><ul><li>Referral Moneys </li></ul><ul><li>Workforce savings </li></ul><ul><li>Training background </li></ul><ul><li>Is this our business (CME) ? </li></ul><ul><li>Charge tuition? </li></ul><ul><li>Shunt it to Observership & Curriculum: </li></ul><ul><ul><ul><li>Documentation </li></ul></ul></ul><ul><ul><ul><li>Selection </li></ul></ul></ul><ul><ul><ul><li>Supervision </li></ul></ul></ul>
  35. 37. Scenario 3: The visa from hell <ul><li>“Our UPP-OZ (Clinical instructor) Maternal-Fetal Medicine Program has an outstanding candidate from country X. Can you help us get a visa which would allow unrestricted licensing, or do we need to create a SIEP? By the way, we have to answer her this week…” </li></ul>
  36. 38. Scenario 3: Issues <ul><li>Timeline pressures </li></ul><ul><li>Justification and cost of exception visas </li></ul><ul><li>Creation of hybrid programs </li></ul><ul><li>Institutional license vs. state license, USMLE regulations </li></ul>
  37. 39. Scenario 4: Great Expectations <ul><li>“A Clinical Instructor in one of our specialty surgery OZ programs is concerned. He thought he matched into a fellowship with ACGME regulations. However, he notes that his contract is more like a faculty contract than a fellow’s…” </li></ul>
  38. 40. Scenario 4: Issues <ul><li>Specialty board matches </li></ul><ul><li>Specialty board program requirements </li></ul><ul><li>Explicit recruiting and offers </li></ul><ul><li>Reason for organization and policies </li></ul>
  39. 41. Scenario 5: T-32 Temptation <ul><li>“ Our department of Ophthalmology is recruiting a research ophthalmologist to come on a training grant. Competing institutions have offered opportunities to generate a salary of $150,000. What can we do…?” </li></ul>
  40. 42. Scenario 5: Issues <ul><li>Fellow = full- time </li></ul><ul><li>Can’t be faculty </li></ul><ul><li>Practice plan exception </li></ul><ul><li>Conscionable limit to money </li></ul><ul><li>Coordination with university office </li></ul><ul><li>Precedent </li></ul>
  41. 43. Scenario 6: The buck stops here <ul><li>“ One of our UPP-OZ (Instructor) fellows scrubbed and attempted to initiate an urgent procedure independently, claiming he was credentialled to do so. The OR manager did not find the procedure on the credentialling log and blocked the procedure until supervising faculty arrived. The family is irate over the delay, the fellow and supervising attending are affronted, the OR manager is on a war path, the Department Chair stands by his faculty, the CEO blames you…” </li></ul>
  42. 44. Scenario 6: Issues <ul><li>Policy, policy, policy </li></ul><ul><li>Level of supervision </li></ul><ul><li>On-demand credentialling </li></ul>
  43. 45. Scenario 7: PLA/MAA Nightmare <ul><li>“Your CT Surgery OZ Program wants a fellow to accompany the attending who will start having clinic and procedures at a newly integrated site in your network. The site will not allow the fellow the same credentialling level as the university hospital…” </li></ul>
  44. 46. Scenario 7: Issues <ul><li>Negotiating with MSO’s in your network </li></ul><ul><li>Writing accommodating PLA’s and MAA </li></ul><ul><li>Expectation at site vs. medical staff regulations at site </li></ul><ul><li>Flexibility of faculty and fellows </li></ul>
  45. 47. Scenario 8: Non-Medical Fellows <ul><li>“It’s a busy week. On Monday, your Dental School requests permission to expand four more slots in its well established SIEP Fellowship, and on Wednesday, your Oncology Division requests advice on an oncologic dermatology offering for foreign professors to spend a month in the melanoma research labs and outpatient clinics…” </li></ul>
  46. 48. Scenario 8: Issues <ul><li>Clinical fellows outside of medicine, outside of CAP </li></ul><ul><li>Research fellowships oversight </li></ul><ul><li>Observership use </li></ul>
  47. 49. Summary <ul><li>Non-Standard Programs cover a wide range of educational offerings </li></ul><ul><li>They can present a wide range of challenges within the institution </li></ul><ul><li>Policy, organization, and communication can minimize problems and enhance education </li></ul>