Non-Standard Programs: One Institution's Approach

Non-Standard Programs: Non-Standard Programs: One Institution’s ApproachOne Institution’s Approach

W. Dennis Zerega, Ed. D.W. Dennis Zerega, Ed. D.Vice President, GMEVice President, GME

Frank J. Kroboth, M DFrank J. Kroboth, M DAssistant Dean, GMEAssistant Dean, GME

AHME April 15, 2009AHME April 15, 2009

Workshop AgendaWorkshop Agenda

Introduction and Overview of the Institution Introduction and Overview of the Institution – University of Pittsburgh Medical Center– University of Pittsburgh Medical Center

History of GME Approach to Non-Standard History of GME Approach to Non-Standard Programs at UPMC: Participants’ Programs at UPMC: Participants’ Experiences to be SharedExperiences to be Shared

Examples of Typical Dilemmas: Examples of Typical Dilemmas: Participants to AdjudicateParticipants to Adjudicate

Documents for Comparison and SharingDocuments for Comparison and Sharing

GME at GME at UPMCMEPUPMCMEP

W. Dennis Zerega, Ed. D.W. Dennis Zerega, Ed. D.

Program SummaryProgram Summary

SummarySummary # Programs# Programs

ACGME Accredited ProgramsACGME Accredited Programs 110110

ACGME Non-accreditedACGME Non-accredited 22

SIEP ProgramsSIEP Programs 4141

OZ ProgramsOZ Programs 4141

Osteopathic ProgramsOsteopathic Programs 1212

University of Pittsburgh ProgramsUniversity of Pittsburgh Programs 77

Podiatry ProgramsPodiatry Programs 22

TotalTotal 215215

ACGME Sponsoring InstitutionsACGME Sponsoring Institutions

HospitalHospital # Prog.# Prog. # Res/Fell# Res/Fell1. NY Presby1. NY Presby 114114 155215521. Mayo Clinic1. Mayo Clinic 114114 1228 1228 2. UPMC2. UPMC 109*109* 1340*1340*3. Mt. Sinai3. Mt. Sinai 96 96 144514454. NY Med. Coll.4. NY Med. Coll. 90 90 135013505. Emory5. Emory 82 82 10221022

*includes Mercy Hospital’s (9) Prog. & 147 Res/Fell.*includes Mercy Hospital’s (9) Prog. & 147 Res/Fell.

GME PledgesGME PledgesTo continually evaluate and offer the highest quality GME residencies and To continually evaluate and offer the highest quality GME residencies and fellowships that attract the best candidates possible for our programs.fellowships that attract the best candidates possible for our programs.To offer creative, engaging and state of the art training. To offer creative, engaging and state of the art training. To promote diversity and respect for all human differences. To promote diversity and respect for all human differences. To provide prompt, collegial and respectful academic material by a To provide prompt, collegial and respectful academic material by a respected and fully committed faculty. respected and fully committed faculty. To tailor training to the special needs of the residents and fellows To tailor training to the special needs of the residents and fellows composed of the carefully designed and published guidelines. composed of the carefully designed and published guidelines. To provide residents and fellows a wide variety of information and To provide residents and fellows a wide variety of information and experiences in a timely and efficient manner. experiences in a timely and efficient manner. To interact with our residents in a respectful manner cognizant of their To interact with our residents in a respectful manner cognizant of their status as adult learners. status as adult learners. To respond in a rapid, sensitive and non-confrontational manner to To respond in a rapid, sensitive and non-confrontational manner to requests that will enhance residents learning experiences. requests that will enhance residents learning experiences. To provide residents with an experience that will encourage them to value To provide residents with an experience that will encourage them to value their residency experience throughout their careers and honor UPMC with their residency experience throughout their careers and honor UPMC with positive comments, interest and support as they savor their experiences positive comments, interest and support as they savor their experiences with us. with us.

We PledgeWe PledgeTo inspect and prepare the freshest, highest quality fish and To inspect and prepare the freshest, highest quality fish and shellfish.shellfish.To assure you of a clean and comfortable environment.To assure you of a clean and comfortable environment.To promote diversity and respect for all human differences.To promote diversity and respect for all human differences.To provide prompt, friendly and courteous service by a To provide prompt, friendly and courteous service by a knowledgeable and highly-trained staff.knowledgeable and highly-trained staff.To be sensitive to special dietary needs and provide a list of To be sensitive to special dietary needs and provide a list of ingredients upon request.ingredients upon request.To deliver all foods and beverages, prepared to guest To deliver all foods and beverages, prepared to guest satisfaction, in a timely and efficient manner.satisfaction, in a timely and efficient manner.To feature a wine list that represents the best overall value in To feature a wine list that represents the best overall value in America.America.To respond in a rapid, sensitive and non-confrontational manner To respond in a rapid, sensitive and non-confrontational manner to requests that will enhance your dining experience.to requests that will enhance your dining experience.To provide you with an experience that will encourage you to To provide you with an experience that will encourage you to return.return.

GME Mission StatementGME 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.

GME STRENGTHSGME STRENGTHS

Stable Team with a well-defined succession planStable Team with a well-defined succession planStrong support from the UniversityStrong support from the University– Annual Chair’s EvaluationAnnual Chair’s EvaluationNew cultural imperativesNew cultural imperatives– Top Talent Program for recruitmentTop Talent Program for recruitment– 4.7 Year Accreditation Cycle4.7 Year Accreditation Cycle– Those who follow GME Processes have a history Those who follow GME Processes have a history

of dramatic improvementof dramatic improvementGMEROCSGMEROCSPSD Relationship has already shown promisePSD Relationship has already shown promise

ORGANIZATIONAL CHARTORGANIZATIONAL CHARTUniversity of Pittsburgh Medical Center Medical Education Program (UPMCMEP)

University of PittsburghAssociate Dean & DIO

Chair, GMEC

UPMCVice President, GME Office

Vice Chair, GMEC

GME Committee MembershipPeer-Selected Residents & Fellows from Core Programs

Program Directors from all Accredited ProgramsHospital Leadership

UPMCPresident, UPMC Physician Svc. Div.

President, Univ. of Pittsburgh Physicians

UPMCMEP BoardUniversity of Pittsburgh Medical Center (UPMC)

University of Pittsburgh

UPMC GME Office

University of Pittsburgh Assistant Dean GME

Fellowships

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 ChairsGME 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

Z CalcZ Calc

Z CALC= TOTAL FTE # BBA'97 ALLOWANCEFY04 50.48 1208.42 919.68FY05 89.93 1226.5 919.68FY06 126.57 1258.5 919.68NEW 27.3 1018.95FY07 156.29 1286.35 919.68NEW 57.02 OVER the CAP 1019FY08 44.05 1299.35 1019FY'09 77.99 1347 1018.95

Note: This does not include out rotations (typically 2 FTE's/yr.)Note: This does not include non-clinical research adjustment (typically 10 FTE's /yr.)Note: SFHS backfill n=30 Note: This does not include ANES AGH residents (n=12 in FY'04 or n=7 in FY'05)This does not include other events which causes a resident to be non-reimbursable by CMS

EVOLVING ISSUESEVOLVING ISSUES

Flat Revenue – CAP ManagementFlat Revenue – CAP Management

Increased CMS ComplexityIncreased CMS Complexity

Unbridled Accreditation & Certification Regulations Unbridled Accreditation & Certification Regulations and expense ($377K). and expense ($377K).

Bringing Housestaff more intimately into Patient Bringing Housestaff more intimately into Patient Safety & Quality InitiativesSafety & Quality Initiatives

Gamma Mu EpsilonGamma Mu Epsilon

Non-Non-Standard Standard

Programs, Programs, UPMCUPMC

Frank J. Kroboth, M.D.Frank J. Kroboth, M.D.

STANDARD AND NON-STANDARD TRAINING PROGRAMS

ACGMEProfessional

Societies

UPP-OZ ClinicalInstructor Programs I

Accredited Residencies and Fellowships

Special InstitutionalEducation Programs I

ABMS

Special InstitutionalEducation Programs II

UPP-OZ Clinical Instructor Programs II

Mini Fellowships

Post Doc Scholars

Non-Standard Programs

Programs Fellows

SIEP 41 57

OZ 41 55

Total 82 112

Special Institutional Education Programs

Anesthesiology (6):• Cardiothoracic• Hepatic• Neuro• Obstetrical• Orthopedic• RegionalCardiovascular Institute (1):• Heart Failure/TransplantCritical Care Medicine (2):• CCM-EM• Pediatric CardiacDermatology (2):• Cutaneous Oncology• PediatricEmergency Medicine (1):• Mini-FellowshipFamily Medicine (1):• Faculty Development

Internal Medicine (5):• GIM• HIV• Transplant Infectious Disease• Pulmonary Transplant• Endocrinology, Diabetes and

MetabolismNeurology (1):• InterventionalOrthopaedic Surgery (3):• Foot and Ankle• Orthopaedic Trauma• Spinal CordOtolaryngology (1):• PediatricPediatrics (2):• Research Track in Neonatal• Research Track in Pediatric

Endocrinology

SIEP – con’t

Pathology (1):• Pathology InformaticsPhysical Medicine and

Rehabilitation (1):• Advanced Spinal Cord InjuryPsychiatry (1):• Public Service PsychiatryRadiology (1):• Vascular InterventionalSurgery (8):• Advanced Cardiac• Advanced General Thoracic

• Breast Surgery• Micro-vascular Reconstructive• Bariatric• Surgical Oncology• Multi-Organ• Intestinal and Multi-VisceralWomen’s Health (4):• Reconstructive Surgery• Gynecologic Oncology• Maternal-Fetal• Reproductive Endocrinology

UPP-OZ Clinical Instructor Programs

Dermatology (2):• Cosmetic• PediatricEmergency Medicine (3):• EMS International• Mini-Fellowship• University of Pittsburgh

InternationalInternal Medicine (3):• Cardiac Imaging• GIM• Renal TransplantNeurosurgery (1):• Pediatric

Ophthalmology (5):• Cornea• Glaucoma• Oculoplastic• Vitreo Retinal• PediatricOtolaryngology (5):• Oncologic• Pediatric• Laryngology/Voice• Cranial Base• SinonasalPediatrics (1)• Academic Pediatric

OZ Programs – con’tPhysical Medicine and

Rehabilitation (1):• Brain InjuryPsychiatry (1):• Public Service PsychiatryRadiology (4):• Abdominal Imaging• PET/CT• Musculoskeletal• Women’s ImagingSurgery (12):• Acute Care• Advanced Cardiac Mini• Advanced Cardiac

• Advanced General Thoracic• Body Contouring• Liver, Pancreas, Intestine• Micro-vascular Reconstructive• Bariatric• Pediatric Cardiothoracic• International• Plastic Surgery• Surgical OncologyWomen’s Health (3):• Contraceptive Research• Gynecologic Endoscopy• Reproductive Infectious

Diseases

Participants’ Present StatusParticipants’ Present Status

DiscussionDiscussion

PolicyPolicy

Organization and Faculty DevelopmentOrganization and Faculty Development

Review and EnforcementReview and Enforcement

Graduation AttestationGraduation Attestation

Outcome TrackingOutcome Tracking

Year OneYear One

Mandate: enroll, monitor, enhance Non-Mandate: enroll, monitor, enhance Non-Standard ProgramsStandard Programs

Peer Group SurveyPeer Group Survey

SIEP (Special Institutional Education SIEP (Special Institutional Education Program) conceptualized, policy writtenProgram) conceptualized, policy written

Presented to Council of ChairsPresented to Council of Chairs

Enrollment Process BegunEnrollment Process Begun

SIEP Subcommittee initiatedSIEP Subcommittee initiated

Year TwoYear Two

Mandate: Include Attending-Level Mandate: Include Attending-Level ProgramsProgramsWorking GroupWorking GroupTracking by FellowTracking by FellowPolicy EvolvedPolicy Evolved

Meanwhile, back in SIEP-Land:Meanwhile, back in SIEP-Land:– GME ROC’s and Duty HoursGME ROC’s and Duty Hours– Internal ReviewsInternal Reviews

Year ThreeYear Three

UPP-OZ Clinical Instructor ProgramsUPP-OZ Clinical Instructor Programs

Policy to LegalPolicy to Legal– SupervisionSupervision– CredentiallingCredentialling– Duty HoursDuty Hours

Policy Reviewed AgainPolicy Reviewed Again

Back to the Council of ChairsBack to the Council of Chairs

Mini-Fellowships and ObservershipsMini-Fellowships and Observerships

Year ThreeYear Three

Meanwhile, back in SIEP-LandMeanwhile, back in SIEP-Land

Updated Enrollment SurveysUpdated Enrollment Surveys

Rapid Response Communiques begunRapid Response Communiques begunPerks and LiabilitiesPerks and Liabilities

Summative EvaluationSummative Evaluation

Mini FellowshipMini Fellowship

Definition:Definition:1-6 month duration1-6 month durationnot accredited or ABMSD certifiednot accredited or ABMSD certifiedmay be externally supportedmay be externally supported

Questions:Questions:CME vs. GME vs. BusinessCME vs. GME vs. BusinessSelection of candidatesSelection of candidatesRigor of educationRigor of educationDegree of SupervisionDegree of SupervisionWhat documentation/certificationWhat documentation/certificationProcess of enrollment, credentiallingProcess of enrollment, credentiallingParticipants in processParticipants in process

Benefits of Mini FellowshipsBenefits of Mini Fellowships

Dissemination of Specialty Knowledge and Dissemination of Specialty Knowledge and ProceduresProcedures

Enhancement of ReputationEnhancement of Reputation

Business and Financial GainBusiness and Financial Gain

Service Needs SatisfiedService Needs Satisfied

Liabilities of Mini-FellowshipsLiabilities of Mini-Fellowships

Dilution of the Primary Educational MissionDilution of the Primary Educational Mission

* * Competition for CasesCompetition for Cases* Faculty time* Faculty time* Morale* Morale

Credentialling BoundariesCredentialling BoundariesOrientation and PolicyOrientation and PolicyClinical Performance IssuesClinical Performance IssuesCertification QuestionsCertification Questions

Recent MailRecent Mail

Classification, Enrollment, Communication IssuesClassification, Enrollment, Communication Issues 1414

Custom ProgramsCustom Programs 1010

Mini-FellowshipsMini-Fellowships 44

Mixed or Transitioning ProgramsMixed or Transitioning Programs 88

Perks and LiabilitiesPerks and Liabilities 22

Visa, Credentialling, LicensingVisa, Credentialling, Licensing 1010

You Make the Call, Scenario 1: You Make the Call, Scenario 1: The The Ad HocAd Hoc Program Program

““The spouse of our newest molecular The spouse of our newest molecular biology mega-recruit is a cardiologist who biology mega-recruit is a cardiologist who needs/desires an extra year of training in needs/desires an extra year of training in transplant cardiology – We have designed transplant cardiology – We have designed a curriculum…”a curriculum…”

Scenario 1: IssuesScenario 1: Issues

Easy Case -Easy Case -You You wantwant the spouse the spouse

Hard Case -Hard Case -Cardiology doesn’t want the spouse, but Cardiology doesn’t want the spouse, but

CT CT Surgery does.Surgery does.

How to work this out or end it?How to work this out or end it?Who pays the slot?Who pays the slot?

Scenario 2: The For-Profit MiniScenario 2: The For-Profit Mini

““A small referring institution in the region has A small referring institution in the region has requested four-month update experiences requested four-month update experiences for its three cardiologists in our busy for its three cardiologists in our busy Cardiac Pavilion and CCU…”Cardiac Pavilion and CCU…”


Regional educatorRegional educatorProtector of residenciesProtector of residenciesReferral MoneysReferral MoneysWorkforce savingsWorkforce savingsTraining background Training background Is this our business (CME) ?Is this our business (CME) ?Charge tuition?Charge tuition?Shunt it to Observership & Curriculum: Shunt it to Observership & Curriculum:

DocumentationDocumentationSelectionSelectionSupervisionSupervision

Scenario 3: The visa from hellScenario 3: The visa from hell

““Our UPP-OZ (Clinical instructor) Maternal-Our UPP-OZ (Clinical instructor) Maternal-Fetal Medicine Program has an Fetal Medicine Program has an outstanding candidate from country X. outstanding candidate from country X. Can you help us get a visa which would Can you help us get a visa which would allow unrestricted licensing, or do we need allow unrestricted licensing, or do we need to create a SIEP? By the way, we have to to create a SIEP? By the way, we have to answer her this week…”answer her this week…”


Timeline pressuresTimeline pressures

Justification and cost of exception visasJustification and cost of exception visas

Creation of hybrid programsCreation of hybrid programs

Institutional license vs. state license, Institutional license vs. state license, USMLE regulationsUSMLE regulations

Scenario 4: Great ExpectationsScenario 4: Great Expectations

““A Clinical Instructor in one of our specialty A Clinical Instructor in one of our specialty surgery OZ programs is concerned. He surgery OZ programs is concerned. He thought he matched into a fellowship with thought he matched into a fellowship with ACGME regulations. However, he notes ACGME regulations. However, he notes that his contract is more like a faculty that his contract is more like a faculty contract than a fellow’s…”contract than a fellow’s…”


Specialty board matchesSpecialty board matches

Specialty board program requirementsSpecialty board program requirements

Explicit recruiting and offersExplicit recruiting and offers

Reason for organization and policiesReason for organization and policies

Scenario 5: T-32 TemptationScenario 5: T-32 Temptation

““Our department of Ophthalmology is Our department of Ophthalmology is recruiting a research ophthalmologist to recruiting a research ophthalmologist to come on a training grant. Competing come on a training grant. Competing institutions have offered opportunities to institutions have offered opportunities to generate a salary of $150,000. What can generate a salary of $150,000. What can we do…?”we do…?”


Fellow = Fellow = full-full-timetime

Can’t be facultyCan’t be faculty

Practice plan exceptionPractice plan exception

Conscionable limit to moneyConscionable limit to money

Coordination with university officeCoordination with university office

PrecedentPrecedent

Scenario 6: The buck stops hereScenario 6: The buck stops here

““One of our UPP-OZ (Instructor) fellows scrubbed One of our UPP-OZ (Instructor) fellows scrubbed and attempted to initiate an urgent procedure and attempted to initiate an urgent procedure independently, claiming he was credentialled to independently, claiming he was credentialled to do so. The OR manager did not find the do so. The OR manager did not find the procedure on the credentialling log and blocked procedure on the credentialling log and blocked the procedure until supervising faculty arrived. the procedure until supervising faculty arrived. The family is irate over the delay, the fellow and The family is irate over the delay, the fellow and supervising attending are affronted, the OR supervising attending are affronted, the OR manager is on a war path, the Department Chair manager is on a war path, the Department Chair stands by his faculty, the CEO blames you…”stands by his faculty, the CEO blames you…”


Policy, policy, policyPolicy, policy, policy

Level of supervisionLevel of supervision

On-demand credentiallingOn-demand credentialling

Scenario 7: PLA/MAA NightmareScenario 7: PLA/MAA Nightmare

““Your CT Surgery OZ Program wants a Your CT Surgery OZ Program wants a fellow to accompany the attending who will fellow to accompany the attending who will start having clinic and procedures at a start having clinic and procedures at a newly integrated site in your network. The newly integrated site in your network. The site will not allow the fellow the same site will not allow the fellow the same credentialling level as the university credentialling level as the university hospital…”hospital…”


Negotiating with MSO’s in your networkNegotiating with MSO’s in your network

Writing accommodating PLA’s and MAAWriting accommodating PLA’s and MAA

Expectation at site vs. medical staff Expectation at site vs. medical staff regulations at siteregulations at site

Flexibility of faculty and fellowsFlexibility of faculty and fellows

Scenario 8: Non-Medical FellowsScenario 8: Non-Medical Fellows

““It’s a busy week. On Monday, your Dental It’s a busy week. On Monday, your Dental School requests permission to expand four School requests permission to expand four more slots in its well established SIEP more slots in its well established SIEP Fellowship, and on Wednesday, your Fellowship, and on Wednesday, your Oncology Division requests advice on an Oncology Division requests advice on an oncologic dermatology offering for foreign oncologic dermatology offering for foreign professors to spend a month in the professors to spend a month in the melanoma research labs and outpatient melanoma research labs and outpatient clinics…”clinics…”


Clinical fellows outside of medicine, Clinical fellows outside of medicine, outside of CAPoutside of CAP

Research fellowships oversightResearch fellowships oversight

Observership useObservership use

SummarySummary

Non-Standard Programs cover a wide Non-Standard Programs cover a wide range of educational offeringsrange of educational offerings

They can present a wide range of They can present a wide range of challenges within the institutionchallenges within the institution

Policy, organization, and communication Policy, organization, and communication can minimize problems and enhance can minimize problems and enhance educationeducation

Non-Standard Programs: One Institution's Approach

Documents

Transcript of Non-Standard Programs: One Institution's Approach