Feasibility Assessment

This assessment is utilized to help determine if and how Graduate Medical Education can be integrated into a hospital’s resources and vision for the future. This is done from a range of recommendations to steering committees that include what programs to foster and the process for accreditation. This assessment also allows Germane to be involved in the hospital’s goals for the future, make recommendations for GME programs specialty, and identify resources needed for said programs, as well as their financial implications.

Accreditation Maintenance

Becoming initially accredited and continuing to uphold the standards of said accreditation are equally significant. Therefore, Germane also has methodologies that support a hospital’s continued accreditation and addresses any accreditation concerns. One such methodology is the Accreditation Gap Analyses: it is used to determine what resources are necessary for a hospital to achieve accreditation standards. This analysis assesses the requirements of an accrediting body and compares these standards to hospital data to identify any areas where these metrics are not met.

Institutional and New Program Application

New Program Application and Institutional Accreditation Preparation are also ways in which Germane can prepare an institution for accreditation. A New Program Application is prepared and submitted to the primary accrediting bodies for Graduate Medical Education. Institutional Accreditation preparation includes training and development of the Graduate Medical Education Committee, foundational policies and procedures, and submission of an ACGME-compliant application.

Site Visit Preparation

Germane assists with Site Visits to ensure a hospital has the knowledge, resources, preparation, competence and confidence to successfully execute a site visit by the accrediting body. A mock site visit is emulated to reflect what actual site visits entail. This process helps hospitals prepare the proper documentation and answers any questions a hospital might have.

These case studies provide insight to how we put these offerings together to create value for you.

Accreditation Case Study: Our Accreditation is At Risk — What Do We Do?

Germane received an urgent request for support from a sponsoring institution who received an ACGME notice of adverse action, Institutional Accreditation Withdrawn. This institution supported multiple residency and fellowship programs with hundreds of trainees. As it was the institution who lost accreditation, all programs would close as a result, and trainees displaced in less than 60-days. The loss of accreditation, programs, and trainees would create a multi-million-dollar loss for the system and affect workflow of the inpatient and ambulatory teams.

The Challenge

This institution, working alongside Germane, faces primary challenges: obtaining institutional accreditation, maintaining program accreditation, retaining all Residents and/or Fellows. Similarly, these challenges require meetings with leadership, reviews and assessments, as well as focused accreditation support to addressed comprehensively. The institution also suffers from a number of citations to be reviewed and addressed. Of course, regaining accreditation is of utmost importance to the institution, as they would lack all recognition and legitimacy without the status.

The Solution

As stated previously, the primary challenges can be addressed by three strategies of support. Beginning with the first, leadership coaching helps the institution navigate the complex ACGME and AOA Policies & Procedures to strategize maintenance of one or more forms of Accreditation. Second, Germane works with the institution to conduct an Environmental (or Culture) Review and give appropriate support with documentation. The former is a review of documentation and individual, confidential interviews with residents, fellows, administration, coordinators, faculty and program directors; while documentation support is used to update policies, procedures, contracts, and some program-specific curriculum to most recent ACGME and AOA requirements while collecting supplemental documentation and responding to 25 institutional citations. Lastly, Germane assists the institution in regaining accreditation by filing for Appeal of Adverse Action with the ACGME, applying for initial ACGME accreditation for the sponsoring Institution and reaccreditation application to the AOA, and site visit preparation.

The Outcome

The institution benefitted greatly from Germane’s assistance. Most importantly, it was approved for ACGME Initial Accreditation. This accreditation was maintained by each of the six Residency/Fellowship programs. This was done with a 100% retention rate for Residents and/or Fellows, and complete compliance for all Institutional Policies. Also, the institution was able to absolve 84% of all institutional citations. The institution, lastly, achieved an AOA Institutional Accreditation Reinstatement.

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