OUR ACCREDITATION IS AT RISK — WHAT DO WE DO?
Germane received an urgent request for support from a sponsoring institution that received an ACGME notice of adverse action, Institutional Accreditation Withdrawn. This institution supported multiple residencies and fellowship programs with hundreds of trainees. As it was the institution that 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 the workflow of the inpatient and ambulatory teams.
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.
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 the 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 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.