GME-annual-2016-screen-res

ANNUAL REPORT 2015–2016

GRADUATE
MEDICAL
EDUCATION

Letter from the DIO

It is my pleasure to provide this year’s Graduate
Medical Education (GME) Annual Report for
the University of South Florida Morsani College
of Medicine. Annual Year (AY) 2015-2016 was a
successful year in GME and I am pleased to share
our progress and outline the future endeavors for
USF GME. The USF Morsani College of Medicine
(MCOM) has been active in GME activities since
1971 and currently sponsors 80 programs, of which
62 are ACGME accredited residency programs with
723 residents and fellows in various specialties. The
majority of the residency/fellowship training takes
place at six major affiliated institutions and a full
Graduate Medical Education spectrum of outpatient and ambulatory sites.
functions under the expert USF GME and the Graduate Medical Education
leadership of Charles N. Paidas, Committee (GMEC) have broad oversight of program
MD, MBA,Vice Dean for GME and institutional accreditation. The GME office also
and Designated Institutional manages new trainee orientation, human resource
Official (DIO). functions, credentialing activities as well as other

GME related functions. GME ensures the allocation
of proper resources, both financial and technical, to support training programs.

A few highlights from 2015-2016 include our programs matching 100% in the Main
Match, all programs other than initial programs having Continued Accreditation,
ACGME citations decreasing to a low of 14, and the successful reorganization of the
GMEC to include subcommittees in Program Evaluation, Special Assessment, CLER,
Annual Institutional Review, and Research.

This annual report provides an overview of our accomplishments, information regarding
various educational programs and activities, and a summary of goals for 2016-2017 in
USF MCOM GME.

In closing, I thank each member of the GME community for their dedication and
diligence to ensure that we provide the highest level of training while delivering the best
medical care for our patients and community.

Let’s continue the great progress!

Charles N. Paidas, MD, MBA
Vice Dean, Graduate Medical Education
ACGME Designated Institutional Official
Chief, Pediatric Surgery
Professor of Surgery, Pediatrics
USF Health, Morsani College of Medicine

2 Morsani College of Medicine GME

USF Graduate
Medical Education
Hospital Par tners

Primary Affiliates

•  Tampa General Hospital
•  Johns Hopkins All Children’s Hospital
•  Moffitt Cancer Center
•  Morton Plant Mease
•  James Haley VA Hospital
•  Bay Pines VA Healthcare System

Organizational Chart

Charles (Charly) Lockwood, MD, MHCM
Dean, USF Health

MorsaniCollege of Medicine

Linda Snell, Sr.Admin Asst. Charles N. Paidas, MD, MBA Cuc Mai, MD
Program Directors Vice Dean, GME GMEC Chair

Education Coordinators Sue Middleton, MHA
Director, GME

Amy Fioramonte, DeLaura Shorter Aiying Zhen Victoria Leonard
PhDAsst Dir., GME Academic Services Fiscal & Business Administrative
(New Innovations)
Administrator Specialist Specialist

Patti Taylor, MS Airin Giltner Laura DeCedeno Kristin Morda, MA
Asst. Dir., GME Academic Services Fiscal & Business GME Librarian
(Human Resources, 0.2 FTE
New Innovations, Administrator Specialist
Affiliate Contracts) (TGH Liaison)

Morsani College of Medicine GME 3

USF ACGME
ACCREDITATION
STATUS

The USF MCOM received continued accreditation from the ACGME effective July 29,
2013 with an approximate date for the next site visit as April 2021.

As part of the ACGME Next Accreditation System (NAS), programs complete an annual
internal Self-Study with an ACGME site visit every 10 years.

Program Accreditation Status Last RRC Self Study Date
Site Visit Date
Addiction Psychiatry Continued Accreditation October 1, 2020
Advanced Heart Failure and Transplant Initial Accreditation February 29, 2012 July 1, 2017 (Site
Cardiology N/A Visit)
Allergy & Immunology Continued Accreditation February 1, 2019
Cardiovascular Disease Continued Accreditation January 16, 2008 January 1, 2019
Child & Adolescent Psychiatry Continued Accreditation September 21, 2010 October 1, 2020
Clinical Cardiac Electrophysiology Continued Accreditation June 10, 2008 January 1, 2019
Clinical Neurophysiology Continued Accreditation September 23, 2010 November 1, 2016
Colon and Rectal Surgery Continued/ w warning March 1, 2012 March 1, 2023
Cytopathology Continued Accreditation September 11, 2012 October 1, 2019
Dermatology Continued Accreditation October 27, 2011 October 1, 2023
Dermatopathology Continued Accreditation January 29, 2013 October 1, 2023
Emergency Medicine Continued Accreditation October 12, 2011 September 1, 2019
Emergency Medical Services (EMS) Fellowship Initial Accreditation January 15, 2010 N/A
Pediatric Endocrinology Continued Accreditation November 9, 2016 October 1, 2018
Endocrinology, Diabetes, Metabolism Continued Accreditation May 27, 2010 January 1, 2019
Family Medicine Continued Accreditation October 1, 2009 June 1, 2019
Family Sports Medicine Continued Accreditation November 3, 2008 June 1, 2019
Female Pelvic Medicine and Continued Accreditation April 5, 2012 December 1, 2019
Reconstructive Surgery November 13, 2013
Forensic Pathology Continued Accreditation
Gastroenterology Continued Accreditation January 14, 2010 October 1, 2019
Geriatric Psychiatry Continued Accreditation March 25, 2008 January 1, 2019
Hematology / Oncology Continued Accreditation June 16, 2010 October 1, 2020
Hematopathology (Hematology) Continued Accreditation April 9, 2008 January 1, 2019
Infectious Disease Continued Accreditation January 30, 2013 October 1, 2019
March 26, 2008 January 1, 2019

4 Morsani College of Medicine GME

Program Accreditation Status Last RRC Self Study Date
Site Visit Date
Internal Medicine Continued Accreditation January 1, 2019
Internal Medicine/Pediatrics Continued Accreditation March 18, 2008 October 1, 2018
Interventional Cardiology Continued Accreditation May 5, 2009 January 1, 2019
Interventional Radiology- Integrated Initial Accreditation September 22, 2010 September 1, 2018
April 28, 2016 (Site Visit)
Musculoskeletal Radiology Continued Accreditation January 1, 2020
Neonatal-Perinatal Medicine Continued Accreditation February 26, 2013 October 1, 2018
Nephrology Continued Accreditation November 9, 2011 January 1, 2019
Neurological Surgery Continued Accreditation March 27, 2008 June 1, 2023
Neurology Continued Accreditation February 28, 2012 November 1, 2016
Obstetrics and Gynecology Continued Accreditation May 25, 2010 December 1, 2019
Ophthalmology Continued Accreditation May 3, 2011 November 1, 2019
Orthopaedic Sports Medicine Continued Accreditation February 29, 2012 January 1, 2020
Orthopaedic Surgery Continued Accreditation May 5, 2011 January 1, 2020
Otolaryngology Continued Accreditation September 30, 2009 February 1, 2025
Pain Medicine Continued Accreditation June 14, 2013 November 1, 2016
Hospice & Palliative Medicine Continued Accreditation April 24, 2013 January 1, 2019
Pathology - Anatomic And Clinical Continued Accreditation April 4, 2012 October 1, 2019
Pediatrics Continued Accreditation November 6, 2008 October 1, 2018
Pediatrics - Allergy & Immunology Continued Accreditation May 26, 2010 August 1, 2016
Physical Medicine And Rehabilitation Continued Accreditation April 1, 2010 August 1, 2017
Plastic Surgery - Integrated Continued Accreditation October 25, 2011 November 1, 2018
Preventative/Occupational Medicine Continued Accreditation July 10, 2008 March 1, 2017
Psychiatry Continued Accreditation January 18, 2011 October 1, 2020
Pulmonary Disease & Critical Care Continued Accreditation June 15, 2010 January 1, 2019
Radiation Oncology Continued Accreditation September 29, 2010 September 1, 2020
Radiology - Diagnostic Continued Accreditation March 30, 2010 November 1, 2018
Rheumatology Continued Accreditation February 16, 2009 January 1, 2019
Sleep Medicine Continued Accreditation February 28, 2012 January 1, 2019
Spinal Cord Injury Medicine Continued Accreditation May 6, 2009 August 1, 2017
Surgery Continued Accreditation May 23, 2012 February 1, 2021
Surgical Critical Care Continued Accreditation October 26, 2011 February 1, 2021
Surgical Oncology Initial Accreditation May 4, 2011 April 1, 2017
w/ warning December 15, 2015 (Site Visit)
Urology Continued Accreditation May 1, 2021
Vascular & Interventional Radiology (Miami) Continued Accreditation September 28, 2010 November 1, 2018
Vascular & Interventional Radiology (Tampa) Continued Accreditation November 19, 2008 November 1, 2018
Vascular Neurology Continued Accreditation November 18, 2008 November 1, 2016
Vascular Surgery Continued Accreditation May 22, 2012 February 1, 2021
Vascular Surgery - Integrated Continued Accreditation June 11, 2008 February 1, 2021
June 12, 2008

Morsani College of Medicine GME 5

USF ACGME ACCREDITATION STATUS

ACCREDITATION
IMPROVEMENTS

GME has demonstrated a significant reduction in citations: CITATIONS BY CATEGORY

200 CITATION TREND 2010–2015 6 2015–2016

5 2014-2015 Educational Program
Evaluation
150 4 2013-2014 6
Institutional Support 1
151 3 2012-2013 Program Personnel & Resources
100 115 112 109
5
66
2 2011-2012 2
50
2010-2011
14 1

0 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 0

6 Morsani College of Medicine GME

CLINICAL LEARNING
ENVIRONMENT REVIEW (CLER)

The ACGME added the Clinical Learning Environment Review (CLER) in 2014, which
occurs approximately every 18 months. In a CLER visit, ACGME reviews integration of
education in our affiliate hospitals.
The USF MCOM hosted our first ACGME CLER site visit September 22-24, 2014 at
Tampa General Hospital and the USF South Tampa Center. Over 25 clinical locations
were visited by the review team. Residents and fellows, faculty members, program
directors, and other clinical staff were questioned in six focus areas:

This table lists the areas Supervision QI and Health
of focus identified for Disparities
improvement in the 2014
CLER site visit based on Patient Safety
resident interviews and
observation.

Transitions Professionalism
of Care
Duty Hours and
Fatigue Mitigation

Morsani College of Medicine GME 7

CLER AREAS OF IMPROVEMENT

Participation in a QI Activity Directed by Hospital Administration Resident
Tampa General Hospital 26%
National Averages 51%
Variance -25%
Participation in a QI Project of Their Own or Department Design
Tampa General Hospital 57%
National Averages 76%
Variance -19%
QI Project was Linked to the Hospital’s Goals
Tampa General Hospital 34%
National Averages 52%
Variance -18%
Resident Access to Organized Systems for Collecting/Analyzing Data for the Purpose of QI
Tampa General Hospital 45%
National Averages 63%
Variance -18%
Knowledge of Priorities for Improving Transitions of Care
70%
Tampa General Hospital 82%
National Averages -12%
Variance
Is There a Written Template to Facilitate the Hand-off Process 67%
78%
Tampa General Hospital -11%
National Averages
Variance 13%
Objective Way of Knowing Which Procedures a Particular Resident was Allowed to Perform 33%
with or without Direct Supervision -20%
Tampa General Hospital
National Averages 25%
Variance 42%
Fatigue Management: % of Residents Who Indicated They Would Notify a Supervisor -17%
and Expect to be Taken Off Duty
Tampa General Hospital
National Averages
Variance

* Comparisons are based on the Sept 2014 Tampa General Hospital CLER Site Visit Report from Sept 2014 and the
Detailed Findings from the CLER National Report from 2012-2015. ‘Resident’ refers to both residents and fellows.

8 Morsani College of Medicine GME

GME REPORTING DASHBOARD
data at the institutional level as well as for individual
This year GME implemented a reporting dashboard to programs. It is regularly presented at the GMEC and
provide a quick, visually engaging format that clearly Education Coordinator meetings. It includes multiple
highlights areas requiring additional focus via the use of measures and is currently being expanded to include
color coding. The majority of information is from the program information outside of ACGME or New
ACGME data repository with additional data from the Innovations data sources. Below is a snap shot of the
GME New Innovations system. The dashboard includes base dashboard.

RESIDENT SUPERVISION junior trainee. Using the Procedure Logger in New
Innovations, faculty and hospital personnel will be
GME continues to monitor program supervision able to access privilege reports that list residents’ scope
policies to ensure compliance with the ACGME of authority for performing procedures. The Privilege
common and program specific requirements. GME reports will be made available in 2016-2017. Procedures
developed individual scope of practice procedure sets and scope of supervision can be displayed by procedure
within New Innovations. The data indicate if a resident or by group to display all logs for each group.
can perform specific procedures independently or with
direct supervision, or in some cases supervise a more

Morsani College of Medicine GME 9

GME FINANCIALS

Educational Funds and Program Director Protected Time

GME commits significant resources to Category Amount Percentage
the residency educational programs. Books 159,649.03 7.73%
These resources include over $3.34 Catering/Events 61,452.26 2.97%
million devoted to program director and Conferences 563,247.56
coordinator salaries. Program director Consulting 165,426.94 27.26%
salaries are protected at the ACGME Educational Tools/Technology 44,159.52 8.01%
Residency Review Committee required Facility Fees 33,049.92 2.14%
percentages using AAMC Associate Graduation 28,628.09 1.60%
Professor 25th percentile for salary. In Memberships/Subscriptions 61,002.06 1.39%
addition to salary contribution, GME Printing 17,144.08 2.95%
allocates over $2.06 million each year Recruiting 103,250.66 0.80%
to the educational needs of programs as Registration/Tuition 115,418.50 5.00%
detailed in the GME Education Funds by Simulation Center 598,798.00 5.60%
Category Chart. Supplies 14,126.37 28.99%
Rent 33,287.06 0.68%
* Other includes intra-department transfers, parking, Other* 67,219.51 1.61%
postage, depreciation, record scanning, gift/meal TOTAL 2,065,859.56 3.25%
cards, etc. 100.00%

10 Morsani College of Medicine GME

Other Affiliates 3% USF Dept. Funded 5% Graduate Medical
Education Funding
JAHVA 24% TGH 44%
USF GME contracts annually with
USF Health MCOM affiliated
hospitals to fund 95% of our
residents and fellows. Departmental
funds – including research projects
and grants – account for the
remaining 5%.

MPM 4% Moffitt 15% GME EDUCATION
JHACH 3% FUNDS BY CATEGORY
Fiscal Year 2016
BPVA 2% (July 1, 2015–June 30, 2016)

Resident Salaries RESIDENT SALARIES 2015/2016 Annual Salary
(by Postgraduate Year) $49,648
PGY Level $51,315
As provided for in the House Officer PGY-1 $53,099
contract, the University of South Florida PGY-2 $55,191
Morsani College of Medicine and its PGY-3 $57,369
affiliated hospitals provide competitive PGY-4 $59,305
resident salaries for the southeastern PGY-5 $60,086
United States based on the Association PGY-6 $61,887
of American Medical Colleges (AAMC) PGY-7
Annual Survey Southeast mean. PGY-8

Morsani College of Medicine GME 11

INCOMING RESIDENTS AND FELLOWS
in AY 2015/16 totaled 242. Approximately 45%
started at Tampa General Hospital, 25% at the
James Haley VA Hospital, 15% at Moffitt Cancer
Center, and the remainder at various other sites
including USF Health patient care clinics.

Internal Medicine welcomed the largest number
(73) of new residents and fellows, followed by
Surgery (25).

RESIDENT DEVELOPMENT

2015-2016 Orientation Resident Responsibilities

The 2015-16 New Resident/Fellow orientation was held Resident responsibilities are delineated in the GME house
on June 30, 2015 at the University of South Florida officer contract and in the House Staff handbook. Both
Alumni Center located on the USF Tampa campus, and can be found on-line on the GME website:
included presentations by key Program Directors, the http://health.usf.edu/medicine/gme/
President of the Residency Advisory Committee (RAC),
and a Welcome Introduction to USF Health GME by In addition, GME Leadership meets monthly with
the DIO/VP for GME. Incoming residents and fellows the Resident Advisory Committee to discuss pertinent
were provided with access to institutional resources, resident concerns and new initiatives.
such as Human Resources representatives, benefits
information, Healthcare Administration, Security Residency Assistance Program
and IT access, and more. Representatives from major
affiliated hospitals were also in attendance to provide The Residency Assistance Program (RAP) continues to
additional information to the new trainees. be an important resource for residents. The quarterly
RAP newsletter addresses such concerns as stress, fatigue,
Residents on Committees and family troubles. RAP continues to be a self-referral
program that can be accessed 24 hours a day, 7 days a
In 2015-2016, peer selected residents served on both week by calling 813-870-3344. Pamphlets describing
the Resident Advisory Committee (RAC) and the RAP are available from all residency coordinators, at the
GME Committee (GMEC). The RAC is comprised GME office at the College of Medicine, and in the lounge
of 11 elected members, each representing the affiliated and study/call rooms at Tampa General. GME also lists
hospitals. All members of the RAC attend monthly information regarding RAP on the GME website. RAP
RAC and GMEC meetings. The RAC affiliate hospital trained psychologists confidentially address individual
representatives also attended various quality and safety resident needs and provide ongoing counseling and
committee meetings at their assigned hospitals. referrals as needed. In addition, the Office of Professional
Development in the MCOM acts to identify systematic
The 2015-16 RAC members, in conjunction with the problems within programs and assists residents in
GME Office, developed and presented a Resident Exit navigating issues and concerns. The office was made
process document to assist graduating trainees with available to GME beginning in calendar year 2011, and
helpful information, options, and deadlines relative to access is provided through each Program Director.
continuation of insurance and retirement benefits after
separation from the University.

12 Morsani College of Medicine GME

Evaluations GMEC subcommittee reviews the results of the surveys
compared to the benchmark of 20% below the national
GME monitors program compliance of the evaluation average but also looks at trends from year to year.
process. Compliance includes timely evaluation of a The 2015-2016 ACGME Resident Survey revealed
resident after a rotation, anonymous evaluations of that 92% of the USF MCOM residents rated their
faculty, semi-annual evaluations of the resident by the program as Very Positive or Positive. The institution’s
program director, annual program evaluations and response rate to the ACGME Resident survey was 94%.
summative evaluations when a resident has completed Programs with any responses below 20% of the national
training. average are required to develop a plan of action to
address the issues.
Our structure and functions have been modified to
address issues arising from resident surveys after we
receive the survey results. The Program Evaluation

2015-16 GME Resident/ Of those who responded to the survey, 44% indicated
Fellowship Exit Survey they planned to go into “patient care/solo or group
practice,” 16% planned to go into “academic medicine,”
Trainees completing their respective residency and 5% planned to go into government/VA medicine;
fellowship programs in 2016 were given the opportunity and 35% planned to further their training. Of those
to complete an exit survey to identify factors affecting responding, 33% indicated that they intended to
graduates’ choice of practice location, gather feedback practice Florida, and 61% intended to practice out-of-
on their self-rated level of competency training, and state. Of those planning to practice in Florida, 27%
assessment of their training program. intended to remain in the southwest region. Over four-
fifths of the respondents would recommend their USF
The survey was used to obtain respondents’ reactions to MCOM training program to others.
their residency training, and their plans after graduation,
including where they intended to practice. A total of
204 graduates were invited to participate on the survey,
of which 109 responded, yielding a 53.43% response
rate.

Morsani College of Medicine GME 13

USF GME RESIDENT
DATA
BY THE 2014-15
NUMBERS
512 RESIDENTS
800 211 FELLOWS
723 TOTAL
USF RESIDENT/FELLOW GROWTH
2012– 2016

700 726 723
696 704

600 FY 12/13 FY 13/14 FY 14/15 FY 15/16

Number of Resident and Fellow Positions by fiscal year

14 Morsani College of Medicine GME

NRMP
Match Results

for March 2015

The GME residency and fellowship programs had In 2015-2016 GME set the goal of an average incoming
an outstanding Match Year and continue to be trainee USMLE Step 2 CK score of 245. The current
competitive both within Florida and nationally. All average incoming score is 240. We continue to work with
139 positions offered in the Main NRMP Match programs to ensure the highest quality candidates using a
filled on the Monday “Did I Fill?” report at the broad look at qualities in additional to STEP 2 scores.
beginning of Match Week 2016. In the remaining
matches conducted through the NRMP Match, the Current incoming foreign medical graduates are 9.2%
San Francisco Match, and the AUA Match, USF of all incoming trainees. The percentage of trainees who
Health filled 95 positions. Our 2015-16 residents attended US News and World Report Top 40 Medical
and fellows brought diversity, originating from 210 Schools is 9.7% and the percentage of Alpha Omega Alpha
different medical schools worldwide.
(AOA) Honor Society Membership is 9.4%.

Faculty and Resident
Scholarly Activity

(Academic Year 2015-2016)

Between July 1, 2015 and June 30, 2016,
publications included the works of 41% of

Core GME teaching faculty and
22% of USF MCOM trainees.

Morsani College of Medicine GME 15

The Office of GME developed and hosted several Program Director Workshops and faculty
development programs. A Program Director Workshop was also hosted by the Stanford
University Designated Institutional Officer (DIO) and Program Manager on the topic of
Annual Program Evaluation (APE).
In addition, the Office of GME at the MCOM continues to facilitate faculty educational
sessions/Lunch n Learns which are geared toward meeting the faculty development needs of
GME Program Directors, Assistant Program Directors, and key GME faculty. These sessions
are teleconferenced to remote areas in order to include as many participants as possible.
The 2015-2016 Program Director Workshops and Educational Sessions included the following:

FACULTY
PROFESSIONAL
DEVELOPMENT

Program Directors’ (PD) Workshop

Title: AAMC’s Teaching for Quality (Te4Q) Faculty Development Program
Presenters: Karyn Baum
Associate Chair of Clinical Quality, Dept. of Medicine
Medical Director, Utilization Review, UMMC
Senior Consultant, Educating for Quality Initiatives, AAMC
Anju Sonia Dayal, MD, FACP
Associate Program Director, Internal Medicine Residency
Geisinger Medical Center
Dates: October 15, 2015; October 16, 2015; and March 25, 2016

Title: How to Create a Successful Game Plan for Annual Program Evaluations
and Self-Studies
Presenters: Nancy Piro, PhD
GME Education Specialist/Program Manager
Stanford University School of Medicine
Ann Dohn, MA
Designated Institutional Officer and Director of GME
Stanford University School of Medicine
Dates: January 28, 2016 and January 29, 2016

16 Morsani College of Medicine GME

Lunch 'n Learn Education Series

Title: Tackling the ACGME Survey
Presenter: Anne L. Champeaux, MD, FCAP
Program Director, Anatomic &
Clinical Pathology Residency
Date: August 14, 2015

Title: Professionalism
Presenter: Amy Lewis Bergen, LCSW, JD
Associate General Counsel
Date: October 8, 2015

Title: Quality Improvement vs. Research: Program Coordinator
Can We Draw a Line in the Sand?
Presenter: Verena Jorgensen, MD
Associate Professor, College of Professional Development
Medicine, Pediatrics/Medicine
Date: December 3, 2015 Between July 2015 and June 2016, GME offered and
sponsored professional development opportunities
for program coordinators. GME held several New
Title: Key Components of Survey Design Innovations training sessions covering evaluation
Presenter: Jeffrey La Rochelle, MD, MPH
Associate Professor of Medicine, reporting, block and assignment scheduling, IRIS
reporting, FTE reporting, duty hours, procedure
University of the Health Sciences, logger, and custom reports. GME also hosted several
Bethesda, Maryland Partners’ Webinars including Evaluations to Support
Date: February 12, 2016
Milestone Assessments, Dashboards, New Institutional
Accreditation, GME Funding and Financial
Title: Conversations with the C-Suite Implications. The annual ‘Education Coordinator
Presenters: Cuc Mai, MD
Program Director, Internal Medicine Retreat’ was held November 6, 2015 in downtown
Tampa and covered the topics of IRIS reporting, the
Sue Middleton, MHA monthly billing process, and visiting residents.
GME Director
Date: April 5, 2016 In 2015-2016, GME continued to conduct monthly
Education Coordinator meetings in which institutional
information regarding GME and accreditation, affiliated
Title: Tools to Make Interview Session hospital, resident issues, and other relevant items were
Smoother; ERAS and Interview Broker disseminated and discussed. GME also sponsored two
Presenter: Brad Clark, MS program coordinators to attend the February 2016
Internal Medicine Program ACGME annual conference in Maryland.
Administrator
Title: Re-Vamping the Interview Season
Considerations and Lessons Learned
Presenter: Charlotte Derr, MD
Associate Program Director, Emergency
Medicine

Title: Using the Hartman Value Profile in the
Resident Selection Process
Presenter: Michael Harrington, MD
Program Director, Plastic Surgery
Date: May 3, 2016

Morsani College of Medicine GME 17

Institutional Self Study

THE ANNUAL
INSTITUTIONAL
REVIEW (AIR)

Areas of Accomplishment in 2015-16

•  The AIR Committee noted the following •  In order to better understand how the Research
accomplishments in FY 16. The GMEC added the subcommittee is able to best serve the GME
subcommittees of Research, Program Assessment, research community, the committee devised
Special Assessment, and CLER. Committees were an anonymous, online survey, consisting of 13
structured to meet on alternate months to the questions. The main purpose of the survey was to
GMEC and each made significant progress in their evaluate trainees’ perceptions of barriers to pursuing
respective agendas. scholarly activity and conducting research. The
survey was distributed to all USF GME trainees.
•  The CLER subcommittee assessed the barriers to Survey results are still being evaluated but early
reporting system errors and developed educational findings show that a large majority of respondents
material for trainees to use to facilitate use of are interested in participating in scholarly activity
the Tampa General Hospital and the USF error and most felt that the research environment at our
reporting system. The subcommittee assessed institution was average or better. The survey results
program specific transition of care policies and are being evaluated further to discover opportunities
recommended changes to programs that lacked for the subcommittee to help address the needs and
appropriate processes. bridge the gap between research idea and scholarly
output.
•  The Program Assessment subcommittee developed
a standardized approach for review of annual •  The USF Institutional Review Board requires that
program evaluations and WebADS submissions. GME review and approve all research studies that
The subcommittee also implemented a standardized request GME trainees’ participation. Working
Annual Program Evaluation format in New with the GMEC chair, the subcommittee devised a
Innovations to ensure completion of all ACGME standardized review process. Additionally, a research
required elements. protocol review template was developed to help
guide the review process and provide feedback to
•  The Special Assessment subcommittee developed the Principal Investigator.
a special assessment policy that was approved by
the GMEC. The subcommittee reviewed programs •  The GMEC successfully increased resident
having initial site visits and programs identified by attendance at the GMEC and subcommittee
policy as needing a review. The group developed a meetings.
team of qualified reviewers and completed a self-
assessment process evaluating their review results •  Program citations totaled only 14 as of July 1, 2016.
compared to ACGME program recommendations.

18 Morsani College of Medicine GME

The Annual Institutional Review (AIR) is an ACGME required institutional level self-study. The review
content is predetermined and approved by the Graduate Medical Education Committee (GMEC).
In 2015-16, the data content reviewed for the self-study included the most recent minutes/action
plans of GMEC subcommittees; the GMEC AIR action plan monitoring grid from the prior year;
GMEC attendance; most recent Resident and Faculty ACGME Survey results with trend data; overall
data dashboard of citations, board pass rates, and other key indicators; citation data from ACGME;
suggested areas for improvement from ACGME; and finally, the 2015 Annual Report.

Targeted Areas for Improvement in 2016-17

Areas targeted for improvement in 2016-17 include:
•  Develop a brief guide on CLER for hospital

leadership and training programs to increase
engagement and participation in CLER initiatives.
•  Develop individual trainee privilege sets in New
Innovations for residents/programs that conduct
bedside procedures.
•  Continue to present core program data dashboard
elements to the GMEC.
•  The Special Assessment subcommittee will continue
to refine the special assessment process, particularly
to determine where the assessment process did/did
not agree with ACGME findings.
•  Work to create a Tampa General Hospital fellowship
position in patient safety/quality improvement.
•  Monitor the New Annual Program evaluation
process in New Innovations.
•  Incorporate a standard hand-off process across
programs with assessment and adjustments as
needed.
•  Reduce the number of PD members of GMEC to
a core of programs with 10 or more trainees and
adding other ACGME required individuals.

Morsani College of Medicine GME 19

USF Morsani College of Medicine
Graduate Medical Education
17 Davis Blvd., Suite 308 • Tampa, FL 33606
Phone: (813) 250-2506
health.usf.edu/medicine/gme/