2012-2013 Annual Institutional Review Report Graduate Medical Education

48 Pages·2013·0.6 MB·English

2012-2013
Annual Institutional Review
Report
Graduate Medical Education

Robert C. Fore, EdD, FACEHP, CCMEP
Associate Dean and
Designated Institutional Official
November 21, 2013

2012 – 2013 Annual Institutional Review Report
Graduate Medical Education

INDEX
Topic Page

Rationale ....................................................................................................................................1
Description of the Sponsoring Institution and Organizational Structure ...................................1
Program Leadership ...................................................................................................................2
Institutional and Program Accreditation ....................................................................................4
Continued Support and Accomplishments.................................................................................7
Graduate Medical Education Filled Positions..........................................................................11
Graduate Medical Education Committee .................................................................................12
ACGME General Competencies ..............................................................................................14
Internal Reviews ......................................................................................................................15
Resident Supervision ...............................................................................................................15
Resident Responsibilities .........................................................................................................17
Resident Evaluation .................................................................................................................18
Duty Hours ...............................................................................................................................19
Patient Care ..............................................................................................................................19
Patient Safety and Quality Improvement .................................................................................20
Office of Research ...................................................................................................................24
Annual Research Methods Nuts and Bolts Symposium ..............................................25
Annual Research Week and Awards............................................................................25
Resident Stipends and Benefits ................................................................................................26
Strategic Planning and Goals
Clinical ................................................................................................................................28
Educational .........................................................................................................................28
Research ..............................................................................................................................29
Community .........................................................................................................................29

Attachments
Institutional Organizational Chart........................................................................ Appendix 1
Accreditation Grid – Current Accreditation ........................................................ Appendix 2
Accreditation Grid – Categorization of Citations ................................................ Appendix 3
Faculty Development Activities .......................................................................... Appendix 4

Office of Graduate Medical Education
960 East 3rd Street, Suite 104
Chattanooga, TN 37403
Phone: [phone]. Fax: [phone].
Website: www.utcomchatt.org

2012 – 2013 Annual Institutional Review Report on Graduate Medical Education
University of Tennessee College of Medicine Chattanooga
November 21, 2013
Robert C. Fore, EdD, FACEHP, CCMEP
Associate Dean for Academic Affairs and
Designated Institutional Official (DIO)

Rationale
Pursuant to the Accreditation Council for Graduate Medical Education (ACGME) Institutional
Requirements, the following information is submitted as an Annual Institutional Review Report
from the Designated Institutional Official (DIO) for academic year July 2012 – June 2013. The
existing ACGME Institutional Requirements state that the “DIO and/or the Chair of the GMEC
must present an annual report to the Organized Medical Staff(s) (OMS) and the governing
body(s) of the Sponsoring Institution. This report must also be given to the OMS and governing
body of major participating sites that do not sponsor GME programs. This annual report will
review the activities of the GMEC during the past year with attention to, at a minimum, resident
supervision, resident responsibilities, resident evaluation, compliance with duty-hour standards,
and resident participation in patient safety and quality of care education.”

Description of the Sponsoring Institution and Organizational Structure
The University of Tennessee Health Science Center and its College of Medicine sponsor a
Statewide Graduate Medical Education (GME) System with training sites in Memphis, Jackson,
Nashville, Knoxville, and Chattanooga. Due to the size of the programs and their distances from
the main medical school in Memphis, the Chattanooga and Knoxville sites are separately
accredited to sponsor Residency education by the Accreditation Council for Graduate Medical
Education (ACGME). The University of Tennessee College of Medicine Chattanooga
(UTCOMC) has been a major component of the University of Tennessee College of Medicine
since 1973. The UTCOMC is an academic center that has been accredited as the sponsoring
institution for medical education programs at its major affiliated training site, Erlanger Health
System – the area’s recognized leader in health care. Other participating sites include Memorial
Hospital, Parkridge Medical Center, Hospice of Chattanooga, Athens Regional Medical Center,
Siskin Hospital for Physical Rehabilitation, Siskins Children’s Institute, and SkyRidge Medical
Center. All participating hospitals have continued to maintain accreditation by the Joint
Commission for Healthcare Institutions.

The UTCOMC mission is to provide quality medical education, patient care, research, and
community service, emphasizing the following: Medical Student Education, Graduate Medical
Education, Continuing Medical Education, patient care and quality improvement, evidence-based
medicine, patient safety, research and scholarly activity, and community service. The UTCOMC
is the sponsoring institution for a total of 13 accredited Residency and Fellowship programs and
two non-accredited Fellowships in Minimally Invasive Gynecologic Surgery and Orthopaedic
Trauma Surgery. 457 paid and clinical (volunteer) faculty are involved in training and
supervising Residents and Medical Students. [Appendix 1 is an updated institutional
organizational chart detailing the structure of the UTCOMC.]
Page 2 of 29
The 2012-2013 programs have trained 173 individual Residents and Fellows. The chief
executive officer for UTCOMC is the Dean, David C. Seaberg, MD, FACEP. David C. Seaberg,
MD, FACEP, CPE, UTCOMC Dean, has continued to serve as an integral part of Erlanger
Health System’s key leadership groups: Executive Team, Medical Executive Committee,
Executive Leadership Council, and Officers Council. He also serves on the governing board of
the Southside/Dodson Avenue Community Health Centers. Deans at each campus (Memphis,
Knoxville, and Chattanooga) report to the Executive Dean for the statewide College of Medicine,
and ultimately report to the University of Tennessee Health Science Center (UTHSC)
Chancellor. The Chattanooga Associate Dean for Academic Affairs, Robert C. Fore, EdD,
FACEHP, CCMEP, also serves as the Designated Institutional Official (DIO) for Chattanooga
and reports directly to the UTCOMC Dean. Working with the Dean and DIO to provide
oversight for medical education programs are the Director of Graduate and Medical Student
Education, Pamela D. Scott, and the Graduate Medical Education Committee (GMEC). Louis
Lambiase, MD, Assistant Dean for Clinical Affairs, also reports to the Dean in Chattanooga.
UTCOMC Chairs report directly to the Dean in Chattanooga. Chairs either serve as Program
Directors or appoint separate Program Directors, with the approval of the Dean, Associate Dean
for Academic Affairs, and GMEC, for their accredited Residency and Fellowship programs.

Program Leadership 2012-2013:
Department Program Chair Program Associate
Director Program
Director
Emergency Medicine Emergency James H. Creel, Sudave Benjamin
Medicine Residency Jr, MD, FACEP, Mendiratta, MD Smith, MD
Interim Chair,
Department of
Emergency
Medicine (also
serves as Chief
Medical Officer
for Erlanger)
[Note: Dr.
Seaberg has been
appointed Chair
of the
Department of
Emergency
Medicine for
2013-2014.]
Family Medicine Family Medicine J. Mack Stephen M. James W.
Residency Worthington, Adams, MD Haynes, MD
MD, FAAFP
Medicine Internal Medicine Mukta Panda, Lisa J. Staton, Jennifer
Residency MD, FACP MD Dooley, MD,
and Victor
Kolade, MD
2012-2013 UTCOMC Annual Report for GME
Page 3 of 29
Program Leadership (Continued)
Department Program Chair Program Associate
Director Program
Director
Medicine Hospice/Palliative Mukta Panda, Robert W.
Care Fellowship MD, FACP, Goldmann, MD
(Chair,
Department of
Medicine)
Obstetrics/Gynecology OB/GYN Residency Paul G. Stumpf, William Gist,
MD, FACOG MD
(through June 27,
2013)
[Note: Garrett
Lam, MD, was
appointed Chair
effective
November 1,
2013.]
Obstetrics/Gynecology Minimally Invasive Paul G. Stumpf, Stephen Rich,
Gynecologic MD, FACOG MD
Surgery (approved (through June 27,
by the Association 2013)
of American [Note: Garrett
Gynecologic Lam, MD, was
Laparoscopists) appointed Chair
November 1,
2013.]
Orthopaedic Surgery Orthopaedic Surgery Richard G. W. Michael
Residency Alvarez, MD Tew, MD
Orthopaedic Surgery Orthopaedic Trauma Richard G. Pete
Fellowship Alvarez, MD Nowotarski, MD
(accredited by the
Orthopaedic Trauma
Association)
Pathology None Richard Hessler,
MD
Pediatrics Pediatrics Residency Alan Kohrt, MD, Janara J. Huff, Marielisa
FAAP MD Rincon, MD
Plastic Surgery Plastic Surgery Larry A. Sargent, Mark A. Jason Rehm,
Residency MD, FACS, Brzezienski, MD
FAAP MD
Radiology None R. Kent Hutson,
MD
Surgery Surgery Residency R. Phillip Burns, Joseph B. Cofer, Richard A.
MD, FACS MD, FACS Moore, MD,
PhD, FACS;
Ben Dart, MD,
FACS; Heath
Giles, MD
2012-2013 UTCOMC Annual Report for GME
Page 4 of 29
Program Leadership (Continued)
Department Program Chair Program Associate
Director Program
Director
Surgery Colon and Rectal R. Phillip Burns, Richard A. Daniel Stanley,
Surgery Fellowship MD , FACS Moore, MD, MD, FACS
(Chair, PhD, FACS
Department of
Surgery)
Surgery Surgical Critical R. Phillip Burns, Robert A.
Care Fellowship MD , FACS Maxwell, MD,
(Chair, FACS
Department of
Surgery)
Surgery Vascular Surgery R. Phillip Burns, L. Richard
Fellowship MD, FACS Sprouse, MD,
(Chair, FACS
Department of
Surgery)

Free-Standing Program Sponsors Program Director Associate Program
Program Director
Transitional Year Internal Medicine and Mukta Panda, MD, Jennifer Whitley
Residency Pediatrics FACP Dooley, MD
Institutional and Program Accreditation (ACGME)
Institutional Accreditation
Previously, the Chattanooga Campus was awarded Continued Accreditation in the December 16,
2011 letter from the ACGME’s Institutional Review Committee (IRC). The IRC granted the
“maximum accreditation cycle of five years until the next institutional site visit (approximately
October 2016) and commended the institution for its demonstrated substantial compliance
with the ACGME requirements for Graduate Medical Education without citation.’” Due to
changes in the ACGME accreditation system, called the “Next Accreditation System” (NAS),
institutional site visits are being transitioned to self-study site visits, and ours is tentatively
scheduled for October 2023 (a maximum 10 year cycle).

Program Accreditation
All 2012-2013 Residency and Fellowship programs are ACGME-accredited with the exception
of the Minimally Invasive Gynecologic Surgery and Orthopaedic Trauma Surgery Fellowships,
and ACGME accreditation is not required for those subspecialties. All programs have Continued
Accreditation with none on probation. [Appendix 2 is an accreditation grid denoting the
current accreditation information for each program, and Appendix 3 is a grid categorizing
all current citations as reported by the Institutional Review Committee.]

All programs are funded through Erlanger and the UT College of Medicine except:
• Hospice and Palliative Care Fellowship funded by Hospice of Chattanooga and
• Orthopaedic Trauma Surgery Fellowship funded by the American Orthopaedic
Association - Synthes, Inc.
2012-2013 UTCOMC Annual Report for GME
Page 5 of 29

2012-2013 Site Visits
Two programs participated in site visits by the ACGME during 2012-2013:
1. Colon and Rectal Surgery Fellowship (October 25, 2012)
The program is a one-year program requiring at least five prior years of training.
Effective February 22, 2013, the Colon and Rectal Surgery Fellowship received
Continued Accreditation for one fellow with a four-year cycle until the next site visit
(February 2017). The RRC “commended the program for its demonstrated
substantial requirements ACGME requirements for Graduate Medical Education”.
The RRC “commended the program for the active involvement of the resident in a quality
improvement project focused on PICC-associated DVTs. The RRC identified this
learning activity as a potential notable practice and requests the Program Director’s
permission to include it in a notable practices database available on the ACGME
website.” Two citations were identified, and a progress report was requested by August
8, 2013. Due to accreditation changes under NAS, the regular site visit in 2017 will be
replaced by a Self-Study Visit in September 2020.
2. Transitional Year Residency (October 24, 2012).
The program is a one-year residency at the PGY-1 level for residents planning to enter
advanced residency specialties including Anesthesiology, Dermatology, Neurology,
Ophthalmology, Pathology, and Radiology. Effective May 02, 2013, the program
received Continued Accreditation for up to eight residents with the maximum five-year
cycle until the next site visit (May 2018). The RRC identified three documentation
citations (one regarding the Transitional Year Education Committee responsibilities; one
regarding documentation faculty credentials; and one regarding documenting an
evaluation process for residents’ competence in communicating with team members in
the hand-over process). The RRC did acknowledge that the program has established
formal hand-off mechanisms and had already included a question about competency in
transitions of care in each end of rotation evaluation instrument. Due to accreditation
changes under NAS, the regular site visit in 2018 will be replaced by a Self-Study Visit
in May 2023.

Other RRC Accreditation Letters Received during 2012-2013
• OB/GYN Residency (Site Visit - January 31, 2012)
The official RRC Notification Letter for the four-year OB/GYN Program was received
October 17, 2012, in which the program received Continued Accreditation with a four-
year accreditation cycle. This represented incredible efforts from the program,
University, and hospital leadership since the program had been on probation prior to the
site visit in early 2012. The program was approved for 16 residents, effective May 17,
2012, with the next site visit scheduled for May 2016. The RRC “commended the
program for its demonstrated substantial compliance with the ACGME
requirements for Graduate Medical Education … The Committee commended the
program for a 100% Board pass rate for program graduated over the past five to
six years. The Program Director and Chair have done a remarkable job addressing
the concerns that led to a probationary status, changing the culture of the Program
and improving the residents’ morale.” The RRC identified three citations regarding
procedural experience and education in spontaneous deliveries, abdominal
2012-2013 UTCOMC Annual Report for GME
Page 6 of 29
hysterectomies, and abortion procedures. Due to accreditation changes under NAS, the
regular site visit in 2016 will be replaced by a Self-Study Visit in June 2020.
• Hospice and Palliative Medicine Fellowship (Site Visit - February 2, 2012)
Hospice and Palliative Medicine received Continued Accreditation for one Fellow with a
four-year accreditation cycle. The program is a one-year fellowship. The RRC
“commended the program for its demonstrated compliance with the ACGME
requirements.” The RRC identified two citations (faculty scholarly activity
documentation and a structured core curriculum conference to augment the fellow’s
clinical experience. The next site visit was projected for May 2016; however, due to
accreditation changes under NAS, the regular site visit in 2016 will be replaced by a Self-
Study Visit in June 2021.
• Plastic Surgery (Site Visit - May 24, 2012)
Plastic Surgery received Continued Accreditation in the RRC letter of December 4, 2012,
with approval for five residents in the three-year program (effective October 11, 2012)
with the maximum five-year accreditation until the next site visit 2017. The RRC
“commended the program for its demonstrated compliance with the ACGME
requirements.” The RRC identified one procedural documentation citation. Due to
accreditation changes under NAS, the regular site visit in 2017 will be replaced by a Self-
Study Visit in October 2020.

All Program Information Forms (PIFs) and documentation, including results from ACGME
Annual Online Resident and Faculty Surveys were reviewed by the Dean, Associate Dean/DIO,
and Director of Graduate and Medical Student Education prior to submission to the individual
RRC’s. All correspondence between programs and RRC’s has also been reviewed by the
GMEC. As required by the ACGME, the GMEC has approved all appointments for new
Program Directors, new programs, progress reports, requests for changes in complement, etc.

Program Leadership Changes in 2012-2013
New Program Directors
• Mark Brzezienski, MD, Plastic Surgery Residency
• William Gist, MD, OB/GYN Residency
• William Goldmann, MD, Hospice and Palliative Care Fellowship
• Sudave Mendiratta, MD, Emergency Medicine Residency

Chair
After the successful site visit for the OB/GYN Program Paul G. Stumpf, MD, FACOG, Professor
and Chair of the Department of Obstetrics and Gynecology, resigned at the end of June 2013 in
order to join his family in New Jersey. Garret Lam, MD, was appointed Interim Chair in August
2013 and was named Chair of the Department on November 1, 2013.

Associate Program Directors
• Jennifer Dooley, MD, Internal Medicine Residency (Inpatient Medicine)
• W. Heath Giles, MD, Surgery Residency
• Victor Kolade, MD, Internal Medicine Residency (Outpatient Medicine and Research)
• Jason Rehm, MD, Plastic Surgery Residency
• Benjamin Smith, MD, Emergency Medicine Residency
2012-2013 UTCOMC Annual Report for GME