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• Site Visit Manual (pages: 1 - 19)

• Site Visit Workbook (pages: 19 - 28)

Osteopathic Obstetric and Gynecology


Residency Training Programs:

American Osteopathic Association


and the
American College of Osteopathic Obstetricians and Gynecologists
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TABLE OF CONTENTS

INTRODUCTION 4

AOA RESIDENCY PROGRAM APPROVAL 5


• Recognition
• Benefits of AOA and ACOOG Program Approval
• Approval Process
• Criteria for Continuing Approval REC Recommendations
• One-Year Approval/Denial of Program Approval

SITE VISITORS 7
• Eligibility and Selection of the Site Visitor
• Site Visitor Responsibilities

PREPARING FOR THE SITE VISIT 8


• Responsibilities of Site Visitor Prior to the Visit
• Travel Arrangements
• Policies

COLLECTING INFORMATION DURING THE SITE VISIT 10


• Site Visit Agenda
• Preliminary Meeting with Program Director
• Review of Documents
• Explanation of Documents
• Selection of Charts from Medical Records
• Clinical and Teaching Facilities
• Chart Review
• Interviews with Residents
• Interviews with Department Faculty, DME, Institution Administration
• Completion of Site Visit Reports
• Final Meeting

REPORTING FINDINGS OF THE SITE VISIT 16

ACOOG GLOSSARY AND ACRONYMS 17

APPENDIX 19
• Site Visit Workbook for Osteopathic OB/GYN Residency Training Programs

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SITE VISIT MANUAL
INTRODUCTION
This manual has been developed by the American College of Osteopathic Obstetricians and
Gynecologists (ACOOG) Residency Evaluation Committee (REC). The REC is responsible for
developing and maintaining residency training standards as well as making recommendations to the
American Osteopathic Association (AOA) Program and Trainee Review Committee (PTRC) on whether
training programs meet the established standards for program approval. Residency training standards for
obstetrics and gynecology are posted on the AOA website, www.do-online.org.

This manual is designed to:


• Describe the process for assessing the compliance of osteopathic residencies with the
AOA/ACOOG standards;
• Clarify the expectations of the ACOOG regarding the responsibilities of site visitors, program
directors, directors of medical education, and the training institution;
• Enhance the reliability, consistency, and validity of the decisions regarding the compliance of
training programs;
• Assist the Program Director to describe how the program complies with the residency training
standards; and,
• Prepare the Program Director, Director of Medical Education, and institution for a site visit.

Questions? Contact the ACOOG at 800-875-6360 or visit the ACOOG web site, www.acoog.org.

ACOOG Mission Statement


ACOOG is passionately committed to excellence in women's health. With integrity, we shall
educate and support osteopathic health care professionals to improve the quality of life for
women. In doing so, we will provide opportunities for fellowship and joy in our profession.

ACOOG Core Values


1. ACOOG will foster INTEGRITY by:
™ Treating each person with respect and dignity
™ Maintaining our values at all times and under any
circumstances
™ Demonstrating responsibility and honesty

2. ACOOG is COMMITTED to:


™ Promoting excellence in women's health
™ Promoting osteopathic education in women's health
™ Improving all aspects of our organization
™ Developing an innovative vision for the future

3. ACOOG will foster EXCELLENCE by:


™ Promoting educational programs that are innovative,
visionary, inclusive and socially relevant
™ Providing service to members, their patients and the public
™ Providing avenues for fellowship, communication and
teamwork

ACOOG Vision Statement


ACOOG will be the premier leader in the physical, emotional and spiritual health of women.

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AOA RESIDENCY PROGRAM APPROVAL
Recognition

The AOA is the only organization recognized by federal and state authorities to establish and maintain
standards for osteopathic postdoctoral medical education. The AOA has assigned this responsibility to
the ACOOG and the AOA Program and Trainee Review Committee (PTRC), a component of the AOA
Bureau of Osteopathic Education.

Benefits of AOA and ACOOG Program Approval

Approval by the ACOOG and AOA assures that an osteopathic obstetrics and gynecology residency
program has demonstrated sufficient evidence of the capability to successfully educate osteopathic
gynecologists and obstetricians, and that the program should continue to do so in the future.

The ACOOG REC serves as an advisory body to the AOA’s Program and Trainee Review Committee
(PTRC) for the approval of individual residents’ training and of obstetrics and gynecology training
programs. The REC’s primary functions are to develop and maintain residency training standards and to
assure that residency programs and individual physicians seeking AOA approval comply with the training
standards. Program approval signifies that the residency program meets or exceeds the AOA residency
training standards.

Successful completion of a residency training program approved by the ACOOG and AOA is a
prerequisite for a physician to be certified by the AOA through the American Osteopathic Board of
Obstetrics Gynecology (AOBOG).

Approval Process

Prerequisites for AOA program approval and the process of approval for new programs are explained in
the residency training standards. In summary, the institution obtains application materials from the
Department of Education, Division of Postdoctoral Training, Inspection Services of the AOA. The
institution must submit a new program application along with a program description, information on scope,
volume and variety of patients, the qualifications of the Program Director and faculty, copies of affiliation
agreements, and fees. This information is reviewed by the AOA staff and forwarded to the ACOOG REC.

The ACOOG REC may decide to take action on a request based on the information provided, or may
request that a consultant, identified from a list of experienced site visitors, review the submitted materials
(requesting additional materials if necessary), conduct a site visit, and report their findings to the AOA and
ACOOG.

The ACOOG REC reviews the application. If a site visit was required, the site visitor’s report is included
in this review. The Committee makes a recommendation regarding program approval to the AOA’s
PTRC. Recommendations for denial are accompanied by an explanation of program deficiencies that are
cross-referenced to the residency training standards.

All new programs must be re-visited within one (1) year of residents enrolling in the residency program. If
no resident is recruited within three (3) years, the program lapses, and must begin the approval process
as a new program.

Procedures for continuing approval of established programs are described in the residency training
standards. When a residency program is due for a site visit, the ACOOG assigns site visitors to visit
specific programs. The ACOOG informs the AOA of the selected site visitor. The AOA confirms the
name of the site visitor with the Program Director and Director of Medical Education (DME).

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The site visitor arranges a visitation date with the program, conducts the site visit to validate compliance
with the training standards, and submits a completed site visit workbook with appropriate documentation,
to the AOA and ACOOG REC for review. The ACOOG REC makes a recommendation to the PTRC.

Criteria for Continuing Approval REC Recommendations

ACOOG REC recommendations for continuing program approval always specify the number of years
before another site visit is necessary. Excellent programs may be approved by the PTRC for up to five
(5) years before the next site visit. Programs that meet most standards but have some deficiencies or
appear to be in transition are recommended for approval with a re-visit within two (2) to four (4) years.
The REC adheres to the following criteria for continuing approval recommendations to the AOA:

Approval with re-evaluation in five (5) years: An EXEMPLARY program is an outstanding program
that sets the standard for excellence in post-graduate
medical education. There are no or only minor
administrative deficiencies present. Any deficiencies, if
present, have not been persistent or recurrent and are
easily correctable once recognized. Such deficiencies
have no bearing on the academic and clinical quality of
the program and do not adversely affect the
administrative functioning and oversight required.
Standards and practices are in place to ensure that all
trainees have the opportunity to fulfill all competencies.

Approval with re-evaluation in four (4) years: An EXCELLENT/GOOD program is one that meets or
exceeds academic and clinical standards. Deficiencies
are minor, not persistent or recurrent. Correction of
these deficiencies should be able to be completed within
90 days with little or no potential for recurrence. Such
deficiencies should have no bearing on the overall
academic and clinical quality of the program. Standards
and practices are in place to ensure that all trainees
have the opportunity to fulfill all competencies.

Approval with re-evaluation in two (2) years: A SATISFACTORY program is one that may have either
minor academic or clinical deficiencies, major or multiple
minor administrative deficiencies or a combination of
both. These deficiencies, although of concern, do not
clearly affect the opportunity of the trainee to fulfill all
competencies. Correction of these deficiencies will likely
require a concerted effort by the program director, DME,
OPTI and institution. Correction of these deficiencies
should be able to be completed within six months.
Additionally, a program that has recently been on
probation or a new program at first full inspection may
receive a satisfactory evaluation to ensure that
consistency is maintained.

NOTE: The two-year recommendation is to be used for programs which have correctable deficiencies or
document in a transition which may affect the quality of training, but require an early re-visit to evaluate
the correction of deficiencies (AOA/ACOOG Basic Standards for Residency Training in Obstetrics and
Gynecology.)

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Approval with re-evaluation in one (1) year: A PROBATIONARY program has major and/or multiple
(may be withor without the ability to recruit) minor deficiencies that have a significant potential to
affect the opportunity of the trainee to fulfill all
competencies. Correction of these deficiencies will
require an intensive coordinated effort by the program
director, DME, OPTI and institution. Correction of
deficiencies that jeopardize the attainment of
competency for the trainee must be completed within 90
days. The remaining deficiencies should be corrected
within six months.

A program with major deficiencies fails to address one or more of the following standards:
1. Qualified active Program Director and sufficient faculty who teach, evaluate, and support the
program
2. Institution’s support to run the program effectively
3. Sufficient operative experience for the residents that are enrolled
4. An effective planned curriculum that covers the scope of the specialty
5. An effective and comprehensive evaluation system for the residents and the faculty
6. An internal evaluation system for the program that focuses on improvement
7. A good balance of service and education – i.e. good education and good clinical experience
8. Evidence of osteopathic application

Deficiencies considered minor are administrative in nature and unrelated to the basic structure and quality
of the training.

NOTE: In deliberation of deficiencies, the REC will determine the significance of deficiencies in relation to
the program.

One-Year Approval/Denial of Program Approval

Programs that meet most standards but are not in compliance with one (1) or more major standard may
be approved with a re-visit within one (1) year, with a requirement that the program immediately
correct any deficiencies. Such programs are informed of the specific deficiencies, referenced to the
specific residency training standards. Any established residency program which has received AOA
approval for one (1) year because of deficiencies will not be permitted to contract with a new resident until
such time as the program receives AOA approval of two (2) or more years although such programs may
continue to contract with residents already in training. After appropriate review and recommendation from
a specialty college, the PTRC may waive this requirement. All one (1) year continuing program approvals
shall be considered probationary status, unless deemed otherwise by the REC. Furthermore, failure to
correct deficiencies will result in denial of program approval. Institutions that are unable to correct
deficiencies may choose to voluntarily terminate their programs.

If programs are recommended for denial of continuing approval or for approval with a re-visit within one
(1) year, the program may appeal the decision by entering the AOA PTRC appeal process.

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SITE VISITORS
Eligibility and Selection of the Site Visitor

The ACOOG selects site visitors from a list approved by the REC and PTRC. Any person deemed
qualified by the ACOOG REC and AOA and who has expressed an interest in serving as a site visitor, is
AOA or AOBOG board certified, attended an Inspectors Workshop, and has experience in the training of
residents, may serve as a site visitor.

In an effort to reduce the cost of a site visit, a site visitor may be asked to conduct two (2) or three (3) site
visits in the same geographic area, to avoid additional airfare. However, cost considerations are
secondary to those of specialty expertise and conflict of interest.

The term “consultants” refers to experienced site visitors who are capable of recommending program
improvements in addition to providing the reports required by the AOA and the ACOOG. The AOA uses
the term “consultation” both for site visits to new programs which have not previously been approved, and
for site visits to programs which have been identified as having at least one (1) major deficiency and
therefore have been recommended for approval with a re-visit within one (1) year.

Efforts are made to avoid conflict of interest in assignment of site visitors. Site visitors may not practice
in the same geographic area as the program being inspected. Site visitors also should not agree to visit a
program for which they have a personal conflict of interest – for example, if the Program Director is a
relative; if the site visitor’s employment/staff privileges were ever terminated by the institution being
inspected; if the site visitor is a candidate for employment/staff privileges at the institution or if there are
any other personal or professional relationships, either positive or negative, which might influence or
might appear to influence the site visitor’s judgment regarding the program. It also is preferable that site
visitors not visit programs at institutions where they trained or practiced. If the potential site visitor or
program being visited has questions about a possible conflict of interest, he or she should contact the
ACOOG for clarification regarding the site visit assignment.

An REC member should not evaluate a program in which there is a real or perceived conflict of interest,
such as reviewing a program in the region in which they practice. REC members will absent themselves
from the REC meeting room when their program is reviewed by the REC or when they serve as a site
visitor or educational consultant for a program being reviewed by the REC.

Site Visitor Responsibilities

The site visitor’s primary responsibility is to confirm the training program’s adherence to the AOA/ACOOG
training standards and to collect supporting data for the REC to review and evaluate.

The site visitor is representing both the AOA and the ACOOG. The site visitor must remain professional
and objective at all times. The site visitor is acting as an advocate for educational improvement.
Derogatory comments are unacceptable and will not be tolerated. The site visitor also should avoid social
activities with institution representatives that might be perceived as creating a conflict of interest (i.e. -
accepting expensive dinners or entertainment).

While the ACOOG welcomes suggestions for improvement of standards and site visit procedures from all
members of the profession, the site visit is not an appropriate time to voice objections to AOA or ACOOG
policy or procedures. During a site visit, site visitors are expected to be supportive of the AOA, the
ACOOG, the standards developed by these professional organizations, and site visit procedures.

Site visitors must assist in defusing any hostility towards the site visit process and work in a collegial, fair
and impartial manner. This is particularly important for assignments with programs that have been cited
for previous deficiencies, or that feel they were unfairly treated in the past. The site visitor must maintain
and communicate the need for adherence to educational standards, and exhibit behavior which is beyond
reproach and fully professional.

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PREPARING FOR THE SITE VISIT
Responsibilities of the Site Visitor Prior to the Visit

After a site visitor has agreed to conduct the site visit, the ACOOG confirms the site visit in writing to the
site visitor with copies to the AOA and the Program Director. The AOA staff sends a letter to the site
visitor and to the residency Program Director at the institution to confirm the name of the site visitor, the
due date for completion of the site visit, and preparations to be completed in advance of the site visit.
The letter to the site visitor should include the AOA travel policies that must be followed by the site visitor
in order to be reimbursed for their site visit expenses. The AOA forwards copies of all correspondence to
the ACOOG, DME, and OPTI administrative staff. The letter from the AOA to the residency Program
Director should instruct the residency Program Director of the materials to be available at the time of the
visit (see Appendix, Part B).

The Program Director is required to send one (1) copy of the following materials to the site visitor
approximately 30 days prior to the site visit:

• A current program description (includes mission statement, goals and objectives, curriculum,
summary of academic and clinical experience, resident-patient care responsibilities, rules
and regulations)
• Departmental segregated totals of patient scope and volume on ACOOG approved forms for
the last full year (NOTE: The patient load of the residency program must be sufficient to train
a minimum of three (3) residents.);
• Current curriculum vitae of the Program Director;
• A list of department members and their current certification status;
• Current affiliation agreements for all outside rotations, and,
• Completed standards worksheet (Part C of the workbook) by the institution/training program.
(NOTE: All deficiencies must be explained.)

If the site visitor has not received the required materials listed above at least two (2) weeks before the
date of the site visit, this may be interpreted as non-compliance with the standards and may jeopardize
the approval status of the program.

As soon as the site visitor receives a formal confirmation letter from the AOA, the site visitor should
contact the Program Director to arrange a specific date for the visit. The site visit should be conducted on
a weekday which is not a holiday, on a date when the institution’s DME and program faculty will be
available to meet with the site visitor, and when the program residents are on-site and available for
interview. Other schedules (such as a weekend day) may be negotiated if mutually agreeable to the site
visitor and Program Director, if necessary personnel are available. The site visitor must inform the AOA
or ACOOG of the date of the site visit.
NOTE: The Program Director is responsible for arranging a date suitable for the DME and faculty. The
site visit must be completed within a 30-day time frame before or after the due date identified by the AOA
in the confirmation letter.

In preliminary telephone conversations with the Program Director, the following should be discussed:

• Specific date of the site visit;

• Expected arrival time of the site visitor;

• Materials to be sent in advance, including a map to the institution and name and phone number of a
local hotel and airport, if necessary; and,

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• Characteristics of the room in which the site visitor will be working (a board room or private
conference room is most desirable), the room should be able to accommodate all required materials
and allow privacy for interviews;

• Materials to be available at the institution at the time of the site visit (see Appendix, Part B);

• The agenda for the site visit (see page 10);

• Specific individuals whom the site visitor wishes to interview, including the DME, administration, and
residents; and,

• Individuals to be available for the final meeting, including the DME and Program Director.

The site visitor must be completely familiar with the site visit manual and completed workbook
prior to the site visit. The site visitor must read the workbook completed by the Program Director as well
as any supplemental documents. The site visitor also should read the site visit materials provided by the
AOA, including the report of the last site visit of the program. If the site visitor has other reasonable
requests for materials or if there appear to be inconsistencies or inaccuracies in the submitted materials,
the site visitor should ask the residency Program Director to send corrected or additional documentation.

Travel Arrangements

The site visitor is expected to make his or her own travel arrangements. If all policies of the AOA are
followed, full reimbursement can be obtained from the AOA for travel expenses. The site visitor should
carefully follow the policies regarding reimbursement which accompany the AOA letter confirming the
appointment as site visitor for a particular program. (These policies are subject to change, and
therefore not included in this manual.) If the AOA does not provide a copy of the travel policies, the
policies should be requested from the AOA Division of Postdoctoral Training Inspection Services.
Questions about travel expenses should be directed to the AOA at (800) 621-1773.

Policies

Timeline for Site Visits


Written correspondence from the AOA will notify both the site visitor and the Program Director of the
timeline for the site visit. This correspondence will state the due date for the site visit. A copy of the
correspondence also will be forwarded to the DME of the institution. NOTE: Inspections should be
arranged four months prior to the due date determined by the AOA. Inspections must occur within a
30-day timeframe before or after the AOA due date.

If the site visit is not performed within the time frame for completion of the site visit because of an
unreasonable deferral by the Program Director, the ACOOG staff will notify the Program Director in
writing that the REC may take action to administratively withdraw the program’s approval at the next
scheduled REC meeting for failure to follow the policies and procedures of the REC and AOA. This
correspondence will be copied to the DME and OPTI.

Administrative Withdrawal of Accreditation for Non-compliance with Approval Actions and Procedures
A Program Director may be deemed to have withdrawn from the voluntary process of approval and
the REC may take appropriate action to withdraw approval if a Program Director does not comply with
the following actions and procedures:
• To adequately prepare for or undergo a site visit as required within the required time period;
• To follow policies, procedures or recommendations for corrective actions(s) associated with an
approval action;
• To supply the REC with requested information.

Administrative withdrawal of approval for non-compliance with approval actions and procedures is not
subject to the ACOOG/AOA appeals process.

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COLLECTING INFORMATION DURING THE SITE VISIT
Site Visit Agenda

The specific agenda of a site visit should be confirmed in advance by the site visitor and the Program
Director. Generally, the visit should be designed to collect the most information possible in the time
available, with minimum disruption to the day-to-day activities of the institution being visited. The
following general schedule may be helpful in planning the agenda (although this schedule may be altered,
including expansion to two (2) days, if necessary).

SAMPLE AGENDA

Activities for each time period are discussed in detail in the sections below.

8:00 a.m. Site visitor arrives; preliminary meeting with Program Director

8:30 a.m. Review with the Program Director to be sure all required documents are
available/selection of charts to be pulled

8:40 a.m. Review standards worksheet (Part C of the workbook) completed by the program with the
Program Director

8:50 a.m. Review affiliation agreements and discuss out-rotation scheduling with the Program
Director

8:55 a.m. Review written curriculum and discuss how it is implemented with the Program Director

9:00 a.m. Review resident logs, with identification of charts needed from medical records, operating
log book, mortality book, and records of adherence to duty work hour requirements

10:00 a.m. Review of clinical, educational, and departmental facilities

11:00 a.m. Start chart review, examine scientific papers, review other documents provided or
requested

Noon Working lunch/interviews with residents

1:30 p.m. Interviews with department faculty, DME, institution administration

2:30 p.m. Complete chart review, complete site visitor’s workbook (complete Parts A and B, and
verify Part C); meet again with Program Director if necessary

4:30 p.m. Conduct final meeting.

PRELIMINARY MEETING WITH PROGRAM DIRECTOR (8:00 – 8:30 A.M.)

Review of Day’s Schedule. The first item of business should be clarification regarding the day’s
schedule, and when individuals will be interviewed. (If residents are on out-rotations, the site visitor may
obtain telephone numbers so that telephone interviews can be arranged). The site visitor should be
flexible regarding reasonable changes in the scheduling of agenda items, while continuing to insure that
adequate time is available with the necessary individuals to obtain needed information. The site visitor
also should know whom to contact for additional information, if needed during the day (i.e., the telephone
number for the Program Director’s secretary, who would know how to respond to any requests).

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Review of Final Meeting. The site visitor also should clarify expectations regarding the final meeting
(see page 16), to be sure that the Program Director understands the format of that meeting and knows
whom to have in attendance.

Overview Discussion of the Residency Program. Finally, the site visitor should ask the Program
Director to provide an overview of the residency program – its history, current status, administrative
support, out-rotations, affiliation agreements, curriculum, and what the director regards as the program’s
strengths and weaknesses.

REVIEW OF DOCUMENTS (8:30 – 10:00 a.m.)

At the beginning of the visit, the site visitor should verify that all requested documents are available.
(Detailed review of the content is done later in the day.) When the site visit was scheduled, the AOA
advised the Program Director that the following documents were to be available in the room at the time of
the site visit. (For a new program, the list must be modified, i.e., expect a list of proposed lectures rather
than lectures given.)

If any documents are missing, request them so they will be available for review. Documents include:

1. Resident logs, annual reports, and scientific papers for each resident for their current and
previous year(s)

2. Ob-Gyn department/division minutes for the current and previous year

3. Current Ob-Gyn department/division rules and regulations

4. List of lectures for current and previous year

5. Journal Club minutes for current and previous year(s)

6. Evaluations of each resident for in-hospital and outside rotations for current and previous year

7. List of journals and books available in the hospital library and/or via online services in this
specialty

8. Each resident’s evaluations of the program since last inspection

9. Completed standards worksheet (see Appendix, Part C)

10. Operating room log book for current/previous year relating to Ob-Gyn cases.

11. Mortality book for current/previous year if applicable

12. Tumor board meeting minutes for current/previous year

13. Quality assurance board meeting minutes for current/previous year

14. Current resident manual, including resident dismissal/grievance process, and resident duty hour
policies and procedures

16. Current program description (includes a mission statement, goals and objectives, curriculum,
summary of academic and clinical experience, resident-patient care responsibilities, rules and
regulations)

17. Current CVs of Program Director and department members participating in the training program

18. Current affiliation agreements for all out-rotations

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19. Program segregated totals for the last year or last complete training year

20. Resident duty work hour logs for the last 12 months

21. Current contracts for each resident

22. Documentation attesting to each resident’s professional qualifications to include:


• Official graduation transcript from the college of osteopathic medicine;
• Certificate and letter of recommendation from the DME of the internship program
of graduation;
• Current licensure as a physician in the state where the training program and
clinical training site(s) are located; and,
• Membership in the AOA. (These should be in the Resident files)

Explanation of Documents

Obstetric and Gynecological curriculum provides an outline of the actual residency training program.
The review will determine if the curriculum is current and relevant and if the AOA core competencies have
been integrated into the curriculum.

Meeting minutes and or log are reviewed primarily to assess resident participation in these activities.
Review of minutes should document participation by residents in all professional staff activities involving
patient care.

Affiliation agreements are required by the AOA for all out-rotations. The documents are reviewed to
determine if they are current and to ensure adherence to the standards and program curriculum.

Lecture schedules are reviewed to assess the adequacy of the didactic program. Lecture topics should
encompass the entire gamut of obstetrics and gynecology over the years of the program. Teaching
should be conducted by faculty of the institution, outside consultants, and residents.

Evaluations of resident performance are reviewed to monitor the timeliness and quality of feedback
given to residents. These evaluations, in combination with the resident logs, provide information
regarding the nature of clinical rotations, particularly for out-rotations that may be a critical part of the
resident’s experience.

Resident evaluations of their rotations should be reviewed before the interviews with residents, so that
the site visitor can discuss with residents whether the issues they raised in their evaluations were
adequately resolved by the program director and hospital administration.

Resident evaluations of the Program Director and Program Faculty should be forwarded along with
other documents at least thirty days prior to the site visitor by the ACOOG for the years since the last site
review. These have been available to the Program Director annually through the online anonymous
method established previously and should have been shared with the DME in the interest of total quality
improvement.

Resident contracts are reviewed to ensure that the number of contracts do not exceed the number of
AOA-approved resident positions.

Segregated totals are reviewed to determine if the program provides adequate scope and volume in the
procedures afforded to the residents.

Resident duty work hour logs are reviewed to ensure compliance with AOA standards.

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Selection of Charts from Medical Records

During most Ob-Gyn program site visits, the next item is selection of charts to be pulled by medical
records, so that these charts will be available for review later that morning. Resident logs are reviewed to
evaluate the volume and mix of patients being seen, and the resident’s level of participation. At least
twenty (20) charts total should be pulled, to review residents’ participation in care provided. Charts
requested should include some principle Gyn surgeries and some case complications, as well as charts
representing the range of cases in the Obstetrics discipline. The site reviewer at his or her discretion may
request additional charts. All patient identifiable information must remain at the training site.

During the review and evaluation of health care facilities’ postdoctoral training programs, health care
facilities may disclose or otherwise provide to the site visitor certain Protected Health Information (“PHI”)
as defined in 45 C.F.R. 164.501, that may be subject to protection under the Health Insurance Portability
and Accountability Act of 1996 (“HIPAA”) and/or regulations promulgated thereunder. AOA has entered
into business associate agreements with the healthcare facilities to which it provides review and
evaluations of postdoctoral training programs and the terms of such business associate agreements
require AOA and ACOOG to ensure that any site visitor that receives, uses, or has access to such health
care facility’s PHI, comply with the same restrictions, conditions and requirements regarding the use
and/or disclosure of PHI and safeguards for PHI that apply to AOA/the ACOOG, and/or are required by
law. In addition, the ACOOG has entered into a business associate agreement with the AOA that requires
that site visitors shall not remove or take any PHI from the healthcare facilities that the site visitor reviews
and evaluates for AOA and ACOOG.

REVIEW OF CLINICAL, EDUCATIONAL, & DEPARTMENTAL FACILITIES (10:00 – 11:00 a.m.)

The library is a critical area, which should contain adequate facilities and references to allow
independent learning. Note the availability of audio-visual resources and computer access to the Internet
for residents. The site visitor has the responsibility for determining if the resources are current and
adequate in number to fully train residents. The site visitor must also determine if the resources are
available to residents a reasonable number of hours each day and that adequate access to references is
provided for emergency use.

In the operating room, the site visitor should note patient flow, number of rooms, and whether equipment
is up-to-date. The capability for immediate frozen sections and radiographs should be noted. The site
visitor should look at the operating room schedule for the day, and note resident participation in current
cases. Site visitor may inspect OB/GYN/surgical division Policies and Procedures Manuals.

On the obstetric, or labor and delivery floor, the site visitor should look at current charts to see the
level of resident participation. In the outpatient surgery area, the site visitor should look at charts to
evaluate resident participation in pre-operative and post-operative care.

The walk-through of clinical facilities also should include review of the following: radiology, ultrasound; CT
scan; blood bank; and blood chemistry lab.

CHART REVIEW (11:00 a.m. – 12:00 noon)

The major purpose of the chart review is to evaluate whether residents are getting progressive
responsibility consistent with the level of training. Chart review also assesses resident involvement in the
pre-operative and post-operative management of cases. AOA standards require that residents be given
progressively increasing responsibility for patient care. All patient identifiable information must
remain at the training site.

14
The site reviewer is to give a narrative assessment of the program (see page 16). The narrative must
include an assessment of the charts reviewed addressing the following chart review elements:

1. Number of records reviewed


2. Categories
3. Completeness – (H and P’s, consults discharge summaries, progress notes cancer staging)
4. Evidence of resident participation
5. Diagnosis, appropriate surgical management
6. Evidence of osteopathic principles and application
7. Pathology reports and operative reports

INTERVIEWS WITH RESIDENTS (12:00 noon - 1:30 p.m.)

If possible, all residents in the program should be interviewed either in person or by telephone, rather
than allowing the Program Director to select only a small proportion to meet with the site visitor.
Residents may be interviewed either as a group or one-to-one. The residents should be advised that the
site visitor is seeking information for program approval and program improvement, and that while the
general results of the interview will be included as part of the report, the identity of any individual resident
will not be revealed. Interviews with residents should focus on two (2) major issues:

1. The degree to which the program teaches, rather than just using residents for clinical service;
and,

2. The extent to which residents are actually allowed appropriate, progressive, and increasing
responsibility, rather than only being allowed to watch or assist.

The interviews also should serve to verify the written information provided, or “fill the gaps” in the
documentation. Interviews should solicit resident reactions to learning activities. The Program Director
should know that these are sample questions the residents may expect to make comments on. Specific
questions to consider include:

1. What is the balance between education and service?

2. Is there a current written curriculum for the residency training program? Does it fulfill or follow the
ACOOG model curriculum?

3. Do you have adequate time to study?

4. What are your out-rotations like?

5. Are there areas where you should have out-rotations but don’t?

6. Do you have opportunities for pre-op and post-op experience?

7. To what extent are residents allowed to perform surgery?

• Do you ever follow-up with patients in the doctor’s offices?

8. What is your relationship with the DME office?

9. Do you get enough feedback on your performance?

• What is the time frame for evaluations?


• How often are you evaluated?
• Are strengths and weaknesses identified? Are the evaluations constructive?
• Do you receive suggestions for improvement? Is remediation offered?
• Is the in-service exam important to you? Is the in-service exam used effectively?

15
10. What is the didactic program like?

• Are lectures given as scheduled?


• What are the department/committee meetings like? Are they good learning experiences?

11. Are residents working on scientific research papers, and do they understand the AOA/ACOOG
requirements for the paper?

12. Does the program adhere to AOA resident work hour limits?

INTERVIEWS WITH DEPARTMENT FACULTY, DME, INSTITUTION ADMINISTRATION


(1:30 - 2:30 p.m.)

Interviews with department faculty and hospital administration also focus on the relationship between
education and service, and the extent to which residents are given progressive responsibility consistent
with their level of training. The site visitor should ask about work time/time off for residents; moonlighting;
time and funding for lecture; philosophy regarding out-rotations; the selection process (specifically,
determine whether procedures followed match written selection policies); and how the program handles
weak residents, the kinds of remediation used, and how dismissals of residents are handled (whether
faculty are aware of written policies, and whether these policies are followed).

Questions to learn more about the quality of the faculty are:

1. How is faculty recruitment and selection performed?

2. Have any faculty been successfully recruited to the program since the last AOA approval?

3. What are the desired qualifications of potential faculty?

4. What are expectations for new faculty and continuing expectations of senior faculty? How are
they evaluated?

5. Do you have a formal program for faculty development?

• Are time and funds provided for faculty development training opportunities?
• Has the program offered you an opportunity to develop teaching skills?

6. Describe the relationship between the training institution’s administration and the program.

7. Is there an in-hospital evaluation of the residency program to determine if the program is meeting
stated goals?

COMPLETION OF SITE VISIT REPORTS (2:30 – 4:30 p.m.)

During the site visit, the site visitor will collect all necessary information and complete Parts A and B and
verify part C of the Site Visit Workbook (see Appendix). The Site Visit Workbook helps summarize data
the site visitor has obtained from charts, audits, review of documents, interviews with all parties, and other
information collected during the site visit. The Site Visit Workbook should be completed before the final
meeting. Non-compliance with a standard must be supported with a written explanation of the
deficiency.

16
Within two (2) weeks of the site visit, the site visitor is required to forward the completed Site Visit
Workbook and required documents (see Appendix, Part A) to the AOA with duplicate copies to the
ACOOG REC Coordinator (an express mail envelope for this specific purpose in included in the packet of
materials with instructions). The completed Site Visit Workbook submitted to the AOA by the site
reviewer must include the program director’s assessment as well as the site reviewer’s assessment (see
Appendix, Part C).

FINAL MEETING (4:30 p.m.)

A final meeting will be held as an opportunity for the site visitor to thank the participants involved in the
site visit. The Program Director and Director of Medical Education are expected to attend this session.

Prior to departure, the site visitor should confirm that the program has provided the information necessary
for the review. The site visitor must not make recommendations for improvements. If it becomes
apparent from the site visit that the Program Director is in need of program development assistance, the
ACOOG will provide consultation.

REPORTING FINDINGS OF THE SITE VISIT

Submitting the Site Visit Report

The completed workbook, required documents (see Appendix, Part A), and a written summary narrative
must be submitted to the AOA within two (2) weeks of the site visit (duplicate copy to the ACOOG as
previously stated). The site visitor must not delay the report to wait for receipt of additional information
from the institution. The site visit is completed when the visitor leaves the institution, and the report must
be based on the information available at that time. Any further information provided by the institution
goes directly to the ACOOG and AOA, not to the site visitor. NOTE: One complete workbook must be
submitted to the AOA by the site reviewer that includes the program director’s assessment and the site
reviewer’s assessment of the program.

The written summary narrative completed by the site visitor should be an overall assessment of the
residency program. It must include:
• the date of the visit;
• names of participants;
• program strengths;
• program weaknesses and deficiencies;
• assessment of charts reviewed addressing the following chart review elements:
• number of records reviewed
• categories
• completeness
• evidence of resident participation
• diagnosis, appropriate surgical management
• evidence of osteopathic principles and application
• pathology reports and operative reports
• how the program develops resident core competencies in the following areas:
• osteopathic principles and practices,
• patient care,
• medical knowledge,
• practice-based learning and improvement,
• interpersonal and communication skills,
• professionalism, systems-based practice.

17
ACOOG GLOSSARY and ACRONYMS

GLOSSARY

Affiliation: An accredited healthcare facility that provides a required educational experience for
resident training. A current institutional agreement is required for all affiliations.

Affiliated training site: The hospital or other medical facility providing clinical experiences in a
residency program.

Board eligibility: A physician who has successfully completed an AOA-approved training


program and who has been found eligible for the AOA certification process by an AOA
certifying board, as a time-limited designation.

Chief resident: A resident who is in the final year of training and who has been assigned senior
responsibility/ies.

Compliance: A term that connotes a program that has demonstrated conformance with
published AOA/ACOOG standards. (The opposite term is non-compliant.)

Curriculum: The sum total of learning activities for a subject or discipline which should
include the cognitive, psychomotor, and affective components; recommended learning activities
for the resident; goals and objectives; measurement parameters; and recommended educational
resources.

Desirable, highly desirable, encourage/d: Terminology used to describe aspects of a training


program that may be suggested or recommended, but are not mandatory for program approval.

Faculty: Physicians and other healthcare professionals who provide didactic or clinical
education for resident training.

Must, shall or essential: Approval terms used to describe a standard or criterion that is
mandatory or required.

OPTI: Osteopathic Postdoctoral Training Institution

Osteopathic institution: An AOA-accredited college of osteopathic medicine or healthcare


institution.

Primary training institution: The primary clinical training site responsible for, and providing
the majority of, required clinical experience for an approved training program.

Program director: The AOBOG or ABOG certified physician who is responsible for the
administration of a residency program.

18
Should: An approval term used to describe a standard or criterion that is so important that its
absence must be justified by a program. The use of this term provides programs with the
opportunity to develop alternative methods to demonstrate compliance with the referenced
standard. It should not be interpreted as permissive.

Sponsoring institution: The legal entity responsible for the support and conduct of training
programs, i.e., generally defined as an AOA-accredited College of Osteopathic Medicine or
hospital, or a consortium of healthcare facilities (OPTI).

Sufficient or adequate: A term which connotes that an approval standard or criterion meets
compliance as judged by their peers, e.g., sufficient operative experience.

ACRONYMS

AOA American Osteopathic Association

AOBOG American Osteopathic Board of Obstetrics and Gynecology

ACOOG American College of Osteopathic Obstetricians and Gynecologists

Board Board of Trustees of the AOA

BOE Bureau of Osteopathic Education of the AOA

Division Division of Postdoctoral Training of the AOA

DME Director of Medical Education

PTRC Program and Trainee Review Committee

REC Residency Evaluation Committee of the ACOOG

19
APPENDIX A
WORKBOOK

20
Site Visit Workbook for
Osteopathic OB-GYN
Residency Training Programs:

Obstetrics and Gynecology

American Osteopathic Association


and the
American College of Osteopathic Obstetricians and Gynecologists

21
Introduction and Instructions

The Site Visit Workbook for Osteopathic OB/GYN Residency Training Programs is
designed to assess compliance with the AOA/ACOOG Basic Standards for Residency
Training. The Program Director is required to complete Part C: Standards Worksheet
with appropriate documentation (see Part A) and send one copy to the site visitor
approximately 15 days prior to the inspection date. During the site visit, the site visitor
verifies the program’s adherence to the standards by reviewing the Program Director’s
completion of Part C and the appropriate documentation. In addition, at the conclusion
of the visit the site visitor will have completed Parts A and B of the workbook and
submitted those along with Part C which has been forwarded to site visitor by the
program director 15 days prior to the inspection.

This workbook includes the following forms:

Part A Program Identification Data


Part B Required Documents Checklist and Signature Sheet
Part C Standards Worksheet

Questions about this workbook or reports should be forwarded to:

American College of Osteopathic Obstetricians and Gynecologists


8851 Camp Bowie West, Suite 120
Fort Worth, TX 76116
Phone: 800-875-6360
Fax: 817-377-0439
or e-mail : rec@acoog.org
and
American Osteopathic Association
Division of Postdoctoral Training, Inspection Services
142 East Ontario Street
Chicago, Illinois 60611
Phone: (800) 621-1773

Members of the ACOOG Residency Evaluation Committee are available to serve as


advisors to site reviewers, as necessary.

22
Part A: Program Identification Data
(The site visitor is required to complete all information below.)

Date of Current Site Visit: _________________________

Training Site/Base Institution: ___________________________________________________________

City/State: ___________________________________________________________________________

OPTI Name/Affiliation: _________________________________________________________________

Surgical Specialty: ____________________________________________________________________

Name of designated Program Director: ____________________________________________________

Name of Director of Medical Education: ____________________________________________________

Number of participating trainers in the department: ___________________

Number of these trainers who are ABS or AOA Board certified: ___________________________

Total number of AOA-approved resident positions for this program: ______________________________

Actual number of residents in training, by year:

OGME 2 __________ OGME 4 __________ OGME 6 _________


OGME 3 __________ OGME 5 __________ OGME 7 _________

Date of last site visit: __________________________

Deficiencies cited at last site visit:

23
(Part A continued.)

The following materials must be submitted by the site visitor to the AOA AND a copy to be forwarded to
the ACOOG within two weeks of the site visit.

‰ AOA application (for new programs only)

‰ Departmental segregated totals

‰ Program description (includes a mission statement, goals and objectives, curriculum, summary of
academic and clinical experience, resident-patient care responsibilities, rules and regulations.)

‰ Current affiliation agreements for all outside rotations

‰ Curriculum vitae of the program director

‰ List of departmental faculty with current certification status

‰ Completed Site Visit Workbook (Part C)

‰ Summary narrative

__________________________________________________________
Site Visitor’s Name (print)

__________________________________________________________ _____________
Site Visitor’s Signature Date

24
Part B: Required Documents Checklist and Signature Sheet
(To indicate compliance with the site review process, the site visitor is required to read and sign Part B.)

Institution: __________________________________________________________________________

Program Specialty: ___________________________________________________________________


This checklist serves as confirmation that the following documents were provided by the training
institution during the site visit to support specific standards of the AOA/ACOOG Basic Standards for
Residency Training.

YES/NO DOCUMENTS STANDARDS

Resident logs, annual reports, and scientific papers 1.1.2.4, 1.4.6, 2.0.1.2, 2.0.2.3,
for each resident for the current and previous year. 3.2.5, 4.2.3, 4.2.4

OB/GYN department/division minutes for the current 1.4.5, 1.4.5.2


and previous year.

List of lectures presented to residents for the current 2.0.1.1


and previous year.

Journal Club minutes for the current and previous 2.0.1.1


year.

Evaluations of each resident for base institution and 1.5.3, 2.0.2.4, 5.0
outside rotations for the current and previous year.

Aggregate resident evaluations of the program. 3.2.1, 3.2.8, 5.1, 5.2, 5.2.1

Operating room log book for the current and previous II-D-7 (AOA Basic Documents for
year. Postdoctoral Training, Policies
and Procedures for Residency
Training)

Mortality book for the current and previous year. 4.1.3.1, 2.0.1.1

Tumor board meeting minutes. 1.0.1.1, 1.4.6.2

Quality assurance board meeting minutes for the 1.0.1.1, 1.4.6.2


current and previous year.

25
II-D-7 (AOA Basic Documents for
Postdoctoral Training, Policies
Program segregated totals for the last complete and Procedures for Residency
training year. Training), 1.4.6, 2.0.2, 2.0.2.2,
3.2.4

Current OB/GYN department/division rules and Standard III


regulations.

List of journals and books available in the hospital 1.1.2.2


library and/or via online services for this specialty.

Current resident manual, including resident 1.6, 2.1, 2.1.3, Standard III, 4.1
dismissal/grievance process and work hour policy.

Duty work hours for each resident for the last 12


months. 2.1, 2.1.1.1-2.1.1.9

Current program description (includes a mission 1.0.1.2, 1.0.2, 1.3.3, 2.0.1,


statement, goals and objectives, curriculum, 2.0.2.1, 4.1.8
summary of academic and clinical experience,
resident-patient care responsibilities, rules and
regulations.

Current CVs of department members participating in 1.1.2.5, 1.4.3, 1.4.3.1, 1.4.4.1,


the training program. 3.0.2, 3.0.3

Current affiliation agreements for all rotations. 1.4.6, 1.4.6.2, 1.5, 1.5.1, 1.5.2,
3.2.2

Current resident contracts for all residents. 1.3.1, 4.0.1.5

Documentation attesting to each resident’s 4.0


professional qualifications to include:
ƒ Official graduation transcript from the college
of osteopathic medicine;
ƒ Certificate and letter of recommendation
from the DME of the internship program of
graduation;
ƒ Current licensure as a physician in the state
where the training program and clinical
training site(s) are located; and,
ƒ Membership in the AOA.

26
NOTE: ALL PATIENT IDENTIFIABLE INFORMATION MUST REMAIN AT THE TRAINING SITE.

The findings of the site visit represent the site visitor’s best judgement and are to assess the program’s
compliance with the residency training standards. The site visitor does not make a recommendation
to the ACOOG REC regarding continuing approval of the program. The REC will make a
recommendation to the AOA PTRC for continuing approval or denial based upon the site visit report. The
recommendation does not become final until reviewed and acted upon by the AOA PTRC.

__________________________________________________________
Site Visitor’s Name (print)

__________________________________________________________ _____________
Site Visitor’s Signature Date

27
Part C: Standards Worksheet

Instructions

The Standards Worksheet is used to assess a program’s compliance with the AOA/ACOOG Basic
Standards for Residency Training.
Program Directors are required to complete a
narrative self-assessment of program compliance with the standards
and submit the self-assessment to the site visitor approximately 15
days prior to the site visit date. During the site visit, the site visitor must validate program
compliance with each standard by checking “Yes” or “No”. Program Directors and site visitors indicating
non-compliance must provide written comments in their narrative referencing the standard and explaining
how/why the program is not in compliance with the standard. In addition, the site visitor must indicate if
the required documentation validates compliance with the standard. The completed workbook forwarded
to the ACOOG must include both the program director’s narrative assessment of compliance and the site
reviewer’s narrative validation of compliance of the program.

Training Institution: ___________________________________________________________

City: ______________________________________ State: __________________

OPTI Affiliation: ______________________________________________________________

___________________________________________
Program Director’s Name (print)

___________________________________________ _________________
Program Director’s Signature Completion Date of
Self-assessment

___________________________________________
Site Visitor’s Name (print)

___________________________________________ _________________
Site Visitor’s Signature Date of Site Review
(Validation of
Compliance)

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ACOOG Residency Inspection Worksheets

Narrative Description ACOOG Basic Standards (ABS) Agree Disagree


Basic Documents for
Postdoctral Training (BDPT)
Article (Roman Numeral)
Section (Capital Letter)
Paragraph (Number)
Subparagraph (Small letter)

CORE COMPETENCY PLAN DOCUMENTATION


The residency program is required to provide a curriculum that promotes and
ABS. II, C
assesses competencies in seven areas;
ACOOG Basic Standards Agree Disagree
Interpersonal and Communication Skills: Residents are expected to
demonstrate interpersonal and communical skills that enable them to establish
ABS. II, C, 1
and maintain professional relationships with patients, families, and other
members of health care teams.
Demonstrate effectiveness in developing appropriate doctor-patient
ABS. II, C, 1, a
relationships.
Exhibit effective listening, written and oral communication skills in professional
ABS. II, C, 1, b
interactions with patients and health professionals.
ACOOG Basic Standards Agree Disagree

Systems-Based Practice: Residents are expected to demonstrate an


understanding of health care delivery systems, provide effective and qualitative ABS. II, C, 2
patient care within the system, and practice cost-effective medicine.

Understand national and local health care delivery systems and how they
ABS. II, C, 2, a
impact patient care and professional practice.
Advocate for quality health care on behalf of patients and assist them in their
ABS. II, C, 2, b
interactions with the complexities of the medical system.

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Medical Knowledge: Residents are expected to demonstrate and apply
knowledge of accepted standards of clinical medicine, remain current with new
ABS. II, C, 3
developments in medicine, and participate in life-long learning activities,
including research.
Demonstrate competency in the understanding and application of clinical
ABS. II,C,3,a
medicine to patient care.
Know and apply the foundations of clinical and behavioral medicine
ABS. II,C,3,b
appropriate to their discipline.
ACOOG Basic Standards Agree Disagree

Osteopathic Philosophy and Osteopathic Manipulative Treatment - Residents


are expected to demonstrate and apply knowledge of accepted standards in
Osteopathic Manipulative Treatment (OMT) appropriate to their specialty. The ABS. II,C,4
educational goal is to train a skilled and competent osteopathic practitioner
who remains dedicated to life-long learning.

Demonstrate competency in the understanding and application of OMT


ABS. II,C,4,a
appropriate to obstetrics and gynecology
Understand and integrate Osteopathic principles and philosophy into all
ABS. II,C,4,c
clinical and patient care.
ACOOG Basic Standards Agree Disagree

Practice-Based Learning and Improvement: Residents must demonstrate the


ability to critically evaluate their methods of clinical practice, integrate evidence-
based medicine into patient care, show an understanding of research methods, ABS. II,C,5
and improve patient care practices. Treat patients in a manner consistent with
the most up-to-date information on diagnostic and therapeutic effectiveness.

Perform self-evaluations of clinical practice patterns and practice-based


ABS. II, C, 5, a
improvement activities using a systematic methodology.
Understand research methods, medical informatics, and the application of
ABS. II, C, 5, b
technology as applied to medicine.

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Professionalism: Residents are expected to uphold the Osteopathic Oath in the


conduct of their professional activities that promote advocacy of patient
welfare, adherence to ethical principles, collaboration with health professionals,
ABS. II,C,6
life-long learning, and sensitivity to a diverse patient population. Residents
should be cognizant of their own physicial and mental health in order to
effectively care for patients.

Demonstrate respect for patients and families and advocate for the primacy of
ABS. II, C, 6, a
patients welfare and autonomy.
Adhere to ethical principles in the practice of medicine. ABS. II, C, 6, b

Demonstrate awareness and proper attention to issues of culture, religion, age,


ABS. II, C, 6, c
gender, sexual orientation, and mental and physical disabilities.

ACOOG Basic Standards Agree Disagree


Patient Care: Residents must demonstrate the ability to effectively treat
patients, provide medical care that incorporates the osteopathic philosophy,
patient empathy, awareness of behavioral issues, the incorporation of
preventive medicine and health program. Gather accurate, essential ABS. II,C,7
information for all sources, including medical interviews, physical
examinations, medical records, and diagnostic/therapeutic plans and
treatments. .
Validate competency in the performance of diagnosis, treatment and
ABS. II, C, 7, a
procedures appropriate to obstetrics and gynecology.

Provide health care services consistent with osteopathic philosophy, including


preventive medicine and health promotion that are based on current scientific ABS. II, C, 7, b
evidence and understand of behavioral medicine.

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Institutional Requirements Basic Documents
Institution meets all the requirements in Residency Training Requirements of
ABS. III,A BD PT. I,A
the AOA

Sufficient patient load to properly train a minimum of three residents (also see
ABS. III,B BD PT. .II,D,7
scope and volume requirements under IV,D,1,a and b and IV,D,2,b)

Adequate medical library with carefully selected texts, latest journals and other
ABS. III,C BD PT. .I,B,1
publications
Qualified medical librarian in charge of the library ABS. III,C BD PT. I,B,1
Institution shall maintain internet access and electronic mail (Email) addresses
ABS. III,C
for program director and all residents
Adequately organized, full time pathology and radiology services ABS. III,D BD PT. II,D,3a,b
Residents are given the benefits of cooperation from all professional areas,
ABS. III,F
departments and services

There are outpatient clinics or a formal rotation in an outpatient facility ABS. III,G

Outpatient clinics under the supervision of the teaching staff or the OB-GYN
ABS. III,G
department
The program director and the DME reviewed and revised the written outline of
the training program at a minimum of every four years and submitted the ABS. III,H,2
revision to the AOA and ACOOG
Each new resident was provided a copy of the most recent outline of the
ABS. III,H,3,c
training program
A revised written outline of the training program was submitted to the AOA
and ACOOG if any of the following events occurred:
Change in Program Director ABS. III,H,4
Hospital ownership/affiliation ABS. III,H,4
Request for increase in residency positions ABS. III,H,4

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Institutional Requirements (continued)
A copy of the most recent written outline of the training program is available
ABS. III,H,5
for this inspection
Residency Program is conducted at more than one site, there is an associate
ABS. III,H,6
program director at that site
The Medical Education Office shall maintain documentation of completion of
ABS. III, H, 7
the resident research requirement.

Radiology, Pathology, Internal Medicine, and General Surgery must all have
ABS. III,J
qualified or certified persons responsible for training the residents

There is a written policy and procedure for selecting residents. Selection is


based on the following criteria: personal observation, personal interview,
ABS. III,K,1-6
references, NBOME scores, performance in osteopathic medical school
including a dean's letter
There is no discrimination of the applicants on the basis of gender, sexual
ABS. III,K
orientation, race/ethnicity or religion
Each resident has a contract in accordance with the Residency Training
ABS. III,L
Requirements of the AOA
The Institution shall provide administrative support to the residency director
by virtue of an appointed residency coordinator whose time commitment is ABS. III,O
commensurate with the number of residents.

The position of program director shall be compensated commensurate with the


ABS, III, P
number of residents and duties inherent in the training program

The institutiton shall fund professional development of the program director


including yearly attendance at the program director's meeting and one ABS, III, Q
residency evaluation committee meeting every four years

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Program Requirements
The program exists in one of the following structures:
1. A four year residency following completion of an AOA approved rotating
internship (Refer to the Summary of Four Year Training Program after Regular
Rotating Internship and the Model Program in Obstetrics/Gynecology for Four ABS. IV,B,1
Year Residency Following a Regular Rotating Internship documented in IV,H
of the Basic Standards).

2. A three year residency following completion of an AOA approved specialty


track internship in obstetrics and gynecology (note: a specialty track internship
may only be offered in an institution that has an OB-GYN residency) (Refer to
ABS. IV,B,2
the Summary of Four Year Specialty Track Training Program and the Model
Program in Obstetrics/Gynecology Starting with a Specialty Track Internship
documented in IV,H of the Basic Standards).

The program must count OB-GYN specialty track interns as a resident towards
ABS. IV,B,3
the total number of approved resident positions in OB-GYN

The program includes training in gynecology, obstetrics, perinatology, genetics,


endocrinology, infertility, family planning, human sexuality, oncology,
ABS. IV,B
psychosomatics, ultrasound and all other means of diagnosis and treatment
through clinical and didactic experience.

Osteopathic philosophy, principles and practices are an integrated and ongoing


ABS. IV,B
feature of the program.
Adequate basic science training should be present and emphasize anatomy,
pathology, physiology, biochemistry and bacteriology as they relate to OB- ABS. IV,C
GYN.

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Program Requirements (continued)
The program provides adequate scope and volume of cases to assure that each
ABS. IV,D,1,a
resident has the opportunity to develop competency in obstetrics

Adequate experience is provided in high risk or medically complicated


ABS. IV,D,1,b
pregnancies and antenatal diagnosis and genetic counseling

Antepartum and Postpartum care is provided in outpatient clinics through the


ABS. IV, D, 1, c
institution or affiliated institutions or Board Certified Ob/Gyn office.

A comprehensive and clinically pertinent didactic program is present in


ABS. IV,D,1,d
obstetrics
Resident is taught the principles of peroperative and postoperative care and
ABS. IV, D, 2, a
how to deal with postoperative complications.

The program provides adequate scope and volume of cases to assure that each
ABS. IV,D,2,b
resident has the opportunity to develop competency in gynecology

Ambulatory gynecology has adequate scope and volume to offer the resident
ABS. IV,D,2,c
instruction in common office procedures
A comprehensive and clinically pertinent didactic program is present in
ABS. IV,D,2,d
gynecology
The program enhances the ability of the resident to understand the behavioral
aspects of health and illness and to develop a mature concern regarding the ABS. IV,D,3
quality of patient care

Research is encouraged and resources are provided whenever possible ABS. IV,D,4

The department holds regularly scheduled quality improvement and


educational meetings such as CPC's C-Section reviews and morbidity and ABS. IV,D,5
mortality reviews

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Program Requirements (continued)
The Program must provide suitable arrangements for outside rotations to
insure the complete education of the resident and for broadening the scope of ABS. IV, E
training.
All rotations meet the standards as formulated in the Residency Training
ABS. IV, E
Requirements of the AOA.
The base institution may arrange for supplemental training in a subspecialty or
in special procedures. The institution may arrange for up to a total of 25% of
ABS. IV, F
the residency program as an outside rotation and not to exceed 50% without
prior approval.
All resident training programs in OB/GYN shall consist of a minimum of 48
ABS. IV,G
months of postgraduate training.

The program is in compliance with the number and types of rotations as


ABS. IV,H
outlined in the Model Program including the required continuity clinics

Advanced standing for a resident with prior experience in another specialty


residency has been granted only after successful completion of at least one year ABS. IV,I
of an AOA approved OB-GYN residency
No more than two years of credit has been granted to a resident for previous
ABS. IV,I
training in another specialty

A resident may be granted full credit for previous training in an AOA OB-GYN
residency or an ACGME OB-GYN residency if they first completed an AOA ABS. IV,J
internship.The resident may receive up to two years credit for previous training

If the residency is conducted in multiple institutions then there is a qualified


obstetrician/gynecologist on site appointed as associate program director ABS. IV,K
reporting to the primary program director

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ACOOG Residency Inspection Worksheets

ACOOG Basic Standards Agree Disagree


Qualifications and Responsibilities of Program Director
The program director is certified by the AOA through the AOBOG ABS. V,A,1
The program director is qualified by experience and teaching ability to
ABS. V,A,1
implement and conduct the residency training program
The program director meets the standards of the position as formulated in
ABS. V,A,2
Residency Training Requirements of the AOA
The program director is a member of the ACOOG as well as the AOA ABS. V,A,3
The program director's authority in directing the residency is defined in the
ABS. V,B,1
institution's program
The program director arranges affiliations and/or outside rotations necessary
ABS. V,B,2
to meet program objectives
The program director in cooperation with the AOA prepared the required
ABS. V,B,3
materials for the inspection
The program director has provided to the residents all documents pertaining to
the program including the requirements for satisfactory completion of the ABS. V,B,4
program

The program director has submitted to the DME and the administrator of the
ABS. V,B,5
institution quarterly reports on the residents progress in the program

The program director has submitted annual reports to the ACOOG ABS. V,B,5
The program director has made certain that all residents have submitted their
annual reports, including the research report form within 30 days of completion
ABS. V,B,6
of their training year (Note: a copy of the research project is to be kept at the
institution).
The program director has attended at least alternate meeting of the ACOOG
ABS. V,B,7
Annual Program Director's Meeting
In the program director's absence at the ACOOG Annual Program Director's
Meeting a member of the department ,who is actively involved in the program, ABS. V,B,7
attended
The program director participated in this inspection at the request of the
ABS. V,B,8
ACOOG and/or AOA

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ACOOG Residency Inspection Worksheets

ACOOG Basic Standards Agree Disagree

Qualifications and Responsibilities of Program Director (cont.)

Program director maintains and informs the ACOOG of an Email address ABS. V,B,9

Program director provides guidance on the certification process for AOBOG


ABS. V, B,10
and AOA
Program Director along with the insttution will be responsible for compliance
ABS. V, 11
with the work hours policy
Program director shall attend a meeting of the AOBOG Clinical Examination
ABS. V, 13
every four years.

Program director shall review the Annual CREOG exam with the residents ABS.V, 14

Program director or his designee will provide appropriate guidance to the


ABS. V, 15
resident for completion of a satisfactory research project
ACOOG Basic Standards Agree Disagree
Resident Requirements
Applicants must have: graduated from a AOA accredited college of osteopathic
medicine, be and remain members of the AOA, hold license in the state of ABS. VI,A, 1-4
training

The residents have submitted records of work performed to the program


ABS. IV, B,1
director every month and is filed with the Department of Medical Education

The residents have submitted annual reports to the ACOOG ABS. VI,B,2

The residents have met the research requirements by the time of graduation ABS. VI,B,3

The residents participate in staff committees involving quality improvement


and education such as morbidity and mortality review, tumor board, CPC's, ABS. VI,B,4
etc.
The residents participate in the teaching of interns and externs ABS. VI,B,5
The residents take the annual residency evaluation examination ABS. VI,B,6

updated 09-07
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ACOOG Residency Inspection Worksheets

Resident Requirements (continued) ACOOG Basic Standards Agree Disagree


The residents submits annually on proper forms of the ACOOG evaluations of
ABS. VI,B,7
the program director and faculty
Second year residents attended the ACOOG Fall Conference (Extended to third
year if formal written excuse is submitted by the program director to the ACOOG ABS. VI,B,8
REC)
Resident maintains and informs ACOOG of an Email address ABS. VI,B, 9
ACOOG Basic Standards Agree Disagree
Appendix I - Resident Work Hours Policies Basic Documents
Residents do not work in excess of 24 consecutive hours, inclusive of morning
ABS. Appendix I,A,1,a
and noon education programs
If moonlighting is permitted, the 80 hour per week limit and moonlighting shall
ABS. Appendix I,A,1,b
be inclusive
Residents have alternate 48 hour weekends (Sat & Sun) off or at least 1 24 hour
ABS. Appendix I,A,1,c
period off each week

A minimum of 12 hours is scheduled off between all assigned duty shifts ABS. Appendix I,A,1,d

Residents will not be scheduled longer than 12 hour shifts when on Emergency
ABS. Appendix I,A,1,e
department rotations
Residents are not assigned to call more often than every third night averaged
ABS. Appendix I,A,1,f
over any consecutive four week period

The institution provides a clean and comfortable on-call room with a telephone. ABS. Appendix I,A,1,g

Toilet and shower facilities are in or convenient to the room BD PT. Appendix I
Nourishment is available during night call BD PT. Appendix I
Adequate back-up by a senior resident and/or an attending physician is
BD PT. Appendix I
present
The program has a sufficient number of clinical trainers ABS. Appendix I, C
The residents are receiving progressive supervision adjusted to their training
ABS. Appendix I, C
and qualification level
The residents are receiving progressive clinical responsibility ABS. Appendix I, C
Supervision is available at all times throughout the entire residency program in
ABS. Appendix I, C
both hospital and ambulatory training sites

updated 09-07
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ACOOG Residency Inspection Worksheets

Appendix II - Model Osteopathic GME Policy on Academic and


ACOOG Basic Standards Agree Disagree
Disciplinary - Dismissals
The institution and the program follows the recommended due process as
ABS. Appendix II
outlined in this appendix

updated 09-07
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