Any discussion of the corrective action process must be grounded in an understanding of the AOA's continuing approval process for internships, residencies, and fellowships, which is very similar to the accreditation process used by the Accreditation Council of Graduate Medical Education. It is important for OGME programs to have AOA approval to ensure quality and uniformity of training among a large number of programs. For example, 2 osteopathic physicians graduating from the same college of osteopathic medicine can enter 2 different family medicine residencies at 2 different hospitals and be certain that they will both receive 4 weeks of training in women's health during the first OGME year (assuming the programs are meeting the standards outlined in the AOA's
Basic Standards for Residency Training in Osteopathic Family Medicine and Manipulative Treatment).
2 This document outlines sufficient training procedures for specialty and subspecialty, whereas AOA approval exists to provide oversight and verify that standards are met.
The AOA approval process for an existing program begins with a
program site review (previously called an
inspection) conducted by a site reviewer using a crosswalk. A crosswalk is a document with checkboxes that lists (1) all the standards to be reviewed and (2) the amount of points of each deficiency, enabling a final score to be tabulated for the program. When the site reviewer notices a standard that has not been met, he or she describes the deficiency and references the appropriate standard listed in the crosswalk. The site reviewer then issues a final report that outlines any areas in which the program does not meet AOA OGME standards.
3 Each crosswalk is customized for a given specialty or subspecialty and is designed to include all relevant standards that ensure trainees receive sufficient immersion and education in their field. The Council on Postdoctoral Training oversees approval of standards and crosswalks before the final approval by the AOA Board of Trustees. Current AOA-approved standards and crosswalks can be found online at
http://www.osteopathic.org/inside-aoa/accreditation/postdoctoral-training-approval/postdoctoral-training-Standards/.
The specialty college education committee reviews the final report, and then the committee submits a resolution recommending the program's next term of continuing approval to the AOA's Program and Trainee Review Council (PTRC). The resolution details the program's basic information, any deficiencies, the site reviewer's verbatim description of each deficiency, and a recommended length of approval for the program (the amount of time until the next site review). Three weeks before the PTRC meeting, the program's Osteopathic Postdoctoral Training Institution (OPTI)—which is the academic sponsor for the program—receives a copy of the continuing approval resolution for their program. If the OPTI notices that any deficiency was cited in error, the OPTI and the program are allowed to submit evidence (ie, an “error in fact” request) to the specialty college and PTRC for review. The PTRC will determine if the deficiency was indeed cited in error and should be removed from the final recommendation. At each PTRC meeting, the AOA receives 3 to 5 “error in fact” requests from OPTIs or OGME programs. The PTRC makes the final determination on any deficiencies and the final continuing approval length.
Within 2 weeks of the PTRC meeting, a letter is sent to the OGME program detailing the final determination, any applicable deficiencies, and the site reviewer's comments on exactly how the standard was not met. Any program cited with deficiencies is required to submit a corrective action plan explaining how it will meet the standards.
4 This plan must first be submitted to the program's OPTI within 45 days of receiving the PTRC letter. The OPTI then has 30 days to review the plan. If the plan is approved by the OPTI, the plan is then forwarded to the AOA. The AOA performs an administrative review of the plan and then forwards it to the specialty college for review and final approval. The specialty college then notifies the AOA of its decision, and the AOA writes the final letter to the OGME program informing it of the specialty college's approval or denial. When the program receives the approval letter, it has 9 months to submit evidence of implementation of the corrective action plan to their OPTI. The OPTI then approves that evidence and informs the AOA. The process for a given program is then considered closed as soon as the AOA receives the evidence of approval from the OPTI. The
Figure summarizes the corrective action process described above.
The AOA tracks all steps involved in the approval or denial process. It does not, however, track programs for which deficiencies have not been cited.
If a program was cited with deficiencies during PTRC review, an AOA staff member enters the program's name into an Excel spreadsheet (Microsoft Corporation), along with the following data: specialty area, specialty college, OPTI name, dates (reviewed by PTRC, plan received by AOA, forwarded, approved, verified by OPTI), and additional comments. The spreadsheet documented 772 program records at the time of this writing. The data were divided by year to determine if there were any patterns or inferences that could be made from year-to-year changes in the data and changes in postdoctoral training policies. The AOA tracks all programs that have received continuing approval at the PTRC level in a given year. Therefore, it was simple to find the population size (N) for each year. This tracking process made it possible to compare data on program approval, citation of deficiencies, compliance, and a specialty college's denial of an OGME program.
A z score was used to compare different years and determine if the difference between 2 years was statistically significant. Differences of P<.05 were considered statistically significant.