Instructions for Completing the Survey

General Survey Instructions

The following information includes comprehensive instructions on completing the Professional Education Supplemental Pool (PESP) Survey for the GME Reform Incentive Pool.

Select Hospital

Select your hospital and operating certificate number from the drop down menu if it does not already appear, then click select. A consortium must enter the data for each individual facility separately.

General Information Section

Consortium

If you registered with the Department of Health to be a member of a consortium, please indicate the name of the consortium.

Attestation

This information must be entered. The CEO/CFO of the facility or the Chair of the consortium governing body must certify the accuracy and completeness of the submitted information to the best of his/her knowledge in order for a distribution to be calculated for the facility. Please be advised that the information submitted is being audited to the electronic interns and residents survey previously submitted and used in the calculation of your hospital's indirect medical education (IME) reimbursement. Discrepancies between these documents may result in adjustments to either the incentive pool distributions, the IME reimbursement, or both.

Administrator/CEO

Enter the name and title of the individual attesting to the accuracy and completeness of the submitted information.

Contact's Name

Enter the name, title, phone and fax numbers and e-mail address of the individual who can respond to inquiries from NYS Department of Health staff regarding the data submitted in this survey.

Data

Data on the number of residents (including fellows) and graduates should be reported on a Full Time Equivalent (FTE) basis. Data on the number of programs in questions 5, 6 and 11 and faculty in questions 9 and 10 should be reported using whole numbers.

Base Period (Questions 1, 2, 5 - 8)

  • The base period is 1995 (July 1, 1995 through June 30, 1996), unless your facility participated at any time in the CMS Medicare GME Demonstration Project, in which case you may choose a base period of 1995, or 1996 (July 1, 1996 through June 30, 1997).
  • Facilities that applied for the Incentive Pool in previous years should not submit base period data for any Survey question that was reported at that time, since that data should not have changed from what was previously reported to the department.
  • Facilities that did not apply for the Incentive Pool in previous years must submit base period data for all the questions.

Base Period (Questions 3 and 4)

  • The base period is 1999 (July 1, 1999 through June 30, 2000) for all facilities regardless of participation in the HCFA Medicare GME Demonstration Project.

Rate Period (Questions 1- 11)

  • The rate period for all hospitals is July 1, 2007 through June 30, 2008.
  • All facilities must submit rate period data for all Survey questions.

Answer Data Questions

1. Number of Residents in Accredited Programs

Report the number of residents in programs that have received accreditation from a nationally recognized accreditation body and/or in programs approved by any other nationally recognized organization (i.e., specialty boards) for medical, osteopathic, podiatric or dental residency programs. Report residents and fellows in programs that have no accreditation body or other nationally recognized organization, since such programs are not able to be accredited.

2. Number of Residents in Non-Accredited Programs

Report the number of residents in programs that are eligible but that have not received accreditation from a nationally recognized accreditation body nor are approved by any other nationally recognized organization (i.e., specialty boards) for medical, osteopathic, podiatric or dental residency programs.

3. Number of Residents Training in Ambulatory Care Sites

Report the number of residents that train in ambulatory care sites. This should be reported on an FTE basis, based on the amount of time spent training in ambulatory care sites. (Include only those FTE's that are included in the total number of residents in accredited programs, as reported in Question number 1.) Ambulatory care sites are defined as any: (1) Article 28 hospital-based ambulatory care facility (excluding emergency departments); (2) Article 28 freestanding ambulatory care facility; and, (3) private physician practice.

4. Number of Residents Training in Ambulatory Care Sites Located in Underserved Areas

Report the number of residents in Question 3 (training in ambulatory care sites) that are located in an underserved area. To determine if the location is in an underserved area, please refer to the file Regents - Designated Service Shortage Areas.

5. Number of Designated Priority Programs

Report the number of programs that are designated in writing as Priority Programs by the Commissioner of Health. Only programs in the following specialties are eligible for DPP status: Family Medicine; Pediatrics; Internal Medicine; Combined Internal Medicine/Pediatrics; and Obstetrics and Gynecology.

6. Number of Non-Designated Priority Programs with 5 or More Residents Eliminated from the Base Period

Report the number of programs that are not Designated Priority Programs that were eliminated and had 5 or more residents in the base period.

7. Number of Residents in Designated Priority Programs

Report the number of residents in Designated Priority programs, as defined above in question number 5. To determine the maximum number of approved positions in DPP programs, please refer to the reference file Maximum Number of Approved Positions in DPP by Hospital.

8. Number of Underrepresented Minority Residents

Use the following two definitions to report the number of underrepresented minority residents:

Sponsoring Institution

The term "sponsoring institution" refers to the entity, including but not limited to a hospital, medical school or educational consortium, that assumes final responsibility for a program of graduate medical education, as defined in the American Medical Association's Graduate Medical Education Directory, or other appropriate directory.

Underrepresented Minority

Underrepresented minority residents (URM's) are defined as: (a) Black/African American, American Indian, Alaskan Native, or Hispanic; and (b) United States medical school graduates, United States citizens, or permanent residents of the United States.

Report the number of URM's by using the following methodology:

Sponsoring institutions should determine the percentage of residents in "accredited programs" that are URM's for both the base and rate periods. Sponsoring institutions should also provide their URM percentages to their affiliate hospitals. For the purpose of this survey, "affiliate hospitals" shall include all hospitals that participate in the training of residents from a sponsoring institution. Affiliate hospitals, and sponsoring institutions that are teaching hospitals, which train residents from a single sponsoring institution should apply the URM percentages to the Number of Residents in Accredited Programs previously reported to the department for both the base and rate periods on an FTE basis.

Affiliate hospitals that train residents from more than one sponsoring institution, and sponsoring institutions that are teaching hospitals that also train residents from other sponsoring institutions, should use the discrete URM percentages from the appropriate sponsoring institution and apply these percentages to the "Number of Residents in Accredited Programs" previously reported to the department for both the base and rate periods, on an FTE basis, who rotate from the given sponsoring institution. These numbers should be totaled to determine an aggregate FTE count of URM residents from all sponsoring institutions practicing at the hospital. The following provides an example of how URM's should be reported:

Hospital A sponsors 1,000 residents, 150 of which (15%) are URM's
(Hospitals B and C are affiliate hospitals that do not sponsor any residents)
Hospital Sponsor A's URM Percentage Number of Sponsor A's Residents which Train at Each Hospital Number of URM's Reported by Each Hospital
Hospital A 15% x 700 FTE's = 105 FTE's
Hospital B 15% x 200 FTE's = 30 FTE's
Hospital C 15% x 100 FTE's = 15 FTE's*
TOTAL 1,000 FTE's 150 FTE's

* If Hospital C is an affiliate hospital that also receives residents from two other sponsoring institutions, Hospital C should report the following:

Sponsoring Hospital Sponsor's URM Percentage Number of Sponsor's Residents which Train at Affiliate Hospital C Total Number of URM's Reported by Affiliate Hospital C
Hospital A 15% x 100 FTE's = 15.0 FTE's
Hospital D 10% x 200 FTE's = 20.0 FTE's
Hospital E 13% x 50 FTE's = 6.5 FTE's
TOTAL 350 FTE's 41.5 FTE's

A consortium has the option to list the total number of URM residents, on an FTE basis, practicing in all hospitals in that consortium, rather than listing the number of URM residents by each hospital. If a consortium chooses this option, a representative from the consortium should submit under separate cover the number of URM's, on an FTE basis, for both the base and rate periods. The Chair of the consortium governing body must certify the accuracy and completeness of this information.

9. Number of Faculty with Medical School Appointments

Report the number of faculty who maintain a faculty appointment at a medical school and are employed or contracted for employment by the hospital or paid through its affiliated faculty practice plan. Use whole numbers (individuals not FTEs) in this question.

10. Number of Faculty with Medical School Appointments who are Underrepresented Minorities

Report the number of faculty in Question 9 who are underrepresented minorities (Black, African American, American Indian, Alaskan Native or Hispanic).

11. List all Academic Pipeline Programs Targeted for Underrepresented Minority Students

List information about programs that the facility sponsors or substantially supports which are targeted for underrepresented minority (Black, African American, American Indian, Alaskan Native or Hispanic) students in order to increase participation in medicine or the health professions or provide academic support in science or mathematics. Programs can be for students anywhere along the academic pipeline, from grade school through medical residency. Student enrollment must be targeted to accommodate, through admission criteria, at least 50 percent underrepresented minorities. Facilities may submit information for all minority pipeline programs. Programs must enroll at least eight students and at least 35 percent of the students must be URMs.

Cultural Competence Training

Use the following definition of Cultural Competence:

Culture consists of a body of learned beliefs, traditions and guides for behaving and interpreting behavior that are shared among members of a particular group. This includes values, beliefs, customs, communication styles, behaviors, practices and institutions with visual aspects of culture such as clothing, art and food. Varying cultures differ in values, norms, worldviews and expectations. There is a significant influence of culture upon health and related outcomes, therefore health care providers should be culturally competent to provide optimum care to patients. Health care provisions in the context of cultural competence consists of awareness and recognition of cultural differences and the impact they have on interactions with health care professionals and health practices as well as an ability and willingness to adapt to fit a patient's culture. (This information was obtained from the Medical University of South Carolina´s website

Only respond to questions 1-10 if there has been a change in the Cultural Competence Training Plan from a previously approved submission.

1. Describe the training formats and the number of hours residents will spend in each format

Provide the training formats, e.g. grand rounds, small group discussion, presentations, site visits, etc. that will be used for Cultural Competence education. The training must occur in more than one format and be interactive. Also, provide time the residents will spend training under each format over the course of the academic year.

2. Describe the goals and topics covered in training

Provide information on what topics will be discussed in the training to address cultural attitudes as well as the knowledge and skills needed for cultural competence. Also, provide the expected goals to be reached in health care delivery by providing cultural competence training.

3. Describe how residents will be scheduled

Provide an anticipated schedule of when and where each of the training formats will occur.

4. When will training begin

Report when the training commenced.

5. Who will provide training

Provide the name and title of an expected person(s) or group that will provide the training and whether the person is internal or with an external organization. If the person(s) or group providing training is external, provide the name of the institution or organization the person(s) or group is affiliated.

6. How will faculty be recruited for the training

Describe the method to recruit faculty to participate in the training formats.

7. How will the institution document and track that 80% of residents received 8 hours of training

Describe the process the institution will use to determine that 80% of residents have received 8 hours training.

8. Does the training include faculty as trainees and trainers

Answer Yes or No that the faculty will be trained in cultural competence as well as act as trainers.

9. Are non-physician staff included in the training

Answer Yes or No that non-physician staff will be trained in cultural competence. It is recommended, not required, that non-physician staff participate.

10. Contact person at sponsoring institution

Provide the name, phone number and e-mail address of a person at the sponsoring institution that can be contacted to answer questions and provide additional information, if necessary, on cultural competence training.

11. I certify that all residency training programs at this institution comply with the Guidelines for Medical Residents as Primary and Specialty Care Providers

Answer Yes or No to certify that all the residency training programs at the institution comply with the Guidelines for Medical Residents as Primary and Specialty Care Providers developed for the use of residents in the Medicaid Managed Care Program, Child Health Plus and Family Health Plus. Please refer to the reference file Guidelines for Medical Residents as Primary and Specialty Care Providers. These guidelines can also be found under the Managed Care Organization Qualifications Guidelines website.

12. Resident Training Table

Respond to each question individually by post-graduate year (PGY).

# of Residents Training at Institution

The number of residents training at the institution should be counted as individuals and not FTEs. This would include any resident that has practiced at the institution for any period of time during the reporting year.

# of Residents Receiving 8 hours of Cultural Competence Training at Institution

The number of the residents training at the institution that received cultural competence training for 8 hours at the institution should be reported.

# of Residents Receiving 8 hours of Cultural Competence Training at Another Institution

The number of the residents training at the institution that received cultural competence training for 8 hours at another institution during the reporting year should be reported

Total Residents Receiving Cultural Competence Training

Number of residents receiving cultural competence training at your institution and those receiving training at another institution during the reporting year.

Names of Other Institutions Providing Training

List the names of the other teaching hospitals or GME consortium that provided cultural competence training during the reporting year for the residents that practiced at your institution.