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Program Site Visit

Who conducts the site visit?

Accreditation site visits are conducted by members of the ACGME field staff. These field staff representatives are professional site visitors employed by the ACGME.

The role of the site visitor is to produce a written report that verifies and clarifies information the program submitted through the ACGME-I Accreditation Data System (ADS) and downloaded attachments, including the Advanced Specialty Program Information Form (AS-PIF). To collect the information for his or her report, the site visitor interviews the program director, core faculty members, department chair/division chief, and the designated institutional official (DIO) and/or other administrative representatives. For transitional year programs, the site visit also includes interviews with representatives from other departments with which the program interacts.

What are the key elements to consider when preparing the program’s information?

An important aspect of preparing for a site visit is the compilation of program information, including the application. A detailed description of the information needed to document compliance with the International Foundational Requirements is contained in the Program Director Guide to the International Foundational Program Requirements, available on the ACGME-I website (click here).

Well-prepared documents describe the residency/fellowship program accurately, completely, and truthfully. They should be comprehensive, specific, and concise, and should answer questions thoroughly. Incomplete or inaccurate documents can contribute to an ACGME-I Review Committee specifying areas of non-compliance with the standards (known as “citations”) and a negative accreditation decision.

Before preparing the program information, the Foundational and Advanced Specialty Program Requirements, as well as the Institutional Requirements, should be reviewed. Allow sufficient time to gather the data needed for completing these documents, and in doing so, remember that the site visitor and ACGME-I Review Committee members will not be familiar with the specifics of the program. Avoid the use of jargon or local naming conventions for postings or rotations that do not clearly describe the purpose of a clinical assignment or didactic session. Do not rely on the site visitor to relate to an ACGME-I Review Committee all information that is relevant to compliance with the Program Requirements (accreditation standards). If something is relevant to the review, include it in the documents.

ACGME-I staff members are available to answer questions throughout the process. E-mail acgme-i@acgme-i.org with any questions about the program information required. E-mail WebADS@acgme.org with any technical problems or questions, and be sure to add the applicable program number in the subject line of the e-mail.

Regardless of who completes the documents, an independent third party should review the entire document for consistency, accuracy, and clarity before it is submitted to the DIO for final review, signature, and submission to the ACGME-I.

Will a program currently without residents/fellows have a site visit?

If it is due, the ACGME-I will schedule a site visit+ even if there currently are no residents/fellows in the program.

If a program does not plan to accept residents/fellows and would like to voluntarily withdraw accreditation, a request for Voluntary Withdrawal (VW) status must be made online in ADS (this menu option is available when logged into the system). Once approved and submitted in ADS by the DIO, a VW status cannot be changed.

All requests for VW must include an effective date that should coincide with the end of the current academic year. Programs may seek re-accreditation after a period of 12 months following the effective date of the VW.

Are ACGME-I Resident and Faculty Survey reports used during the site visit?

Yes. For programs seeking Continued Accreditation, trends in data from the ACGME-I Resident and Faculty Surveys will be used by the site visitor to focus his or her questions, and by the ACGME-I Review Committee during its program review.

All accredited Advanced Specialty and Subspecialty programs will be surveyed every year between January and May. Programs will be notified directly when their participation is required. This notification will include detailed information on accessing the surveys, as well as a deadline for completion. Residents/fellows and faculty members will have four weeks to complete the surveys following notification. Programs must achieve a 70 percent completion rate on the surveys. Aggregate data summary reports will be made available to programs if that 70 percent response rate is reached for their participants, and when four or more residents/fellows have completed the survey.

What is the schedule for the day of the site visit?

On the day of the visit, the site visitor will meet with the program director, core faculty members, department chair/division chief, the DIO or another administrative representatives, and residents/fellows.

ACGME-I staff members will provide detailed instructions and work directly with the program director and/or DIO to finalize the day’s schedule, to identify program staff member roles and functions that require interviews, and to identify specific staff members to participate in the site visit interview sessions.

    What logistical preparations should be made for the day of the site visit?

  • The site visitor will not be familiar with the institution and will need directions to the facility. Arrange a place and time to meet the site visitor (often this is the main lobby of the building) and escort him or her to the room reserved for the site visit.

  • Provide the site visitor with an emergency phone contact number (program director or coordinator) prior to the visit. This is strictly precautionary, in case the site visitor needs to contact the program the day/evening before the visit.

  • The site visit (except for tours of on-call rooms or other facilities, as required) should take place in a single, well-lit conference room with a table sufficiently large to allow the site visitor to do his or her work.

  • If lunch is scheduled during the site visit, please keep the menu simple. Please be aware that the site visitor cannot accept gifts.

  • The program director needs to clear his or her schedule for the entire time of the site visit, including turning off his or her cell phone and/or pager, arranging for coverage, and responding only to urgent matters during the course of the visit.

  • The letter announcing the site visit will include a list of documents that should be available for the site visitor to review the day of the visit. These should be complete and organized, and readily accessible to the site visitor throughout the day.

  • The core faculty group interview

    • The core faculty group interview is an important component of the site visit, and core faculty members scheduled for the interview need to turn off their cell phones and/or pagers and arrange for coverage for the duration of the session.

    • The interview group should include no more than 10 core faculty members, including any associate program director(s).

  • The resident/fellow group interview

    • The resident/fellow group interview is an important component of the site visit. For programs with 10 or fewer residents or fellows, the interview group should include all residents/fellows currently in the program. If there are more than 10 residents/fellows in a program, the site visitor will interview 10 peer-selected residents/fellows representing all years of education. “Peer-selected” means that the program residents/fellows vote for 10 of their resident/fellow colleagues to participate in the interview. Residents/fellows in a full research year should not be included.

    • If the site visit is to review an application, the site visitor must meet with residents/fellows currently in the non-accredited program as indicated above.

    • Participating residents/fellows need to turn off their cell phones and/or pagers and arrange for coverage for the duration of the session.

  • The chair/chief interview

    • The site visitor’s discussion will cover departmental or divisional support and resources for the program, and organizational structures that affect the program.

  • The DIO interview

    • The site visitor’s discussion will cover the institutional support and oversight of the program, the DIO’s perceptions of the program, and the DIO’s review and approval of the application and its attachments, including the Advanced Specialty Application.

What happens on the day of the site visit?

On the day of the site visit, be flexible and understand that schedules may be changed or delayed to accommodate the site visitor’s information collection needs. The site visitor's role is to verify and clarify the information provided in the submitted materials, annual data, and Resident/Faculty Surveys, and to note any accreditation standards with which compliance was not confirmed. The ACGME-I Review Committee makes the final evaluation and accreditation decision for each program.

At the end of the visit, the site visitor may ask additional clarifying questions if there are open issues that have not been fully resolved/explained. The site visitor cannot give any detailed feedback since he or she is not the final decision maker; however, he or she may be able to offer general observations regarding the program’s strengths and opportunities for improvement. Please note that any observations made by the site visitor are solely based on his or her specialty-specific experience, and do not indicate any decisions or implications regarding the program’s accreditation status.

Can changes be made to the applications or attachments after they have been submitted in ADS?

The documents sent to the ACGME-I must be in final form; the DIO’s signature confirms this. No changes can be made after they have been submitted in ADS and before the day of the site visit. Minor discrepancies can be clarified with the site visitor on the day of the visit.

If errors are discovered on the day of the site visit, it is acceptable to make minor changes to selected pages, provided this can be done before the site visitor departs. The site visitor should not be asked to wait while extensive changes are made. Once pages have been changed, a copy of the revised pages should be given to the site visitor with the changes highlighted.

What happens after the site visit?

After the visit, the site visitor submits a written report to ACGME-I staff members who review the document for completeness. The ACGME-I Review Committee’s evaluation of a program is based on the application and attachments, including the Advanced Specialty Application, the site visitor’s report, and any other information relevant to that particular program (e.g., Resident and Faculty Surveys, Case Log reports, etc.). The ACGME-I Review Committee makes the final accreditation decision.

Within five business days of a Review Committee meeting at which a program is reviewed, the program director and DIO will be notified via e-mail of the program’s accreditation status. A Letter of Notification detailing the accreditation decision(s) related to International Foundational and, if applicable, Advanced Specialty Accreditation, including any citations, will be posted in ADS between 30 and 60 days following receipt of the e-mail. See the Key to Standard Program Notification Letter for a template of the letter available on the ACGME-I website (click here). The DIO will be notified of the ADS posting.

 

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