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Phase 4: Act

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Undergo an Accreditation Site Visit

The fourth phase of the ACGME-I Self-Study process is to undergo an accreditation site visit. The program must update ADS by the date indicated in the Site Visit Announcement Letter sent prior to the date of the visit. Responses to citations must be complete and up to date, and the block diagram must accurately reflect the clinical curriculum.

It is also important to add information to the Major Changes and Other Updates section in ADS. Examples of information that can be included are results of any SWOT analyses, details of interventions designed to improve the program, the metrics used to measure success, and a summary of any improvement data collected to date. Information in the Major Changes and Other Updates section are available to the Accreditation Field Representative and the Review Committee-International. Although ADS can be updated at any time, any changes in ADS past the deadline date set for the site visit will not be available to the Accreditation Field Representative or the Review Committee-International.

The accreditation site visit will take a half to a full day, depending on the size of the program. Visits to affiliated subspecialty programs will take less time, and will be conducted during the same week as the core residency program site visit. The assigned Accreditation Field Representative will contact the program regarding details of the visit, including individuals to be interviewed, the time to allocate for these meetings, and the organization of the room and other logistics.

The Accreditation Field Representative will develop a Site Visit Report, which will document the program’s compliance with ACGME-I Foundational and Advanced Specialty Requirements. The Review Committee-International will then review data submitted in ADS, results of the annual Resident and Faculty Surveys, and the Site Visit Report to make an accreditation decision for the program. The program’s Self-Study Summary or the Summary of Achievements will not directly affect the Committee’s review and accreditation decision.

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