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Site Visit FAQs

Frequently Asked Questions (FAQs) Related to the Accreditation Site Visit


Below are responses to general questions about the site visit process. Specific questions or topics not covered in these FAQs should be addressed to the staff of the Department of Field Activities or the staff of the relevant Review Committee. Information about site visits for applications can be found in a response to FAQs addressing the accreditation of new programs, program mergers, program and institutional name changes, and changes in sponsorship.

What is the purpose of the accreditation site visit?


The purpose of the accreditation site visit is the on-site collection and aggregation of relevant data into a narrative, factual, objective report used by ACGME’s Review Committees (the specialty Review Committees, the Transitional Year Review Committee, and the Institutional Review Committee) to make accreditation decisions. The Accreditation Field Representatives are not the decision makers; accreditation decisions are the purview of the Review Committees.

ACGME accreditation site visits are either Full or Focused. The ACGME uses full site visits: (1) for all core program applications and applications for some subspecialty programs (the applications for other subspecialty programs and those for Sponsoring Institutions are generally reviewed without a site visit); (2) at the end of the two-year Initial Accreditation period, to ensure that a Sponsoring Institution or program is compliant with the applicable accreditation requirements; (3) to address broad concerns identified during the review of data submitted to the ACGME annually; (4) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee; and (5) to assess overall compliance and ongoing improvement in a Sponsoring Institution or program during the scheduled 10-Year Accreditation Site Visit.

The ACGME uses focused visits: (1) to conduct timely, in-depth explorations of potential problems arising out of a Review Committee’s review of annually submitted accreditation data; and (2) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee.

Who conducts accreditation site visits?


Accreditation site visits for Sponsoring Institutions and programs are conducted by Accreditation Field Representatives, who are professional site visitors employed by the ACGME. Biographical sketches outlining their professional background and tenure with the ACGME are available on the ACGME website.

Site visits for larger programs and some Sponsoring Institutions, are conducted by a team of two Accreditation Field Representatives. Site visits for other programs may use a team at the discretion of the Department of Field Activities leadership. The site visit announcement letter will indicate the type of visitor (team or individual), as well as the name(s) and contact information of the assigned Accreditation Field Representative(s).

How much advance notice does program leadership receive for a site visit?


When programs do not need to prepare documents specifically for a site visit, a shorter announcement period is feasible. The minimum amount of notice for announced site visits is 30 days. This applies to programs scheduled for a full or focused site visit arising out of the review of data submitted annually to the ACGME, for applications for accreditation that require a site visit, and for osteopathic programs with a status of Pre-Accreditation during the transition to a single GME accreditation system.

At times, when it is critical to get programs on the schedule for their Review Committee’s next meeting, the notice may be somewhat shorter. Department of Field Activities staff members will work with the program when a shorter site visit notice period is necessary.

Programs with a status of Initial Accreditation, receive a 60-day advance notice for a site visit preceding their anticipated transition to Continued Accreditation, as they are expected to prepare an updated specialty-specific application document for this visit.

Programs scheduled for a 10-Year Accreditation Site Visit receive a 90-day advance notice of the date. Programs also receive advance notice of the month during which they should begin conducting their Self-Study.

Unannounced visits occur on rare occasion at the discretion of the Review Committee, when there may be a potentially serious problem. Generally, a 14-day advance notice is given for such a visit. For the even less frequent site visit to assess an alleged egregious violation, the advance notice is at the discretion of the leadership team that made the determination of the need for the visit.

For most types of site visits, the Department of Field Activities provides additional advance notice whenever possible. Notification to programs occurs via an e-mail sent by the Department of Field Activities. Concurrently, a site visit announcement letter, with a set of detailed instructions on how to prepare for the visit, is posted in the “Letters” page of the program’s Accreditation Data System (ADS) record. Program leadership should review the letter carefully, and contact the Department of Field Activities staff member(s) identified in the letter with any questions.

What documents must be submitted prior to an accreditation site visit?


Many types of site visits require only the information collected via the Accreditation Data System (ADS), and program leaders and other staff members may not need to complete additional documentation. If no additional documentation is required, Sponsoring Institutions and programs should ensure currency of all data in ADS prior to the site visit, with a focus on responses to citations, changes in the Sponsoring Institutions or program since the last ADS Annual Update, and the other “updateable” data elements (as noted in responses to other questions below).

A number of site visits require additional documentation, including:

  1. applications for accreditation
  2. the full site visit at the end of the two-year period of Initial Accreditation, which also requires completion of an updated version of the specialty-specific portion of the application
  3. a 10-Year Accreditation Site Visit, which also requires completion and uploading of a Self-Study Summary 18 to 24 months before the site visit date, as well as completion of a Summary of Achievements (improvements the program made in areas identified through the Self-Study)

For some site visits, Review Committee staff members may request additional documents to be provided to the (primary) Accreditation Field Representative for appending to the Site Visit Report.

The announcement letter for the site visit contains specific instructions if completion and uploading of any documents is required. It also specifies how and when to update information in ADS, and other directions particular to the Sponsoring Institution or program.

What data can be updated immediately prior to a site visit?


For all full site visits and, as requested by ACGME staff, for some focused visits, excluding for new program applications and programs with a status of Pre-Accreditation, the information below can be updated in the Accreditation Data System (ADS) prior to the visit. To be included in the site visit documents, information must be updated in ADS by the date indicated on the first page of the site visit announcement letter.

Data elements are listed by their name and tab location in ADS:

  • Updated Responses to Citations
  • Major Changes and Other Updates Updated Block Diagram
  • Updated Faculty Roster
  • Updated Program Director CV
  • Updated Participating Sites
  • Updated Overall Evaluation Methods
  • Updated Clinical Experience and Educational Work

Of note, information that can be updated immediately prior to a site visit includes a section entitled “Major Changes and Other Updates.” This free-text field (4000 characters) offers the program a means for conveying to the Accreditation Field Representative(s) and the Review Committee any information that may be useful to the review process. This may include recent changes or improvements in the program, or interventions to address lower-scoring items in the ACGME Resident or Faculty Surveys.

What additional document needs to be updated and uploaded prior to a site visit for a program with Initial Accreditation?


The site visit at the end of the period of Initial Accreditation is a full accreditation site visit. Programs must complete an updated version of the specialty-specific application document that was submitted for their application two years earlier. This needs to describe the current status of the program. Programs should also update the common program information. Other documents to be updated are the: (1) Policy for Supervision of Residents; (2) Competency Goals and Objectives; (3) Program-Specific Evaluation Tools; and (4) Block Diagram. Board certification data for faculty members should also be reviewed for currency.

What is a site visit following review of the program’s Annual Data?


In the ACGME model of accreditation, programs with a status of Continued Accreditation are subject to an annual screening of key accreditation data. This includes the results of the ACGME Resident and Faculty Surveys; Case Log data for specialties that collect this information, and surveys about adequacy of patient volume and variety for other specialties; information on scholarly activity for residents/fellows and faculty members; resident/fellow and/or faculty member attrition; and transitions in program and/or institutional leadership. If any of these areas suggests a potential problem, the Review Committee may ask the program to provide clarifying information or a progress report, or it may schedule a site visit. Data-prompted site visits may be full or focused visits, at the discretion of the Review Committee.

Programs generally do not need to complete additional documentation for a data-prompted visit. Program leadership needs to review the data that can be updated in ADS immediately before a site visit (See above for a list of this information).

What documents is requested for on-site review for each type of site visit?


All site visits use information uploaded into the Accreditation Data System (ADS), and site visits other than those for new program applications use data from the ACGME Resident and Faculty Surveys, data on resident and faculty scholarly activity, and Case Log and patient experience data, as relevant to the specialty.

The list of documents for on-site review varies by the type of site visit. A standard list of each type is attached to the ACGME site visit announcement letter. Less is requested for the site visit associated with a new application, as documents were submitted through ADS.

The ACGME has shortened the list of documents for on-site review to reduce the burden of document aggregation, and is looking for further ways to streamline this aspect of the site visit. Much of this information is now gathered from resident/fellow files. For residents/fellows with academic or other performance problems, there should be documented evidence of follow-up, including remediation, probation, non-renewal, or dismissal, as applicable.

Some Review Committees request a few additional documents for review at the site visit. The assigned Accreditation Field Representative will inform the program director or coordinator about these requests.

In what format should evaluation documents be available during a site visit for programs that use electronic resident evaluation systems?


The ACGME and its Council of Review Committee Chairs have clarified expectations regarding information that should be available to the Accreditation Field Representative(s) to enable them to verify the existence of a functioning evaluation process, including discussion of evaluations with residents/fellows. Evidence of this can be offered via either traditional paper-based evaluation forms or print-outs of electronic evaluations, including evidence that these evaluations were reviewed with the resident/fellow, such as the resident’s/fellow’s signature.

A growing number of programs/institutions use electronic evaluation systems or data management “suites” for collection, aggregation, and presentation of a variety of data related to the administration of residency/fellowship programs, and during the site visit may present this information in electronic form.

How should residents/fellows be selected to meet with the field representative(s), and what is expected of them during these interviews?


The resident/fellow interview is crucial to the site visit. If a program has 15 or fewer residents/fellows, the Accreditation Field Representative will interview all residents on duty the day of the visit. If a program has more than 15 residents/fellows, 15 to 20 peer-selected residents/fellows representing all required years of education will be interviewed.

Trainees beyond the required years of residency (such as fourth-year internal medicine chief residents), or not in the accredited program, may not participate in the interview; they may be included in the faculty interview. For programs with a combined program track, such as internal medicine-psychiatry, representative residents from the combined program must be included in the interview.

For the site visit of a Sponsoring Institution, the interview group should include 15 to 18 residents and fellows representative of the programs sponsored by the institution.

For program site visits, residents/fellows often are interviewed in smaller groups, with those in the most senior year(s) of the program interviewed separately. For some types of site visits, residents/fellows may be interviewed individually. The Accreditation Field Representative or team leader who contacts the program/institution to plan the logistics for the site visit day will indicate the format for the resident/fellow interview. On the day of the site visit, the interview process may change if it appears a different approach will produce better results (such as changing from group to individual interviews).

Residents/fellows and faculty members should be made available for the entire interview period, with their pagers and cell phones turned off.

What happens during a program site visit?


The Accreditation Field Representative or team conducts interviews with the program director (and associate directors, if the program has them), residents/fellows, faculty members, the program coordinator, and the designated institutional official (DIO) and/or other administrative representatives, as well as on-site review of documentation. The documents reviewed vary among different site visits, and a list of required documents is provided as an attachment to the letter announcing the accreditation site visit. For some specialties, or if there were prior citations related to facilities, the Accreditation Field Representative(s) may tour selected clinical facilities.

A clarification interview conducted with the program director at the end of the site visit may include feedback from the Accreditation Field Representative/team, including a succinct summary highlighting two to three key strengths, and suggesting improvement in two to three areas. The feedback is based on the Accreditation Field Representative’s/team’s understanding of the accreditation standards and familiarity with relevant best practices. The Accreditation Field Representative/team will not offer any predictions regarding accreditation outcomes; these decisions are the sole purview of the Review Committee.

Does the Accreditation Field Representative meet with the program coordinator, and what information is discussed?


For most accreditation site visits, the Accreditation Field Representative(s) will meet briefly with the program coordinator. Frequently this is done in conjunction with the document review portion of the visit.

For some visits, such as the 10-Year Accreditation Site Visit and some data-prompted visits, the Accreditation Field Representative(s) may conduct a brief interview with the coordinator and ask about the learning and working environment, institutional support and professional development for coordinators, and more.

What happens after the site visit?


After a site visit, the Accreditation Field Representative/team writes a detailed narrative report that is used by the Review Committee, together with information in the Accreditation Data System (ADS), to make its accreditation decision. Accreditation Field Representatives do not participate in the accreditation decision.

All Review Committees meet two or more times each year, and the ACGME strives to review all Sponsoring Institutions and programs in a timely fashion. The schedule of Review Committee meetings and the agenda closing dates for each meeting are listed on the specialty sections of the ACGME website. Programs can contact the staff of the Review Committee to find out if their program will be reviewed at a given meeting.

A few days after the meeting at which a program is reviewed, the Review Committee sends an electronic notice indicating the accreditation status that resulted from the meeting. The detailed accreditation decision will be posted in the program’s ADS account 60 to 90 days after the meeting.

Can a program request a site visit date change?


Due to the logistics involved in conducting a large number of site visits, once the date of a visit is set, it generally cannot be changed. Exceptions are made in certain circumstances, and all requests to change a site visit date must be made by telephone to Andrea Chow (312.755.5009) or Penny Iverson-Lawrence (312.755.5014) in the Department of Field Activities. Requests must be made within five calendar days of receipt of the site visit announcement letter. Programs have the option of one postponement, if the request meets ACGME justification criteria. Requests for changes or postponements made more than five days after the date of the site visit announcement need to be accompanied by a letter from the institution’s designated institutional official (DIO) or Chief Executive Officer. The letter must indicate that the institution agrees with the request for a change in the site visit date. Programs may be charged a fee for the late notice of the request to postpone the visit.

How does a program prepare for a site visit related to an accreditation application in the transition to a single GME accreditation system?


An osteopathic program that applies for ACGME accreditation immediately receives a status of Pre-Accreditation. Core programs and subspecialty programs in surgical specialties require a site visit prior to review by the specialty Review Committee (for other subspecialty programs the Review Committee reviews the application documentation without a site visit).

For initial review by the Review Committee, a program with Pre-Accreditation status needs to demonstrate how it complies or will comply with the ACGME Common and specialty-specific Program Requirements, and it is important that the application documents describe this (vs. compliance with the standards of the American Osteopathic Association).

During the site visit, the Accreditation Field Representative will interview residents/fellows, faculty members, and program and institutional leadership. Residents/fellows and faculty members will be asked about the current status of the program in areas pertinent to ACGME standards, such as the educational curriculum, patient volume and variety at the primary and participating sites, supervision, availability of faculty members, faculty member teaching skills and interest in teaching, resident/fellow assessment, and resident/fellow and faculty member scholarly activity. The Accreditation Field Representative may ask about the composition and work of the Clinical Competency Committee and the Program Evaluation Committee.

While the Accreditation Field Representative will be able to answer questions about the site visit and the ACGME accreditation process during the site visit, the primary resource for osteopathic programs with questions about accreditation is the Executive Director of the Review Committee, and his/her staff, at the ACGME.

What are the key dates for the program Self-Study and the 10-Year Accreditation Site Visit?


Programs with a status of Continued Accreditation are expected to conduct a Self-Study before undergoing their 10-Year Accreditation Site Visit. A comprehensive Self-Study is a key component of the ACGME’s accreditation model, and is designed to facilitate program improvement.

The initial Self-Study date for all programs with Continued Accreditation was set by the applicable specialty Review Committee, with dates ranging from 2015 through 2024. For programs accredited more recently, the Review Committee sets the date for the initial Self-Study at the time the program is reviewed to transition to Continued Accreditation, after the two-year Initial Accreditation period.

At the conclusion of the Self-Study, programs complete a Self-Study Summary that is uploaded into the Accreditation Data System (ADS). This summary requests data on key attributes of the Self-Study, but does not ask about areas for improvement or other information that could negatively affect the accreditation process.

A gap of at least 18 to 24 months between the Self-Study and the 10-Year Accreditation Site Visit is intended to give programs time to initiate or make improvements in areas identified during the Self-Study.

How does the ACGME tell a program to initiate its Self-Study?


Approximately seven to eight months prior to the Self-Study date shown in the Accreditation Data System (ADS), the Department of Field Activities e-mails the program to initiate the Self-Study. This e-mailed letter includes a link to resources for conducting the Self-Study.

Programs should start their Self-Study at that time, and can begin sooner. Program and Program Evaluation Committee leaders are encouraged to review the Self-Study resources page on the ACGME website for additional information.

Can a program request an extension for uploading the Self-Study Summary?


Ideally, the Self-Study should be conducted and the Summary uploaded during the assigned period, to allow the program at least 18 months to make improvements prior to its 10-Year Accreditation Site Visit. In some circumstances, an extension will be granted. Submit requests to Andrea Chow in the Department of Field Activities: achow@acgme.org, 312.755.5009.

Does a program that recently transitioned to Continued Accreditation need to conduct a Self-Study?


Programs that recently transitioned to a status of Continued Accreditation may not yet have the improvement trajectory to warrant a full Self-Study. These programs may instead perform an Annual Program Evaluation with a focus on program aims and an environmental assessment (see the information on the Self-Study web page for guidance on setting aims and conducting an environment review). Before deciding whether to conduct a Self-Study or Annual Program Evaluation, program leadership should check with the designated institutional official (DIO), as some DIOs prefer that all programs conduct a Self-Study.

Programs with a status of Initial Accreditation do not complete a Self-Study.

When and where does the program upload the Self-Study Summary?


After the Self-Study has been completed, leadership completes a Self-Study Summary (the template for this is on the Self-Study web page), and uploads the document into the Accreditation Data System (ADS).

The date for uploading the Self-Study Summary is noted in ADS as the first day of a given month (e.g., September 1, 2018). The portal for uploading the Self-Study Summary opens on the first day of the prior month, and closes on the last day of the designated month (i.e., if a program’s Self-Study date in ADS is September 1, 2018, the program can upload the Self-Study Summary between August 1, 2018 and September 30, 2018).

To upload the completed Self-Study Summary into ADS, click the Overview tab, and scroll down to Self-Study Uploads. Click View. Under Self-Study Summary, click Upload, select the appropriate document, and then select Upload. The document is automatically saved in ADS.

Are any additional documents required with the Self-Study Summary?


No additional documents or attachments need to be uploaded with the Self-Study Summary.

Who reviews the Self-Study Summary once it is uploaded?


The Self-Study Summary will be saved in the Accreditation Data System (ADS) until the program’s 10-Year Accreditation Site Visit. During that site visit, the Accreditation Field Representative(s) will review the document, along with the Summary of Achievements that details the improvements the program has made in areas identified in its Self-Study. Both documents will be verified and clarified during the site visit, and will be provided to the Review Committee as part of the reviewer materials, along with a Site Visit Report by the Accreditation Field Representative(s) that verify and clarify these documents.

When is a 10-Year Accreditation Site Visit program scheduled?


The 10-Year Accreditation Site Visit is scheduled 18-24 months after the program has submitted its Self-Study Summary. The interval is deliberate—to give the program time to make improvements in areas identified in the Self-Study.

For example, if a program’s Self-Study date is September 2018, its 10-Year Accreditation Site Visit will be scheduled between March and September 2020; the program will receive a 90-day advance notice of the actual site visit date. Core and subspecialty programs with the same Self-Study dates will be scheduled in a grouped visit.

For the 10-Year Accreditation Site Visit, program leaders are asked to complete a Summary of Achievements, a brief document that details improvements made in areas identified in the Self-Study. Programs may also complete an update to their Self-Study document if there were significant changes since the Self-Study, or if the Self-Study Summary was uploaded prior to May 2017, when a new format was instituted. Completing the Self-Study Update document is optional.

Does a program that recently transitioned to Continued Accreditation need to have a 10-Year Accreditation Site Visit?


This is generally an issue for subspecialty programs with the same 10-Year Accreditation Site Visit date as their core program. Programs that recently had a site visit to transition to a status of Continued Accreditation may not need another site visit. The ACGME tries to avoid more than one site visit in a 12-month period, and may be able to forego a site visit if one occurred within 24 months. The final decision is made by the Review Committee Executive Director.

What are key attributes of site visits for Sponsoring Institutions?


Visits to Sponsoring Institutions are conducted after two years of Initial Accreditation status, as a data-prompted visit, an annual visit for an institution with a status of Probationary Accreditation, and as a 10-Year Accreditation Site Visit.

The Accreditation Field Representative conducts interviews with the designated institutional official (DIO), the institution’s chief executive officer, members of the Graduate Medical Education Committee (GMEC), selected program directors who are not members of the GMEC, and a representative group of peer-selected residents and fellows.

During the site visit, the Accreditation Field Representative will use these interviews to verify and clarify the information in the Institutional Review Questionnaire, with a focus on assessing and documenting institutional oversight of the accredited residency and fellowship programs.

Ideally, faculty representatives from all sites should be present. If that presents a hardship due to geography or other factors, the ACGME will schedule prefer a brief separate interview (video or phone) with the local site director (and, if desired, one additional faculty member).

Updated: June 12, 2018

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