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The Accreditation Council for Graduate Medical Education (ACGME)
The Role of the ACGME The Accreditation Council for Graduate Medical Education (ACGME) is a private professional organization responsible for the accreditation of nearly 7,800 residency education programs. Residency education is the period of clinical education in a medical specialty that follows graduation from medical school, and prepares physicians for the independent practice of medicine. The ACGME's volume of accredited programs makes it one of the largest private accrediting agencies in the country, if not the world. Stakeholders of the ACGME's accreditation process are residency programs, their sponsoring institutions, residents, medical students, the specialty boards of the American Board of Medical Specialties (ABMS), patients, payers, government and the general public. Accreditation offers these stakeholders assurance that a given residency program and its sponsoring institutions meet an accepted set of educational standards. The ACGME accredits residency programs in 110 specialty and subspecialty areas of medicine, including all programs leading to primary Board certification by the 24 member boards of the American Board of Medical Specialties. Completion of an ACGME-accredited residency program is a prerequisite for certification in a primary board. Completion of an ACGME-accredited subspecialty program is also required before an individual can sit for board certification in the majority of subspecialties. In a few subspecialties, the ABMS-member boards approve advanced training programs in the absence of ACGME accreditation standards; in several others the ACGME accredits subspecialty training programs, but no board certificate is offered. The ACGME does not accredit training in combined programs, such as Internal Medicine-Pediatrics, or Internal Medicine-Psychiatry. These programs function as “educational tracks” within their ACGME-accredited core residency programs, and the relevant ABMS-member boards have determined that individuals who have completed a combined program are eligible to sit for the board certification in their specialties. To develop and refine its accreditation standards and to review accredited programs for compliance with the standards, the ACGME relies on experts in the various medical specialties. Twenty-six specialty-specific committees, known as Residency Review Committees (RRCs), periodically initiate revision of the standards and review accredited programs in each specialty and its subspecialties. The standards revision process includes solicitation of comment from interested parties and the public. The ACGME Board of Directors is ultimately responsible for standards revision and accreditation decisions. There is a separate Review Committee for the Transitional Year, a one-year program that prepares newly graduated physicians for entry into a specialty that accepts residents at the second residency year, and an Institutional Review Committee for the review of the more than 400 institutions that sponsor programs in two or more specialties. The membership of the residency review and transitional year committees is made up of physicians. Often, these are medical educators who have gained a reputation for expertise in residency education. Appointing organizations to all RRCs include the American Medical Association (AMA) and the member boards of the American Board of Medical Specialties (ABMS). In many specialties, the academic specialty organization also appoints a portion of the RRC members. Nominating organizations to the ACGME's Board of Directors include the ABMS, the American Hospital Association (AHA), the AMA, the Association of American Medical Colleges (AAMC), and the Council of Medical Specialty Societies (CMSS). Joining an RRC or the ACGME Board of Directors is considered prestigious and offers individuals an opportunity to make a meaningful contribution to medical education. In addition to twenty representatives nominated by the five member organizations, the Board of Directors includes one resident physician member, the Chair of the Council of Review Committee Chairs and three public members. A federal government representative and the resident physician who chairs the RRC Resident Council have the right of attendance and voice at meetings of the board of directors, but do not vote. The ACGME uses a public director model, in which the public members pay careful attention to issues that would interest and affect the general public. The appointment of a public member begins with the Board of Directors soliciting the names of qualified candidates. Candidates may not be health professionals, and must have a record of public service, understand board obligations, be conversant with and sensitive to a host of public policy issues and fully understand the independent nature of ACGME's accreditation mission. The ACGME purpose of working to promote the quality of resident education to contribute to improving the quality of health care is an imperative to all members of the board, but particularly its public members. While there is no efficient way to “report to the public,” the opinions and votes of its public members are of critical importance to the any governing board that understands its public mission and obligations. The ACGME's recognition of the important contribution of its public members is evidenced by the positions its public directors hold, including chairing of the Monitoring Committee, and membership on the committees that formulate and implement the ACGME's standards for resident duty hours. The increasing “public” posture and outreach of ACGME is another proof of its commitment to its public representation. The Accreditation Process To gain and maintain accreditation, residency programs are expected to comply with the Accreditation Standards for their discipline. In addition, institutions sponsoring residency programs are expected to adhere to a set of Institutional Requirements. Compliance with the ACGME's standards is measured through periodic review of all programs. Each year, the RRCs review nearly one-half of all accredited programs. Approximately 2,200 of these reviews involve a formal on-site visit to the program; the remaining reviews are based on documents each program provides to the ACGME. On average, each accredited residency program is site visited every 3.7 years. Sponsoring institutions are also site visited periodically. The interval between site visits ranges from one to five years, with a longer period indicating that the ACGME and RRCs are more confident about the ability of a given program or institution to provide quality education. All new residency programs begin as applications, and go through a period of “provisional” accreditation. Programs that have demonstrated compliance with the accreditation standards receive full accreditation. If a program is found to have areas of non-compliance (deficiencies), the ACGME lists these as specific citations in its accreditation letter to the program, and expects the program to come into compliance. The RRCs often monitor programs' progress in addressing deficiencies. If a program has significant deficiencies, it may be given a warning or be placed on probation. The intent is to alert the program and its sponsoring institution to the need to show improvement in the areas identified as deficient by the RRC, or face more serious action by the ACGME. Ultimately, programs that fail to comply with the standards have their accreditation withdrawn. It is rare that a program's accreditation is withdrawn because of failure to comply with a single standard, but this can occur for very serious deficiencies. The ACGME's actions in establishing standards, and in withdrawing the accreditation of programs that fail to demonstrate compliance, have been affirmed by several court decisions. The ACGME's accreditation activities are funded through accreditation fees paid by all accredited programs. ACGME also receives grant support for its effort to base its accreditation system increasingly on educational outcomes, and some income from its educational programs. Accreditation fees are established and approved by the Board of Directors. The ACGME seeks to keep fees low and constant over several years to facilitate institutional budgeting. It has been successful in achieving this goal in the face of increasing demands for use of data in the accreditation process; consistent, rigorous monitoring of compliance; and efforts to advance to a 21 st Century model of accreditation. A listing of all Accredited Programs and their accreditation status and time interval to the next site visit can be found on the ACGME Web site. For a more detailed discussion of the accreditation process, see the section on GME Useful Information. The Accreditation Site Visit The formal periodic review of programs involves an on-site inspection, which is based on the Program Information Form (PIF), a comprehensive self-study document completed by the program that is being reviewed. Each year approximately 1,900 programs are site visited by the members of the ACGME field staff, and around 150 programs are site visited by Specialist Site Visitors (SSVs). SSVs are volunteer experts who conduct a small number of site visits in their specialty during a given year. Members of the field staff are ACGME staff members. They are either physicians or individuals with a PhD or similar doctoral degree who are knowledgeable in the review of programs in all accredited specialties and subspecialties. In the ACGME's approach to accreditation, the site visitor is not the decision-maker regarding quality of a given educational program. Site visitors are fact-finders whose role is to verify and clarify the information provided in the Program Information Form (PIF). The PIF and the site visitor's report form the basis of the RRC's review and accreditation decision. Prior to the site visit, the site visitor (field staff or SSV) is expected to have reviewed the self-study document prepared by the program, as well as the Program and the Institutional Requirements governing accredited residencies. The site visit consists of interviews with the program director, members of the teaching faculty, residents, and often administrators and other key personnel. Following the visit, the site visitor composes an objective narrative report of the information that he or she collected during the interviews. This document is factual and non-judgmental, and reports omissions or discrepancies between the PIF and the information collected during the interviews. Site visitors are prohibited from making recommendations and from interjecting personal Resident Duty Hours Standards In the past two years, considerable public attention has focused on resident duty hours, and concerns about the impact of duty hours in the safety of patient care, resident learning, and the safety of the residents themselves. The ACGME's role in setting and enforcing Residency education has multiple goals – quality education, safe and effective patient care, and resident safety – that underlie the ACGME's standards. These standards, and the system that fosters compliance by programs, treat duty hours, supervision, support for non-educational tasks and the educational environment a program provides as related matters. Safeguarding by residency programs against residents becoming exhausted while providing patient care involves more than attention to the number of duty hours. Supervision and back-up systems are also important in contributing to education, safe patient care, and resident safety. The ACGME has well-defined supervision standards, and its requirements stipulate “programs must ensure that residents are provided appropriate backup support when patient care responsibilities are especially difficult and prolonged.” The ACGME tracks compliance with its duty hour and related standards, and programs that fail to comply with these or other important elements of the accreditation standards may face accreditation consequences that can include probationary accreditation and, ultimately, withdrawal of accreditation. ACGME Staff In order to carry out its accreditation activities, the ACGME and its RRCs are supported by approximately 100 staff members. Nearly one-half of these serve the RRCs directly. Twenty-eight individuals are responsible for carrying out activities related to the accreditation site visit, and the remaining staff support a growing range of data management activities, research to advance the ACGME's accreditation activities, and administrative and support functions. The ACGME's staff has grown to support an increasing focus on collection and analysis of data to make the accreditation process more data- and evidence-based. An important activity is the move toward the use of educational outcomes. Others include ensuring fair, rigorous and consistent monitoring of programs' and institutions' adherence to the accreditation standards, and generally improving the accreditation process. Finally, the approximately 250 physician experts on the ACGME's review committees collectively contribute more than 40,000 volunteer hours annually toward formulating and refining standards and reviewing programs. 21st Century Accreditation Activities Under the direction of its Board and Executive Director, David Leach, MD, the ACGME has increased its efforts to assess and improve its accreditation effectiveness, with the goal of using state-of-the-art concepts from education and health care in the accreditation process. In the near future, health care will increasingly focus on the outcomes of care, and a concurrent movement within education has placed emphasis on educational outcomes. The ACGME's goal is to apply these advances and promote educational excellence in a changing health care environment through a focus on educational outcomes. It has initiated this process by identifying six general competencies that are important to the practice of medicine: (1) patient care, (2) medical knowledge, (3) interpersonal and communication skills, (4) professionalism, (5) practice-based learning and improvement, and (6) systems-based practice. The goal of this effort, called the “ACGME Outcome Project” is to base a program's accreditation status on how well it educates its residents and prepares them for practicing medicine. In summary, the ACGME's role is to ensure the quality of residency education for the next generation of physicians, and to contribute to safe and effective patient care. The ACGME is committed fully to the task of improving the quality of resident education in the United States. |
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