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The Accreditation Process and the Role of the ACGME Site Visitor
The Accreditation Process The Accreditation Council for Graduate Medical Education (ACGME) is a private not for profit organization responsible for the accreditation of more than 7,800 US residency education programs. The Council accredits residency programs in 118 specialty and subspecialty areas of medicine, including all programs leading to primary certification by the 24 member boards of the ABMS. Completion of an accredited residency program is a prerequisite for primary board certification and for certification in the majority of subspecialty boards. Accreditation is a credential that signifies that an accreditor has determined that an educational program substantially complies with the accreditation standards. Accreditation comprises three basic functions: (1) establishment and periodic revision of publicly available accreditation standards; (2) accreditation decisions, i.e., the measuring of compliance by programs and schools with accreditation standards; and (3) publication to the general public of a program or school’s accreditation status in written materials, on websites, and otherwise. Numerous individuals and entities, including residents, prospective residents, professional certifying boards, governmental payers, the Educational Commission for Foreign Medical Graduates (ECFMG) and the general public, rely on the ACGME’s accreditation decisions. 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. The 26 specialty-specific Residency Review Committees (RRCs) and the Transitional Year Review Committee (TYRC) periodically revise the accreditation standards and review accredited programs against these standards. The process for revising the standards includes solicitation of comment from interested parties and the public. An Institutional Review Committee reviews the more than 400 institutions that sponsor residency programs in two or more specialties. Appointing organizations to all RRCs include the AMA, the member boards of ABMS, and in some specialties, the academic specialty organization. To gain and maintain accreditation, residency programs are expected to comply substantially with the Program Requirements for their specialty, and the institutions sponsoring them are expected to comply with a set of Institutional Requirements. Compliance is measured through periodic review of all programs. Each year, the RRCs review nearly one-half of all accredited programs. Approximately 2,000 of these reviews involve a formal on-site visit to the program; the remainder is based on documents the programs provide to the ACGME. On average, each accredited residency program is site visited every 3.7 years. Intervals between site visits range from one to five years. A longer period indicates the ACGME and RRCs are more confident about a program’s ability to provide quality education. The ACGME Site Visit The formal periodic review of programs involves an on-site inspection. It is based on a Program Information Form (PIF), a comprehensive self-study document prepared by the program being reviewed. Site visits are conducted either by a member of the ACGME field staff or by a Specialist Site Visitor (SSV). SSVs are volunteer experts who conduct a small number of site visits in their specialty during a given year. In the ACGME’s approach to accreditation, the site visitor is not the decision-maker regarding quality of a given educational program. The site visitor is a fact-finder, whose role is to verify and clarify the information provided in the PIF. The PIF and the site visitor’s report form the basis of the RRC’s review and accreditation decision. The site visit consists of interviews with the program director, members of the teaching faculty, resident physicians, and often administrators and other key personnel. Following the visit, the site visitor composes an objective narrative report of the information he/she collected during the interviews. This document is factual and nonjudgmental, and reports omissions or discrepancies between the PIF and the information collected during the interviews. These reports present the information gathered at the visit, without any effort to sway the RRC for or against the program. The Role of the Site Visitor The ACGME field representatives carry out the majority of the ACGME’s accreditation site visits. Among them, they conduct approximately 1,900 visits each year. In early 2004, the ACGME field staff consists of 15.5 full-time equivalent representatives. It comprises 24 individuals, six of whom work on a full-time basis. A full-time field representative conducts approximately 115-125 site visits each year. A variety of educational backgrounds and medical specialties are represented on the ACGME field staff, including sixteen physicians, six PhDs, one dentist and one doctor of public health. The medical specialties represented by the group of physicians include internal medicine, neurology, obstetrics and gynecology, ophthalmology, orthopaedic surgery, pediatrics, plastic surgery, psychiatry, radiology, surgery, and thoracic surgery. Among the PhD members of the staff the disciplines of education, sociology and health education are represented. The most senior member of the field staff has been with the ACGME for more than 24 years. In addition, 12 field representatives have performed site surveys for the ACGME for 5 or more years. The Director of Field Activities is a trained administrator, who has responsibility for all aspects of the ACGME’s site survey activities, including recruiting, training, continuing education and supervision of the field representatives. She is responsible for organizing an eight- to nine-week comprehensive orientation program for new field representatives, and an ongoing program of continuing professional education for all members of the field staff. The latter consists of two annual in-service and discussion workshops, regular communication regarding developments and updates related to the educational standards and the review process, and periodic attendance at meetings of the Residency Review Committees and other relevant national professional meetings. The ACGME field representatives carry a very heavy travel schedule. They travel nationwide in order to carry out whatever assignments have been made by the Director of Field Activities. In the interest of containing cost and maintaining the physical resources of the field staff, the Director makes reasonable efforts to schedule work in such a way as to carry out the maximum volume of work with the minimum cost and expenditure of time and physical resources of the field staff. In a typical week a field representative conducts site visits of three programs. Ordinarily he or she leaves home on Monday, travels to a remote site and conducts site visits on Tuesday, Wednesday and Thursday. At the end of the week, on Thursday evening or Friday morning, the field representative returns home. At that point he/she will finish the reports for the given week, contact programs with upcoming site visits, submit their completed site visit reports to the ACGME, and perform other administrative tasks. Field representatives are aware their reports must objectively reflect their observations of the program at the time of the site visit, by verifying and clarifying the information the program submitted in the PIF and other data collection for the accreditation process, such as surgical case logs information on the general competencies. The term verify is used for confirming that attributes described in the PIF are truly found as described. Clarify is used to denote the field surveyor’s collection of added information for areas where information in the PIF is missing or is ambiguous. The audience for the field representatives’ reports are the RRC reviewers. The reports reflect the representatives’ high professional standard. They are written in a readable, clear and concise fashion, without personal editorializing. An important qualification for a field representative is the ability to recognize that his/her role in the accreditation process is narrowly defined, focusing on the verification and clarification of the information in the PIF. Despite this narrow focus, the members of the field staff play a crucial role in the accreditation enterprise. If their job is done well, they can take satisfaction in helping the Residency Review Committees formulate fair and accurate judgments about the educational quality of the residency education programs accredited by the ACGME. |
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