Institutional Self-Study

1. Purpose

The Institutional Self-Study provides a framework for an ACGME-accredited Sponsoring Institution to improve graduate medical education (GME) by developing and implementing a strategic plan aligned with an institutional GME mission. To complete the Institutional Self-Study, a Sponsoring Institution convenes an Institutional Self-Study team that analyzes GME performance and identifies actions that can be taken to achieve defined institutional aims. The Institutional Self-Study may be used to address institutionally defined priorities that may include, but are not limited to, transforming education through GME innovation, optimizing health systems for learning, and demonstrating a commitment to excellence in patient care.

2. Team Members

The designated institutional official (DIO), on behalf of a Sponsoring Institution, has primary responsibility for convening a team to complete the Institutional Self-Study. At a minimum, this team includes (1) the DIO; (2) one or more peer-selected residents/fellows; and (3) a representative of the Sponsoring Institution’s senior administration. If the Sponsoring Institution has one or more institutional coordinators, their participation is recommended. Graduate Medical Education Committee (GMEC) members, program directors, and program coordinators may also be team members. Other team members may be added to ensure that the Institutional Self-Study represents the perspectives of multiple institutional GME stakeholders.

3. Institutional GME Mission and Performance

The first task of the Institutional Self-Study team is to consider how the Sponsoring Institution’s GME mission relates to its performance. The team reviews the institutional GME mission statement, and identifies information that could be used to evaluate institutional progress consistent with the mission.

4. Analysis of Institutional Performance

The team gathers information about institutional performance from the previous three to five years. The ACGME does not require the Institutional Self-Study team to use any particular sources and encourages the team to consider how information can be used to understand institutional performance related to the GME mission.

The team should use Annual Institutional Review (AIR) executive summaries from the previous three to five years as one source of information about institutional performance. In addition to these, the team has flexibility to incorporate various types of information, including, but not limited to, that obtained from local strategic planning efforts, Clinical Learning Environment Review (CLER) Program reports, and summaries of program Self-Studies.

The team also identifies any areas of risk of non-compliance with ACGME requirements. The team should communicate such areas to a Sponsoring Institution’s GMEC for action through existing accreditation oversight mechanisms of the Sponsoring Institution.

Based on the analysis of institutional performance, the team summarizes the Sponsoring Institution’s strengths and areas for improvement, and identifies current threats and opportunities for the institution.

5. Institutional Aims

After summarizing strengths, areas for improvement, opportunities, and threats, the Institutional Self-Study team defines three to five discrete aims of the Sponsoring Institution that are relevant to its GME mission. When defining aims, Sponsoring Institutions may refer to areas of institutional achievement as defined by the ACGME’s national learning community for Sponsoring Institutions. (The national learning community is under development, consistent with Recommendation 2 of the Report of the Sponsoring Institution 2025 Task Force.)

The team should identify the resources, processes, and policies that will support achievement of the aims, and should describe actions the Sponsoring Institution will take to facilitate achievement over the next three to five years.

6. Institutional Self-Study Summary

The Institutional Self-Study team completes the Institutional Self-Study Summary form, which summarizes the institutional mission, opportunities, threats, aims, and recommended actions. The form excludes information about the team’s analysis of institutional performance, and identification of strengths and areas for improvement.

7. Summary of Achievements

In advance of the 10-Year Institutional Accreditation Site Visit, the Institutional Self- Study team completes an Institutional Self-Study Achievement form describing efforts towards achieving aims since submission of the Institutional Self-Study Summary. The team also reviews actions that were previously recommended, updating them as needed.

8. Institutional Self-Study Role in Institutional Accreditation

The ACGME’s accreditation model requires each Sponsoring Institution to complete an Institutional Self-Study every 10 years. The DIO and institutional coordinator(s) are notified when the institution is expected to begin its Institutional Self-Study, and the full process should take no longer than six months to complete.

A Sponsoring Institution documents its completion of the Institutional Self-Study by submitting a summary that includes a GME mission and an action plan at least 24 months before the approximate date of a 10-Year Accreditation Site Visit, and a Summary of Achievements after that site visit is scheduled. The Institutional Self- Study Summary must be reviewed and approved by the GMEC, and must be signed by representatives of the Sponsoring Institution’s senior administration and governing body.

The Sponsoring Institution should harmonize the process, planning, and monitoring of the Institutional Self-Study with its AIR process. In the year of its Institutional Self-Study submission, the GMEC may choose not to complete an AIR, and the Institutional Self-Study Summary may be submitted by the DIO to the Sponsoring Institution’s governing body in lieu of one AIR executive summary.

After a 10-Year Accreditation Site Visit, the Institutional Review Committee reviews the Institutional Self-Study Summary form to determine whether a Sponsoring Institution has completed its required Institutional Self-Study. Apart from verifying completeness, the Institutional Review Committee does not utilize the contents in the institutional accreditation process.

The final version of the completed Institutional Self-Study Summary form is reviewed and approved by the GMEC. The form is signed by the DIO, a representative of the Sponsoring Institution’s senior administration, and a representative of the Sponsoring Institution’s governing body. The final form, with all signatures, must be uploaded in the ACGME’s Accreditation Data System (ADS) by the Self-Study Due Date.

9. Process for Single-Program Sponsoring Institutions

A single-program Sponsoring Institution is a Sponsoring Institution with one specialty program (with or without subspecialty programs reviewed by the same Review Committee as the specialty program), or with no specialty programs and one subspecialty program. These institutions are subject to 10-Year Accreditation Site Visits, and their GMECs should use the AIR to complete a review of compliance with ACGME requirements that would otherwise occur as part of the Institutional Self-Study. Whenever possible, the ACGME will schedule 10-Year Accreditation Site Visits for small Sponsoring Institutions to coincide with the 10- Year Accreditation Site Visit of its specialty or subspecialty program.

A single-program Sponsoring Institution may use its AIR process to complete its Institutional Self-Study. However, it would modify its AIR so that performance indicators are based on three to five years of data, and action plans are developed for a three- to five-year period. A single-program Sponsoring Institution may submit an executive summary of its Institutional Self-Study in lieu of the Institutional Self- Study Summary form; if it does so, it should include all required elements of AIR executive summaries, as indicated in Institutional Requirements I.B.5.b) and I.B.5.b).(1)-(2).

Contact Us:
Executive Director, Institutional Review Committee
Paul Foster Johnson , MFA
312.755.5005
Associate Executive Director, Institutional Review Committee
Olivia Orndorff, MSLIS
312.755.5491
Senior Accreditation Administrator, Institutional Review Committee
Cassie Pritchard, MPP
312.755.5011
Accreditation Administrator, Institutional Review Committee
Paris Rodgers
312.755.5024
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