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Eight Steps to Prepare for the 10-Year Accreditation Site Visit

The suggested eight-step sequence described here is intended to offer guidance to programs preparing for their first 10-year Accreditation Site Visit.

Click here for Eight Steps for Conducting the ACGME Program Self-Study

The 10-Year Accreditation Site Visit is scheduled at least 24 months after the program has completed its Self-Study and submitted its Self-Study Summary. It is a full site visit and accreditation review of the program against all applicable requirements for programs with a status of Continued Accreditation. This includes a review of program aims, strengths, and improvements made in areas the program identified in its Self-Study.

The 10-Year Accreditation Site Visits for subspecialty programs will be coordinated with the visit of their respective core program.

1. Reassemble the Annual Program Evaluation/Self-Study Group to “Harvest” the Data in Areas for Improvement Identified in the Self-Study

Timing: The time between submission of the Self-Study Summary and the 10-Year Accreditation Site Visit is deliberate to allow programs time to make improvements and conduct one more program evaluation prior to the visit. During this evaluation, the program should assess and document progress in areas for improvement identified during the Self-Study.

Team Composition: The Program Evaluation Committee (PEC) or, if desired, the Self-Study group, should review the data collected for areas of improvement identified during the Self-Study.

Process: When the PEC conducts this evaluation prior to the site visit, a key area to be assessed pertains to the improvements made in areas identified during the Self-Study.

Review these simple-to-use (optional) forms for aggregating data for a single year’s Annual Program Evaluation and for tracking improvements longitudinally across multiple Annual Program Evaluations.

Ideally, the role of data collection, aggregation, and tracking of progress should be assigned to an individual or a small group (with each individual member responsible for a particular area of improvement)

The individual or the team responsible for each improvement area will need to assess progress, as well as identify if improvement has been achieved or if the data constitute early indications of future improvement.

2. Discuss Improvements Made as a Result of the Self-Study with Stakeholders

As part of Annual Program Evaluation, improvements made in areas identified during the Self-Study should be discussed with stakeholders. This may actually constitute another valuable assessment of the changes made, as faculty members and trainees are in an excellent position to inform program leaders on whether a change has had the desired impact, or if further work is required.

This also allows program leadership to obtain input from stakeholders about the fit between the interventions and improvement initiatives and the program’s aims.

3. Reassess Program Aims and Other Elements of the Program’s Strategic Assessment (Strengths, Opportunities, and Threats)

In most cases, aims will take a longer-term perspective. However, aims may change over time, and it is beneficial to reassess them as part of the Annual Program Evaluation. In addition, the program’s context—opportunities and threats—should be reassessed for changes in the environment.

Programs that submitted their Self-Study Summary before April 2017 should also conduct a brief five-year look-back, and a five-year look-forward, as well as answer the question, “What will take this program to the next level?” Programs will provide updated information on these areas in a Self-Study Summary Update they will submit, with their Summary of Achievements, before the “ADS Uploads and Updates Due Date” listed in the site visit announcement letter.

4. Discuss Program Aims, Improvements Achieved, and Other Elements of the Program’s Strategic Assessment with Program Stakeholders

The information on aims and the environmental assessment should be shared and discussed with program leadership and stakeholders prior to the 10-Year Accreditation Site Visit.

This is another opportunity for faculty members, trainees, the program coordinator, and any other appropriate individuals to have an improvement-focused conversation about the program. It will also prepare the group for conversations about the Self-Study process and outcomes, which will constitute the first part of the 10-Year Accreditation Site Visit.

5. Complete and Submit the Summary of Achievements

The ACGME Department of Field Activities will provide approximately 90 days of advance notice for the 10-Year Accreditation Site Visit. Dependent subspecialty programs will be visited with their core program.

Once the data on program aims and improvements achieved have been discussed and finalized, program leaders should prepare the Summary of Achievements, which is a list of the program’s strengths, and improvements made to-date in areas identified during the Self-Study.

For some areas, programs may provide early data on improvements that have not yet been fully realized. See above for a discussion of leading indicators for such longer-term improvements.

Access the Summary of Achievements template

For the 10-Year Accreditation Site Visit, the ACGME will not ask programs to provide any information on areas identified during the Self-Study that have not yet resulted in improvements.

If there have been changes to a program’s aims or environmental assessment, and for programs that completed their Self-Study Summary prior to April 2017, a Self-Study Summary Update should be used to describe any changes or add new information to the original summary.

Access the Self-Study Summary Update

6. Update Data in the Accreditation Data System (ADS) Ahead of the 10-Year Accreditation Site Visit

Programs leaders need to update ADS before the “ADS Uploads and Updates” due date listed in the site visit announcement letter prior to the date of their 10-Year Accreditation Site Visit. Only three sections of ADS program data can be updated at this juncture: (1) current responses to any citations; (2) the open text section entitled “Changes and Other Updates”; and (3) a current block diagram that accurately reflects the program.

Program leadership should ensure that the responses to any citations are current and succinct, and describe recent improvements, and that the block diagram follows ACGME guidelines provided within ADS.

The Major Changes and Other Updates section is an opportunity to explain to the Accreditation Field Representative and Review Committee any current efforts related to program improvement. For example, a program could discuss changes and improvements recently made in response to Resident Survey data for the most recent year, highlight additions or changes to participating sites aimed at improving residents’ patient care or procedural experience, identify changes in evaluation systems, or note the hiring of a new faculty member.

Any updates or changes made after that date will not be reflected in the documents available to the Accreditation Field Representative or the Review Committee reviewers.

7. Ensure Timely Data Submission Prior to the 10-Year Accreditation Site Visit

The Summary of Achievements, and for any updates, the Self-Study Summary Update, must be submitted via ADS before the “ADS Uploads and Updates” due date listed in the site visit announcement letter before the 10-Year Accreditation Site Visit.

Review the Site Visit FAQs for information about site visit scheduling and the ACGME’s announcement notices.
8. Set and Confirm Logistics for the 10-Year Accreditation Site Visit

The assigned Accreditation Field Representative will contact the program regarding the details of the 10-Year Accreditation Site Visit, including the individuals to be interviewed, the time to allocate for these meetings, and the organization of rooms and other logistics. Generally, the ACGME will interview 12 to 18 peer-selected residents or fellows during the site visit (or all available residents for smaller programs), although the assigned Accreditation Feld Representative has the final decision regarding the size of the interview group and the format of the interview. Site visits for very large programs may involve a larger resident/fellow interview group, and may be performed by a team of Accreditation Field Representatives. Teams may also be used for large sequences of core and subspecialty programs.

The 10-Year accreditation site visit for a core program will take a half to a full day, depending on the size of the program, while the visit for a subspecialty program generally will require less time. The ACGME is still refining site visit protocols for how to address the shared components of the Self-Study between core and subspecialty programs. This will be the subject of further study, and guidance will be provided as it is determined.

See the Site Visit Document List for the materials to have available for the Accreditation Field Representative to review during the 10-Year Accreditation Site Visit.

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