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Self-Study

Eight Steps for Conducting The ACGME Program Self-Study

The suggested eight-step sequence described here is intended to offer guidance to programs conducting their first self-study.

The self-study is an objective, comprehensive evaluation of the residency or fellowship program, with the aim of improving it. Underlying the self-study is a longitudinal evaluation of the program and its learning environment, facilitated through sequential annual program evaluations that focus on the required components, with an emphasis on program strengths and “self-identified” areas for improvement (“self-identified” is used to distinguish this dimension of the self-study from areas for improvement the Review Committee identifies during accreditation reviews).

To offer context for the self-study, there are two new concepts: 1) an exploration of program aims; and 2) an assessment of the program’s institutional, local and, as applicable, regional environment. Both are discussed in detail below. The focus on aims and the program’s environmental context is to enhance the relevance and usefulness of the program evaluation, and support improvement that goes beyond compliance with the requirements.

Additional Notes

Conducting the self-study for a dependent subspecialty program

The ACGME has placed added responsibility for oversight of subspecialty programs on the core program and sponsoring institution.

The self-study group for the core program should try to coordinate activities with the self-study groups for any dependent subspecialty programs, to take advantage of common dimensions, explore potential synergies, and reduce the burden that may be associated with conducting an independent self-assessment.

The 10-year site visits for subspecialty programs will be coordinated with the visit of their respective core program.

1. Assemble the self-study group

Membership: The members of the Program Evaluation Committee (PEC) are the ideal core foundation for the self-study group. They are familiar with the Annual Program Evaluation process and the resulting action plans and improvement efforts. Including the program coordinator is also recommended.

Added participants: The ACGME does not require additional participants in the self-study. However, it may be beneficial to have a few individuals to offer an external perspective. Examples include a departmental leader, a clerkship director, a chief resident, or an expert in education, curriculum design, or assessment. These individuals may be included if program leaders think their contributions would be beneficial. For institutional experts, the DIO may be able to provide suggestions.

CCC representative: It may be beneficial to include a member of the Clinical Competency Committee (CCC) on the self-study group, due to the focus on educational outcomes, which makes data on residents’/fellows’ Milestone performance an important component in self-study discussions.

2. Engage program leaders and constituents in a discussion of program aims

The first task of the self-study group is a discussion of program aims. Aims are program and institutional leaders’ views of key expectations for the program, and how it differentiates itself from other programs in the same specialty/subspecialty. Aims may focus on the types of trainees recruited into the program, training for particular careers (clinical practice, academics, research, primary/generalist care), and other objectives, such as care for underserved patients, health policy or advocacy, population health, or generating new knowledge.

Program aims should generally take a longer-term strategic view, but they also may change over time, in response to factors such as local or national demand for a resident workforce with certain capabilities, or new opportunities to train residents and fellows in a different setting.

3. Examine opportunities and threats

The next step is to conduct an assessment of the program’s environment. The rationale for examining opportunities for and threats facing the program is to provide context for the self-study.

Opportunities: Opportunities are external factors that are not entirely under the control of the program, but if acted upon, will help the program flourish. Opportunities take many forms, such as access to expanded populations for ambulatory care at a local health center, partnering with an institution with a simulation center, other collaborations, or availability of new clinical or educational technology through agreements with external parties.

Threats: Threats also are largely beyond the control of the program, and like opportunities, come in many forms. They could result from a change in support for education at the national level, changing priorities at the institutional or state levels, or from local factors, such as erosion of a primary ambulatory system based on voluntary faculty. The benefit of assessing program threats is that plans can be developed to mitigate their effect.

4. Aggregate and analyze data to generate a longitudinal assessment of the program’s improvement

Threats: Threats also are largely beyond the control of the program, and like opportunities, come in many forms. They could result from a change in support for education at the national level, changing priorities at the institutional or state levels, or from local factors, such as erosion of a primary ambulatory system based on voluntary faculty. The benefit of assessing program threats is that plans can be developed to mitigate their effect.

For the data from the Annual Program Evaluation, the focus is on program strengths and self-identified areas for improvement; how improvements are prioritized, selected, and implemented; and follow-up to assess whether interventions are effective. Over time, this process should focus on improvement that goes beyond compliance with requirements, with particular attention to improvements relevant to the program’s aims and environmental context.

Additional data for the self-study should relate to ongoing improvement activities and the perspectives of program stakeholders, such as results of the annual ACGME Resident and Faculty Surveys, and other relevant departmental or institutional data.

5. Obtain stakeholder input

The data should be confirmed and augmented by information from program stakeholders (residents/fellows, faculty members, others as relevant). For some programs, important information may include the perceptions of representatives from other specialties who interact with the residents or fellows. To collect this information, the program may use surveys, meetings with residents/fellows, or a retreat. Feedback from recent graduates could also provide useful data on the program’s educational effectiveness.

6. Interpret the data and aggregate the self-study findings

The next step is to interpret the aggregated data from the self-study. Specific elements of the self-study findings will include:

  1. establishing a working set of program aims;
  2. listing key program strengths;
  3. prioritizing among the self-identified areas for improvement to select those for active follow-up, and define the specific improvement activities;
  4. discussing opportunities that may enhance the program, and develop plans to take advantage of them; and,
  5. discussing threats identified in the self-study, and develop plans to mitigate their impact.

7. Discuss the findings with stakeholders

The self-study findings from Step 6 (above) should be shared with faculty members and residents/fellows. This step should validate the findings and improvement priorities chosen by the self-study group with these key stakeholders.

8. Develop a succinct self-study document for use in further program improvement and as documentation for the program’s 10-year site visit

The final step is for the self-study group or an individual designated by the group to complete a succinct self-study document that describes the process and key findings in the areas of program aims, the environmental assessment, and program strengths and areas for improvement.

The ACGME’s self-study summary template (see below) does not include information on program strengths and areas for improvement. The rationale for this is to allow programs to conduct a frank assessment.  Programs may opt to complete the summary template, and have a separate brief companion document that lists the strengths and areas of improvement that were identified through the self-study.

At the time of the 10-year site visit (12 to 18 months later), the program will be asked to provide a brief written update describing improvements resulting from the self-study. No information will be requested on areas identified during the self-study that have not yet resulted in improvements.

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