Below are responses to general questions about the site visit process. Specific questions not covered below should be addressed to the staff of the Department of Field Activities or the applicable Review Committee team.
What are the different types of accreditation site visits are there?
All ACGME site visits are either Full or Focused site visits. The ACGME uses Full visits: (1) for all core program applications and applications for some subspecialty programs (the applications for other subspecialty programs and those for sponsoring institutions are generally reviewed without a site visit); (2) at the end of the two-year Initial Accreditation period, to ensure that a program or sponsoring institution with Initial Accreditation is compliant with the accreditation standards; (3) to address broad concerns identified during the review of data submitted to the ACGME annually; (4) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee; and (5) to assess overall compliance and ongoing improvement in a program or sponsoring institution during the scheduled 10-year site visit.
The ACGME uses Focused visits: (1) to conduct a timely, in-depth explorations of potential problems arising out of a Review Committee’s review of annually-submitted accreditation data; and (2) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee.
Detailed information about site visits for applications can be found in a separate set of FAQs addressing the accreditation of new programs, program mergers, and changes in sponsorship
What documentation needs to be prepared prior to an accreditation site visit?
For most site visits, the site visitors will use only the information collected via the Accreditation Data System (ADS), and program staff will not need to complete documentation prepared specifically for the site visit. A small number of site visits require documentation prepared specifically for the visit. These include: 1) applications for accreditation; 2) the full site visit at the end of the two-year period of initial accreditation, which requires completion of an updated version of the specialty-specific portion of the application document; and the 10-year site visit, which requires completion and uploading of the self-study summary 12 to 18 months before the site visit data, and completion of a summary of achievements realized through the self-study, uploaded 12 days before the visit.
Programs and sponsoring institutions should ensure currency of all data in ADS prior to a site visit, with a focus on responses to citations, changes in the program since the last Review Committee review, and additional changes the program requests for the site visit. The site visit announcement letter sent by the ACGME contain specific instructions if the given site visit requires the completion and uploading of any documents. It also offers detailed instructions for how and when to update the information in ADS, and any specific instructions for the particular program or sponsoring institution.
What evaluation documents should be available during a site visit for programs that use electronic resident evaluation systems?
The ACGME and the Council of Review Committee Chairs have clarified the expectations regarding information that should be available to site visitors during a site visit to enable them to verify the existence of a functioning evaluation process, including discussion of evaluations with residents/fellows. Evidence of this can be offered via either traditional paper-based evaluation forms or print-outs of electronic evaluations, including evidence that these evaluations were reviewed with the resident/fellow, such as the resident’s/fellow’s signature.
A growing number of programs/institutions use electronic evaluation systems or data management “suites” for collection, aggregation, and presentation of a variety of data related to the administration of residency/fellowship programs. If a program uses an electronic system, a paper record of the final evaluation conducted at completion of a resident’s/fellow’s training should also be retained. For residents/fellows with academic or other performance problems, there should be a hard-copy record to offer evidence of follow-up, including remediation, probation, non-renewal or dismissal.
How much lead time does a program receive for a site visit?
Programs scheduled for a full or focused site visit arising out of the review of data submitted annually through ADS are given a minimum of 30 days of advance notice, with the option of one postponement if the request meets ACGME justification criteria. Because site visits no longer use a program document prepared specifically for the site visit (i.e., the PIF), a shorter announcement period is feasible. The letter from the Review Committee indicating the need for a site visit, and the areas of the program that will be assessed, includes a tentative date, which is generally stated as the first day of the month in which the visit is to occur. This is not the actual site visit date, which is communicated subsequently in a letter sent by the Department of Field Activities.
Applications for accreditation and programs on pre-accreditation generally are provided with 30 days of advance notice. As it is critical to get programs on the schedule for their Review Committee’s next meeting, on occasion the notice may be somewhat shorter. ACGME staff in the Department of Field Activities will work with programs when a shorter site visit notice period is necessary.
Programs on initial accreditation, for the site visit that allows them to attain continued accreditation, generally receive 60 days of advance notice, as they are expected to prepare an updated specialty-specific application document for this visit.
Unannounced visits are used on occasion for some programs, at the discretion of the Review Committee. Generally, a 14-day advance notice is given for this type of visit. For a site visit to assess an alleged egregious violation, the advance notice is at the discretion of the leadership team that made the determination of the need for this type of site visit.
Programs scheduled for a 10-year accreditation site visit will receive a 90-day advance notice of the date. Programs are also given advance notice by the ACGME of the month when they should begin their self-study.
For all site visits, the Department of Field Activities will provide additional advance notice whenever possible. Notification of programs occurs via an e-mail notice sent by the Department of Field Activities. Concurrently, a site visit announcement letter with a set of detailed instructions on how to prepare for the visit is posted in the program’s folder in ADS. Programs should review the letter carefully, and contact Department of Field Activities staff identified in the letter with any questions.
What is the role of the ACGME field staff members who conduct accreditation site visits?
Accreditation site visits for programs and sponsoring institutions are conducted by members of the ACGME field staff. The members of the field staff are professional site visitors employed by the ACGME.
Biographical sketches outlining their professional backgrounds and tenure with the ACGME are available on the ACGME website.
Site visits for larger programs, and for most sponsoring institutions, are conducted by a team of two site visitors. Site visits for smaller programs may use a team at the discretion of the Department of Field Activities. The site visit announcement letter will indicate the type of visitor (team or individual), and the name and contact information for the assigned site visitor(s).
What happens during the site visit?
During the site visit, the site visitor or team uses the data from ADS, the results of the Annual Resident and Faculty Surveys, and other information, such as data on procedural experience, as indicated for the specialty. The site visitor or site visit team conducts interviews with the program director (and associate directors, if the program has them), residents/fellows, faculty members, and the designated institutional official (DIO) and/or other administrative representatives.
The site visitor or team also reviews documentation the program has made available on-site. A list of such required documents will be provided with the letter announcing the accreditation site visit. For some specialties, or if there were prior citations related to facilities, the site visitor or team will tour the physical facilities.
Site visits for a sponsoring institution use a somewhat different set of relevant data, and the interviews involve the DIO, members of the graduate medical education committee (GMEC), institutional leadership, and a representative group of residents and fellows.
A clarification interview conducted with the program director or DIO at the end of the site visit can include preliminary feedback from the site visitor/team. This feedback is provided in the form of a succinct summary that highlights two to three key strengths and offers suggestions for improvement in two to three areas. Both are based on the site visitor’s/team’s understanding of the accreditation standards and familiarity with relevant best practices. The site visitor/team will not offer any predictions regarding accreditation outcomes; these decisions are the sole purview of the Review Committee.
Which residents/fellows should be selected to meet with the site visitor? What is expected of the residents/fellows who meet with the site visitor?
The resident/fellow interview is crucial to the site visit. If a program has 15 or fewer residents/fellows, the site visitor will interview 12-15 of the residents on duty the day of the visit. If a program has more than 15 residents/fellows, the site visitor(s) will interview 15-20 peer-selected residents/fellows representing all required years of education. Chief residents beyond the required years of residency (e.g., fourth-year internal medicine chief residents) may not participate in the interview (they may be included in the faculty interview). For programs with a combined program track, such as internal medicine-psychiatry, representative residents from the combined program must be included in the interview.
For the site visit of a sponsoring institution, the interview group should consist of 15 to 18 residents and fellows that are representative of the programs sponsored by the institution.
For program and institutional site visits, residents/fellows may be interviewed in smaller groups, by training year, or individually. The site visitor who contacts the program/institution to plan the logistics for the site visit day will indicate the format for the resident/fellow interview. Residents/fellows should be made available for the entire interview period, with their pagers and cell phones turned off.
What happens after a site visit?
After a site visit, the site visitor/team writes a detailed narrative report that is used by the Review Committee, together with the information in ADS, to make its accreditation decision. Site visitors do not participate in making the accreditation decision.
All Review Committees meet at least two times per year, and the ACGME strives to review all programs and sponsoring institutions in a timely fashion. The schedule of Review Committee meetings and the agenda closing dates for each meeting are listed on each Review Committee’s web page on the ACGME website. Programs can contact the staff of the Review Committee team to find out if their program will be reviewed at a given meeting.
A few days after the meeting at which the program is reviewed, the Review Committee sends an electronic notice indicating the accreditation status that resulted from the meeting. The detailed accreditation decision will be posted in the program’s ADS account 60-90 days after the date of the meeting.
Can the date of a site visit be changed?
Due to the logistics involved in conducting a large number of site visits, once the date of a visit is set, it generally will not be changed. Exceptions may be made in certain circumstances. All requests to change a site visit date must be made by telephone to Jim Cichon (312.755.5015) or Penny Iverson-Lawrence (312.755.5014) in the Department of Field Activities. Requests must be made within five calendar days of receipt of the site visit announcement letter.
Requests for changes or postponements made more than five days after the date of the site visit announcement must be accompanied by a letter from the institution's DIO or Chief Executive Officer. Such letter must indicate that the institution agrees with the request for a change in the site visit date, and understands it may be charged a fee for the late notice of the request to postpone the visit.
How will the self-study visit be initiated?
The ACGME is conducting a large-scale pilot that will encompass the self-study and 10-year site visit for all Phase I programs scheduled for their 10-Year accreditation site visit between April 2015 and June 2016. Information about the pilot was announced in a memorandum by ACGME Chief Executive Officer Thomas J. Nasca, MD, MACP distributed in February 2015.
Updated: May 27, 2015