Approximately four years ago, the ACGME developed an initial set of responses to frequently asked questions (FAQs) about the entire site visit process. The document below was updated in the fall of 2005, with new responses addressing areas such as the ACGME resident survey and the expectations for providing information on the general competencies in a selected number of subspecialty programs. The responses below offer general answers. Answers to specific questions should be addressed to the Department of Field Activities or the relevant Review Committee (RC) team.
When will our site visit be scheduled?
The notification (or accreditation) letter the program receives after the RC has made an accreditation decision shows the approximate date of the next site visit (stating, for example, that “the program will be resurveyed after April 1, 2008”). Programs generally are scheduled in a 120- to 150-day window around this date. On occasion, a site visit may occur on a later date because each ACGME Field Representative visits three programs per week, and programs can be held back to allow three programs to be scheduled in a given city. In addition, Transitional Year programs and some subspecialties with one required year of residency are generally scheduled during the last nine months of the academic year in order to give their residents an opportunity to gain experience in the program prior to participating in the resident interview.
Programs generally receive at least 110 days of advance notice of the scheduled date of their site visit. If the approximate date of the visit is near and you have not yet received a letter from the ACGME, please contact Amy Dunlap (312/755-5009) or Penny Iverson-Lawrence (312/755-5014) in the Department of Field Activities to find out if a visit date has been set.
Who will conduct the site visit?
The ACGME uses two types of site visitors – Field Representatives and Specialist Site Visitors (SSVs). The ACGME Field Staff is made up of professional site visitors employed by the ACGME. SSVs are members of the discipline who conduct a small number of visits annually. Of the approximately 2,000 site visits conducted annually, more than 1,900 are performed by members of Field Staff, and around 80 are involve SSVs. Biographical sketches for the ACGME Field Representatives , outlining their background, can be found on the ACGME web site. The RC in your specialty decides whether a member of the Field Staff or an SSV will do a given visit. A number of RCs do not use specialists, and others use them only for specific circumstances (such as new program applications).
The role of both types of site visitors is identical – to produce a report that verifies and clarifies the information the program submitted in the Program Information Form (PIF). To collect the information for this report, the site visitor interviews the program director, faculty, residents, and the designated institutional official (DIO) and/or other administrative representatives. For some specialties, the site visit also includes interviews with representatives from other departments the program interacts with.
What do I need to know about preparing the Program Information Form (PIF)?
An important aspect of preparing for a site visit is the preparation of the PIF. A well-prepared PIF describes the residency program accurately, completely and truthfully. It should be comprehensive, specific and concise, and answers all questions completely. An incomplete or inaccurate PIF can be a contributing factor in an unsatisfactory RC review.
To download the PIF for your program from the ACGME's web site, use the instructions provided in the site visit announcement letter (these instructions are also in the response to the FAQ, “How do I download the Program Information Form?”). Before preparing the PIF, you should review your program requirements and the institutional requirements. You should also allow sufficient time to gather the data needed for completing the PIF. In completing the PIF, remember that the RC members will not be familiar with the specifics of your program. Also, you should not rely on the site visitor to relate to the RC information that is relevant to compliance with the accreditation standards. If something is relevant to the review, you should include it in the PIF.
Call the staff of your RC if you need help with any questions in the PIF. If you have a technical problem with any aspect of the PIF, contact the ACGME Help Desk at 312/755-7464 or via e-mail to helpdesk@acgme.org . Whether you complete the PIF yourself or delegate parts to others, a third party should review the entire document for consistency, accuracy and clarity before it is submitted to your DIO for final review and signature.
Can the date of the site visit be changed?
The ACGME surveys approximately 2,000 programs annually. Therefore, once the date of your site visit is set it generally cannot be changed. Exceptions may be made in certain circumstances. All requests to change the date of the site visit must be made by telephone to Jim Cichon , Associate Director (312/755-5015), Penny Iverson-Lawrence , Senior Survey Administrator (312/755-5014) or Ingrid Philibert , Senior Vice President (312/755-5003), all in the Department of Field Activities. Requests must be made within 14 calendar days of receipt of the site visit announcement letter.
The ACGME incurs significant costs in scheduling Field Representatives to conduct site visits, and requests for postponements of a survey received by the ACGME more than 21 days after the date of the site visit announcement letter must be accompanied by a letter from the institution's DIO or Chief Executive Officer (CEO). The letter must indicate that the institution agrees with the request for a change in the site visit date and is aware that it may be charged a fee of $2,750 for late notice of their intent to postpone the visit.
Our program currently has no residents. Will we be site visited?
If a site visit is due, the ACGME may visit your program, even if there currently are no residents in the program. Please contact your RC team, or staff in the Department of Field Activities to discuss.
If the program is not planning to take residents, most RCs allow a period of up to 24 months without residents. After that period, programs are expected to request voluntary withdrawal of accreditation without prejudice. Requests for voluntary withdrawal must be directed to the staff of your RC. In late 2007 and early 2008, the ACGME will begin to use an on-line function to allow you to make the request for voluntary withdrawal of accreditation. You may find this option under your Accreditation Data System menu.
If you have been notified of a site visit and are planning to seek voluntary withdrawal , notify Jim Cichon (312/755-5015) or Penny Iverson-Lawrence (312/755-5014) in the Department of Field Activities as soon as possible of your plans. Failure to do so may result in the program being fined $1,375 for late notice of seeking voluntary withdrawal.
How do I download the PIF?
To download the PIF for your site visit, on the ACGME's web site, access the menu option “Review Committees” to bring up a directory showing all RCs. Probing the line for the given RC will bring up a menu that includes the option to download the program requirements, the PIFs for the core program and any subspecialties, and the instructions for downloading the document in WordPerfect or Microsoft Word. Follow the detailed instructions on the web page to download and complete the PIF and any associated documents. Programs in Internal Medicine and its subspecialties will have received specific software for completing the PIF and other site visit documents. For an institutional review, the Institutional Review Document (IRD) and the Institutional Requirements can be accessed by probing the option in the main menu entitled “Institutional Review” If you encounter problems in accessing or downloading documents from the web, contact the Computer Help Desk either by sending message to helpdesk@acgme.org or calling 312/755-7464.
When will our program complete the ACGME resident survey?
All core specialty programs and subspecialty programs with 4 or more residents/fellows will be surveyed every other year between January and May. Aggregate reports will be made available to programs if a 70% response rate is reached. This survey is not administered in conjunction with a program's site visit, although the information gathered will be used at the time of the program's site visit. The ACGME will notify programs directly when their participation is required. This notification will include detailed information on accessing the survey and a deadline for completion. Residents/fellows will have 4 weeks in which to complete the survey. More detailed information about the ACGME resident survey is available from the ACGME web site at:
How should the program prepare for an assessment of the general competencies?
Programs in all core specialties, the Transitional Year Review Committee, the subspecialties of Internal Medicine and a few other subspecialties are required to provide information on the use of the six general competencies. Your site visit announcement letter will contain detailed instructions on how to download the Competency and Assessment Form from the ACGME's web site. If your subspecialty program uses the competencies in its curricula and evaluations, you may provide information on this on a voluntary basis. It should be placed in the PIF narratives that discuss your curriculum and evaluation process.
What should be done with the completed PIF?
After completing the PIF, you should print four (4) hard copies. One copy should be sent to the address of the Field Representative assigned to your program (shown in the ACGME's letter announcing the site visit date). This copy must be sent to arrive at the Field Representative's address a minimum of 14 days before the date of the site visit. The three remaining copies are turned over to the site visitor on the day of the visit. All four hard copies of the PIF must be identical and must be final. Draft copies are not acceptable to the Field Representative or the ACGME. Failure to send the copy to the Field Representative at least 14 days before the visit can result in cancellation of the site visit at the discretion of the Field Representative (the program is charged a $2,750 fine for cancellation under these circumstances and the visit is rescheduled). All copies should not be bound or stapled and should be held together with a strong rubber band.
How do we set up the schedule for the day of the site visit?
Approximately 30 to 60 days before the scheduled site visit day, the site visitor assigned to your program will contact you by telephone, letter, fax or electronic mail to set up the schedule for the visit. You may also contact the Field Representative at the address listed on the scheduling letter to make the necessary arrangements (the best day to call the Field Representative is Friday). On the day of the visit, the site visitor will need to meet with faculty, residents and the DIO or another administrative representative. For a series in which two or more programs are visited at one sponsoring institution only one meeting with the DIO is necessary, and your site visit day may not include schedule time with the DIO. Some RCs also ask the site visitor to meet with other program or institutional representatives. The site visitor, in consultation with the program director, makes the final determination of the schedule and the individuals who will be interviewed.
You should remember that the site visitor might not be familiar with your town or your institution's facilities, and may appreciate directions to the institution and instructions for parking. You should arrange for a place and time to meet the site visitor. The site visit (with exception of tours of on-call rooms and other facilities, as required) should take place in a well-lighted conference room with a table sufficiently large to allow the site visitor to do his/her work. If lunch is scheduled during the site visit, please keep the menu simple.
What happens on the day of the site visit?
On the day of the survey, be flexible and understand that schedules may be changed or be delayed to accommodate the information collection needs of the site visitor. At the conclusion of the visit, do not expect the site visitor to offer an opinion about your program. The RC evaluates the program and makes the accreditation decision, and the site visitor's role is to verify and clarify the self-study report you provided in the PIF.
If you expect a report at the end of the visit on how your program did, you may be disappointed. Site visitors are not able to give you detailed feedback, because they are not the decision-makers. Accreditation decisions are the purview of the RC. The site visitor may be able to offer preliminary suggestions regarding possible program strengths and opportunities for improvement, but these are solely based on the site visitors' experience with the review process in general.
Can I make changes to the PIF after it has been sent to the site visitor?
The PIF sent to the site visitor and the three copies provided on the day of the visit must be identical and in final form. Changing the PIF after a copy has been sent to the site visitor and before the day of the visit should be avoided at all cost. Minor discrepancies can be cleared up on the day of the visit. The rare exception is a major error or omission in the PIF that profoundly affects the review. In this case, do not send a new PIF. Send the site visitor only the pages that were changed, with the changes clearly highlighted. Notify the site visitor via voice mail or electronic mail that revised PIF pages are being sent. No revisions may be sent any later than 5 to 7 days before the date of the visit. The three copies of the PIF provided to the site visitor on the day of the visit for mailing to the ACGME must be in the revised form.
If errors are discovered on the day of the site visit, it is acceptable to make minor changes to selected PIF pages, provided that it can be done before the site visitor departs. Do not ask the site visitor to wait while you make extensive changes. Once pages have been changed, a copy of the revised pages should be given to the site visitor with the changes highlighted, and the pages with revisions should be inserted in the three copies to be sent to the ACGME before they are packaged for mailing.
How should residents be selected to meet with the site visitor?
The resident interview is crucial to the site visit. Please follow these guidelines: if the program has ten or fewer residents, the Field Representative will want to speak with all residents who are on duty on the day of the visit. If the program has more than ten residents, the Field Representative will want to speak with 10 to 12 residents. Residents must be selected by their peers, with representation from each year of the program. Chief residents beyond the required years of residency (e.g., a fourth-year internal medicine chief) may not participate in the resident interview (they may be included in the faculty interview). If your program operates a combined program track, such as internal medicine-pediatrics or internal medicine-psychiatry, residents from the combined program should be represented in the interview group. Residents should be made available for the entire interview period, with their pagers and cell phones turned off.
What happens during the resident interview?
The resident interview is an important component of the site visit. It generally opens with a brief overview of the accreditation process and the purpose of the site visit. Residents may be asked what instructions were provided about the resident interview. The residents are informed that if an adverse action results the site visit report may be shared with the program. Then the site visitor asks questions based on the information in the program's PIF and concludes with questions about the program's strengths and weaknesses. For the site visit report, answers have to reach consensus level to be reported, or are reported as “a single resident stated” or “the first-year residents as a group indicated.” Individual residents are not identified in the report.
Will the program be billed for the site visit?
Programs are not billed for the visit. Beginning in 2000, the ACGME has used an annual accreditation fee for all accredited programs, which eliminates the previous practice of charging site visit fees and annual resident fees. The annual fee is billed in January, separately from the site visit.
What happens after the site visit?
After the visit, the site visitor submits a written report to the ACGME, which is then forwarded to the RC team and sent to the RC reviewers. The RC's review of your program is based on your PIF and its attachments, and the site visitor's report. The site visitor does not participate in the accreditation decision. His/her job is completed when the finished site visit report is transmitted to the ACGME.
All RCs meet at least two times per year, some that review a large number of programs meet more frequently. The ACGME strives to get each program reviewed in as timely a fashion as possible after the site visit. RCs close out their agendas approximately 60 to 75 days before the meeting date. For a program site visited less than four months before a meeting date, there is no guarantee that it will be presented at the next meeting. Also, on occasion, the RC's agenda may be very full and programs may need to be delayed until the next meeting. The schedule of meetings for the RC and the Institutional Review Committee is available from the ACGME web site at:
RRC Meetings for 2007 and
RRC Meetings for 2008
You may also contact the RC team if you want to find out if your program will be reviewed at a given meeting. After the program has been reviewed, the program director and the designated institutional official will be notified via e-mail of the accreditation status and tentative date of the next site visit. This occurs within a few days of the end of the meeting. The detailed accreditation decision will be sent by mail between 60 and 90 days after the RC meeting.
How do I provide feedback on the site visit?
The ACGME sends a request for an anonymous electronic evaluation to all programs within two weeks of the site visit. The results are aggregated and used in the professional development of the site visitors, and the evaluation of the Department of Field Activities. The request to complete the survey will be in the form of an electronic mail message from the ACGME, with the web portal for the survey embedded in the message.
If you have a complaint or concern about the site visit, or if the site visitor was especially helpful or informative, in addition to filling out the electronic survey you should relate this information to the ACGME Department of Field Activities by contacting Ingrid Philibert , Senior Vice President, at 312/755-5003 or Jim Cichon , Associate Director, at 312/755-5015.
I want to increase my resident complement, but the RRC requires a review. Can I request an early site visit?
A number of RCs require a site visit and review prior to allowing a program to increase its complement. If you are not certain, please check with your RC team to see if a site visit is required. Based on the recommendation of the RC team, you may request an early review. You must contact Ingrid Philibert (312/755-5003) or Jim Cichon (312/755-5015) to ask for an early site visit. Please be prepared to provide the reasons for the early review.
My site visit will occur before the RRC determined next date. How should I time my internal review to be at the mid-point between site visits?
The ACGME also receives questions about the timing of the internal review when site visit dates are moved up at the request of the program or the ACGME. The Institutional Requirements state that the internal review should be conducted approximately at the midpoint between the last RC review and the next site visit. When the visit is moved up, and the internal review has not yet occurred, the Institutional Review Committee expects programs to perform an internal review as soon as possible, even when this places it in close proximity to the site visit date. When an internal review occurs under these circumstances, the reason should be documented in the summary that is included in the Institutional Review Document. |
