Site Visit FAQs

Frequently Asked Questions (FAQs) Related to the Accreditation and Recognition Site Visit

Below are responses to general questions about the accreditation and recognition site visit process. Specific questions or topics not covered in these FAQs should be addressed to the ACGME Field Activities staff or the staff of the relevant Review or Recognition Committee.

Question: What is the purpose of the accreditation and recognition site visit?
Question: What is the purpose of the accreditation and recognition site visit?
Answer:

The purpose of the accreditation and recognition site visit is the collection and aggregation of relevant data, which is put into a narrative, factual Site Visit Report used by the ACGME Review and Recognition Committees to make accreditation or recognition decisions. Accreditation Field Representatives are not the decision makers; accreditation and recognition decisions are the purview of the Review and Recognition Committees.

Question: Who conducts accreditation and recognition site visits?
Question: Who conducts accreditation and recognition site visits?
Answer:

Accreditation and recognition site visits are conducted by Accreditation Field Representatives, who are professional site visitors employed by the ACGME. Biographical summaries of the Accreditation Field Representatives are available on the ACGME website.

Some site visits to Sponsoring Institutions and programs are conducted by a team of two or more Accreditation Field Representatives. The Site Visit Announcement letter will indicate the name(s) and contact information of the assigned Accreditation Field Representative(s) for the visit.

Question: What are the different types of site visits?
Question: What are the different types of site visits?
Answer:

Program Applications
A site visit is conducted to review all specialty (core) and many subspecialty programs when an application for accreditation is submitted. The site visit seeks to verify and clarify the application documents in which institutional and program leadership have described the resources of the program and how it will comply with the Program Requirements. Applications for Sponsoring Institutions and some subspecialty programs are reviewed without a site visit.

Sponsoring Institutions and Programs with Initial Accreditation
All Sponsoring Institutions and programs undergo a site visit at the end of the Initial Accreditation period and prior to a Review Committee’s decision to confer the status of Continued Accreditation.

Continued Accreditation: Annual Data Review Site Visit
Sponsoring Institutions and Programs with a status of Continued Accreditation are subject to an annual screening of accreditation data in ADS. This includes the ACGME Resident and Faculty Survey reports; Case Log data (if applicable); surveys about adequacy of patient volume and variety for other specialties; information on scholarly activity for residents/fellows and faculty members; resident/fellow and/or faculty member attrition; and transitions in program and/or institutional leadership. If any of these areas suggests a problem, the Review Committee may ask the program to provide clarifying information, a progress report, or it may schedule a site visit.

Continued Accreditation: 10-Year Accreditation Site Visits
All Sponsoring Institutions and programs undergo a site visit following the Self-Study process that includes a description of how the Sponsoring Institution or program creates an effective learning and working environment, and how this leads to desired educational outcomes.

Probationary Accreditation
A Sponsoring Institution or program on Probationary Accreditation will need to have a site visit and be reviewed prior to achieving a status of Continued Accreditation or Continued Accreditation with Warning. These site visits often require a team of Field Representatives.

Complaint
After a Review or Recognition Committees considers complaint allegations and the Sponsoring Institution or program’s response to those complaint allegations, the Review Committee may request additional information or a site visit. These site visits often require a team of Field Representatives. Click here for more information about how to report an issue to the ACGME.

Other Site Visits
Review and Recognition Committees can request site visits at their discretion.

Question: What are accreditation and recognition site visit blackout dates?
Question: What are accreditation and recognition site visit blackout dates?
Answer:

There is an accreditation and recognition site visit blackout date function for Sponsoring Institutions and programs within ADS, giving the opportunity to designate dates to avoid when scheduling these visits.

Question: Who can enter blackout dates?
Question: Who can enter blackout dates?
Answer:

Designated institutional officials (DIOs), program directors/directors of osteopathic education, and institutional and program coordinators can enter these dates in ADS.

Question: When can blackout dates be entered?
Question: When can blackout dates be entered?
Answer:

In order to select blackout dates in ADS, the Sponsoring Institution or program must receive an email notice from Field Activities. After receiving this notice, Sponsoring Institutions or programs can enter blackout dates and continue to enter or change them until the date a site visit is scheduled.

Question: How many dates can be selected?
Question: How many dates can be selected?
Answer:

The number of blackout dates depends on the timeframe of the request. The larger the timeframe, the more blackout dates are offered.

Question: Is entering accreditation/recognition site visit blackout dates required?
Question: Is entering accreditation/recognition site visit blackout dates required?
Answer:

No. This option is intended to better align Sponsoring Institution and program and site visit scheduling needs.

Question: Are these the same as Clinical Learning Environment Review (CLER) blackout weeks?
Question: Are these the same as Clinical Learning Environment Review (CLER) blackout weeks?
Answer:

No. CLER blackout weeks are entered separately during the CLER blackout windows by DIOs or institutional coordinators. Click here for details about CLER blackout weeks.

Question: Who should be present for the site visit?
Question: Who should be present for the site visit?
Answer:
Program Site Visit
(Accreditation)
Program director, program coordinator(s), DIO and/or Chair (or representative if unavailable), faculty members, residents/fellows (if applicable)
Institutional Site Visit
(Accreditation)
DIO, institutional coordinator(s), members of the GMEC, other senior institutional officials (e.g., CEO), residents/fellows, faculty members representing all sites
Program Site Visit
(Recognition)
Program director, Director of Osteopathic Education, designated osteopathic residents/fellows, designated osteopathic faculty members

*Field Representatives may request others depending on the type of site visit or by request of the Review or Recognition Committee

Question: How much notice does Sponsoring Institution or program leadership receive ahead of an accreditation and recognition site visit?
Question: How much notice does Sponsoring Institution or program leadership receive ahead of an accreditation and recognition site visit?
Answer:

The minimum notice for all site visits is approximately 30 days. Notice may be less than 30 days if a site visit is required to meet a Review or Recognition Committee meeting deadline or other circumstances. In these cases, ACGME Field Activities staff members will work with the Sponsoring Institution or program leadership to ensure the visit is completed.

Programs scheduled for a 10-Year Accreditation Site Visit receive approximately 90 days’ notice.

On occasion, a site visit request after the review of annual data and a 10-Year Accreditation Site Visit may be combined at the discretion of Review Committee staff. Programs may receive less than 90 days’ notice in this situation.

Question: What is different about a remote site visit?
Question: What is different about a remote site visit?
Answer:

Remote site visits are conducted using an audio/audio-visual format. Click here to read Remote Site Visit FAQs.

Question: How long does it take to become accredited?
Question: How long does it take to become accredited?
Answer:

The Review Committees and the ACGME give priority to new applications. Programs with applications requiring an accreditation and recognition site visit should expect the process to take as long as six to eight months. Applications that do not require an accreditation and recognition site visit prior will be reviewed at the next Review Committee meeting with room on the agenda (generally within six months of receipt of a completed application).

Question: How can a program ensure the Review Committee reviews the application in a timely fashion?
Question: How can a program ensure the Review Committee reviews the application in a timely fashion?
Answer:

Completing the application with careful attention to detail is the most important initial step for the program director. The document submitted should demonstrate how the requirements are met in the Sponsoring Institution or program.

Common errors that may delay scheduling of an accreditation and recognition site visit or Committee review include missing or discrepant information about the planned program, missing signatures, or missing documents, such as Program Letters of Agreement with participating sites. All submissions are considered final.

Question: What documents must be submitted into the Accreditation Data System (ADS) prior to an accreditation or recognition site visit?
Question: What documents must be submitted into the Accreditation Data System (ADS) prior to an accreditation or recognition site visit?
Answer:

All site visits require information that is collected via ADS. Instructions on what needs to be updated in ADS prior to the site visit is listed in the Site Visit Announcement letter under the “Updating ADS” section. Sponsoring Institutions and programs should make sure all data in ADS is current prior to the site visit, focusing on responses to citations (if applicable), and changes in the Sponsoring Institutions or program since the last ADS Annual Update.

Additionally, Review Committee staff members may request additional documents be provided to the (primary) Accreditation Field Representative. Click here to view information that can be updated prior to the site visit.

Question: What documents are required for the site visit?
Question: What documents are required for the site visit?
Answer:

The documents required for a site visit review depend on the type of visit. A standard list of each document required by type of visit is attached to the ACGME site visit announcement letter. Click here to view a list of documents by accreditation or recognition status. Note that this list is in addition to the information that must be uploaded into ADS.

Some committees request additional documents for review at the site visit. The assigned Accreditation Field Representative(s) will indicate if such a request has been made for the particular visit.

Question: In what format should evaluation documents be available during an accreditation and recognition site visit for programs that use electronic resident evaluation systems?
Question: In what format should evaluation documents be available during an accreditation and recognition site visit for programs that use electronic resident evaluation systems?
Answer:

A growing number of Sponsoring Institutions and programs 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. The ACGME and its Review and Recognition Committees have clarified expectations regarding information that should be available to the Accreditation Field Representative(s) 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 traditional paper-based evaluation forms, printouts of electronic evaluations, or the online documents. All formats need to include evidence that these evaluations were reviewed with the resident/fellow, such as the resident’s/fellow’s signature.

Question: What are the ACGME’s expectations for resident and fellow files to be made available during accreditation and recognition site visits?
Question: What are the ACGME’s expectations for resident and fellow files to be made available during accreditation and recognition site visits?
Answer:

Review information regarding the ACGME’s general expectations for the content of resident and fellow files here.

Question: How should residents/fellows be selected to meet with the Accreditation Field Representative(s), and what is expected of them during these interviews?
Question: How should residents/fellows be selected to meet with the Accreditation Field Representative(s), and what is expected of them during these interviews?
Answer:

The resident/fellow interview is crucial to the accreditation and recognition site visit. For small programs, the Accreditation Field Representative(s) will interview all residents/fellows on duty the day of the visit. For larger programs, residents will be peer-selected representing all required years of education will be interviewed.

Those learners beyond the required years of residency (such as fourth-year internal medicine chief residents), or those not in the accredited program, may not participate in the resident/fellow interview but may be in the faculty member interview. For programs with a combined program track, such as internal medicine-psychiatry, representative residents from the combined program must be in the interview.

For the site visit of a Sponsoring Institution, the interview group should include residents and fellows representative of the programs sponsored by the institution. For program site visits, residents/fellows often are interviewed in smaller groups, with those in the most senior year(s) of the program interviewed separately. For some types of site visits, residents/fellows may be interviewed individually. The Accreditation Field Representative or team leader who contacts the Sponsoring Institution or program to plan site visit logistics will indicate the interview format. On the day of the site visit, the interview process may change if it appears a different approach will produce better results.

Residents/fellows and faculty members should be made available for the entire interview period, with their pagers and cell phones turned off.

Question: What happens during a program site visit?
Question: What happens during a program site visit?
Answer:

The Accreditation Field Representative or team conducts interviews with the program director and associate directors (if applicable), residents/fellows, faculty members, the program coordinator, and the designated institutional official (DIO) and/or other administrative representatives, as well as a review of documents. For some specialties, or if there were prior citations related to facilities, the Accreditation Field Representative(s) may tour selected clinical facilities or request a video tour.

A clarification interview conducted with the program director at the end of the site visit may include feedback from the Accreditation Field Representative/team, including a succinct summary highlighting two to three key strengths, and suggested improvement in two to three areas. The feedback is based on the Accreditation Field Representative’s/team’s understanding of the accreditation standards and familiarity with relevant best practices. The Accreditation Field Representative/team will not offer predictions regarding accreditation outcomes, nor will they assess when the program will be reviewed by the Committee; these decisions are the sole purview of the Review or Recognition Committee.

Question: Does the Accreditation Field Representative(s) meet with the program coordinator, and if so, what information is discussed?
Question: Does the Accreditation Field Representative(s) meet with the program coordinator, and if so, what information is discussed?
Answer:

For most accreditation and recognition site visits, the Accreditation Field Representative(s) will meet briefly with the program coordinator, often in conjunction with the document review portion of the visit.

For some visits, the Accreditation Field Representative(s) may conduct a brief interview with the coordinator to ask about the learning and working environment, institutional support and professional development for coordinators.

Question: What happens after the site visit?
Question: What happens after the site visit?
Answer:

After a site visit, the Accreditation Field Representative/team writes a detailed narrative Site Visit Report that is used, together with information in the ADS, by the Review or Recognition Committee to make its decision. Accreditation Field Representatives do not participate in the accreditation or recognition decision.

All committees meet two or more times each year, and the ACGME strives to review all Sponsoring Institutions and programs in a timely fashion. The schedule of committee meetings and the agenda closing dates for each meeting are listed on the specialty sections of the ACGME website. Program directors and DIOs can contact committee staff members to find out if their Sponsoring Institution or program will be reviewed at a given meeting.

A few days after the meeting during which a program is reviewed, the committee sends an electronic notice indicating the accreditation status determined at the meeting. The detailed accreditation decision will be posted in the program’s ADS account 60 to 90 days after the meeting.

Question: Can a Sponsoring Institution or program request to change its site visit date?
Question: Can a Sponsoring Institution or program request to change its site visit date?
Answer:

Due to the logistics involved in conducting a large number of site visits, requests to change a site visit date generally cannot be honored. All Sponsoring Institutions and programs have the opportunity to submit blackout dates before the site visit is scheduled to avoid dates that aren’t ideal for the Sponsoring Institution or program.

Exceptions are made in certain circumstances, and all requests to change a site visit date must be made to Andrea Chow (achow@acgme.org, 312.755.5009) or Penny Iverson-Lawrence (pil@acgme.org, 312.755.5014). 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 need to be accompanied by a letter from the institution’s DIO or Chief Executive Officer. The letter must indicate the institution agrees with the request for a change in the site visit date. Programs may be charged a fee for the late notice of the postponement request.

Question: Will a program’s Self-Study be reviewed at the time of the site visit? What happened to the program 10-Year Accreditation Site Visit?
Question: Will a program’s Self-Study be reviewed at the time of the site visit? What happened to the program 10-Year Accreditation Site Visit?
Answer:

No, the Self-Study will no longer be reviewed during a site visit. Visit the program Self-Study web page for more FAQs about the Self-Study and 10-Year Accreditation Site Visit.

Question: How does a Sponsoring Institution or program know when to initiate its Self-Study?
Question: How does a Sponsoring Institution or program know when to initiate its Self-Study?
Answer:

Seven to eight months prior to the Self-Study date shown in ADS, Sponsoring Institution or program receives an email from the ACGME to initiate the Self-Study. This e-mailed letter includes a link to resources for conducting the Self-Study.

Sponsoring Institutions and programs should start their Self-Study at that time, but can begin sooner. Program and Program Evaluation Committee leaders are encouraged to review the Self-Study resources page on the ACGME website for additional information. Institutional leadership should refer to the Institutional Self-Study guidance on the ACGME website.

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