Accreditation Council of Graduate Medical Education (ACGME)

You can anticipate the approximate date of your next site visit from your prior accreditation letter. It is wise to review your specialty’s Program Requirements and the Common Program Requirements the year before the anticipated review to ensure that you are in substantial compliance and to make certain that all recommendations from your prior internal review have been satisfied. RRCs generally look askance at changes in the program which have been made shortly before a site visit. Program Requirements usually undergo revision approximately every five years. A useful guideline is that the most recent changes are areas which the RRC is currently very concerned about, and which will likely be examined in detail at the time of a site visit. A good example of this is work hours, a current “hot button” issue.

The actual notification occurs at least 90 days in advance of the site visit. The ACGME is now giving an initial electronic notification, which should be followed shortly by written notice. This letter will specify the date of the site visit as well as the name of the field staff member (site visitor) who will be performing the review. The designated institutional official (the current associate dean for McGaw GME) will be copied on the letter.

Sometimes there is a serious conflict with the date provided. In general, it is essential that the program director be present for the site visit. If the chair or division chief is separate from the program director, it is highly desirable that this individual be present as well. However, the ACGME has the discretion to proceed with a site visit in the absence of the chair or division chief. In the event of a serious conflict, you should contact the field staff representative at the ACGME to discuss the possibility of rescheduling the site visit. This request, however, should be based on an important conflict. For example, timing during a national academic meeting would not likely be considered an important conflict unless the program director were the incoming president of that association; whereas the wedding of an offspring may be judged appropriate to justify a re-scheduling. If you request a change in the date of the site visit, please do so within 21 days of notification of the date. If it is later than this, the ACGME will charge $2,000 for the change. This fee will not be carried by the GME office and must be paid by the program.

Site visit preparation information is available on the ACGME's site visit FAQ page. Preparation should begin as soon as a program is notified of the date of the site visit in order to develop a reasonable timeline for activities and input needed. If there are requests for information that you do not understand, contact the McGaw GME office for assistance.

When updating the program's information in the Accreditation Data System (ADS) and completing the specialty-specific application document, particular attention should be paid to format, length of responses, font, etc. It is wise to circulate a draft to key faculty members and housestaff, requesting input as to inaccuracies. It is clearly preferable to clear up discrepancies and inaccuracies prior to the site visit rather than have faculty or housestaff make statements that are inconsistent with what is reported. Such discrepancies are often the subject of noncompliance citations. Prior to the site visit, all submitted final reporting (as well as supporting documentation that will be presented to the visitor when onsite) should be reviewed by each person to be interviewed prior to the site visit.

Typically the site visitor will expect that all of the program's information in the Accreditation Data System (ADS) has been finalized about 14 days ahead of the scheduled site visit.

Please remember that the Graduate Medical Education Committee (GMEC) will need to review and approve the program's Accreditation Data System (ADS) information prior to its finalization, so please submit a solid draft to the McGaw graduate medical education office a month or more ahead of your scheduled site visit. Please refer to the GMEC meeting schedule at the link above.

The site visitor will contact you about a month prior to the site visit. They will designate when finalized ADS information is expected and the approximate schedule of interviews that they expect to conduct on the day of the site visit. Please understand that the details of the schedule the site visitor requests should be respected, both for the individuals to be interviewed as well as the duration of each interview. The site visitor will want to know the exact location for the visit and may request specific directions. Remember that we are very familiar with our own institution, but it can be quite confusing to a site visitor. Please provide cross streets, location of easiest entrance, floor number, etc. Sometimes the site visitor will request to meet with the designated institutional official (DIO). This is the current associate dean for graduate medical education, Joshua Goldstein, MD. Please contact the McGaw GME office to ensure that the DIO will be available for the site visit.

It is essential that an appropriate composition and cross-section of housestaff be available for the site visit. If there are more than 10 housestaff in the program, the site visitor will likely designate the desired complement, for example X number from each year of training. It is important that the housestaff selected to be present are peer-selected. Under no circumstances should the program director decide who should be present on the basis of availability or their anticipated favorable responses to questions asked. The task of selecting those to attend the site visit is best delegated to a chief resident or senior fellow. The site visitor may ask the housestaff present at the site visit how they were selected, thus it is important that they feel comfortable stating that they were selected by their peers. If, on the other hand, there are 10 or fewer housestaff in the program, the site visitor will typically ask to meet with all housestaff. If this is the case, it is important to “pull” housestaff from off-site rotations to be present at the time of the visit.

A copy of the summary page of the Program's internal review should be readily available to show to the site visitor, but not the internal review report itself. A copy of the summary page may be obtained from the McGaw GME office. Remember that the content of the internal review is confidential and will not be requested or reviewed by the site visitor.

The major institutional agreements (between the primary hospitals and McGaw) are usually requested and are available from the GME office. If, however, there are other rotations to non-McGaw institutions, there needs to be a Program Letter of Agreement with that clinic or institution specifying the details of the rotation (who is responsible for supervision, educational objectives, duration of the rotation, who pays the stipend, who covers liability insurance, etc.). If you do not have such agreements, develop them post-haste.

Prior to the site visit, the field staff will review the history of your program, previous accreditation letters and RRC citations/concerns, the recent Institutional Review Committee (IRC) accreditation letter, current Program Requirements and Institutional Requirements, and the program information available in the Accreditation Data System (ADS).

The sponsoring institution (McGaw Medical Center of Northwestern University) must be in substantial compliance with the Institutional Requirements just as an individual program must be in substantial compliance with their specialty Program Requirements. It is useful for a program director to be familiar with the Institutional Requirements prior to a site visit. The GME office can provide a copy of the most recent institutional accreditation letter (if requested) or for the site visit.

Important elements for a successful site visit include the following:

• All individuals to be interviewed should be aware of the importance of being present on time and without interruption (no pagers); separate individuals should be identified to provide coverage for emergencies.
• Housestaff to be interviewed should be freed of obligations and have pagers turned off for the duration of the time with the site visitor.
• Support personnel (e.g., administrator or program coordinator) should have familiarity and ready access to any files or information which might be requested by the site visitor (examples: educational files of housestaff; copy of the manual distributed to housestaff at the beginning of training).
• Typically the site visitor will request to meet with your housestaff during the lunch hour, and that you provide lunch for the site visitor and housestaff. This need not be extravagant, but should represent an appealing and balanced assortment of food.
• It is essential that no substantial change be made in the Accreditation Data System (ADS) between the time that it is finalized for the site visitor's review. If any changes are made, a corrected copy should be provided to the site visitor on the day of the visit and the specific changes indicated by post-it notes or highlighted by other means.
• Typically the site visitor will first discuss in detail the previous citations or concerns and the program’s response in correcting these. It is important that the program director be prepared to answer these queries satisfactorily.

The field staff member who conducted the site visit will file a narrative report of the site visit with the RRC. This will be reviewed by the RRC along with the program's Accreditation Data System (ADS) information. To estimate when the accreditation review will occur by your RRC, look up the ACGME Review Committee meeting dates. It may take a while for the site surveyor to file the report, and generally an RRC cuts off its agenda about six weeks prior to a meeting. Thus, if you are unlucky enough to have a site visit within 8 to 10 weeks of a scheduled RRC meeting, in all likelihood your program will not be reviewed until the subsequent meeting.

Once an RRC meeting occurs, it often takes a month or more for the accreditation letter to be finalized since all letters generated from a meeting must be dictated by the RRC executive director and then approved by the RRC chair. However, you may call the executive director of your RRC the week following the meeting to find out the summary (though not details) of the accreditation action, including the approximate cycle of approval. The actual letter with citations or areas of concern may not be received for several weeks following a meeting.

Once the letter has been received, it will be reviewed by our Graduate Medical Education Committee (GMEC). The program director will likely be asked to file a progress report with the GMEC regarding corrective actions for areas of noncompliance or concern. The RRC may also request a progress report. If so, this will need to be reviewed by the GMEC prior to its submission. Actions based on citations or areas of concern will also be reviewed at the time of the next internal review.