Accreditation Council for Graduate Medical Education
The ACGME Self-Study and 10-Year
Accreditation Site Visit
Academic Internal Medicine Week 2017 Pre-course
The Nuts and Bolts of Accreditation
March 19, 2017
Joseph Gilhooly, MD, Professor Emeritus of Pediatrics,
Department of Field Activities, ACGME
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Disclosures
Joseph Gilhooly, MD is employed by the ACGME
as a member of the field staff
He previously chaired the ACGME Review
Committees for Pediatrics and Transitional Year
© 2017 Accreditation Council for Graduate Medical Education
Objectives
Objectives
• Understand what the Program Self-study entails and how
it is related to the 10 year Accreditation Visit
• Be prepared for your program’s 10 year Accreditation
visit
© 2017 Accreditation Council for Graduate Medical Education
Next Accreditation System
• Annual review of program data elements
• Self-study every 10 years
• Followed 18 months later by the 10 year
Accreditation Visit
© 2017 Accreditation Council for Graduate Medical Education
Site Visits under NAS
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Application visits
Initial Accreditation visits
Single Accreditation System visits
“Ad hoc” visits
• Data Prompted based on the annual data
review
• Follow up on complaints
• 10 year Accreditation Visit
© 2017 Accreditation Council for Graduate Medical Education
Why we are doing this?
• In combination with the Annual Program
Evaluation, the self-study creates internal
drivers for program improvement
• Moving away from citations as a driver for
change
• A focus on program “self” improvement can
drive program innovation…and avoid data
prompted site visits
© 2017 Accreditation Council for Graduate Medical Education
Self Study = Strategic Planning
• Where have you been?
• Where are you now?
• Where are you going?
• How are you going to get there?
© 2017 Accreditation Council for Graduate Medical Education
Self-study and strategic planning
• Many program directors have not had
experience in strategic planning
• Strategic Planning is a team effort
• Sets your direction and priorities
• Gets everyone on the same page
• Simplifies decision making
• Aligns activities and priorities
• Communicates your mission
© 2017 Accreditation Council for Graduate Medical Education
The Elements of the Self-study
• Program aims
• Goals of the program
• What does the program strive to “produce”
• Why are we here?
• Activities to advance the aims
• An environmental assessment: “SWOT”
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Program Aims: No Metrics?
• Self-study Pilot: Most programs could identify their
aims but few had any metrics in place to measure
their achievement
• Why are metrics important?
• Need data to measure needs and success in order to
mobilize both continued and new resources
• Critical for the program improvement phase
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SWOT
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Strengths
Weaknesses
Opportunities
Threats
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Self Study Process Best Practices
• Retreats
• Facilitated by an “expert”
• Focus groups
• Identify broad stakeholders
• Share the workload
• Follow-up group meetings to share results
• …and don’t forget the residents/fellows
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The self-study is not wasted effort!
• Replaces annual program evaluation for the
year
• Fits with departmental strategic planning
• Gives a guiding light to the annual program
evaluation process
• Creates collaboration and engagement of
stakeholders
• Drives program improvement
• Beats doing a PIF
© 2017 Accreditation Council for Graduate Medical Education
Next up….
• Moving the self-study forward
• Prioritizing action items
• Identify short and long term improvements
• Assemble teams of residents and faculty to take
ownership of action items
• Use metrics to measure improvement outcomes
• Looking ahead 18 months to completing the
Summary of Achievements, just prior to the 10
year Accreditation Visit
© 2017 Accreditation Council for Graduate Medical Education
THE FIRST 18 MONTHS OF PROGRAM
IMPROVEMENTS
• Link “change” to aims, or to take
advantage of opportunities or mitigate
threats
• Use the PDSA model for your program
improvements
• Measure your “change”
© 2017 Accreditation Council for Graduate Medical Education
SUMMARY OF ACHIEVEMENTS
• Program Strengths
• How they relate to aims and context
• Achievements in Areas for
Improvement
• How they relate to aims and context
• Process for Improvement
• Metrics
• Lessons Learned
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The Plan for the 10-Year
Accreditation Site Visit
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The 10-Year Accreditation Site Visit
• A full accreditation site visit with review of
all applicable requirements
• 18-month lag period after self-study allows
programs to implement improvements
• Core and subs each have half-day site visit
reviews
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Paperwork to be Reviewed
• Self-Study Summary +/- update
• Summary of Achievements
• ADS Update
• Response to Citations
• Sites, rosters, CV, scholarship, block diagram
• Major Changes and Other Updates
• ACGME Resident/Faculty Surveys
• Strengths and Areas for Improvements from faculty and
residents
• On site: PLAs, resident files, evaluations, goals & objectives,
policies, QI participation
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Interviews by the Site Visitor
• Program Director, Coordinator
• Associate Program Director
• Residents/Fellows
• Chief residents
• “Key” Faculty
• DIO, Department Chair/Division Head,
Vice Chair for Education
• Wrap up with Program Director
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Self-Study Review by the Site Visitor
• Review the process of the self-study for the
core and subs
• Identify common aims, strengths,
opportunities, threats, and improvements
made across the core and subs
• Review of program specific aspects of the
self-study
© 2017 Accreditation Council for Graduate Medical Education
Review Committee Assessment
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Site Visitor’s Report
ADS data, Surveys
Self-study Summary*
Summary of Achievements*
* Feedback only at this time
© 2017 Accreditation Council for Graduate Medical Education
ACGME Self-Study and 10-Year Accreditation Site Visit
• Thank you!
© 2017 Accreditation Council for Graduate Medical Education