The ACGME-I utilizes a qualified site visitor with experience in institutional-level graduate medical education (GME) to conduct a site visit. The site visitor is often a designated institutional official (DIO) or former DIO.
The role of the site visitor is to produce a written report that verifies and clarifies the information the institution submitted in the Institutional Review Document (IRD) and attachments. To collect the information for this report, the site visitor interviews the DIO, program directors, Graduate Medical Education Committee (GMEC) members, residents/fellows, and institutional administrative representatives.
An important aspect of preparing for a site visit is the completion of the IRD, a web-based form that is accessed through the ACGME-I Accreditation Data System (ADS).
A well-prepared IRD describes the institution accurately, completely, and truthfully. It should be comprehensive, specific, and concise, and should answer questions thoroughly. An incomplete or inaccurate IRD can contribute to an ACGME-I Review Committee specifying areas of non-compliance with the standards (known as “citations”) and a negative accreditation decision as outcomes of the institutional review.
Before preparing the IRD, the Institutional Requirements should be reviewed. Allow sufficient time to gather the data needed, and in doing so, remember that the site visitor and ACGME-I Review Committee members will not be familiar with the specifics of the particular institution. Also, do not rely on the site visitor to relay to an ACGME-I Review Committee all information that is relevant to compliance with the Institutional Requirements (accreditation standards). If something is relevant to the review, include it in the IRD.
E-mail firstname.lastname@example.org with any questions about the IRD. E-mail WebADS@acgme.org with any technical problems or questions, and be sure to add the applicable institution number in the subject line of the e-mail.
Regardless of who completes the IRD, an independent third party should review the entire document for consistency, accuracy, and clarity.
All accredited advanced specialty and subspecialty programs will be surveyed every year between January and May. Aggregate data summary reports will be made available to programs if a 70 percent response rate is reached for their participants, and when four or more residents/fellows have completed the survey.
These same reports, and an institutional-level summary report, are available for review by the DIO within ADS. The site visitor will review this data with the DIO on the day of the institutional site visit as part of the verification/clarification of institutional oversight of programs.
On the day of the visit, the site visitor will meet with the DIO, core residency program directors, GMEC members, residents/fellows representing all core programs, and a key institutional administrative representative, such as the Chief Executive Officer (CEO).
ACGME-I staff members will provide detailed instructions and work directly with the institution to finalize the day’s schedule, to help identify the institutional- and program-level staff member roles and functions that require interviews, and to identify specific staff members to participate in the site visit interview sessions.
On the day of the site visit, be flexible and understand that schedules may be changed or delayed to accommodate the information collection needs of the site visitor. The site visitor's role is to verify and clarify the information provided in the IRD, and to note any accreditation standards with which compliance was not confirmed. The ACGME-I Review Committee makes the final evaluation and accreditation decision for each institution.
At the end of the visit, the site visitor may ask additional clarifying questions if there are open issues that have not been fully resolved/explained. The site visitor cannot give any detailed feedback since he or she is not the final decision maker; however, he or she may be able to offer general observations regarding the institution’s strengths and opportunities for improvement. Please note that any observations made by the site visitor are solely based on his or her own institutional experience, and do not indicate any decisions or implications regarding the institution’s accreditation status.
The IRD and attachments sent to the ACGME-I must be in final form; the DIO’s signature confirms this. Minor discrepancies can be clarified with the site visitor on the day of the site visit.
If errors are discovered on the day of the site visit, it is acceptable to make minor changes to selected pages, provided this can be done before the site visitor departs. The site visitor should not be asked to wait while extensive changes are made. Once pages have been changed, a copy of the revised pages should be given to the site visitor with the changes highlighted.
After the site visit, the site visitor submits a written report to ACGME-I staff members who review the document for completeness. The Review Committee-International’s evaluation of an institution is based on the Institutional Review Document and attachments, the site visitor’s report, and other information relevant to the particular institution (e.g., Resident and Faculty Surveys for existing accredited programs). The Committee then makes the final accreditation decision.
The DIO will be notified via e-mail of the accreditation status decision. A Letter of Notification detailing the accreditation decision, including citations, as applicable, will be posted in ADS 30 to 60 days following receipt of the email. See the Key to Standard Institutional Notification Letter for a template of the letter available on the ACGME-I website. The DIO will be notified of the ADS posting.