Institutional Site Visit

Who conducts a site visit?

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.

What are the key elements to consider when preparing the IRD?

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 with any questions about the IRD. E-mail 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.

How are ACGME-I Resident and Faculty Survey data used during the institutional site visit?

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.

What is the schedule for the day of the site visit?

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.

What logistical preparations should be made for the day of the site visit?

  • The site visitor will not be familiar with the institution and will need directions to the facility. Arrange a place and time to meet the site visitor (often this is the main lobby of the building) and escort him or her to the room reserved for the site visit.
  • Provide the site visitor with an emergency phone contact number (DIO or institutional administrator) prior to the visit. This is strictly precautionary, in case the site visitor needs to contact the institution the day/evening before the visit.
  • The site visit should take place in a single, well-lit conference room with a table sufficiently large to allow the site visitor to do his or her work.
  • If lunch is scheduled during the site visit, please keep the menu simple. Please be aware that the site visitor cannot accept gifts.
  • The DIO needs to clear his or her schedule for the duration of the site visit. We ask that he or she turn off his or her cell phone and/or pager, arrange for coverage, and respond only to urgent matters during the course of the visit.
  • The letter announcing the site visit will include a list of documents that should be available for the site visitor to review the day of the visit. These should be complete and organized, and readily accessible to the site visitor throughout the day.
  • The program directors’ interview:
  • If the site visit is to review an institutional application, all future residency/fellows program directors participate in the interview session. If the site visit is to review an institution currently accredited by the ACGME-I, all current program directors of ACGME-I-accredited residencies and fellowships should participate.
  • Program directors scheduled for the interview need to turn off their cell phones and/or pagers and arrange for coverage for the duration of the session.
  • The Graduate Medical Education Committee (GMEC) members’ interview:
  • The site visitor needs to meet with members of the GMEC, including the committee’s chairperson. ACGME-I staff members will notify the DIO prior to the site visit of those GMEC members who need to participate in the interview.
  • GMEC members scheduled for the interview need to turn off their cell phones and/or pagers and arrange for coverage for the duration of the session.
  • The resident/fellow group interview:
  • The resident/fellow group interview is an important component of the institutional site visit.
  • If the site visit is to review an institutional application, the site visitor must meet peer-selected residents/fellows currently in programs for which ACGME-I accreditation is planned.
  • If the site visit is to review an institution currently accredited by the ACGME-I, the site visitor must meet with 10-15 peer-selected residents from ACGME-I-accredited programs. Residents/fellows should represent all years of accredited education. Residents/fellows in a full research year should not be included.
  • All residents/fellows need to turn off their cell phones and/or pagers and arrange for coverage for the duration of the session.
  • The CEO interview:
  • The site visitor needs to interview an organizational executive-level person, such as the CEO.
  • The site visitor’s discussion will include the CEO’s perception of the executive- and governance-level support for and involvement in GME at the institution.

What happens on the day of the site visit?

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.

Can changes be made to the IRD or attachments once it has been submitted via ADS?

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.

What happens after the site visit?

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.