Phase 2: Do

Program Mission and Aims

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Develop a Program Improvement Plan and Submit the Self-Study Summary

The second phase of the ACGME-I Self-Study process involves developing a program improvement plan and implementing the actions needed to address those areas in need of further development.

This phase involves taking a five-year look forward to answer the question, “What actions are needed to realize the program’s aims and will take our program to the next level?” This vision for the future should be shared with faculty members and residents/fellows so that the Self-Study committee’s findings and improvement priorities can be validated by these key stakeholders. For a core residency with affiliated fellowships, there should also be a discussion about any common strengths, areas that need development, and improvement priorities.

Once the improvement plan has been developed and discussed with stakeholders, the ACGME-I Self-Study Summary document can be prepared. The Self-Study Summary submitted to ACGME-I describes the process used to conduct the Self-Study. The Self-Study Summary includes a description of the quality improvement activities have occurred in the past five years, what environmental factors impact the program’s improvement efforts, and what the program plans are for the next five years. The descriptions are brief (less than 2,000 words total) but will summarize the background and the framework of the improvement efforts the program will undertake in the intervening 18 to 24 months prior to the accreditation site visit.


Critical Questions to Ask during Development of a Program Improvement Plan

Required Form

ACGME-I Self-Study Summary Template