This document offers information about all aspects of the accreditation site visit, including preparation and data collection, the on-site portion of the visit, and changes and cancellations. The responses below offer answers to general questions. Answers to specific questions should be addressed to the Department of Field Activities or the relevant Review Committee (RC) team.

When will our site visit be scheduled?
The notification (or accreditation) letter the program receives after the RC has made an accreditation decision shows the approximate date of the next site visit (stating, for example, that "the program will be resurveyed after April 1, 2011"). Programs are scheduled in a 120- to 150-day window around the date determined by the Review Committee at the most recent review. On occasion, a site visit may occur later than this benchmark, due to a program being in a remote location (ACGME Field Representatives visit three programs per week and a program may be delayed so several programs can be scheduled in a given city). This will not occur for any programs on short cycles or those with adverse accreditation status. In addition, Transitional Year programs and subspecialty programs with one required year of training are generally not scheduled during the first 2-3 months of the academic year to give their residents an opportunity to gain experience in the program prior to participating in the resident interview.

How will we be notified of our scheduled site visit?
The ACGME sends an e-mail notice for the site visit approximately 110 days ahead of the scheduled date. At the same time, the detailed announcement letter for the visit is posted in the program's folder in the Accreditation Data System (ADS). Programs should review the letter carefully and follow the instructions.

If the approximate date of the visit is near and you have not yet received a letter from the ACGME, please contact Penny Iverson-Lawrence (312/755-5014) or June Eubanks (312/755-5009) in the Department of Field Activities to find out if a visit date has been set.

Who will conduct the site visit?
Beginning with the 2010-11 Academic Year, all site visits are conducted by members of the ACGME field staff. The Field Representatives are professional site visitors employed by the ACGME. Biographical sketches for the Field Representatives outlining their professional background and tenure with the ACGME can be found on the ACGME web site.

What is the Role of the ACGME Field Representative?
The Field Representative verifies and clarifies the information the program submitted in the Program Information Form (PIF) and provides a detailed narrative report, which the RC uses together with the information provided by the program to make its accreditation decision. Field Representatives interview the program director, faculty, residents, and the designated institutional official (DIO) and/or other administrative representatives, and conduct detailed reviews of documents and, for some programs tours of the physical facilities. For some specialties, the latter is done for all programs. Tours are also scheduled when the program has prior citations for aspects of the physical facility, or technology or equipment. For selected specialties, the site visit also includes interviews with representatives from other departments the program interacts with.

What do I need to know about preparing the Program Information Form (PIF)?
An important aspect of preparing for a site visit is the preparation of the PIF. A well-prepared PIF describes the residency program accurately, completely and truthfully. It should be comprehensive, specific and concise, and answer questions completely. An incomplete or inaccurate PIF can be a contributing factor to an unsatisfactory RC review.

To download the PIF for your program from the ACGME's web site, use the instructions provided in the memorandum that accompanies the site visit announcement letter (these instructions are also in the response to the FAQ, "How do I download the Program Information Form?").

Before preparing the PIF, review your program requirements and the institutional requirements. Allow sufficient time to gather the data needed for completing the PIF. In completing the PIF, remember that the RC members will not be familiar with the specifics of your program. Also, you should not rely on the site visitor to relate to the RC information that is relevant to compliance with the accreditation standards. If something is relevant to the review, you should include it in the PIF.

Call the staff of your RC if you need help with any questions in the PIF. If you have a technical problem with any aspect of the PIF, contact your ADS Representative via e-mail to WebADS@acgme.org. Whether you complete the PIF yourself or delegate parts to others, a third party should review the entire document for consistency, accuracy, and clarity before it is submitted to your DIO for final review and signature.

Can the date of the site visit be changed?
The ACGME surveys approximately 2,000 programs annually. Due to the logistics involved in conducting this number of visits, once the date of your site visit is set it generally cannot be changed. Exceptions may be made in certain circumstances. All requests to change the date of the site visit must be made by telephone to Jane Shapiro, Associate Director (312/755-5015), Penny Iverson-Lawrence, Senior Survey Administrator (312/755-5014) or Ingrid Philibert, Senior Vice President (312/755-5003), all in the Department of Field Activities. Requests must be made within 14 calendar days of receipt of the site visit announcement letter.

The ACGME incurs significant costs in scheduling site visits, and requests for date changes or postponements of a survey received by the ACGME more than 21 days after the date of the site visit announcement notice must be accompanied by a letter from the institution's DIO or Chief Executive Officer. The letter must indicate that the institution agrees with the request for a change in the site visit date and is aware that it may be charged a fee of $2,750 for late notice of their intent to postpone the visit.

Our program currently has no residents. Will we be site visited?
If a site visit is due, the ACGME may visit your program, even if there currently are no residents in the program. Please contact your RC team, or staff in the Department of Field Activities to discuss.

If a program does not plan on taking residents and would like to voluntarily withdraw the program, a request for voluntary withdrawal should be made online through the Accreditation Data System (ADS). You may find this option under your ADS menu.

If you have been notified of a site visit and are planning to seek voluntary withdrawal, notify Jane Shapiro (312/755-5015) or Penny Iverson-Lawrence (312/755-5014) in the Department of Field Activities as soon as possible of your plans. Failure to do so may result in the program being fined for late notice of seeking voluntary withdrawal.

I want to increase my resident complement, but the RC requires a review. Can I request an early site visit?
A number of RCs require a site visit and review prior to allowing a program to increase its complement. If you are not certain, check with your RC team. Based on the RC team's recommendation, you may request an early review. You must contact Ingrid Philibert (312/755-5003) or Jane Shapiro, (312/755-5015) to ask for an early site visit. Please be prepared to provide the reasons for the early review. Another reason for an early visit may be a program with adverse accreditation status, where the leadership feels the program can demonstrate full compliance and return to full accreditation.

My site visit will occur before the RC determined next date. How should I time my internal review to be at the mid-point between site visits?
The ACGME receives questions about the timing of the internal review when site visit dates are moved up at the request of the program or the ACGME or the RC. The Institutional Requirements state that the internal review should be conducted approximately at the midpoint between the last RC review and the next site visit. When the visit is moved up, and the internal review has not yet occurred, the Institutional Review Committee expects programs to perform an internal review as soon as possible, even when this places the internal review in proximity to the site visit date. When an internal review occurs under these circumstances, the reason should be documented in the summary that is included in the Institutional Review Document.

How do I download the PIF?
To download the PIF for your site visit, on the ACGME's web site, access the menu option "Review Committees" to bring up a directory showing all RCs. Click on the link for the given RC for a menu that includes the option to download the program requirements, the PIFs for the core program and any subspecialties, and the instructions for downloading the document in WordPerfect or Microsoft Word. Follow the detailed instructions on the web page to download and complete the PIF and any associated documents. For all specialties some information program is updated in the Accreditation Data System (ADS) and in a select number of specialties the majority of the program information form is completed using ADS.

For institutional reviews, the Institutional Review Document (IRD) and the Institutional Requirements can be accessed by clicking "Institutional Review" on the main menu. If you encounter problems in accessing or downloading documents from the web, contact your ADS representative via email to webADS@acgme.org.

When will our program complete the ACGME Resident Survey?
The ACGME conducts the Resident Survey for all core specialty programs and subspecialty programs with four or more residents/fellows annually between January and May. Aggregate reports are made available to the program and sponsoring institution if the survey had a response rate of 70% or greater. Information from the resident survey is used in the site visit, along with the other information prepared by the program.

While the Resident Survey is not conducted in conjunction with a program's site visit, the information gathered will be used at the time of the program's site visit.

The ACGME notifies programs directly when their residents are scheduled to complete the survey, and provides information on accessing the survey and a deadline for completion. Residents/fellows will have four weeks in which to complete the survey.

What should be done with the completed PIF?
After completing the PIF, you should print four (4) hard copies. One copy should be sent to the address of the Field Representative assigned to your program (shown in the ACGME's letter announcing the site visit date). This copy must be sent to arrive at the Field Representative's address a minimum of 14 calendar days before the date of the site visit. The three remaining copies are turned over to the site visitor on the day of the visit. All four hard copies of the PIF must be identical and must be final. Draft copies are not acceptable to the Field Representative or the ACGME. Failure to send the copy to the Field Representative at least 14 days before the visit can result in cancellation of the site visit at the discretion of the Field Representative (the program is charged a fine for cancellation under these circumstances and the visit is rescheduled). All copies should not be bound or stapled and should be held together with a strong rubber band.

How do we set up the schedule for the day of the site visit?
Approximately 45 to 60 days before the scheduled site visit day, the site visitor assigned to your program will contact you by telephone, letter, fax or e-mail to set up the schedule for the visit. You may also contact the Field Representative at the address listed on the scheduling letter to make the necessary arrangements (the best day of the week to call the Field Representative is Friday).

On the day of the visit, the site visitor will need to meet with faculty, residents and the DIO or another administrative representative. For a series in which two or more programs are visited at one sponsoring institution only one meeting with the DIO is necessary, and your site visit day may not include scheduled time with the DIO. Some RCs also ask the site visitor to meet with other program or institutional representatives. The site visitor, in consultation with the program director, makes the final determination of the schedule and the individuals who will be interviewed.

You should remember that the site visitor might not be familiar with your town or your institution's facilities, and may appreciate directions to the institution and instructions for parking. You should arrange for a place and time to meet the site visitor. The site visit (with exception of tours of on-call rooms and other facilities, as required) should take place in a well-lighted conference room with a table sufficiently large to allow the site visitor to do his/her work. If lunch is scheduled during the site visit, please keep the menu simple.

What happens on the day of the site visit?
On the day of the survey, be flexible and understand that schedules may be changed or be delayed to accommodate the information collection needs of the site visitor. At the conclusion of the visit, do not expect the site visitor to offer an opinion about your program. The RC evaluates the program and makes the accreditation decision, and the site visitor's role is to verify and clarify the self-study report you provided in the PIF.

At the end of the day, the site visitor will conduct a brief clarification interview with the program director to seek to reconcile, as needed, any discrepant information that was received during the visit. During that meeting, the ACGME Field Representative is not able to give you detailed feedback, because he/she is not the decision-maker. Accreditation decisions are the purview of the RC. Many members of the field staff offer preliminary observations regarding possible program strengths and opportunities for improvement, but these are based on the site visitors' experience with the review process and cannot take the place of peer review by the RC.

- 2012 Document Checklist for Program Site Visits

Can I make changes to the PIF after it has been sent to the site visitor?
The PIF sent to the site visitor and the three copies provided on the day of the visit must be identical and in final form. Changing the PIF after a copy has been sent to the site visitor cannot be considered. Minor errors and discrepancies can be corrected on the day of the visit. In the very rare case that a major error or omission in the PIF may profoundly affect the review, it may be preferable to cancel the visit with a fine than to proceed with a flawed PIF. In that case, please contact your assigned field representative to discuss the situation, and collectively make a decision.

If minor errors are discovered on the day of the site visit, it is acceptable to make corrections to selected PIF pages, provided that it can be done before the site visitor departs. Any change must be reviewed by the site visitor as a part of the visit and incorporated in the site visit report. For minor needed changes, the program should provide an addendum to the PIF that clearly identifies the section/page being corrected. The addendum and all pages with changes will need to be sent via FEDEX within 48 hours after the date of the site visit to the attention of Penny Iverson-Lawrence in the Department of Field Activities. Please send only the revised pages; a revised copy of the PIF in its entirety cannot be accepted.

How should residents be selected to meet with the site visitor?
The resident interview is crucial to the site visit. Please follow these guidelines: if the program has 10 or fewer residents, the Field Representative will want to speak with all residents who are on duty on the day of the visit. If the program has more than 10 residents, the Field Representative will want to speak with 10 to 12 residents. Residents must be selected by their peers, with representation from each year of the program. Chief residents beyond the required years of residency (e.g., a fourth-year internal medicine chief) may not participate in the resident interview (they may be included in the faculty interview). If your program operates a combined program track, such as internal medicine-pediatrics or internal medicine-psychiatry, residents from the combined program should be represented in the interview group. Residents should be made available for the entire interview period, with their pagers and cell phones turned off.

What happens during the resident interview?
The resident interview is an important component of the site visit. It generally opens with a brief overview of the accreditation process and the purpose of the site visit. Residents may be asked what instructions were provided about the resident interview. The residents are informed that if an adverse action results the site visit report may be shared with the program. Then the site visitor asks questions based on the information in the program's PIF and concludes with questions about the program's strengths and weaknesses. For the site visit report, answers have to reach consensus level to be reported, or are reported as "a single resident stated" or "the first-year residents as a group indicated." Individual residents are not identified in the report.

What happens after the site visit?
After the visit, the site visitor submits a written report to the ACGME, which is forwarded to the RC team and sent to the RC reviewers. The RC's review of your program is based on your PIF and its attachments, and the site visitor's report. The site visitor does not participate in the accreditation decision. His/her job is completed when the finished site visit report is transmitted to the ACGME.

All RCs meet at least two times per year, with some that review a large number of programs meet more frequently. The ACGME strives to get each program reviewed in as timely a fashion as possible after the site visit. RCs close out their agendas approximately 60 to 75 days before the meeting date. For a program site visited less than four months before a meeting date, there is no guarantee that it will be presented at the next meeting. Also, on occasion, the RC's agenda may be very full and programs may need to be delayed until the next meeting. The schedule of meetings for the RC and the Institutional Review Committee is available from the ACGME web site.

You may also contact the RC team if you want to find out if your program will be reviewed at a given meeting. After the program has been reviewed, the program director and the DIO will be notified via e-mail of the accreditation status and tentative date of the next site visit. This occurs within a few days of the end of the meeting. The detailed accreditation decision will be sent by mail between 60 and 90 days after the RC meeting.

How do I provide feedback on the site visit?
The ACGME sends a request for an anonymous electronic evaluation to all programs within a few days of the site visit. To preserve the anonymity of evaluators, the results are aggregated and used in the professional development of the site visitors, and the evaluation of the Department of Field Activities. The request to complete the survey will be in the form of an e-mail message from the ACGME, with the web link for the survey embedded in the message.

If you have a complaint or concern about the site visit, or if the site visitor was especially helpful or informative, in addition to filling out the electronic survey you should relate this information to the ACGME Department of Field Activities by contacting Ingrid Philibert, PhD, Senior Vice President, at 312/755-5003 or Jane Shapiro, Associate Director, at 312/755-5015.