ACGME Accreditation Council for Graduate Medical Education

The Accreditation Site Visit and the Role of the Field Staff

The Accreditation Site Visit
The accreditation process for programs and sponsoring institutions includes periodic on-site visits to assess compliance with the Program and Institutional Requirements. All accreditation site visits for programs and sponsoring institutions are performed by the members of the ACGME Accreditation Field Staff, who are employed by the ACGME.

A visit is conducted to review the applications of all specialty (core) and many subspecialty programs; applications for some subspecialty programs and for sponsoring institutions are reviewed without a site visit. All programs and sponsoring institutions undergo a full site visit at the end of the two-year Initial Accreditation period, prior to a Review Committee decision to grant full accreditation.

Programs undergo an annual review of accreditation data collected by the ACGME via the Accreditation Data System (ADS). If the review suggests a potential problem, the Review Committee may schedule a site visit to clarify and address aspects of the program needing attention or follow-up.

All programs and sponsoring institutions undergo a full accreditation site visit every 10 years. This is preceded by a comprehensive self-study that includes a description of how the program or sponsoring institution creates an effective learning and working environment, and how this leads to desired educational outcomes. For their self-study, programs are also asked to review their aims, and conduct an analysis of strengths, areas for improvement, external opportunities and threats, and to formulate and document plans for improvement.

Site Visit Process
During the accreditation site visit, the site visitor conducts a detailed assessment of the program that focuses on compliance with applicable program and institutional requirements, and ongoing program improvements. Depending on the size of the program or sponsoring institution, accreditation site visits are conducted by a team or by a single site visitor. 

Prior to conducting a site visit, the assigned team or site visitor reviews the Institutional and Program Requirements, and data submitted to the ACGME by the program or institution as part of the accreditation process. This includes information submitted through ADS, the results of the Annual Resident and Faculty Surveys, milestone data, case and procedural logs and data on residents’/fellows’ patient care experiences, and other information relevant to the specialty.

The site visit for a program entails interviews with the program director, peer-selected residents/fellows, faculty members, the designated institutional official (DIO), and a review of available documentation to verify and expand upon that which the program has already submitted. For the visit of a sponsoring, the visitor or team meets with the DIO, members of the graduate medical education committee, and residents and fellows. The aim is to obtain an accurate and complete reflection of the educational experience offered by the program, and the learning environment it provides. The site visit concludes with a second interview with the program director or the DIO for a sponsoring institution, to clarify missing or discrepant information. During this exit interview, the site visitor or team may offer suggestions for innovative practices based on knowledge from other programs and institutions that have created an effective working and learning environment.

The Site Visit Report
After the site visit, the site visitor or site visit team prepares a comprehensive report that encompasses all aspects of the program or sponsoring institution, and other information identified that is relevant to the accreditation decision. The report is objective, factual, and non-judgmental, and discusses strengths and areas for improvement. The Site Visit Report and the information the program or institution has submitted through ADS inform the Review Committee’s review, and form the basis for the Review Committee’s accreditation decision for the applicable program or institution.

The ACGME Accreditation Field Staff
In 2015, the ACGME accreditation field staff who serve as site visitors for all accreditation site visits of programs and sponsoring institutions consists of 31 individuals with MD or PhD/EdD degrees, and extensive experience in medical education. The MD members include a range of medical specialties, and the non-physician members include individuals with degrees in education, sociology, and psychology. A significant number of field staff members have been with the ACGME for 10 years or more.

The members of the accreditation field staff participate in two formal professional development meetings per year, and also attend Review Committee meetings and medical education meetings for their professional development and to facilitate the exchange of information. The members of the field staff play a crucial role in accreditation process, and take satisfaction in helping the Review Committees formulate fair and accurate judgments about the educational quality of ACGME-accredited programs and institutions.

Updated: March 11, 2015