This document offers general information about aspects of the accreditation site visit, including preparation and data collection, the on-site visit, and changing and canceling site visits. Answers to specific questions should be addressed to the Department of Field Activities or the relevant Residency Review Committee (RRC) or Institutional Review Committee (IRC) team.
When will our site visit be scheduled?
The RRC notifies programs of the approximate date of the next site visit. This includes programs that have already received notification of the date of their first self-study visit in the Next Accreditation System (NAS). Programs are scheduled in a 120- to 150-day window around this approximate date. Site visits for applications, programs on short accreditation cycles or programs with an adverse accreditation status are given first priority in scheduling, Transitional Year programs and subspecialty programs with one required year of training generally are not scheduled during the first two to three months of the academic year to give residents an opportunity to gain experience in the program prior to participating in the site visit.
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, and concurrently posts a detailed site visit “Notification Letter” in the program’s record in the Accreditation Data System (ADS). Programs should review this letter carefully. If the approximate date of the visit is near and you have not yet received a letter from the ACGME, you may contact Penny Iverson-Lawrence (312.755.5014) or Jane Shapiro (312.755.5015) in the Department of Field Activities to find out if a visit has been scheduled.
Who will conduct the site visit?
All accreditation site visits for programs and sponsoring institutions are conducted by members of the ACGME field representatives. Site visits may be conducted by a single field representative or by a team of two or more site visitors. Biographical sketches for the field representatives outlining their professional background can be found on the ACGME website.
What is the Role of the ACGME Field Representative?
Field representative verify and clarify information the program has prepared for the site visit, such as the program information form (PIF), and data from the ACGME Resident Survey (and in NAS Phase I specialties the ACGME Faculty Survey) and write a detailed narrative report the RRC/IRC uses together with the data provided by the program to make an accreditation decision. Field representatives interview the program director, faculty, residents, and the designated institutional official (DIO) and/or other administrative representatives, review documents and for some programs, may conduct tours to assess aspects of the physical facility, technology or equipment.
How do I download the PIF or Institutional Review Document (IRD)?
You may download the PIF from your specialty page on the ACGME website using the “Choose Your Specialty” drop-down menu available below the quick links box. Select your specialty to access links to download the program requirements, the PIFs for the core program and any subspecialties, and the instructions for downloading the document in Microsoft Word. Follow the detailed instructions on the web page to download and complete the PIF and any associated documents. For all specialties, data annually updated in ADS is included in the PIF. In several specialties the entire program information form is completed using ADS.
For institutional reviews, the IRD and the institutional requirements can be accessed by clicking "Institutional Review" under the Quick Links/DIO tab on the ACGME home page.
If you encounter problems in accessing or downloading documents from the web, you may contact an RRC staff member. RRC staff contacts are found via the “Choose Your Specialty” quick menu on the ACGME home page.
If assistance is needed with accessing the electronic portion of the program information through ADS, contact your ADS Representative by sending an e-mail to WebADS@acgme.org.
Preparing the PIF or IRD
A well-prepared PIF offers an accurate, complete and truthful description of the program or institution. The descriptions should be comprehensive, specific and concise, and completely answer the questions. An incomplete or inaccurate PIF or IRD can be a contributing factor to an unsatisfactory accreditation review.
Before preparing the PIF/IRD, review the program and/or institutional requirements. Keep in mind that RRC and IRC members will not be familiar with the specifics of your program or institution, and that you should not rely on the site visitor to relate information relevant to the review. The completed PIF should be reviewed for consistency, accuracy, and clarity before it is submitted to the DIO for final review and signature.
If you need help with questions in the PIF, contact the RRC team (contact information is found on the “Choose Your Specialty” drop-down menu on the ACGME website). If you have a technical problem with the electronic portion of the PIF, contact ADS via e-mail to WebADS@acgme.org or the ADS Representative assigned to your specialty via the “Application Support” link at the bottom of the ACGME home page.
What should be done with the completed PIF or IRD?
Once the PIF or IRD is final, you should print four hard copies (unless the instructions in your PIF dictate differently). One copy should be sent to the address of the Field Representative assigned to your program (to the address in the ACGME's letter announcing the site visit).
The field representative's copy must arrive a minimum of 14 calendar days before the site visit date. The three remaining copies are provided to the site visitor on the day of the visit. All four hard copies of the PIF must be identical and must be final.
Failure to send the field representative’s copy of the PIF/IRD in a timely way may 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. Copies of the PIF should be unbound and held together with a strong rubber band.
Can the date of the site visit be changed? Once the notification of the site visit has been made, the date 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) or Penny Iverson-Lawrence, Senior Survey Administrator (312.755.5014) in the Department of Field Activities. Requests must be made within 14 calendar days of receipt of the site visit announcement letter. Because the ACGME incurs significant costs in scheduling site visits, late requests for date changes or postponements must be accompanied by a letter from the institution's DIO. The letter must indicate the institution’s agreement with the request and understanding that substantial fee may be assessed for the late notice.
Our program currently has no residents. Will it 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 RRC team, or the Department of Field Activities to discuss.
If a program without residents does not plan on taking residents in the next academic year, it may be preferable to voluntarily withdraw the program. Requests for voluntary withdrawal should be made online through ADS. You may find this option under “Change Requests” on in ADS. Also notify Jane Shapiro (312.755.5015) or Penny Iverson-Lawrence (312.755.5014) of your plans in a timely way. Failure to do so may result in the assessment of a fine.
Our program wants to increase its resident complement. Can I request an early site visit?
A number of specialties require a site visit and RRC review prior to allowing a program to increase its complement. If you are requesting a complement increase, please check with your RRC team. Based on the team's recommendation, you may then request an early site visit.
Can I make changes to the PIF after it has been sent to the site visitor?
The PIF sent to the field representative and the copies submitted to ACGME after the site visit must be identical and final. PIFs cannot be changed after the copy has been sent to the field representative. If major errors or omission in the PIF are discovered, 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.
If minor errors are discovered after the PIF has been sent or on the day of the site visit, corrections may be made if this can be done before the field representative departs. Pages with revisions must be provided to the site visitor with the specific changes highlighted. Copies of the revised pages (without highlighting) must be inserted into the three copies of the report to be sent to the ACGME. For changes after the site visit (such as a new faculty hire), an addendum should be prepared to the PIF that clearly identifies the section/pages being corrected. The addendum must be sent via FEDEX as soon as possible after the site visit to increase the likelihood the RRC can consider the added information. The addendum must be sent to the attention of Penny Iverson-Lawrence, Department of Field Activities. Only an addendum may be sent; the RRC cannot accept a new copy of the PIF after the site visit.
How should residents be selected to meet with the site visitor? If the program has 10 or fewer residents, the resident interview should include all residents on duty on the day of the site visit. If the program has more than 10 residents, the interview group should consist of 10 to 12 residents selected by their peers, with representation from each accredited year of the program. Chief residents beyond the required years of training may not participate (they may be included in the faculty interview).
If your program operates a combined program track, such as internal medicine-psychiatry, residents from the combined program should be represented in the interview group. Residents generally are interviewed as one group; however, the field representative may decide to interview residents by year of training or individually. Residents should be made available for the entire interview period, with pagers and cellphones turned off.
How do we set up the schedule for the day of the site visit?
Approximately 45 to 60 days before the site visit date, the field representative assigned to the program will contact the program by telephone, fax or e-mail to set up the schedule for the visit. You may also contact the field representative using the information in the announcement letter to make the necessary arrangements (the best day to call the field representative is Friday).
Shortly before the visit, your field representative will ask you to forward a standard letter to your residents or fellows, asking them to develop a single “consensus list” of up to three program strengths and opportunities for improvement. The letter asks residents to provide this list confidentially to the field representative before the site visit for use during the resident interview.
On the day of the visit, the site visitor will 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 may not include scheduled time with the DIO. Some RRCs 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 to be interviewed. Before the site visit of a residency or fellowship program, please review the general list of documents for program site visits:
2012 Document Checklist for Program Site Visits
Institutional review visits have a separate document list, and for some specialties additional documents requested by the RRC are listed in the PIF.
Along with the final site visit arrangements, provide the field representative with directions to the institution, or arrange for a place and time to meet him/her. The site visit should take place in one well-lit conference room with a table sufficiently large to allow the site visitor to conduct the interview and take notes. Food for the field representative and interviewees should be placed outside the interview room to allow access to it without interrupting or distracting the site visit.
What happens on the day of the site visit?
On the day of the site visit, the schedule may need to be flexible to accommodate collecting needed information and documentation. At the conclusion of the visit, the field representative(s) will conduct a brief clarification interview with the program director to reconcile, as needed, any discrepant information received during the visit. During this meeting, the field representative also will offer a preliminary summary of key program strengths and opportunities for improvement. These are based on the site visitors' experience with the review process and cannot predict the outcomes of peer review by the RRC.
The resident interview during the site visit opens with a brief overview of the accreditation process and the purpose of the site visit. The field representative’s questions to the residents are based on program requirements, the PIF and the responses to the ACGME Resident Survey. The questions conclude with the residents’ assessment of the program's strengths and opportunities for improvement. In the field representative’s report, resident responses are reported as consensus (of the entire group or by training year). Individual residents are not identified. Specific information from the resident interview is confidential and is not shared with the program director unless the residents have given their express permission.
What happens after the site visit?
After the visit, the site field representative submits a written report to the ACGME, which is forwarded to the RRC reviewer(s) for use in the review together with the PIF and other accreditation data. The field representative does not participate in the decision. His or her job is completed when the site visit report is transmitted to the ACGME. RRCs meet at least two times per year; some meet more frequently, and close out their agendas approximately 60 to 75 days before the meeting date (agenda closing dates are posted on the ACGME website). Applications and programs with potential accreditation problems are given priority, and on occasion the RRC agenda may be full and a report that arrived before the closing date may need to delayed until the next meeting. You may contact the RRC team to learn if the program will be reviewed.
A few days after the RRC/IRC has made a decision, the program director and/or DIO are notified via e-mail of the accreditation status. A detailed decision letter will be sent by mail between 60 and 90 days after the meeting.
How do I provide feedback on the site visit?
Feedback is important to the ACGME and the field representative. After the site visit, the ACGME sends a request for an electronic evaluation to the program. To preserve the anonymity of evaluators, the results are aggregated and used in the professional development of the field representatives, and the Department of Field Activities’ evaluation of the site visit process. The request to complete the survey will be in the form of an e-mail message from the ACGME, with the survey link embedded in the message.
If you have a complaint or concern about the site visit or if you want to share positive feedback, in addition to filling out the survey, please contact Ingrid Philibert, PhD, Senior Vice President, at 312.755.5003 or Jane Shapiro, Associate Director, at 312.755.5015.