Graduate Medical Education

Recommendations & Timeline for ACGME Site Visit

The ACGME states: "The single most important responsibility of any program of GME is to provide an organized educational program with guidance and supervision of the resident . . ." A residency program is represented to the ACGME by a package of information and by the experience of a site visitor - both should be as professional and organized as possible.

Most residency programs are site-visited by the ACGME infrequently; thus, the experience is rare for program directors and housestaff coordinators, and there is little opportunity for the development of "institutional memory." How you handle the site visit will reflect how you handle the residency, and these 6-8 hours play a large role in your accreditation status & citations. The site visitor is a professional, and expects the program to present a serious, focused effort. By surveying programs that were reviewed recently, we have gathered some recommendations for the program for which a site visit is scheduled.

Six-twelve months (or earlier) before the site visit:

  1. Your program will undergo an Internal Review (IR) sponsored by the GME Committee. The IR protocol will ask for documentation of items required by the ACGME Institutional Requirements and by the Program Requirements for your specialty. The IR report may suggest areas for work before the site visit. (Be aware of changing Program Requirements for your specialty - many are modified on an almost annual basis, and the Program Requirements in the Green Book may not be the ones you are surveyed by. Look for the most recent at www.acgme.org, the ACGME website.)
  2. Fix any areas of deficiency identified by the IR, and be certain that individuals affected by these changes are notified (e.g., policies affecting residents should be distributed to residents and faculty).

Two-three months before the site visit:

  1. The ACGME site visitor may be a member of your specialty, may be trained in another medical specialty, or he/she may hold a Ph.D. (or other doctorate degree). The ACGME website gives information about the site visitorsÌ professional backgrounds and credentials. The site visitorÌs job is to verify the data in your programÌs PIF - the Program Information Form. The report is submitted to the specialty RRC, and will be reviewed at the next scheduled RRC meeting (dates are listed on the ACGME website). Thus, you can estimate an approximate date for notification about the results of the site visit.
  2. The site visitor will contact your program to schedule the date for the site visit, and to obtain the PIF package. He/she will tell you the best means for communication (some prefer email, others use fax, etc.)
  3. Before you send your PIF package, re-read the current ACGME Program Requirements for your program, and be certain that you are sending all documents required (e.g., if program agreements must be sent with the PIF, be sure they are signed and included in the package). The site visitor will notify you of which faculty and residents with whom he/she will want to meet.
  4. Meet with the Assistant Dean for GME - review institutional citations. The site visitor will be inquiring about both program and institutional citations during the site visit. (The Assistant Dean for GME should also know whether your site visit will be an isolated one, or whether the site visitor will be on campus all week visiting multiple programs.)
  5. Meet with the residents - remind them of the program and institutional policies dealing with GME, the programÌs educational goals & objectives, help them understand the reasons for accreditation, what to expect in the site visit, and appropriate behaviors that day. The site visitor may ask the residents with whom he/she meets, "were you coached?" - so donÌt coach, just educate/remind.
  6. Hold a similar meeting with faculty who are scheduled for meetings with the site visitor - the faculty are expected to be completely conversant with program requirements, educational goals & objectives, policies, etc., and any uncertainty on their part will erode the site visitorÌs confidence in your program.

One month before the site visit:

  1. Firm up plans for the visit. If the site visitor asks to meet with anyone else during the day, make those arrangements.
  2. The program director (PD) and housestaff coordinator (HSC) will be involved with the site visit for the entire day of the visit. Clear their calendars for that day.
  3. The site visitor will usually make his/her own travel and hotel arrangements, and ACGME will pay for those. Some will appreciate help with making reservations - ask.
  4. Send the site visitor a travel packet containing maps, directions, and a parking hang-tag (if driving).
  5. The typical site visit takes about 6-8 hours - usually beginning around 8 a.m. and concluding by 2-3 p.m.
  6. Schedule a room for the site visitor to work in - it should be quiet, have a large table, and be able to accommodate 6-8 people. If the room is near the PD and HSCÌs offices, additional materials (e.g., residentsÌ files) are easily retrieved. If the room you select is far from your offices, you will need an additional person to serve as a "runner." Many programs use a departmental conference room or library for the site visitorÌs "headquarters" - be sure that there is a room nearby for the PD and HSC - a "holding area" - to work in (see below).
  7. Make arrangements for coffee, water, morning pastries, etc. for the "headquarters" room.
  8. Lunch - if the site visitor wishes to meet with individuals over lunch, make arrangements for appropriate meals. The lunch can be nearby, or in the same room, but should not slow the flow of the day. If another location is selected for the meal, brief the staff there that this is an important visitor - try to avoid delays or opportunities for adverse impressions.
  9. Meet with faculty again - be certain that everyone involved is familiar with all requirements, the PIF, etc. Consider clearing the site visit day's schedule for faculty and residents who will be interviewed, to avoid conflicts and delays.

One-five days before the site visit:

  1. Notify UT Police of visitor & approximate time of arrival.
  2. Decide who will host the site visitor (usually PD and HSC) - you will need to meet him/her upon arrival, escort to the location for the interviews, provide coffee, etc. Be sure that the "headquarters" room is orderly, and represents your programÌs best efforts at "an organized educational program."
  3. Anticipate last-minute changes - there may be a power outage in your department, the site visitor or one of your faculty may get held up in traffic, or be sick, etc - make contingency plans. Have an extra resident on stand-by - someone may have a last-minute illness. Identify someone to make any requested photocopies.
  4. Reconfirm meeting times with faculty & residents; plan for them to arrive 15-20 minutes earlier than planned, to avoid delays and allow last-minute briefing. Delayed arrival of scheduled individuals will reflect poorly on the program. Reconfirm lunch plans & any other arrangements outside of the department.
  5. Make extra copies of the itinerary.

The day of the site visit:

  1. Meet the site visitor and escort him/her to the "headquarters" room. Provide coffee and pastries.
  2. Determine from the site visitor how he/she wants to stay on schedule. Some prefer a discreet knock on the door to mark time, while others may have different requests. The HSC and PD need to keep the process flowing smoothly.
  3. Holding area. As scheduled participants arrive (15-20 minutes before their appointed times), the PD and HSC can give any last-minute information, and already-interviewed individuals can be debriefed. If themes are identified (e.g., the site visitor needs more information about a topic, or appears to have a misconception, etc.), those issues can be addressed later in the day.
  4. The schedule may include a wrap-up session - any newly identified issues can be addressed there. Make notes of any remaining documents that will need to be sent to the site visitor, or about which he/she will call (and when). If the site visitor needs to carry bulky materials, offer to fed-ex them, or take them to the post office (campus mail may add days to the turnaround).
  5. If the site visitor plans to depart to the airport, help to secure transportation (or offer to drive him/her there). If he/she is to survey another program the following day, arrange an escort to that department.

Sample Agenda

8:30 - 10:00
Program Director - review of program information forms. (Associate PD and Chair if different may attend)

10:00 - 11:00
Faculty members (may be divided into small groups for 20 minutes each)

11:00 - 11:30
Break or "catch up time"

11:30 - 12:00
Assistant Dean for GME

12:00 - 1:30
Resident interviews. (Pagers turned off and a light lunch served)

1:30 - 2:00
Wrap up with Program Director and review of documents. Possible tour of facilities

Documents to be reviewed generally include the following*:

  1. Faculty evaluations of the residents and documentation of the required resident conferences with the program director
  2. Written goals and objectives for the program by years of training and rotations
  3. ResidentsÌ evaluations of the faculty and rotations
  4. Final summary evaluations for finishing residents
  5. Written descriptions of supervisory lines of responsibility for residentÌs patient care activities.
  6. The programÌs policies for resident selection, evaluation, promotion and dismissal.
  7. Required inter-institutional agreements and letters of affiliation.

(If above are included with the PIF, additional copies may not be required.)

* These are all required in the Program Requirements and Institutional Requirements.

Additional information to be sent with PIF may include:

    1. Literature used in resident recruiting, which may provide site visitor with basic information about your institution and your program.
    2. A final schedule listing the names and titles of the people involved.
    3. Where to meet the site visitor on the morning of the site visit.
    4. Response to citations or concerns expressed by the RRC in last letter or report if not included with PIF.
    5. A disk with the PIF may also be required.
January 2001