1. ACGME Institutional Accreditation
Paul Foster Johnson, MFA
Executive Director,
Institutional Review Committee
ACGME
DIO/DME Forum
Billings, Montana
November 6, 2017

2. Disclosures
I am a full-time employee of the ACGME. I have no conflicts of interest or financial relationships to disclose.

3. Objectives
Review ACGME Institutional Accreditation
Describe required structural elements and qualities of Sponsoring Institutions (SIs) that oversee and support ACGME-accredited graduate medical education (GME) programs
Recognize the roles, responsibilities and activities associated with institutional sponsorship
Describe common challenges in institutional applications

4. ACGME Mission Statement
We improve health care and population health by assessing and advancing the quality of resident physicians' education through accreditation.

5. 831 Sponsoring Institutions
ACGME Statistics
831 Sponsoring Institutions
About 2/3 have >1 accredited program
10,672 ACGME-accredited residency/fellowship programs
4,383 residencies, 6,174 fellowships
129,720 residents/fellows in ACGME-accredited programs
107,013 residents, 22,707 fellows
~150 Specialties and Subspecialties

6. Institutional Accreditation
Sponsoring Institutions must apply for and receive institutional accreditation before applying for program accreditation
Application is the same for all Sponsoring Institutions
Institutional Review Committee (IRC) uses peer review process to determine Sponsoring Institutions’ substantial compliance with ACGME Institutional Requirements

7. IRC Leadership,
Chair Susan E. Kirk, MD Associate Dean for Graduate Medical Education University of Virginia Medical Center Vice Chair Ronald Amedee, MD, FACS Designated Institutional Official Ochsner Clinic Foundation

8. ACGME-Accredited Sponsoring Institution
Definition: The organization (or entity) that assumes the ultimate financial and academic responsibility for a program of graduate medical education. The sponsoring institution has the primary purpose of providing educational programs and/or health care services.
Examples: a university; a medical school; a hospital; a school of public health; a health department; a public health agency; an organized health care delivery system; a medical examiner’s office; a consortium; an educational organization.

9. www.ACGME.org > Designated Institutional Officials > Institutional Review Committee

11. Accreditation Data System (ADS)

12. Application Uploads
Initial Institutional Application
Organizational charts
Statement of commitment to GME
GMEC minutes
GMEC membership
AIR performance indicators
Special Review protocol

13. Institutional Applications
Reviewed by the Institutional Review Committee (IRC) for substantial compliance with ACGME Institutional Requirements
No initial site visit (unlike core program applications)
Considered on a first-come, first-serve basis at one of three annual meetings
Sponsoring Institution remains in “Application” status until IRC review
Possible decisions:
Initial Accreditation
Accreditation Withheld
IRC letter of notification and citations within 60 days

14. Institutional Accreditation
Leadership (Oversight and Support)
Operational Structure (Personnel and Systems)
Clinical Learning Environment (All Residents and Fellows, All Faculty, All Participating Sites, All Programs)

15. ACGME Institutional Requirements
I. Structure for Educational Oversight
II. Institutional Resources
III. Resident/Fellow Learning and Working Environment
IV. Institutional GME Policies and Procedures

16. I. Structure for Educational Oversight
One Sponsoring Institution has ultimate authority and responsibility for its ACGME-accredited programs
The DIO, in collaboration with GMEC, has authority and responsibility for oversight and administration.
The Sponsoring Institution must identify a Governing Body.

17. Designated Institutional Official

18. Designated Institutional Official

19. Designated Institutional Official

20. Designated Institutional Official
ACGME compliance
Resident education (e.g., orientation)
Program director mentorship
GME finance and budget
GME Office administration
Legal and Human Resources issues
Patient safety and quality improvement
Well-being

21. Graduate Medical Education Committee (GMEC)
DIO must be a member, but does not have to be the chair
Program Director(s)
At least 2 peer-selected residents
Quality improvement/patient safety officer
Other stakeholders in GME

22. Graduate Medical Education Committee (GMEC)
Must meet at least quarterly
Must keep detailed minutes that reflect fulfillment of required responsibilities
Can have subcommittees
Resident representatives
GMEC review and approval

23. GMEC Responsibilities
Oversight of program accreditation, learning environments, education, program improvement, and major program decisions
Review and approval of policies, procedures, recommendations for resident stipends/benefits, ACGME submissions
Annual Institutional Review (AIR)
Special Review process

24. I.B.4.a) GMEC Responsibilities: Oversight
Accreditation status of the Sponsoring Institution and each program
Quality of learning and working environment with the Sponsoring Institution, each program, and its participating sites
Quality of educational experiences in each program that lead to measurable achievement of educational outcomes as identified in the ACGME Common and specialty-/subspecialty-specific Program Requirements
Programs’ annual evaluation and improvement activities
All process related to reductions and closures of the Sponsoring Institution, programs, and participating sites

25. I.B.4.b) GMEC Responsibilities: Review and Approval
GME policies/procedures
Stipends/benefits
New program applications
Changes in complement
Program structure or duration of education
Site additions/deletions
New Program Directors
Progress reports
Duty hour exceptions
Voluntary withdrawal of accreditation
Requests for appeal of adverse action
Appeal presentations

26. I.B.5 Annual Institutional Review (AIR)

27. I.B.5 Annual Institutional Review (AIR)
Continuous quality improvement at the level of the Sponsoring Institution
Performance indicators can be anything but must include:
Institutional self-study results
ACGME Resident/Faculty Survey
Program accreditation status

28. Evidence of AIR Oversight
AIR must have monitoring procedures for action plans
Monitoring should be documented in the GME minutes
Written executive summary of AIR submitted by DIO to governing body each year

29. I.B.6 Special Review

30. Effective oversight of underperforming programs
I.B.6 Special Review
Effective oversight of underperforming programs
Special Review Protocol
Establishes criteria for underperformance
Results in report describing quality improvement goals, corrective actions, process for GMEC monitoring of outcomes

31. Oversight via Special Review
GMEC establishes approved Special Review (SR) protocol
GMEC minutes serve as a source that documents:
Need for SR based on protocol criteria
SR completed, reviewed and approved by GMEC
Monitoring of program quality improvement goals/corrective actions

32. II. Institutional Resources
The Institutional Requirements focus on the relationship of the Sponsoring Institution to its programs, as well as to the participating sites where the programs’ residents rotate.
The Sponsoring Institution must ensure that resources are available, even in instances when it does not directly provide the resources.

33. II.A-B Institutional Resources
Institutional GME Operations
DIO Support/Time
DIO Professional Development
Institutional GME Administration
Ensuring Program Resources
Program Director/Faculty Support
Faculty Professional Development
Program Staff
Program Physical Resources and Space

34. II.C Resident/Fellow Forum

35. II.C Resident/Fellow Forum
Only applies to SIs that will have >1 program
Can be an organization, council, town hall, or other forum (electronic)
Must be organized so that any resident can directly participate in the forum and does not need to communicate through representatives
Must have option to conduct the forum without others present (DIO, faculty members, administration)
Must have a mechanism to present forum’s concerns to the DIO and GMEC

36. III.A Resident Learning and Working Environment
The Sponsoring Institution and each of its ACGME-accredited programs must provide a learning and working environment in which residents/fellows have the opportunity to raise concerns and provide feedback without intimidation or retaliation and in a confidential manner as appropriate.
Resident and Faculty Survey
Complaints/Concerns

37. III.B Resident Learning and Working Environment
SI requirements related to resident experiences with:
Patient Safety
Quality Improvement
Transitions of Care
Supervision
Work Hours and Fatigue Mitigation
Professionalism

38. IV. Institutional GME Policies and Procedures
Resident eligibility
Terms and conditions of appointment
Available to applicant by time of interview
Inclusion in resident agreement/contract
Promotion/Renewal/Dismissal
Grievances
Benefits

39. IV. Institutional GME Policies and Procedures
Work Hours
Supervision
Various subject-specific policies
vendors
non-competition
disasters
closure/reduction

40. Institutional Requirements: Focused Revision (Proposed)
Patient Safety
Well-Being
Professionalism

41. Institutional Requirements: The Big Picture
Institutional oversight by the Sponsoring Institution:
extends to all programs at all participating sites
involves clearly defined administrative structure for oversight of the clinical learning environment
Oversight is demonstrated through:
Deployment of institutional resources
DIO/GMEC collaboration
Program accreditation outcomes

42. Common Concerns in Institutional Applications
Connections between application questions and Institutional Requirements (Check the margins!)
Defining the proposed SI: participating sites, number of programs, resident complements
Governing body, senior leadership and reporting relationships within the SI
Statement of commitment language/signatures

43. Common Concerns in Institutional Applications
GMEC minutes
Attendance records
Time range
Reflect fulfillment of required responsibilities (not only IR Section I)
Resident peer selection process (GMEC and subcommittees)
GME program administration elements

44. Common Concerns in Institutional Applications
Resident forum (all required elements in one body)
SI oversight extends to all requirements and participating sites

45. ACGME Accreditation System
Use of outcomes in accreditation
Annual ACGME review in parallel with annual improvement efforts within Sponsoring Institutions/programs
Shift away from administrative process management allows flexibility to innovate

46. ACGME Accreditation System for Sponsoring Institutions
Annual accreditation decisions
Use of data to identify Sponsoring Institutions for IRC annual review
Self-study and 10-year accreditation site visit (under development)
CLER site visits: important for improving clinical learning environments, but unrelated to accreditation

47. Clinical Learning Environment Review (CLER)
Not part of the IRC’s accreditation review process
Not applicable to SIs with Pre-Accreditation, Continued Pre- Accreditation or Initial Accreditation statuses
Periodic, short-notice site visits of one participating site within the SI
Assessment of six focus areas: Patient Safety, Healthcare Quality, Transitions of Care; Supervision; Duty Hours, Fatigue Management and Mitigation (now Well-Being); and Professionalism.
Methodology includes meetings with GME stakeholders, Audience- Response System and “Walk Rounds”

48. Annual Accreditation Decisions
Continued Accreditation (Keep on overseeing, improving, innovating!)
Continued Accreditation w/ Warning
Probationary Accreditation
Accreditation Withdrawn

49. Continued Accreditation
Evidence of substantial compliance with Institutional Requirements
Continue documentation in ADS Annual Update
DIO/GMEC/Sponsoring Institution should continue oversight process
Annual Institutional Reviews (AIRs)
Special Review Protocol
GMEC Minutes
Locally defined oversight mechanisms

50. Continued Accreditation with Warning
Not subject to ACGME appeal process
In next annual review, IRC could grant Continued Accreditation or Continued Accreditation w/ Warning without site visit
Sponsoring Institution should address concerns (and document in ADS Annual Update) before subsequent annual review
Document corrective action and monitoring whenever possible: GMEC minutes, Annual Institutional Review, Special Review

51. Probationary Accreditation
Subject to ACGME appeal process
Automatic site visit within one year
Sponsoring Institution should address concerns (and document in ADS Annual Update) before subsequent annual review
Document corrective action and monitoring whenever possible: GMEC minutes, Annual Institutional Review, Special Review

52. Accreditation Withdrawn
Subject to ACGME appeal process
Failure to demonstrate:
Substantial Compliance with Institutional Requirements
Effective GME structure, oversight and/or support

53. Annual Institutional Review Screening Data Indicators, 2016-17
Sponsoring Institution accreditation status
Unresolved complaints
Referrals from specialty Review Committees
DIO/CEO changes in past year
Program Director changes in past year
Institution-level 2015–16 Resident Survey results
Performance of programs in the aggregate
Trends (above indicators repeated from )

54. Annual Institutional Review Data Components for 2016-2017
Sponsoring Institution accreditation status
Unresolved complaints
Referrals from specialty Review Committees
DIO/CEO changes in past year
Program Director changes in past year
Institution-level 2014–2015 Resident Survey results
Performance of programs in the aggregate
Trends in all of the above

55. Annual Institutional Review, 2016-17
629 of 822 Sponsoring Institutions
Consent Agenda: 586 (93.2%)
Progress Report: 9 (1.4%)
Clarifying Information: 16 (2.5%)
Site Visit: 18 (2.9%)

58. Sponsoring Institution 2025 (SI2025)
18-month project commissioned by the ACGME Board of Directors
Task: develop a future vision for accredited Sponsoring Institutions
19-member task force including DIOs, CEOs, CMOs, residents, public members
Spring/Summer 2016: Data gathering and listening sessions
December 2017: Final report and recommendations in JGME supplement

59. Accreditation, CLER: tools, not ends in themselves
SI2025 in Context
Accreditation, CLER: tools, not ends in themselves
Common Program Requirements: Major Revision
Section VI
Sections I-V
Institutional Requirements: Focused Revision, 2017
Completion of Single Accreditation System, 2020

61. Take-away Points
First things first: structure, leadership and capacity
Planning is essential
The ACGME Requirements tell you the minimum standards
Understanding NAS concepts from the outset will help in the long run
Call us

62. Institutional Accreditation Staff
Kevin B. Weiss, MD, MPH
Senior Vice President, Institutional Accreditation
(312) or
Paul Foster Johnson, MFA
Executive Director, IRC
(312) or
Victoria Shaffer
Accreditation Administrator, IRC
(312) or

63. Thank you!