1. Are you ready? Preparing for your ACGME Site visit
Cheryl Christenson, Hennepin County Medical Center Kelly Wheeler, LMSW SUNY Upstate Medical University

2. Disclosure
The speakers have no conflict of interest, financial relationship, or commercial interest

3. ACGME – GAME ON

4. GOAL
The Review Committee commends your program for its demonstrated substantial compliance with the ACGME's Program Requirements and/or Institutional Requirements without any new citations.

5. How it begins… 1. Self Study letter from ACGME
2. Upload Self Study information
3. Full Site Visit / Self Study 18 – 24 months later

6. Site Visit Notification Letter Arrives
* Take a deep breath
*Read every word in the letter you receive from ACGME
*Schedule a meeting with your Program Director and work out a plan of action and timeline

7. Key Roles for the Program Coordinator
1. Participate in the Annual Program Evaluation (APE)
2. Track action plans for Areas of Improvement
3. Maintain a multi-year record of improvements including what is still being worked on
Our GME office uses an upgraded version of the spreadsheet recommended by ACGME

8. Key Roles for the Program Coordinator
4. Compile and Maintain all Self-Study Data and accreditation required files/documents
5. Coordinate Self Study
6. Coordinate activities on the site visit day
Our GME office uses an upgraded version of the spreadsheet recommended by ACGME

9. My Self Study Experience
Cardiovascular Disease (3 year program)
Critical Care Medicine (2 year program)
Geriatrics Medicine (1 year program)
Best Geriatric Program Director ever!

10. Getting Started ACGME Website is your friend
8 steps to prepare for the 10-Year Accreditation Site Visit
1. Reassemble the Annual Program Evaluation / Self Study Group to harvest the data in Areas for Improvement identified during the self study
2. Discuss Improvement Made as a Result of the Self-Study with Stakeholders
3. Reassess Program Aims and Other Elements of the Program’s Strategic Assessment (Strengths, Opportunities, and Threats)
4. Discuss Program Aims, Improvements Achieved and Other Elements of the Program’s Strategic Assessment with Program Stakeholders
5. Complete and submit the Summary of Achievements
6. Update Data in the Accreditation Data System (ADS) Ahead of the 10 Year Accreditation Site Visit
7. Ensure Timely Data Submission Prior to the 10-Year Accreditation Site Visit
8. Set and Confirm Logistics for the 10-Year Accreditation Site Visit
You can drill down on the ACGME website to find guidance for every step

11. Reassemble your team Who is the team?
Program Evaluation Committee (PEC)
Program Director
Core Faulty
Program Administrator / Coordinator (that’s us!)
Current Fellows
Every institution will be a bit different. My experience was every fellowship for themselves.

12. Step 2: Hold a Meeting
1. Discuss improvements from the previous self study
What worked well
What changes were made
Talk yourselves up!
2. Review and Discuss Program Aims and Strategic Assessments
What are your long term goals for your program
How do you plan / hope to achieve them
What hurdles do you anticipate encountering
This is the time to look at all you’ve done and hope to do and make a plan!

13. Step 3: Put the plan in writing
There are 3 forms to look at during this phase
1. Self Study Summary
This form should be completed about 18 months prior to Site Visit and used as a reference at this time
2. Self Study Summary Update: Department of Field Activities
This form is completed to show any changes to the program since the original self study was completed
Was there a change in Fellow Allocation? New Program Director? New Funding Source?
3. Self Study Summary of Achievements: Department of Field Activities
List Programs Strengths: Interdisciplinary team? Remarkable patient population?
Achievements in Identified Areas for Improvement? How did you fix what was wrong?
This is the place to talk yourselves up! What makes your program so great!
** Some institutions will allow all specialties to work as a unit with regards to threats and aims.

14. Step 4: Update Accreditation Data System (ADS)
3 Sections to focus on:
1. Current responses to any citations
How did you fix what was wrong?
2. Changes and Other Updates open text section
Explain any current efforts related to program improvement
3. Update current block diagram in accordance with ACGME guidelines
*Site visitors have the ability to see and review your entire ADS so in addition to the above 3 points, it is important to ensure the entire site is up to date.

15. Step 5: Submit and Secure Logistics
All information must be submitted through ADS at least 12 days prior to the site visit
A field representative from ACGME will contact your program (or university) regarding
the details of who, what, where, and when the meetings will take place

16. Miscellaneous Preparation Info
1. Websites
Site visitors will be checking your programs webpages, so make sure data is as up to date and current as possible
2. Residents and Fellows
Confidential list of 5 program strengths and 5 areas of improvement to be discussed during the visit
To be sent to the site visitor team directly
MUST BE CONFIDENTIAL AND CAN NOT HAVE ANY AFFILIATION WITH PROGRAM DIRECTOR / COORDINATOR
3. Faculty

17. What to bring to the visit
How to assemble your Binders:
At least 1 binder needed per site visitor, Program Director, and
Program Coordinator
1. Sponsoring and Participating Institutions
2. Resident Appointment and Evaluations
3. Educational Program
4. Faculty and Program Evaluation
5. Duty Hours and Learning Environment
6. Quality Improvement

18. Official Site Visit Document Checklist: https://www. acgme

19. Section 1: Sponsoring and Participating Institutions
1. Current, signed Program Letters of Agreement (PLA’s)
Any off campus site that your fellows work at must have a PLA
PLA’s must be current within 5 years of site visit

20. Section 2: Resident Appointment and Evaluations
- This info was put in a folder separate from the rest as there was so much information to include
1. Files of recent program graduates and current fellows (ERAS app, signed contract, proof of certifications; proof of QI projects
2. Files of any trainees who have transferred in or out of the program within the last 3 years
3. Files of any trainees who have resigned or been dismissed from the program within the last 3 years
4. Fellow evaluations by faculty, peers, patients, other staff, semi-annual and final evaluations to be included

21. Section 3: Educational Program
1. A sample of competency based, educational level-specific goals and objectives for one rotation / assignment
Include a write up for every rotation included on your fellowship: Inpatient vs Outpatient etc
2. Conference schedule for current academic year

22. Section 4: Faculty and Program Evaluations
1. Sample of a completed annual confidential evaluation of faculty by fellow
2. Written description of Clinical Competency Committee
Membership
Semi-Annual fellow evaluation process
Reporting of Milestones Evaluation to ACGME
CCC Advising on Fellow progress including promotion, remediation, and dismissal
3. Written description of Program Evaluation Committee (PEC)
Fellow and Faculty evaluations of the program
Program evaluation and action plan tracking protocols (Annual Program Reviews)

23. Section 5: Duty Hours and the Learning Environment
1. Program specific policies for:
Supervision of fellows (addressing progressive responsibilities for patient care and faculty responsibility for supervision)
Include guidelines for circumstances and events that require fellows to communicate with appropriate supervising faculty members
2. Sample duty hour compliance data demonstrating your monitoring system

24. Section 6: Quality Improvement
1. Sample documents demonstrating fellow participation in patient safety and QI projects

25. In Summary 1. Remember to breathe
2. If you plan ahead and follow the steps from ACGME you will do great
3. At the end of the day, its just a conversation
Know what you do well
Know what can be done better (nobody is perfect)
Know what the plan is to improve your program

26. Congratulations! You did it!
Cheryl Christenson
Kelly Wheeler