PHASE I
Understanding the Significance of the ACGME-I Accreditation Process
he ACGME-I Accreditation Process
The first step of the ACGME-I accreditation Self-Study process involves several important actions. HEAL will help you establish an accreditation committee, collect and analyze data from Annual Program Evaluations, and use this information to pinpoint program strengths and areas needing further development.
HEAL will ensure that the accreditation committee complies with the ACGME-I requirements. The responsibility for determining committee membership, meeting frequency, and overall accreditation strategy rests with the program director. However, HEAL will help the program director to involve a wide range of stakeholders throughout the process, including:
– Residents at different stages of the program
– Program “end users” such as patients or professionals who regularly interact with residents
– External perspective from a program director in another specialty
– Staff members from the institution’s Graduate Medical Education office
– Members of the Program Evaluation Committee (PEC)
– Representation from the Clinical Competency Committee (CCC) to provide educational outcomes data
The Sponsoring Institution’s designated institutional official (DIO) typically plays a direct and collaborative role in the accreditation process. This cooperative nature extends to the accreditation committee, where your input and expertise are highly valued. Notably, core residency and fellowship programs are evaluated jointly. Therefore, it is beneficial for the accreditation committee of a core residency program to include representation from affiliated fellowships and vice versa. HEAL’s inclusion in this process is crucial for its success.
Additional committee members might include departmental leaders, chief residents, and experts in education, curriculum design, or assessment. The DIO can offer recommendations for institutional experts as needed.
Data for the accreditation is drawn from consecutive Annual Program Evaluations. This includes recent improvements, actions to address citations, and progress toward program objectives. HEAL will help survey and document further insights from residents, program graduates, employers, or faculty members to ensure a comprehensive evaluation. For instance, if a program aims to produce high-quality internal medicine physicians, input from senior residents on their post-residency plans or feedback from graduates and employers could be essential.
After gathering and analyzing data, HEAL will support the accreditation committee in using the findings to identify areas requiring development. This is a crucial responsibility that requires all levels of commitment and dedication. HEAL will lead the assessment by considering internal factors within the program environment and external influences that could impact program success. Conducting a SWOT analysis—assessing strengths, weaknesses, opportunities, threats, and aims—can provide a structured approach to this evaluation.
PHASE II
Improvement plan
HEAL prepares the institution for the second phase of the ACGME-I accreditation process by creating a program improvement plan and implementing necessary actions. This includes addressing areas that require further development.
During this phase, HEAL will help you proactively develop a five-year plan to answer the question, “What actions are necessary to achieve the program’s goals and take our program to the next level?” This forward-looking vision should be shared with faculty members and residents/fellows to confirm the accreditation committee’s findings and improvement priorities.
HEAL facilitates a discussion about common strengths, areas needing development, and improvement priorities with affiliated fellowships.
Once the improvement plan has been developed and discussed with stakeholders, a comprehensive Summary document can be submitted to ACGME-I. This summary, which describes the process used to conduct the Self-Study, including the quality improvement activities over the past five years, environmental factors impacting the program’s improvement efforts, and plans for the next five years, is a crucial part of our accreditation process.
HEAL will write the descriptions, which will be brief (less than 2,000 words total) and summarize the framework of the improvement measures the program will embark on 18 to 24 months before the accreditation site visit.
PHASE III
Implementation
In this phase, HEAL is crucial in supporting the organization in implementing the improvement plan. Measures will be implemented to track the progress made in the areas that need development. HEAL will ensure that the Self-Study Summary meets the accreditation site visit requirements.
Key actions in the third phase of the ACGME-I Self-Study process include:
– Evaluating the effectiveness of improvement efforts.
– Keeping accurate records of discussions.
– Sharing information between a core residency program and its associated subspecialty fellowship program(s).
– Ensuring that each planned intervention to address an area of improvement has a measurable metric. HEAL will oversee the assignment of data collection and progress tracking to a small group to ensure the effectiveness of the improvement process.
Approximately 18 to 24 months after completing the Self-Study, HEAL will submit a Summary of Achievements based on the sought standards before the accreditation site visit. This summary, a culmination of the organization’s efforts, will outline the program’s strengths and the improvement outcomes achieved in the plan, underscoring the weight of the organization’s responsibilities.
The time between the Self-Study Summary submission and the accreditation site visit is not just a period; it’s a valuable opportunity. HEAL will help the organization efficiently utilize this period for further improvements and will conduct at least one Annual Program Review to assess progress in the identified areas, emphasizing the urgency and importance of this time.
PHASE IV
Site Visit
HEAL will help prepare the organization for the fourth step of the ACGME-I Self-Study process, which involves an accreditation site visit. HEAL will update ADS by the specified date in the Site Visit Announcement Letter sent before the visit. All responses to citations will be complete and up-to-date, and the block diagram will accurately reflect the clinical curriculum.
Additions to the Major Changes and Other Updates section in ADS are crucial. This can include the results of the SWOT analyses, improvement interventions to the program, success metric measures, and a summary of improvement data collected. Changes made to ADS after the deadline set for the site visit will be available to someone other than the Accreditation Field Representative or the Review Committee-International.
During the accreditation site visit, you will have our full support. The visit will be half a day, depending on the program’s size. Visits to affiliated subspecialty programs will occur during the same week and take less time than the primary visit. The Accreditation Field Representative assigned to the program will guide the organization through comprehensive communication.
Following the site visit, the Accreditation Field Representative will meticulously create a Site Visit Report detailing the program’s compliance with ACGME-I Foundational and Advanced Specialty Requirements. This report, along with the data submitted in ADS and the annual Resident and Faculty survey results, will be studied by the Review Committee-International, ensuring a comprehensive evaluation of our program.