Announcements
2021 09 28: ACGME Self-Study Review Opt In or Opt Out – Please Read_ Important Update Regarding ACGME Program Self-Study Review 9 28 21
Resources
- Self-Study and 10-Year Site Visit (PowerPoint)
- UF Self-Study and Site Preparation Checklist/FAQ by Personnel Type
- Required types of evaluation
- Sample timeline for Self-Study and 10-Year Accreditation Site Visit
Self-Study
Every program, including subspecialties, must perform their own self-study. The Self-Study, required by the ACGME, is an objective, comprehensive evaluation of the residency or fellowship program, with the aim of improving it through:
- an exploration of program aims; and,
- an assessment of the program’s institutional, local and, as applicable, regional environment.
- usually performed by the Program Evaluation Committee (PEC), but can include other personnel
- review of program 5 years back and 5 years forward (“next level”)
Self-Study Summary ACGME’s template –review all the points below to prepare this document needed for ADS upload
Self-Study Summary template with GME Office Hints to work from
- Eight Steps for Conducting the ACGME Program Self-Study – resources and templates listed below
- ACGME Tips on Program Aims
- UF Worksheet and Checklist for Vision, Mission, Aims, Action Plans updated 3 30 2022
- ACGME suggestions for high value data
- ACGME’s quick guide to SWOT analysis
- ACGME’s suggested Annual Program Evaluation Template
- Annual Program Evaluation Form (New Innovations > Administration > Program > APE
- Action Plans: ACGME’s template for Tracking Improvements across multiple APEs
- Sample of Formalized Action Plan (also available in NI: More > Resources: Intranet: Program Directors & Coordinators Group)
- ACGME’s Guidance for Plan-Do-Study-Act (PDSA) process
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Continuous Improvement with multiple PDSA cycles
Timing between Self-Study and 10-Year Accreditation Site Visit
- 10-Year Site Visits occur 18-24 months (per ACGME now realistically ~3 years) after Self-Study to make improvements identified on self-study prior to site visit
- allows for at least 1 Annual Program Evaluation (APE) by the PEC before site visit
- allows program time to make improvements
10-Year Accreditation Site Visit
The 10-Year Site Visit is a full site visit and accreditation review based on program requirements, and a review of 1) program aims, 2) strengths, and 3) improvements made in areas identified by the self-study. Core programs and all affiliated subspecialties are visited at the same time
Summary of Achievements ACGME template — needed for upload in ADS
Self-Study Summary Update ACGME template — may be needed for upload in ADS
Review the bulleted points below to prepare the two self-study documents listed above
- Eight Steps to Prepare for the 10-Year Accreditation Site Visit — resources and templates listed below
- Annual Program Evaluation Form (New Innovations > Administration > Program > APE)
- Action Plans: ACGME’s template for Tracking Improvements across multiple APEs
- NI Action Plan Template and Example (also available in NI: More > Resources: Intranet: Program Directors & Coordinators Group)
Review the bulleted points below to prepare for the site visit itself
- ACGME Site Visit FAQs
- Checklist – Required Documents for Site Visit
- How to Generate NI Reports Needed for Site Visits
Documentation Typically Requested by Site Visitor PRIOR to Site Visit
Initial Accreditation Document List Template example for organizing documents listed below — NEW 11/12/21
- Click here to view ACGME’s expectations for content of resident/fellow files.
Document List for Programs on Continued Accreditation on how to run reports for documents list below — NEW 11/12/21
10-Year Site Visit Data Available to ACGME Review Committee (RC)
- ADS Data
- AAIM: ACGME Resident & Faculty Survey Resources & FAQs New Resource 2/10/22
- Program’s Self-Study Summary and any updates
- Program’s summary of improvements achieved as a result of the self-study (does NOT include data on areas still in need of improvement)
- Site visit report from the 10-year accreditation site visit
- ABMS Board Examination Data
RC Assesses Effectiveness of Self-Study
- Improvements from program reports are paired with program aims and context from self-study summary
- Data on improvements achieved are one measure of effectiveness
Last updated on March 30, 2022