Self-Study and 10-Year Accreditation Site Visit Information

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

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 updated 4 11 2019

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

Review the bulleted points below to prepare for the site visit itself

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
  • 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 November 12, 2021