To maintain accreditation from the Accreditation Council for Graduate Medical Education (ACGME), programs must ensure continuous oversight of key program elements, undergo an internal review, and attest to the ACGME that the required accreditation standards are being met by submitting a comprehensive Program Information Form (PIF) as part of the external (RRC) site visit. If the RRC uncovers any issues, the program may also be required to submit a response addressing any citations in the accreditation letter (the programs should address only those issues for which a progress report is requested). Links to the documents below provide useful information regarding preparation for an RRC site visit, documentation that needs to be submitted prior to the site visit and, when required by the RRC, a response to the accreditation findings.
When will the site visit take place?
The most recent accreditation letter for the program should indicate the expected month/year of the next site visit. Sometimes the date is postponed by the ACGME as much as two-three months, and occasionally the date is moved up by a few weeks or months. Approximately 90 days prior to the site visit, the ACGME will inform the program about the actual date of the visit and the name of the site visitor.
Site visit notification letter
The ACGME letter of notification should include instructions about what to do if the program has to change the date of the site visit. The letter and/or email from the site visitor that follows the initial notification also will include:
- the deadline for sending the PIF (along with the delivery method)
- any additional materials that need to be available for review and
- the schedule s/he desires for the day of the site visit.
PIF Review by the Office of GME
At least two weeks before mailing the PIF to the site visitor, and prior to obtaining the DIO signature, the program needs to submit the PIF to the Office of GME for review by the GME Director assigned to the program.
Site Visits and Program Information Form (PIF)
To assist in site visit and PIF preparation, the following guide provides a step by step process, as indicated by a suggested weekly schedule.
To assist in the PIF preparation process, the following documents provide additional tips from a prior Program Director’s Workshop and exemplary answers to common Program Information Form (PIF) questions.
- Site Visit: Helpful Tips, Pitfalls to Avoid (Presented at March 2010 PD Workshop)
- Site Visit: Preparation Timeline (Presented at March 2010 PD Workshop)
- Site Visit: Coordinator’s Timeline (Presented at the April 2010 Coordinator’s Retreat)
- Notable Practices – Exemplary Answers to Core Competency Questions
Responding to the RRC
Tips for Responding to the RRC
Prior to submission to the ACGME, program response to the RRC needs to be directed to Diane Sheehan (MGH programs) or Irina Knyshevski (BWH programs) for GME Committee review. All documentation is due one month prior to the date of the GMEC meeting.
Education Committee meetings
In addition, the ACGME requires that the sponsoring institution’s Graduate Medical Education Committee (GMEC) develop, implement, and oversee a process for internal reviews carried out approximately at the mid-point of the program’s accreditation cycle. For further information regarding this process please see Internal Reviews.
Program leadership and administrators should refer all matters regarding GME programs to GME Director assigned to their specialty.
GME Topics and Resources
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