Annual Data Submission to the ACGME

 The ACGME Next Accreditation System (NAS) signifies a transition from periodic to continuous assessment of programs and institutions. While the period between scheduled accreditation site visits has increased to 10 years, each Residency Review Committee (RRC) will perform an annual evaluation of programs utilizing the following metrics:

• Annual ADS Updates – The ADS Update window opens for one month between the months of July and September, depending on the ACGME schedule.
  • Faculty and Resident scholarly activity – Scholarly activities should be collected from the previous academic year and reported in the Annual ADS Update. 
• Clinical Experience (e.g., Case Logs) – Trainees of participating programs enter cases in the Resident Case Log System throughout the year and must be monitored by program leadership, since many RRCs have case minimums and graduation requirements.
• Milestones reporting – Trainees are evaluated against the specialty-specific milestones on a semi-annual basis during the Clinical Competency Committee meeting. These milestones are grouped by competency and broken down into sub-competency levels.
• Resident Survey - The program’s annual Resident/Fellow ACGME Surveys are scheduled for one month duration between February and May. All survey results are released to the programs in June. The program is responsible for monitoring completion compliance.
• Faculty Survey – The program’s Faculty Surveys are also scheduled for the same month as the Resident Survey, between February and May. In most cases, the Core Faculty is surveyed and in all cases, the Program Director is surveyed. The Program Director or Program Coordinator is responsible for informing the relevant faculty and for maintaining compliance.
• Board Pass Rate (external) – The Specialty Boards will send the Board Pass Rates directly to the ACGME for inclusion with the Program’s annual data collection materials.
• Hospital accreditation data – The ACGME will monitor the continued accreditation of the hospital, when determining the accreditation status of programs.

Subspecialty programs will have their annual reviews together with their respective core programs.
In order to maintain “Continued Accreditation”, programs must be diligent in successfully completing and submitting all of the required data elements. Following the ACGME annual review, existing programs and sponsoring institutions will be awarded one of the following accreditation status options in an annual notification letter:

• Continued Accreditation
• Continued Accreditation with Warning
• Probationary Accreditation
• Withdrawal of Accreditation
• Administrative Withdrawal

Page was reviewed 3/31/21.