Site Visit

In the Next Accreditation System (NAS) the traditional site visit and the maximum five-year accreditation cycle have been replaced with a program self-study followed by a site visit that are scheduled  every ten years. The ACGME will provide a 12 to 15-month advance notice of the approximate month of a self-study, as well as a 90 to 120-day advance notice with the specific date of the site visit. The 10-year site visit is based on a comprehensive self-study, which includes a description of how the program or sponsoring institution creates an effective learning and working environment, and how this leads to desired educational outcomes, and an analysis of strengths, weaknesses, and plans for improvement. The self-study of the subspecialty programs are concurrent with those of the core programs. The details of the format for the self-study and the 10-year site visit are available on the ACGME website: http://www.acgme.org/What-We-Do/Accreditation/Self-Study. 

Programs with Initial Accreditation will undergo a full site visit within two years of the effective date of the Initial Accreditation status. If a program demonstrates substantial compliance at that time, a status of Continued Accreditation will be conferred. If a program doesn’t demonstrate substantial compliance, the Review Committee may withdraw accreditation or confer a status of Initial Accreditation with Warning for a period of one year. At the end of this additional year, the program must demonstrate substantial compliance with the requirements to achieve a status of Continued Accreditation, or else accreditation will be withdrawn. 

Programs may have a focused or full site visit if the Residency Review Committee (RRC) identifies an issue or concern during its annual review of program data. A focused site visit may be used to address selected areas of concern that require attention or follow-up, or to evaluate the merits of a complaint against a program. A full site visit is typically scheduled when the RRC identifies several concerns that warrant the assessment of program compliance with all applicable standards, encompassing all aspects of a program.

Page was reviewed 3/31/21.