New Expectations For Your ACGME Site Visit

IMAG1053New Expectations for your ACGME Site Visit

Preparation for a site visit requires months of preparation to demonstrate your program’s ability to comply with accreditation guidelines and as these guidelines change, so too does the evidence of compliance.

The ACGME has requested the following new documentation for an upcoming site visit. Programs should take note and plan accordingly.

Program Evaluation

  1. Written description of program’s Clinical Competency Committee (CCC) advising on resident progress including promotion, remediation and dismissal.
  2. Written description of program’s Program Evaluation Committee (PEC) development of written Annual Program Evaluations and improvement action plans resulting from the Annual Program Evaluation.

Duty Hours and Learning Environment

  1. Policy for supervision of residents/fellows (addressing progressive responsibilities for patient care, and faculty responsibility for supervision) including protocols defining common circumstances requiring faculty involvement.
  2. Program policies and procedures for residents’/fellows’ duty hours and work environment including moonlighting policy.
  3. Sample documents for episodes when residents’/fellows’ remain on duty beyond scheduled hours
  4. Resident duty hour compliance data (exception reports)

Quality Improvement

  1. Sample documents offering evidence of resident/fellow participation in quality and safety improvement projects.