Residency Accreditation Toolkit: Initial Accreditation Process

The Review Committee staff members serve as the primary resource for programs as questions arise during the application process. Their contact information can be found in the respective specialty’s section of the website. Here is a link to the family medicine support staff.

There are three parts to the application:

1. The common application (housed in the ACGME’s Accreditation Data System, also known as "ADS")
2. The specialty-specific application (a Word document the program must complete and upload into ADS)
3. Attachment documents (policies and sample evaluations that are uploaded into ADS)

ADS is accessed through a web browser. All information required for the program application must be entered or uploaded into ADS.

This checklist from ACGME includes required application documents that must be uploaded into ADS with a program application.

Each ACGME program applying for accreditation must be associated with an ACGME-accredited Sponsoring Institution. The DIO of the ACGME-accredited Sponsoring Institution initiates the program application in ADS.

After the DIO initiates the application, enters basic information about the program, and identifies the program director, the program director receives an email with ADS login information.

All new specialty (residency) programs, and some subspecialty (fellowship) programs, must undergo an accreditation site visit prior to review by the applicable Review Committee. This table shows the subspecialties that do not require an accreditation site visit with an initial program application. Some family medicine subspecialities do not require site visits.

Upon receipt of a completed program application, an accreditation site visit is scheduled for the program if one is required. It can take approximately 3–6 months to schedule the visit.

The initial site visit is usually a one-day event. The site visitor will review the application in advance, flagging any areas of concern. The site visitor will contact the program at least 30 days in advance and specify the itinerary for the day in detail, even down to how they want lunch and breaks scheduled.

They will meet with the program director, administration from the sponsoring institution, and faculty, and will want to tour facilities—usually the family medicine clinic and possibly select hospital areas. Follow their directions exactly, and if any changes are necessary get them approved in advance. They will also ask to see documents such as rotation goals and objectives, evaluation forms, etc. Have everything required available. Ask in advance if the visitor prefers to see electronic forms on a computer screen or have a paper printout.

Site visitors are often not family medicine specialists. You will be notified in advance who your visitor is and what their credentials are. Even if your site visitor is a family physician, be prepared to present your program as compliant with the requirements to the “letter of the law.”

The Review Committee will review the application, along with the Site Visit Report (if applicable) for substantial compliance with the specialty/subspecialty Program Requirements at its next scheduled meeting with an open agenda. The RC-Family Medicine meets quarterly. This guide will help locate the Review Committee meeting and agenda closing dates. The site visit report must be submitted to complete the application before the agenda closing date or your application will be delayed to the next meeting.

If the Review Committee finds the program to be in compliance with the Program Requirements, it will give a status of Initial Accreditation. If the Review Committee finds the program is not in substantial compliance with the Program Requirements, it will give a status of Accreditation Withheld and the program will need to submit a new application if it would like to continue to pursue accreditation.

Citations

Citations are common, particularly for new applications. Although there is no grading system for citation severity, it will be evident from the wording and requested follow-up how seriously the RC takes a particular citation. Citations may be as minor as clarifying some vague wording or correcting an internal inconsistency in the application, or as severe as a major requirement clearly not being met.

The follow-up plan also indicates how serious the citation is. It may be:

• Noted for the next normal site visit
• Written response required
• A focused site visit required
• Accreditation may be withheld

When responding to citations, don’t take them personally or get defensive. The RC does not have the intimate familiarity with your program that you do. Addressing citations can be a worthwhile program improvement process and should be approached in that mindset. Citation responses are entered into the ADS.