The Program Self-Study and the 10-Year Site Visit: Rationale for a New Approach.

Abstract

When the leadership of the Accreditation Council for Graduate Medical Education (ACGME) conceptualized what came to be known as the Next Accreditation System, a key component was a comprehensive self-study for programs and sponsoring institutions. The intent for the self-study, and for the overall approach to accreditation, was to promote improvement and recognize that most programs already comply with the vast majority of standards. This required a self-study that would allow programs to set aspirational aims, to analyze community needs, and to initiate activities to further these aims, to facilitate improvement in areas where the program already complied with the accreditation standards. This focus on ongoing improvement, through the annual program evaluation and a more formal self-examination every 10 years, was intended to make the accreditation process more relevant and meaningful for the majority of programs already in substantial compliance, and to convert the national graduate medical education “enterprise” into one that seeks excellence beyond satisfaction of minimum standards. The intent was a comprehensive self-study with a subsequent site visit that would be based on “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.”1 The ACGME’s initial plans for the self-study called for a review of the findings during the program’s 10-year site visit and an assessment during that site visit “that the self-study document offers an objective, factual description of the learning and working environment.”1 During late winter and spring of academic year 2014–2015, as the dates for the first program self-studies and associated site visits neared, ACGME leadership undertook a comprehensive reexamination of the proposed approach to the self-study. This was done in response to input from the graduate medical education community, which suggested that the review of the self-study during an accreditation site visit might create a barrier to a frank assessment. It also became clear that the timing initially envisioned, with the self-study being followed closely by an accreditation site visit, would not allow programs to make improvements in areas identified in the self-study. This would reduce the effectiveness of the self-study in facilitating program improvement, as well as the ability of the new accreditation system to document ongoing improvements in all programs to meet the ACGME goal of public accountability for the quality of physician education. In response to the concerns voiced by the community, a new approach to the self-study and the 10-year site visit was developed in an iterative fashion, with input from experts, the community, and ACGME governance. It has 4 components, shown in the box. They are described in more detail below, along with the rationale for each element. box Components of the New Approach to the Self-Study and the 10-Year Site Visit Protecting information on areas for improvement identified in the self-study from use in accreditation A 12- to 18-month time lag between the self-study and the accreditation site visits to allow programs to make improvements in areas identified in the self-study An added voluntary self-study pilot visit to receive feedback on the self-study process and findings Asking programs to report on improvements in areas identified in the self-study for the 10-year site visit Protecting Information on Areas for Improvement From Use in Accreditation The first component seeks to protect the information the program collects and uses in its self-assessment and self-improvement process from use in program accreditation. The rationale is to preserve the intent for the self-study as an introspective deliberation on the program’s aims, the context in which it operates and the community it serves, and how the program improves and innovates in ways that are relevant to the aims, context, and community. The chosen approach ensures that information on program areas of improvement is not disclosed before or during the 10-year site visit. This change was made to address concerns that program leaders might be less willing to identify and explore areas for improvement out of concern that this information, if presented during an accreditation site visit, may result in citations by the Review Committee.