The purpose of the accreditation or recognition site visit is collection and aggregation of relevant data. This information is put into a narrative, factual Site Visit Report used by the ACGME Review and Recognition Committees to make accreditation or recognition decisions. Accreditation Field Representatives are not the decision makers; accreditation and recognition decisions are the purview of the Review and Recognition Committees.

Accreditation and recognition site visits are conducted by Accreditation Field Representatives, who are professional site visitors employed by the ACGME. Biographical summaries of the Accreditation Field Representatives are available on the ACGME website.

Some site visits to Sponsoring Institutions and programs are conducted by a team of two or more Accreditation Field Representatives. The Site Visit Announcement letter will indicate the name(s) and contact information of the assigned Accreditation Field Representative(s) for the visit.

Accreditation Field Representatives may be assigned alone or in groups of two or more.  The assignment of multiple Field Representatives may be  for reasons related to training needs for new staff members, and/or the complexity of a particular site visit

Applications

A site visit is conducted to review all specialty and many subspecialty programs when an application for accreditation is submitted. The Accreditation Field Representative will verify and clarify the application documents in which institutional and program leaders have described the resources of the program and how it will comply with the Program Requirements. Applications for Sponsoring Institutions, some subspecialty programs, and Osteopathic Recognition are typically reviewed without a site visit.  More information about the application process can be found on the Program Applications page of the ACGME website.   

Initial Accreditation or Initial Recognition Statuses

All Sponsoring Institutions and programs undergo an accreditation or recognition site visit at the end of the Initial Accreditation or Recognition period and prior to a committee’s decision to confer the status of Continued Accreditation or Continued Recognition

Continued Accreditation or Continued Recognition Statuses: Site Visit Requested after the Review of Annual Data

Sponsoring Institutions and programs with a status of Continued Accreditation are subject to annual review of data submitted as part of the  ADS Annual Update process. This includes but is not limited to ACGME Resident/Fellow and Faculty Survey reports; Case Log data (if applicable); certifying board pass data for program graduates; scholarly activity data for residents/fellows and faculty members; resident/fellow and personnel attrition; and program changes. Review Committees may ask the program to provide additional information or a progress report, or request a site visit.

Continued Accreditation Statuses: Random Sampling of Programs

The ACGME selects programs on Continued Accreditation statuses for site visits. These site visits are identified through a random sampling process and that supports the ACGME’s assurance responsibility to the public. Programs are eligible if they have not had a site visit in nine years or more.

Continued Accreditation Statuses: 10-Year Accreditation Site Visits for Sponsoring Institutions

All Sponsoring Institutions undergo a site visit following the Self-Study process that includes a description of how the Sponsoring Institution creates an effective learning and working environment, and how this leads to desired educational outcomes.

Continued Recognition Statuses: 10-Year Recognition Site Visits for Programs

Programs with Continued Recognition statuses undergo a 10-Year Recognition Site Visit, but do not need to complete a Self-Study prior to the visit.

Probationary Accreditation or Probationary Recognition

A site visit is required for a Sponsoring Institution or program on Probationary Accreditation or Probationary Recognition prior to the next review and accreditation or recognition status decision.

Complaint

Review or Recognition Committees may request a site visit to review complaint allegations and determine the disposition of a complaint. Such site visits often require a team of Field Representatives. Click here for more information about how to report an issue to the ACGME.

Other Site Visits

Review or Recognition Committees can request site visits at their discretion.

The “Date of Next Site Visit (Approximate)” is a target date for the site visit and not the actual date of the site visit. The approximate date is always the first of a given month.  The approximate date will be replaced by an actual date once Field Activities requests site visit blackout dates.

All types of Sponsoring Institution and program accreditation and recognition site visits could potentially be conducted remotely or in person. Safety and well-being of ACGME staff members and the graduate medical education community is of the utmost priority in determining the modality of an individual visit.

The decision regarding the modality of the accreditation or recognition site visit (in-person or remote) is made by the ACGME.

Sponsoring Institution and program personnel will be informed about the modality of a site visit when they receive the accreditation or recognition site visit blackout date request.

Sponsoring Institutions and programs are provided the opportunity to designate dates in ADS for the ACGME to avoid when scheduling accreditation or recognition site visits.

Designated institutional officials (DIOs), program directors/directors of osteopathic education, and institutional and program coordinators can enter blackout dates in ADS.

In order to select blackout dates in ADS, the Sponsoring Institution or program must first receive an email notice from Field Activities staff members. After receiving this notice, Sponsoring Institution or program personnel can enter blackout dates and continue to enter or change them until the date a site visit is scheduled.

The number of blackout dates depends on the timeframe of the request. The larger the timeframe, the more blackout dates can be provided.

No. This option is intended to better accomodate Sponsoring Institution and program and site visit scheduling needs and is not required.

No. CLER site visit blackout dates are entered separately during designated CLER blackout dates windows.  Click here for details about CLER blackout dates.  

Due to the logistics involved in conducting a large number of site visits, requests to change a site visit date generally cannot be honored. All Sponsoring Institutions and programs have the opportunity to submit blackout dates before a site visit is scheduled to avoid dates that aren’t ideal for the Sponsoring Institution or program.

Devices (e.g., desktop computer, laptop computer, smartphone, tablet) with audio and visual capability that can run the Zoom application are required. The ACGME recommends all participants for a remote site visit download and set up the free version of the Zoom application. Registration for Zoom or creation of a Zoom account is not required. An alternative technology platform will be used if a Sponsoring Institution or program cannot access Zoom per the institution's’ security policy.

Participants must have a stable, high-speed internet connection. A laptop or desktop computer with an ethernet connection is preferred for the DIO/program director and institutional/program coordinator meetings.

A quiet environment without interruptions and with good lighting for facial visibility is optimal. Ideally, participants in group sessions would call into the remote interviews individually through their device from a private office or other location. If participants meet as a group in a conference room, the camera needs to show all participants and the microphone should be placed so all participants can be heard by the Accreditation Field Representative(s).

All site visits require information that is collected via ADS. Sponsoring Institutions and programs should make sure all data in ADS is updated prior to the due date provided in the Site Visit Announcement letter.

Review and Recognition Committee staff members may request that Sponsoring Institutions or programs provide additional documents to the Accreditation Field Representative(s). View a checklist for updating ADS prior to the site visit here: Updating ADS for Upcoming Accreditation or Recognition Site Visits.

The minimum notice for all   accreditation or recognition site visits is approximately 30 days. Notice may be less than 30 days if a site visit is required to meet a Review or Recognition Committee meeting deadline or other circumstances. In these cases, ACGME Field Activities staff members will work with the Sponsoring Institution or program leadership to ensure the site visit is completed.

Program Accreditation Site Visit
Program director, program coordinator(s), DIO and/or chair (or representative if unavailable), faculty members, residents/fellows (if applicable).

Institutional Accreditation Site Visit
DIO, institutional coordinator(s), program director(s), program coordinator(s), members of the Graduate Medical Education Committee, other senior institutional officials (e.g., chief executive officer), residents/fellows, faculty members representing all sites

Program Recognition Site Visit
Program director, Director of Osteopathic Education, designated osteopathic residents/fellows, designated osteopathic faculty members

*Field Representatives may request other interviewees depending on the type of site visit or by request of the Review or Recognition Committee

The resident/fellow interview is crucial to the accreditation and recognition site visit. For small programs, the Accreditation Field Representative(s) will interview all residents/fellows on duty the day of the visit. For larger programs, residents/fellows that will be interviewed will be peer-selected representing all required years of education.

Those learners beyond the required years of residency (such as fourth-year internal medicine chief residents) or those not in the accredited program may not participate in the resident/fellow interview but may be in the faculty member interview. For programs with a combined program track, such as internal medicine-psychiatry, representative residents from the combined program must be in the interview.

For the site visit of a Sponsoring Institution, the interview group should include residents and fellows representative of the programs sponsored by the institution. For program site visits, residents/fellows often are interviewed in smaller groups, with those in the most senior year(s) of the program interviewed separately. For some types of site visits, residents/fellows may be interviewed individually. The Accreditation Field Representative or team leader who contacts the Sponsoring Institution or program to plan site visit logistics will indicate the interview format. On the day of the site visit, the interview process may change if it appears a different approach will produce better results.

Residents/fellows and faculty members should be available for the entire interview period, with all electronic devices turned off.

All Sponsoring Institutions and programs must upload a signed Site Visit Attestation Statement prior to the site visit. The purposes of the attestation are to: ensure the privacy and confidentiality of the remote interview sessions; affirm that the interview sessions will not be recorded; and state that the Sponsoring Institution or program must not retaliate in any way against any resident/fellow for participation in the site visit or for any statements made by a resident/fellow to the ACGME relating to this site visit.

The Accreditation Field Representative(s) review documents and conduct interviews with identified key stakeholders depending on the type of site visit (Sponsoring Institution, program, accreditation, recognition). For some specialties, or if there were prior citations related to facilities, the Accreditation Field Representative(s) may tour selected clinical facilities or request a video tour.

A clarification interview conducted with the program director at the end of the site visit may include feedback from the Accreditation Field Representative. The feedback is based on the Accreditation Field Representative’s understanding of the accreditation or recognition requirements and familiarity with relevant best practices. The Accreditation Field Representative(s) will not offer predictions regarding accreditation or recognition outcomes, nor will they assess when the program will be reviewed by the applicable committee; these decisions are the sole purview of the Review or Recognition Committee.

For most accreditation and recognition site visits, the Accreditation Field Representative(s) will meet briefly with the program or institutional coordinator, often in conjunction with the document review portion of the visit.

For some visits, the Accreditation Field Representative(s) may conduct a brief interview with the coordinator to ask about the learning and working environment, institutional support, and professional development for coordinators.

Yes. Messages can be sent to the primary Accreditation Field Representative through the Zoom application via the chat function. Site visit participants will not be able to message each other using that function during an interview.

The Sponsoring Institution’s information technology department will need to be able to support the technology used during the remote accreditation or recognition site visit. ACGME Audio/Visual staff members will provide support for the ACGME Field Representative(s) who conduct a visit.

Tips for a successful remote site visit can be found here.

Sponsoring Institutions and programs frequently use electronic evaluation systems or data management suites for collection, aggregation, and presentation of a variety of data related to the administration of residency/fellowship programs. The ACGME and its Review and Recognition Committees have clarified expectations regarding information that should be available to the Accreditation Field Representative(s) to enable them to verify the existence of a functioning evaluation process, including discussion of evaluations with residents/fellows. Evidence of this can be offered via traditional paper-based evaluation forms, printouts of electronic evaluations, or the online documents. All formats need to include evidence that these evaluations were reviewed with the resident/fellow, such as the resident’s/fellow’s signature.

After a site visit, the Accreditation Field Representative(s) write a detailed, objective, narrative Site Visit Report that is used, together with information in ADS, by the Review or Recognition Committee to confer its decision. Accreditation Field Representatives do not participate in making or conferring accreditation or recognition decisions.

All committees meet two or more times each year, and the ACGME strives to review all Sponsoring Institutions and programs in a timely fashion. The schedule of committee meetings and the agenda closing dates for each meeting are listed on the applicable pages of the ACGME website. DIOs and program directors can contact committee staff members to find out if their Sponsoring Institution or program will be reviewed at a given meeting.

A few days after the meeting during which a Sponsoring Institution or program is reviewed, the committee sends an electronic notice indicating the accreditation or recognition status determined at the meeting. The detailed accreditation or recognition decision and Letter of Notification will be posted in the Sponsoring Institution’s or program’s ADS account 60 to 90 days after the meeting.

The Review and Recognition Committees and the ACGME give priority to new applications. Programs with applications requiring an accreditation or recognition site visit should expect the process to take as long as four to 12 months. Applications that do not require an accreditation or recognition site visit will be reviewed and have a decision conferred generally within six months of receipt of a completed application. More information can be found on the Program Application Information webpage.

Completing the application with careful attention to detail is the most important first step for the program director. The document submitted should demonstrate how the requirements are met in the Sponsoring Institution or program.

Common errors that may delay scheduling of an accreditation or recognition site visit or Committee review include missing or discrepant information about the planned program, missing signatures, or missing documents, such as Program Letters of Agreement with participating sites. All application submissions are considered final.

Programs must complete a Self-Study (Common Program Requirement V.C.2.), but effective October 2023 the program Self-Study is not linked to or reviewed during a site visit. Programs can access guidance on how to complete a program Self-Study here. Sponsoring Institutions must also complete a Self-Study ( Institutional Requirement I.A.8.) and the Sponsoring Institution Self-Study will be linked to and reviewed during the Sponsoring Institution 10-Year Accreditation Site Visit. For more information, visit the Institutional Self-Study page  

Seven to eight months prior to the Self-Study date shown in ADS, the Sponsoring Institution receives an email from the ACGME to initiate the Self-Study, that includes resources for conducting the Self-Study.