The purpose of the accreditation and 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 with a team member. If included, the second Accreditation Field Representative is available to conduct interviews, manage participants, assist with technology, and help maintain the security of the remote site visit. Other Accreditation Field Representatives may participate for training purposes.

Program 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 and some subspecialty programs are reviewed without a site visit.

Sponsoring Institutions and Programs with Initial Accreditation
All Sponsoring Institutions and programs undergo a site visit at the end of the Initial Accreditation period and prior to a Review Committee’s decision to confer the status of Continued Accreditation.

Continued Accreditation: Annual Data Review Site Visit
Sponsoring Institutions and programs with a status of Continued Accreditation are subject to an annual screening of accreditation data in ADS. This includes ACGME Resident and Faculty Survey reports; Case Log data (if applicable); surveys about adequacy of patient volume and variety for other specialties; information on scholarly activity for residents/fellows and faculty members; resident/fellow and/or faculty member attrition; and transitions in program and/or institutional leadership. If any of these areas suggests a problem, the Review Committee may ask the program to provide clarifying information or a progress report, or it may schedule a site visit.

Continued Accreditation: 10-Year Accreditation Site Visits
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.

Probationary Accreditation
A Sponsoring Institution or program on Probationary Accreditation will need to have a site visit and be reviewed prior to achieving a status of Continued Accreditation or Continued Accreditation with Warning. These site visits often require a team of Field Representatives.

Complaint
After a Review or Recognition Committee considers complaint allegations and the Sponsoring Institution’s or program’s response to those complaint allegations, the Review or Recognition Committee may request additional information or a site visit. 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 and Recognition Committees can request site visits at their discretion.

All types of accreditation and recognition site visits could potentially be conducted remotely, including for both Sponsoring Institutions and programs. Details and decisions on timing and format will be shared as the ACGME considers the impact of the COVID-19 pandemic on the safety and well-being of ACGME staff members and the graduate medical education community.

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

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

There is an accreditation and recognition site visit blackout date function for Sponsoring Institutions and programs in ADS, which provides the opportunity to designate dates for the ACGME to avoid when scheduling these 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 are offered.

No. This option is intended to better align Sponsoring Institution and program and site visit scheduling needs.

No. CLER visit blackout dates are entered separately during designated CLER blackout 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. Instructions on what needs to be updated in ADS prior to the site visit are provided in the Site Visit Announcement letter under the “Updating ADS” section. Sponsoring Institutions and programs should make sure all data in ADS is current prior to the site visit, focusing on responses to citations (if applicable), and changes in the Sponsoring Institutions or program since the last Annual Update.

Review Committee staff members may request additional documents be provided to the (primary) Accreditation Field Representative. Click here to view information that can be updated prior to the site visit.

The minimum notice for all 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 Site Visit (Accreditation)
Program director, program coordinator(s), DIO and/or Chair (or representative if unavailable), faculty members, residents/fellows (if applicable)

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

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

*Field Representatives may request others 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.

Below are links to the Attestation Statements. Note that the upload function for the attestation statement becomes available in ADS only when the Sponsoring Institution or program is scheduled for a site visit.

• Attestation Statement for Sponsoring Institutions
• Attestation Statement for Programs

The Accreditation Field Representative(s) conducts interviews with the program director and associate directors (if applicable), residents/fellows, faculty members, the program coordinator, and the DIO and/or other administrative representatives, as well as a review of documents. 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, including a succinct summary highlighting two to three key strengths, and suggested improvement in two to three areas. The feedback is based on the Accreditation Field Representative’s understanding of the accreditation standards and familiarity with relevant best practices. The Accreditation Field Representative(s) will not offer predictions regarding accreditation outcomes, nor will they assess when the program will be reviewed by the 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 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.

The documents required for a site visit review depend on the type of visit. A standard list of each document required by type of visit is attached to the ACGME site visit announcement letter. Click here to view a list of documents by accreditation or recognition status. Note that this list is in addition to the information that must be uploaded into ADS.

Some committees request additional documents for review at the site visit. The assigned Accreditation Field Representative(s) will indicate if such a request has been made for the particular visit.

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 during an interview.

The Sponsoring Institution’s IT 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) writes a detailed narrative Site Visit Report that is used, together with information in the ADS, by the Review or Recognition Committee to make its decision. Accreditation Field Representatives do not participate in accreditation or recognition decision making.

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 specialty or recognition sections 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 will be posted in the institution’s or program’s ADS account 60 to 90 days after the meeting.

The Review Committees and the ACGME give priority to new applications. Programs with applications requiring an accreditation and 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 prior will be reviewed at the next Review or Recognition Committee meeting with room on the agenda (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 initial 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 and 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 submissions are considered final.

The Self-Study will no longer be reviewed during a site visit. Visit the program Self-Study web page for more FAQs about the program Self-Study and 10-Year Accreditation Site Visit.

Seven to eight months prior to the Self-Study date noted in ADS, a Sponsoring Institution or program will receive an email from the ACGME to initiate the Self-Study. This emailed letter includes a link to resources for conducting the Self-Study.

Sponsoring Institutions and programs should start their Self-Study at that time but can certainly begin sooner. Program and Program Evaluation Committee leaders are encouraged to review the Self-Study resources page on the ACGME website for additional information. Institutional leadership should refer to the Institutional Self-Study guidance on the ACGME website.