RE: 10-Year ACGME Site Visit

Program Director’s Corner – November 2018

RE: 10-Year ACGME Site Visit

Andrew G. Gianoukakis MD, FACE
Professor of Medicine
David Geffen School of Medicine at UCLA
Program Director, Endocrinology and Metabolism Training program
Division of Endocrinology and Metabolism
Harbor-UCLA Medical Center


Dear Program Director Colleagues,

While any evaluation can be anxiety provoking, even for physicians who are accustomed to being repeatedly evaluated at every turn, I must say that at our recent ACGME site visit was, a much more pleasant experience than what I anticipated. I would describe it more like a visit from company headquarters to assure local compliance with company policies and documentation needs, and to achieve a convergence of visions of the stakeholders (PD, faculty and trainees) for the program. The overarching goal seemed to be to provide guidance as opposed to punitive action. Mind you, my experience may be reviewer specific. Furthermore, as of the writing of this newsletter, we have yet to receive our official ACGME site visit report; so you may want to check back with me.


  1. We were notified of the site visit approximately 6 months in advance of the visit.
  2. I would suggest going to the ACGME website, searching for ’10 year site visit’ and reading about the objectives of the visit and how to prepare for the site visit. The site contains ‘Eight steps to prepare for the 10 year ACGME site visit,’ as well as other helpful information.
  3. Approximately 3 months in advance we received a letter from ACGME offering and requesting specifics of the visit.
    1. 90 min Initial Meeting with Program Director and Program Coordinator

Review of Program, including the Self-Study and the Summary of Achievements; initial discussion about the information entered and uploaded to ADS (response to citations [if applicable], major changes [including actions in response to issues identified on the ACGME Resident and Faculty Surveys], block diagram, current faculty’s board certification and medical license information) and a review of documents (see below)

  1. 75 min meeting with all available Fellows
    1. The fellows were asked to prepare and submit directly to the reviewer, a single collective (consensus) list of up to five strengths, and five areas for improvement for the program.
  2. 60 min meeting with up to 6 Key Faculty
    1. The faculty were asked to prepare and submit directly to the reviewer a single collective (consensus) list of up to five strengths, and up to five areas for improvement of the program
  3. 30 min Concluding Meeting with Program Director & Program Coordinator

Take home points:

  • In my view, the ACGME would like to see that the annual program evaluations, action plans generated as a result of the APE, goals outlined in your self-study as well as the comments of the other stakeholders (trainees and faculty) are in sync and that all stakeholders are moving in the same direction with common goals
  • Cross your T’s and dot your I’s.

Preparing Documents for the Site Visit

  • Update data in Accreditation Data System (ADS)
  • An updated summary must be completed and uploaded through ADS a minimum of 12 days before the date of the 10-Year Site Visit.
    • Two types of updates can be made: 1) to identify changes in the program since the Self-Study Summary was submitted; and 2) to provide information on new dimensions of the Self-Study that were added in July 2017.
    • Using the template available from the ACGME 10-Year Site Visit web page, prepare the summary of achievements. This document provides a list of the program’s strengths and the improvements that have been achieved to date in areas identified during the initial self-study.

Site Visit Document Checklist for the 10-Year Accreditation Site Visit

Sponsoring and Participating Institution

  1. Current, signed program letters of agreement (PLAs).

Resident Appointment and Evaluations

  1. Files of recent program graduates and current fellows (1-2 in each year of training); files of any trainees who have transferred in or transferred out of the program, or have resigned or been dismissed in the past three years. Resident/fellow evaluations by faculty, peers, patients, self, other staff; semi-annual evaluations; and final evaluations are assessed during review of the fellow files.

Educational Program

  1. A sample of competency-based, educational level-specific goals and objectives for one


  1. Conference schedule for current academic year.

Faculty and Program Evaluation

  1. Sample of a completed annual confidential evaluation of faculty by residents/fellows.
  2. Written description of Clinical Competency Committee (CCC): membership and SOP.
  3. Written description of Program Evaluation Committee (PEC): membership and SOP.

Work Hours and the Learning Environment

  1. Program-specific (not institutional) policies for supervision of fellows.
  2. Sample work hour compliance data demonstrating your monitoring system.

Quality Improvement

  1. Sample documents demonstrating fellow participation in patient safety and quality improvement projects.

Annual Program Evaluation and Self-Study Documents

(NOTE: The documents below will NOT be accessed or reviewed by the site visitor, but should be available to the program director for a discussion of the program’s ongoing improvement efforts.)

  1. Annual Program Evaluations for the past five years, action plans resulting from these evaluations, data tracked and information on improvement activities.
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