ACGME Accreditation Process
For programs navigating the transition to ACGME accreditation, trying to glean the best application advice from the plethora of tips, tricks, and online resources and translate that into actionable steps can be a bit overwhelming.
A seasoned consultant with extensive ACGME and AOA experience, Franklin Medio, PhD, President, Consulting Services for the Health Professions, assists programs through the AOA’s Single Accreditation System Application Assistance Program. Here he guides osteopathic programs applying for initial ACGME accreditation status as well as those in continued pre-accreditation status.
The #1 Tip
The most important features of a successful ACGME application are complete, accurate, and comprehensive responses. Do not leave a response empty or a table/chart incomplete. If you currently do not meet the standard(s) or have the data requested, describe how your program will soon meet the requirement(s) or specify when data will become available. Do not leave blanks in charts or tables - if the answer is zero, put a 0 in the box. Limit your responses to the requested information; do not provide additional information. Some responses have word limits. Be sure to adhere to them. Note “key words” in some items because they are helpful when formatting your response (e.g., the item requesting your residents’ experience with quality improvement projects suggests four components in the response).
Remember: your application projects an image of your program to the Review Committee (RC) members—make it a strong, positive one!
General Tips for the Application Process
Application writing and review should be a team effort. Be sure to leverage the expertise and interests of faculty and other key program staff by involving them in writing responses for specific sections of the application. When your application is finished, select one person to do a final review (edit and proofread for completeness and accuracy) to ensure your application reads as a single cohesive voice. Prior to submission, it is helpful to ask an individual outside your program to read the application for clarity and internal consistency of the information. Be sure everyone who will be involved in the site-visit has read and understood the submitted application prior to the visit. Any questions should be addressed before the site-visit.
Remember that many application items are not asking what you are currently doing; but what you will do to ensure compliance with your RC’s accreditation requirements. If appropriate, clearly describe what you are doing or describe what you will do to meet each requirement - for example block diagrams may include current rotations but also need to describe your plans for the future. You must also be prepared for specific Next Accreditation System (NAS) requirements - both a Clinical Competency Committee (CCC) and a Program Evaluation Committee (PEC) must be established. Additionally, all of the Program Letters of Agreement (PLAs) must be completed and signed/executed in accordance with the specific requirements (even for rotations that will not start until the program is accredited). PLAs cannot simply auto-renew – you must have current PLAs in place for ACGME accreditation. A sample PLA from the ACGME is provided here.
Avoid the Application Pitfalls that Tend to Lead to Citations
Pay careful attention to the Common Program Requirements (CPRs), particularly CPR VI. Make sure all GME policies and procedures included with your application reflect the most up-to-date CPRs found on the ACGME website here. Remove all references to the AOA, OGME, and AOA specialty colleges from your GME policies and procedures for your ACGME application. Carefully review and address any other program requirements established by your specialty review committee (RC).
Develop a detailed plan for faculty “scholarly activity”– especially if your program faculty do not have extensive records of scholarly activity. The ACGME review committees (RCs) are aware that osteopathic GME programs have not traditionally required the same amount of scholarly activity as ACGME programs. However, they require transitioning programs to demonstrate their intent to bring scholarly activities up to the required levels by including a detailed plan in the application.
At a minimum this faculty plan should include: 1) a didactic curriculum on research design and methodology, 2) a research coordinator, non-clinical research faculty member or other personnel to assist faculty, 3) criteria and a timeline for assessing faculty productivity, and 4) the personnel and resources available to assist with manuscript preparations, conference presentations, etc. It should state that the program or sponsoring institution will provide financial support for faculty to present their research at state, regional and/or national meetings.
Follow your Review Committee’s exact directions when filling out the faculty roster and CVs. Pay careful attention to the directives of each RC, as the ordering of faculty and other instructions vary across RCs. When completing the CVs for Program Director and core faculty, follow the directions of each RC and conform to the stated time periods for publications, presentations, etc.
Goals and Objectives have a specific format. Each Review Committee requires programs to have three sets of goals and objectives: 1) overall program, 2) PGY-level specific, and 3) rotation-specific. Each set must address the Six ACGME Competencies. Programs can certainly modify their existing goals and objectives to meet this requirement, but should remove any references to the AOA Competency for OPP/OMT (this latter point also applies to the evaluation forms). For programs applying for Osteopathic Recognition, OPP/OMT may instead be integrated within the six ACGME competencies. It’s probably a good idea to talk with a colleague in an ACGME accredited program in your specialty to compare goals and objectives as well as evaluation forms to assure that you are on the right track.
Responding to Citations: Three Critical Points
If you receive a Letter of Notification with citations, do not feel pressured to submit your responses before the next scheduled RC meeting. It is better to submit your responses to the Letter of Notification citations only when you have the information or documentation to show you have addressed the citation(s). When preparing responses to citations, remember three points: 1) the response should be clear, concise and contain specific information describing what you’ve done to address the deficiency/problem, 2) the response should not explain why the deficiency or non-compliance continues, and 3) the response should not include a statement such as, “this complies with (or satisfies) the ACGME requirement.” That determination is to be made by the RC members.
Each Review Committee has an Executive Director (ED) who can be a critical resource for any program (or institution) transitioning through the single GME accreditation process. Communicating with the ED can be illuminating and help avoid errors arising from misunderstandings or differences in terminology between the AOA and ACGME accreditation systems. View the ACGME’s ED contact list.
Finally, before submitting your application, invite your senior or Chief Residents to provide feedback on the application. These individuals, who are often overlooked as reviewers, provide a unique perspective and another set of eyes to ensure clear communication to the RC about the content and operation of your residency program.
For more application resources and updates on the single accreditation system transition, visit AACOM’s website. For direct assistance from consultants through the AOA’s single accreditation system application assistance program, contact singleGME@osteopathic.org.