MSUCOM / SCSStatewide Campus System

AOA to ACGME Accreditation

Application – 2 parts

  • Word file – address compliance with specialty-specific  program requirements.
  • Web ADS – this is where you will address your program’s compliance with Common program requirements (common to all GME programs). Once entered, this data will be updated annually by your coordinator.


  • Program Data
    • Basic Program information
    • PD/Coordinator information
    • # Resident Positions
    • Duty Hour Info
    • Participating sites
    • Evaluation Methods
  • Resident Data
    • Add new residents (files can be uploaded)
      • Email required
    • Confirm all active and graduating residents
  • Faculty Data – could list everything we need to collect
    • Add/remove faculty
    • Update CVs for core faculty

Attachments (* Important note – each attachment can only be one file. So, if you have multiple evaluations to submit for the evaluation forms attachment, you will need to make them all one file and upload that.)

  • Policy for Supervision of Residents - Policy for supervision of residents (addresses residents’ responsibilities for patient care and progressive responsibility for patient management and faculty responsibilities for supervision).[IR III.B.4]
  • Program Policies and Procedures - Program policies and procedures for resident duty hours and work environment including policies on moonlighting. [CPR II.A.4.j; CPR VI.G; IR IV.J]
  • Overall Educational Goals - Overall educational goals for the program. [CPR IV.A.1]
  • Competency Goals and Objectives and Faculty Evaluation of Residents -A sample of competency-based goals and objectives for one assignment at each educational level [CPR IV.A.2], a blank copy of the forms that will be used to evaluate residents at the completion of each assignment. [CPR V.A.1.a]
  • Letters of Agreement - All Program Letters of Agreement (PLAs) with participating sites. [CPR I.B.1]
  • Semiannual and Summative Evaluations - A blank copy of the form that will be used to document the semiannual evaluation of the residents with feedback. [CPR V.A.2.b.(4)], and a blank copy of the final (summative) evaluation of residents, documenting performance during the final period of education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision [CPR V.A.3]
  • Program Specific Evaluation Tools - Blank copies of tools the program will use to provide objective assessments of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. [CPR V.A.2.b.(1)] For multiple tools, create one PDF.
  • Forms Used for Faculty and Program Evaluation - Blank copies of forms that residents will use to evaluate the faculty and the program. [CPR V.B.3; CPR V.C.2.d.(1)]
  • Sample Block Diagram - Provide a sample block diagram for each year of training. Use number of months for each block rotation.


PDFBlock Diagram Instructions

  • Common Errors:
    • Table of Contents Inaccurate
    • Pages not numbered or not numbered correctly
    • Document not spell-checked
    • Response does not answer the question asked
    • Statistics not added correctly
    • % of time for faculty inconsistent within the application
  • Be Careful - read the questions carefully...
    • One example does NOT mean several
    • “How” does not mean “we do”
    • Do not write:  “the program will…” or “we plan to…”
    • Do not include: “see attached” or “see below”

Site Visit Scheduled

  • Upon submission of the application you will be granted “pre-accreditation” status.
  • You will receive notification of your site visit which will occur approximately 4-6 weeks after application submission.

Mock Site Visit

  • We highly recommend you conduct a mock site visit approximately one week before your actual visit.
    • 1 hour: DIO interview PD and coordinator and document review
    • 1 hour: interview faculty
    • 1 hour: interview residents

Site Visit

  • The site visit is approximately 4 hours in length and conducted by one field staff.

Sample agenda:

    • 1 hour: Meet with program director and coordinator and document review  
    • 45 minutes: interview PGY-1 and -2 residents
    • 45 minutes: interview PGY-3, -4 and -5 residents
    • 45 minutes: interview faculty
    • 30 minutes: interview DIO, and Dept chair
    • 30 minutes: exit meeting with program director and coordinator

One of our member institutions created this list of files you should have on hand

XLSXFaculty data you'll need to collect

On the Day of the Visit, Please Have these Documents Available for Review by the Site Visitor(s):

Common Program Requirements
Sponsoring and Participating Institution
1. Current Program Letters of Agreement (PLAs)

Resident Appointment
2. Files of current residents/fellows and most recent program graduates
3. If applicable, files of current residents/fellows who have transferred into the program including documentation of previous experiences and competency-based performance evaluations
4. If applicable, files of residents/fellows who have transferred out of this program into another program

Educational Program
5. Overall educational goals for the program
6. Competency-based goals and objectives for each assignment at each educational
level. NOTE: If your program is 1 year in length and operates under the 1 year common program requirements, instead of the goals and objectives, provide a list of the skills and competencies the trainee will be able to demonstrate at the conclusion of training.
7. Didactic and conference schedule for each year of training.

Evaluation (Programs using computerized evaluation system may generate and print
summary reports, rather than show individual records)

8. Evaluations of residents/fellows at the completion of each assignment
9. Evaluations showing use of multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff)
10. Documentation of residents'/fellows' semiannual evaluations of performance with feedback
11. Final (summative) evaluation of residents/fellows, documenting performance during the final period of education and verifying that the resident/fellow has demonstrated sufficient competence to enter practice without direct supervision
12. Completed annual written confidential evaluations of faculty by the residents/fellows
13. Documentation of program evaluation and written improvement plan
14. Documentation of duty hours for resident/fellows in this program
15. Written description of the Clinical Competency Committee (CCC) for this program including structure, membership, semi-annual resident evaluation process, semi-annual reporting of resident Milestones evaluation to ACGME, and protocols for the CCC advising the program director regarding resident progress including promotion, remediation, and dismissal.
16. Written description of the Program Evaluation Committee (PEC) for this program including structure, membership, evaluation and tracking protocols, development of the written Annual Program Evaluation, and protocols for the development and monitoring of improvement action plans resulting from the Annual Program Evaluation. In addition, copies of the last three (3) PEC meeting minutes should be available for review.

Duty Hours and the Learning Environment
17. Policy for supervision of residents/fellows (addressing progressive responsibilities for patient care, and faculty responsibility for supervision) including protocols defining common circumstances requiring faculty involvement
18. Program policies and procedures for residents'/fellows' duty hours and work environment including moonlighting policy
19. Sample documents for episodes when residents/fellows remain on duty beyond scheduled hours
20. Sample documents offering evidence of resident/fellow participation in Quality Improvement and Safety Projects

Table of Contents for Binders for Site visit – from DMC

  Common Program Information
Pages 1 – 27 of application
Table of Contents
Section 1 Accreditation Information
Section 2 Physician Faculty Roster/ CV's
License Verification
Case Log Attending Roster
Section 3 Program Resources
Grand Rounds Weekly
Site Weekly Group Review
Journal Club Monthly
Sim Lab
Statewide Campus System Events
Section 4 Actively Enrolled Residents
Individual Contracts in Resident Binder
Section 5 Resident Appointments
Block Schedule
G & O by Year by Rotation
Other Learners – Medical Students
Section 6 Evaluation
Evaluation Forms
Section 7 Duty Hours, Patient Safety and Learning Environment
Table of Contents
Resident Manual
Supervision Policy Transition of Care Policy
Evaluation Forms in Section 5
Duty Hour Policy/GME Compliance Report
Moonlighting Policy/Letter Example
Approved Moonlighting List
Orientation Agenda Fatigue Management Education
Section 8 Resident Scholarly Activity
Resident Scholarly Activity Report
  Specialty Specific New Application Information
Pages 29-64 of application
Table of Contents
Section 1 Application
Section 2 Faculty Expertise
See Common Program Binder
Section 3 Resources
Grand Rounds Schedule
Multidisciplinary Conference
Surgical Sim Lab
Library Services
Section 4 Institutional Data
Case Logs

Tips for the site visit

  • In addition to the documents they will tell you that you need in the letter, have the “Cheat List” documents (the list on Page 1) ready as well.
    • Print the letter off that they send you with their checklist
  • Make copies of PLAs; the site visitor asked for copies to review at their leisure.
  • Have a copy of your residency manual available.
  • Have a copy of “Direct/Indirect” procedures available if your program has them.
  • The inspector expects coordinators to know your program better than your Program Director. Although they don’t expect you to know everything, they (inspectors) do expect you to know a lot.
  • Prepare, prepare, prepare. Don’t wait until the last minute to get all of your materials together. If possible, try to have binders ready at least a week in advance. Look at them a few times before the visit. Have a binder for each “main player” in the inspection (Inspector, PD(s), yourself). Ask your PD if he wants his binder before the visit to review. Hold a mock site visit 1 week before the actual visit
  • Review your specialty specific application.
  • The inspector will ask for things that you may not have on hand during your meeting.
  • Block Schedules: the site visitor wanted my intern year to be very specific. Stating “Hospital Name X” wasn’t enough. State: Rotation, Location, and Supervising Physician (General Surgery, Hospital X, Supervising Physician’s Name).
  • Statistics: If they’re in your application, go over them with a fine tooth comb. Make sure stats are in the right columns, headings are easily identifiable. If you need a key/legend add it.
  • They appreciate organization so use binders and tabs and color coordinate documents. Have the room set with materials before they arrive because not only will this organization help them, but your site visit will go much smoother.
  • CVs/Licensure: Have a copy of faculty CVs readily available. Our inspector told us that it was common for many of the applications to need clarification with training/certification.
  • In the back of your mind….think, “What do we do in Medical Education?”. A lot of the questions your PD will be able to answer in regards to education, curriculum, etc…but what about questions like, “How do you track duty hours? Attendance at didactics? Duty Hour violations? How are they reported?” These are things your PD might not know.
  • If you see your PD struggling with an answer and you know it’s something we have or do, speak up!
  • It seemed most of our questions were clarification of what was already in the application.

More tips from recently completed site visits

  • Our site visitor spent time on our block diagram. He stated that the ACGME RRC folk love diagrams, are "religious" about resident surveys and of course faculty and resident scholarly activities (QI projects, etc). Faculty and resident scholarly activities is a weakness for our program, which we knew from the onset. Site visitor recommended an article to help us understand the definition of scholarly activity, which encompasses discovery, integration, application and teaching. The article is entitled, "Defining scholarly activity in graduate medical education", PMID 24294446, J Grad Med Educ. 2012 Dec; 4(4):558-61.
  • Site visitor suggested that our program director read and know the ACGME requirements for chief residents. It is important that chief residents establish continuity of care and autonomy with faculty and residents.
  • Programs Directors should be prepared to answer how they feel they are qualified to transition from AOA to ACGME, from a teaching and clinical competency standpoint. Residents said the site visitor asked them about the overall structure of our program. ACGME wants to see that the faculty and residents are on the same page. He subtly mentioned that we can put anything on our pre-accreditation application, but does it line up with how the residents see our program and what the program is actually doing.
  • Submit a thorough and complete application. If the program does not have something in place, then state that the program is in the process of implementing and transitioning towards ACGME requirements and compliance.
  • Make sure the faculty and residents all know their coordinator’s dedicated time (if new).  Urol pgm now has a 0.75 FTE dedicated coordinator, did not have this much time for their program before
  • In complex structures, it is worthwhile to make sure everyone knows who the actual sponsoring institution is.  In the case of Urology at Sparrow, Sparrow is the SI, even though they spend a lot of time at McLaren GL, GMEI is the employer and MSU SCS is the academic partner.  Org charts are good to have everyone familiar with.
  • In addition to knowledge of a policy, verify everyone knows the process for handling a duty hour violation – how it is reported, to who, what happens as a result.  (And at all sites if multiple sites are used)
  • Ensure the residents have a forum for free and open communication and they all know what that is.  Having multiple ways to express concerns anonymously is good.  Urol at Sparrow has a resident forum, but also periodically a Poll Everywhere electronic town hall, and a phone tip line at MCLaren GL as well.
  • The program also had a separate session earlier that was organized by the PD to explain the milestones, what they are, how they will be used, what the expectations are for residents, etc.  So the residents were well aware of them and the CCC.

All faculty and residents need to know:

  1. how and where to report patient safety events (at multiple sites if applicable)
  2. be able to express how they are involved in quality improvement initiatives,
  3. how to access their rotation goals and objectives,
  4. what the competencies/milestones are, and
  5. talk about their scholarly activity (products, resources, faculty support).

Site Visit Report

The site visitors type up their report identifying weaknesses and areas where the program is not meeting program requirements, and then submit their report to WebADS. Program Directors and DIOs will NOT be able to access this report.

Once the report is submitted to WebADS, both the report and program application will be forwarded to the appropriate RC. This will be added to the next open agenda (ie., each agenda has a closing date. If the report is uploaded after the agenda closing date, it will be added to the NEXT agenda).

Accreditation Decision

Once the RC has reviewed the application and the site visit report, the RC will render its decision:

  1. Initial Accreditation
  2. Continued Pre-Accreditation

Within 5 days of the decision, your status in WebADS will be updated to reflect the committee’s decision. Within 60 days, the DIO and PD will receive a letter explaining the deficiencies / areas for improvement that need to be addressed before the application can be reconsidered.

If the program is moved to Initial Accreditation, the program can expect to have a full site visit in 2 years to try to obtain full accreditation. The program can request its accreditation date be moved back to the start of the academic year. Please note that if you do this, your 2-year clock starts with your accreditation effective date. So if you move it back, you will have less than 2 years before your next site visit.