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Accreditation Overview

The ACGME implemented the Next Accreditation System (NAS) in the 2013-2014 academic year.  This is a continuous accreditation model that moved its focus from process to outcomes, and increased the expectation that GMEC provides greater oversight of outcome measures and program quality improvement. 

Two processes implemented with the NAS are the Annual Institutional Review (AIR) and the Annual Program Evaluation (APE). 

You can find more information on the APE in the Common Program Requirements: http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements

SIU GMEC requires a specific protocol for programs to conducting and document their APE.  Please refer to the APE Information Guide and APE Manual in New Innovations.

You can find more information on the AIR in the Institutional Requirements at https://www.acgme.org/Designated-Institutional-Officials/Institutional-Review-Committee/Institutional-Application-and-Requirements .

The NAS also replaced program accreditation site visits with Clinical Learning Environment Review (CLER) visits and program Self-Study visits.  The CLER visits are focused in only one hospital and are expected to occur approximately every eighteen months to two years. The CLER Program focuses on the hospitals, medical centers, and ambulatory care practices where residents and fellows train. It is part of the NAS, but is separate from the accreditation process, and is linked to accreditation only in that every institution must undergo a visit every 18 months or so. It is designed to provide formative feedback that presents GME leaders and the executive leadership with information on these areas of focus: patient safety, health care quality (including health care disparities), care transitions, supervision, duty hours/fatigue management and mitigation, professionalism and well-being.  Although many PDs, faculty and residents participate in CLER site visits, the responsibility for organizing the visits and disseminating the feedback falls to OGME and the visited hospital.  However, this the CLER focus areas inform most of our educational endeavors, everyone involved in GME should have a working knowledge of them. You can learn more about CLER at http://www.acgme.org/What-We-Do/Initiatives/Clinical-Learning-Environment-Review-CLER

The program self-study visits are slated to occur every ten years, unless areas of concern are identified. The self-study is an objective, comprehensive evaluation of the program with the aim of improving it. Your APEs in the years leading up to the self-study are seen as the foundation of program improvement. The self- study is seen as a longitudinal evaluation of the program and its learning environment, with an emphasis on program strengths and “self-identified” areas for improvement (“self-identified” is used to distinguish this dimension of the self-study from areas for improvement the Review Committee identifies during accreditation reviews). In addition, the program will be asked to explore its aims and conduct a SWOT analysis. The focus on aims and the program’s environmental context is to support improvement that goes beyond compliance with ACGME Requirements.

Your program will have about 9 months to complete the Self-Study and upload a summary of your process, aims and environment into WebADS. The summary does not include your self-identified strengths or weaknesses.

Your Site Visit will occur 12-18 months after the completion of your Self-Study. During those months, you are expected to conduct a plan of improvement for weaknesses identified in the self-Study (think educational PDSA) and submit a summary of these achievements just before the Site Visit.

The ACGME has placed added responsibility for oversight of subspecialty programs on the core program and sponsoring institution. The 10-year site visits for subspecialty programs will be coordinated with the visit of their respective core program. The self-study group for the core program should try to coordinate activities with the self-study groups for any dependent subspecialty programs, to take advantage of common dimensions, explore potential synergies, and reduce the burden that may be associated with conducting an independent self-assessment.

 Programs may also have a focused site visit at the discretion of the RRC, to assess potential problems as adjudged by annual program review, or evaluate a complaint about the program.  http://www.acgme.org/What-We-Do/Accreditation/Self-StudyandSiteVisit

Accreditation fees are paid by the Affiliated Hospitals.