ACGME Accreditation

The ACGME utilizes a continuous assessment model for programs and sponsoring institutions, consisting of annual program review, Self Study and Accreditation Site Visit. Each Residency Review Committee conducts an annual evaluation of programs utilizing the following metrics:

  • Faculty and resident scholarly activity – From WedADS
  • Clinical experiences (e.g. case logs) – From WebADS
  • Resources (including faculty qualifications, attrition, and clinical resources) – From WebADS
  • Milestone reporting compliance - From WebADS
  • Resident and Faculty surveys - WebADS
  • Board pass rate – Specialty Boards send information directly to ACGME
  • Past citations and Areas for Improvement (AFIs) – From WebADS

Following the RRC annual review, programs as well as the sponsoring institution will receive an annual notification letter with the following accreditation status options.

  • Continued Accreditation
  • Continued Accreditation with warning
  • Probationary Accreditation
  • Withdrawal of Accreditation.
  • Administrative Withdrawal

Subspecialty programs are reviewed together with their respective core programs and may or may not receive an individual letter.

Annual WebADS Updates.

Sometime between July and September, programs and the institution are asked to update the information in WebADS. Much of the annual review information comes directly from this update. When RRCs are reviewing WebADS updates, they want to know that programs are attentive to ACGME requirements, are cognizant of potential problems and, most importantly, are addressing them. If there are omissions, errors or inconsistencies RRCs will assume that the program is not paying attention. You will be asked to complete your update prior to the due date, to allow time for OGME to review. The following sections are particularly important:

Response to Citations - Citation language is entered by WebADS. Please make use of this narrative to inform the RRC how you have addressed the citation(s) and how you are assessing the outcome of any steps taken. If you have citations, please also make sure that addressing them is reflected in your Annual Program Evaluation (APE) action plan for that year. This section should be clear and provide enough detail to let the RRC know what you are doing. Be specific and clear in describing the time course and current status of any improvements or initiatives. For example, is the initiative in the planning stages vs. scheduled to be implemented on a specific date vs. already implemented on a specific date. For initiatives already implemented, also describe your outcome measures and monitoring process. If GMEC has been involved, include the steps GMEC took. If you had already addressed a problem before receiving the citation, be sure to note that (i.e. “We had restructured this rotation based on feedback from residents as of July 1, 2022, prior to the February 22, 2023 Notification letter with this citation. Resident input obtained via resident evaluations of the rotation has been very positive”). It may be meaningful to your RRC to know you addressed the problem proactively. There may be times when you don’t feel the citation is warranted (or even rational), or you don’t see the value of the requirement on which the citation is based. In this case please take a deep breath before you formulate your response (!), and make sure the tone of the response is neutral and respectful.

Physician Faculty Roster - the RRC utilizes this roster to see if your program has the requisite number of faculty with the appropriate qualifications. Board certification data is prepopulated in WebADS for each faculty by ACGME and the Certifying Boards, check to be sure the certification information for each faculty member is accurate. If you have faculty who are not board-certified, outline their plan to become board certified. Pay close attention to the clinical site designation for your key faculty, and make sure you have faculty with a primary designation at all sites.

Faculty and Resident scholarly activity – all scholarly activity from the previous academic year should be included and reported in the update. Articles published in peer-reviewed journals are listed per author by their PMID. WebADS provides a guide to help you capture other recognized forms of scholarship such as grand rounds presentations, presentations at national meetings, etc. It’s important to capture all of these.

Resident and Faculty Surveys – Please review these before doing your WebADS update.  If there is even one item with a low rating or low %age of compliance, please address it in the appropriate narrative section and explain how it was assessed/addressed by your program. It is important to remember that you may have received the surveys 3-8 months before doing the update and survey items with an easy fix may have escaped your memory, but the RRC reviews the surveys and WebADS update at the same time - the data is fresh to them. 

Other Narratives- In addition to the response to citations section, there are two helpful narrative sections. The Major Changes and Other Updates section is a good place to proactively address any AFIs from your annual Notification Letter, areas of concern from the resident or faculty surveys, case logs, etc. Again, anything that is important enough to mention here should be addressed in an APE goal. Even if the problems have not been completely solved, your RRC will take solace in knowing that you are on top of it. When issues are actively being addressed via APE, it also gives them a comfort level that programs are utilizing the APE as a quality improvement tool. The second helpful section asks the program to set priorities for learning environment and describe the steps you are taking to get there. 

Case Logs - Many RRCs have procedural case minimums and specific graduation requirements. Trainees are expected to enter cases in the resident case log system throughout the year. The ACGME expects that programs are monitoring case logs in real time and will hold the program director responsible if residents are less than conscientious about recording. If your RRC has case requirements or minimums, WebADS provides you with reports on individual resident or resident class attainment, and where the program is nationally. Please make use of these.

Block Diagrams – Programs are often asked to provide a block diagram of their curriculum. Many RRCs place a high level of importance on using the exact WebADS block diagram structure. When submitting any block diagrams to WebADS, please use the template provided (Sites-Block Diagram Upload-Block Diagram Instructions/Sample).