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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2725_Библиотеки_им_академика_М_И_Перельмана.pdf
9 Family Medicine Residency Accreditation
Table 9.1 Six core competencies [4]
Patient care: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health.
Medical knowledge: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and socialbehavioral sciences, as well as the application of this knowledge to patient care
Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
Interpersonal and communication skills: Residents must demonstrate interpersonal and communication skills that result in the effective
exchange of information and collaboration with patients, their families, and health professionals
Practice-based learning and improvement: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise
and assimilate scientic evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning
Systems-based practice: Residents must demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well
as the ability to call effectively on other resources in the system to provide optimal healthcare
45
spend a signicant portion of their training. Thus, was born
the basis for “the practice is the curriculum”—a concept that
has served as a bedrock for training in family medicine, distinguishing it from virtually all other specialties that primarily train residents in hospital-based settings or similar
institutions.
With the transition to ACGME oversight and administration, the program requirements for all specialties, including
family medicine, underwent a transformation in the 1980s
and 1990s, expanding the number of requirements, largely to
accommodate the development of standardized common
program requirements (CPRs) shared by all specialties. The
CPRs addressed issues such as the work environment, training resources and faculty requirements for all specialties, a
rst step to ensure that all residents would have a similarly
safe working and learning environment regardless of their
chosen specialty. Initially, these CPRs were woven into each
specialty’s program requirements (SPRs).
Family medicine was no different, with requirements
expanding from two to several pages which addressed resident and faculty qualications as well as the work environment, scholarship expectations, and evaluation process.
More details regarding the family medicine curriculum were
included with a special emphasis on the interaction with
other specialty services (such as pediatrics, obstetrics, surgery, etc.) as well as specications for what was called the
Family Practice Center (FPC). SPRs addressed the space,
stafng, and patient care services of the FPC, recognizing
that residents must learn the clinical aspects of family medicine as well as critical practice management functions for
successful independent practice. Cornerstones of family
medicine, accessible continuity of care and comprehensive
coordinated care oriented toward the family and community
were highlighted alongside a strong emphasis on behavioral
health, codifying what had previously been general curricular principles into a detailed set of SPRs. The emergence of
concerns around resident working conditions, brought to
national attention by the Libby Zion case, led to duty hour
requirements in 2003, modied in 2011, to which all specialties had to adapt. These changes along with the development
of six core ACGME competencies (Table 9.1) and a shift
toward competency-based medical education resulted in the
expansion of family medicine program requirements to over
60 pages by the year 2020.
The Purpose andOutcomes ofResidency
Accreditation: Standardization Versus
Innovation andFlexibility
Why Accreditation Matters
Accreditation is a review process that helps to evaluate,
improve, and recognize a residency program’s compliance
with certain standards of education. Accreditation improves
healthcare by assessing and enhancing the quality of resident
physician education for the benet of the public. Accreditation
is not permanent; it requires periodic renewal to ensure the
quality of education is maintained. Recognition by an independent accrediting body is a statement that an institution
meets a dened level of educational standards. Accreditation
is the term applied to standards maintained by an institution
or program; the terms certication and licensure apply to
individuals.
Accreditation through the ACGME is achieved through a
voluntary process of evaluation and review based on published accreditation requirements. ACGME accreditation
provides assurance that a Sponsoring Institution, an entity
that oversees, supports, and administers one or more
ACGME-accredited residency or fellowship programs, and
individual programs meet the quality standards (CPRs and
SPRs) of the specialty or subspecialty for which it prepares
its graduates. ACGME accreditation for each specialty is
overseen by a Review Committee, made up of volunteer specialty experts from the eld, that sets accreditation standards
and provides peer evaluation of Sponsoring Institutions, specialty residency programs and subspecialty fellowship
programs.
The focus of the ACGME is on institutional and programmatic standards. The RCFM assesses programs for their
46
G. S. Hoekzema et al.
compliance with CPRs and SPRs specic to family
medicine.
ACGME accreditation conrms that sponsoring institutions and programs meet both institution-wide and programspecic requirements, in terms of the training provided to
residents and fellows. Accreditation means the institution
and its residency and fellowship programs have been peerevaluated to ensure quality.
Self-regulation is a fundamental professional responsibility and the ACGME system for assessing the quality of
physician educational programs answers to the public for the
graduates it produces. The ACGME serves the public trust by
setting and enforcing standards that govern the specialty
education of the next generation of physicians.
When the ACGME was established in 1981, it worked to
reduce variability in the quality of resident education, and it
focused on formalizing subspecialty education. Since
ACGME accreditation has been established, performance on
certifying examinations has improved, residents are better
prepared to deal with dramatically increased volume and
complexity of information within their specialty, and graduates and academic institutions have contributed to clinical
advances and educational innovation that benet the public
[3].
Specialty-Specic Program Requirements
andCore Competencies
Accreditation standards codied in the CPRs and SPRs
have several aims. Common program requirements expected
of all specialty training programs outline a unied set of core
competencies across six domains. (Table9.1—ACGME core
competencies).
Specialty-specic requirements aim to embody the core
tenets of each unique specialty. The specialty-specic
requirements in family medicine begin with a page-long definition of a family physician, physicians who provide rstcontact, comprehensive, compassionate, and high-quality
care within the context of patients’ families and communities
over the continuum of a patient’s lifespan. Family medicinespecic requirements outline dened minimum expectations
for resident patient care experiences and program curricular
elements. For example, in the July 1, 2023, family medicine
program requirements, it is specied that residents must have
at least 600hours (or 6months) and 750 patient encounters
dedicated to the care of hospitalized adults. Some program
requirements are written to allow for a degree of exibility in
how individual programs achieve them.
Major revisions to the family medicine program requirements occur every 10 years. New training requirements
effective July 1, 2023, take into account the historical origins
and core values of the specialty and strive to ensure family
physician trainees are prepared for independent practices of
the future in diverse communities and are able to adapt to a
changing healthcare environment. The requirements represent an important evolutionary step toward more competencybased medical education, moving away from proscriptive
numerical requirements to more curricular exibility so programs can adapt to the needs of their unique communities
and still meet the goal of producing comprehensive personal
physicians [5].
How Board Certication Diers fromProgram
Accreditation
While the ACGME accredits institutions and residency programs, the American Board of Medical Specialties (ABMS)
oversees a process to certify individual physicians.
Specically, for family physicians, the American Board of
Family Medicine (ABFM) certies MD or DO family physicians who satisfactorily complete ACGME-accredited residency programs and meet other established requirements.
ABFM board-certied physicians are designated as
Diplomates. The American Osteopathic Association Bureau
of Osteopathic Specialists and AOBFP fulll similar roles
for the osteopathic physician community.
The primary function of each ABMS/AOA member board
is to certify physicians in their primary specialty and subspecialty areas and to support the professional development of
board-certied physicians throughout their careers. This is
accomplished through a comprehensive process involving
setting educational requirements, professional peer evaluation, examination, and professional development.
Board certication is voluntary and requires high standards of patient care and a lifelong commitment to learning
and professional development. In addition to maintaining
ethical standards, diplomates must continuously hold a medical license as specied by their certifying board.
Board certication in family medicine assures patients
and the public that an individual physician is highly skilled
and effective at improving patient healthcare by having met
specic residency training standards and continuing to maintain high professional standards. In family medicine, after
physicians obtain board certication, they must maintain
certication by meeting an ongoing series of requirements.
Meeting family medicine continuous certication requirements reects a physician’s commitment to ongoing education, an expectation shared by patients and the public. For
ABFM board certication, physicians must complete activities in four categories: (1) Professionalism, (2) Selfassessment and Lifelong Learning, (3) Cognitive Expertise,
and (4) Performance Improvement.
ABFM board certication requires satisfactory completion of an ACGME-accredited residency program. Family
9 Family Medicine Residency Accreditation
47
medicine residents are required to participate in ongoing
board certication activities before sitting for their initial
board certication examination, which can be taken toward
the end of the third year of residency. Residents begin the
board certication process during residency, a process that is
distinct from ACGME program accreditation. The AOA
board certication process is similar but distinct from the
ABFM process. The RCFM must work with the ABFM and
AOA to ensure that residency program accreditation and
resident board eligibility are synchronized.
The RCFM collaborates with the ABFM and AOA to promote better healthcare education and drive better outcomes.
To this end, the ABFM and AOA each nominate three members to the RCFM, and have a non-voting ex-ofcio member
who attends the RCFM meetings. Although the ex-ofcio
member does not vote on accreditation decisions, they are
allowed to speak on matters of importance to the board. One
reason for this is to ensure requirements for accreditation
coincide with board eligibility. The aggregate 5-year board
(ABFM or AOBFP) pass rate for rst time graduate testtakers is a major outcome measure for program accreditation. A 5-year aggregate pass rate of <80% for either
certifying board is considered to be an accreditation ag and
would be cited. This specic measure is an example of data
sharing between the board certifying organizations and the
RCFM. Another example of this partnership is the ability of
the ACGME to obtain the board certication and Family
Medicine Continuous Certication status for all faculty
listed in the ACGME’s Annual Data System (ADS).
ACGME Organization: Mission, Vision,
Organizational Structure, andtheFamily
Medicine Review Committee
This section will outline and discuss the ACGME mission
and vision, the organizational structure of the ACGME, and
the appointment of members to the Review Committee for
Family Medicine. The mission and vision of the ACGME are
denoted in Table9.2.
ACGME Organizational Structure
The ACGME describes itself in the following way. “The
Accreditation Council for Graduate Medical Education
(ACGME) is an independent, 501(c) [3], not-for-prot
organization that sets and monitors voluntary professional
educational standards essential in preparing physicians to
deliver safe, high-quality medical care to all Americans.
Graduate medical education (GME) refers to the period of
education in a particular specialty (residency) or subspecialty (fellowship) following medical school; the ACGME
oversees the accreditation of residency and fellowship programs. The ACGME does not accredit US medical schools.
The LCME accredits US allopathic medical schools and is
sponsored by the AAMC and the AMA.The Commission
on Osteopathic College Accreditation of the American
Osteopathic Association accredits US osteopathic medical
schools.” [6].
As of academic year 2021–2022, the ACGMEaccredited 12,740 residency and fellowship programs with
a total of 153,843 active full and part-time residents and
fellows. One in seven physicians in the United States is a
resident or fellow. There were 182 recognized specialties
and subspecialties. There are 871 ACGME-accredited
sponsoring institutions. In 2023, 4530 medical school
graduates matched into 773 family medicine residency
programs through the National Resident Matching Program
(NRMP).
The ACGME does not accredit all residency and fellowship programs. The ACGME accreditation is a voluntary
process that programs and their sponsoring institutions
choose to complete. Not all residency and fellowship programs in the USA are ACGME accredited. In some cases,
this is because the ACGME does not yet accredit a particular
specialty or subspecialty. For example, there are some fellowship programs in family medicine that are offered to
graduates of family medicine residency programs that are
not accredited by the ACGME.Examples include Maternal
Healthcare, Rural Medicine, Global and International Health
and Integrative Medicine. In a few circumstances, programs
Table 9.2 ACGME mission and vision
ACGME Mission: The mission statement of the ACGME is: “We improve health care and population health by assessing and enhancing the
quality of resident and fellow physicians’ education through advancements in accreditation and education.” [7]
ACGME Vision: The vision statement of the ACGME is: “We envision a health care system in which the Quadruple Aim has been realized. We
aspire to advance a transformed system of graduate medical education with global reach that is:
• Competency-based with customized professional development and identity formation for all physicians;
• Led by inspirational faculty role models overseeing supervised, humanistic, clinical educational experiences;
• Immersed in evidence-based, data-driven, clinical learning and care environments dened by excellence in clinical care, safety, costeffectiveness, professionalism, and diversity, equity, and inclusion;
• Located in healthcare delivery systems equitably meeting local and regional community needs; and,
• Graduating residents and fellows who strive for continuous mastery and altruistic professionalism throughout their careers, placing the needs
of patients and their communities rst.” [7]
https://www.acgme.org/about/overview/mission- vision- and- values/
48
G. S. Hoekzema et al.
and/or sponsoring institutions have opted not to apply for
accreditation from the ACGME though residency programs
must be accredited by the ACGME to be eligible for CMS
(Centers for Medicare & Medicaid Services) Direct Graduate
Medical Education (DGME) and Indirect Medical Education
(IME) funding.
The ACGME has a Board of Directors. The ACGME
leadership staff includes Review Committee executive directors, accreditation eld representatives, and Clinical Learning
Environment Review (CLER) eld representatives.
The ACGME has an international arm (ACGME-I) that
accredits GME programs internationally. The ACGME-I has
set separate requirements and is overseen by a separate board
of directors. A full description of the ACGME-I can be found
at: https://www.acgme- i.org/about- us/mission/
Review andRecognition Committees
There are three types of Review Committees:
1. Specialty Review Committees
2. Transitional Year Review Committee
3. Institutional Review Committee
After the formation of the Single Accreditation System
(SAS), a separate Osteopathic Recognition Committee
(ORC) was formed to oversee the recognition of programs
that sought to maintain distinctive osteopathic training within
their residency. The ORC does not accredit programs but
grants Osteopathic Recognition status to programs that meet
certain standards that promote and maintain osteopathic
principles throughout the training program.
Each specialty has a designated Executive Director (ED).
The ED and Review Committee (RC) staff are experienced,
knowledgeable, and helpful resources for all matters pertaining to accreditation. When a Program Director (PD) has a
question about accreditation or program requirements, they
are encouraged to contact the ED and RC staff. The ED and
staff manage communication with programs about RC decisions, serve as liaisons between the ACGME leadership and
committee members and organize the work of the RCFM,
including review committee meetings. The RCFM leadership, which includes the Chair, the Vice-Chair and the ED,
work in concert with each other on ofcial public communications to the family physician community. Only the Chair,
Vice-Chair or ED may speak for the committee with regard
to ofcial policies, accreditation decisions or procedures.
Contact information can be found on the ACGME RCFM
web page which is a helpful resource to use as a starting
point for most accreditation related questions or concerns.
The Family Medicine Review Committee (RCFM)
The RCFM has members with expertise in family medicine
residency education and family medicine accredited fellowships or other relevant expertise and a member who is a resident or fellow in an ACGME-accredited program and a
public member. All committee members (except the resident
and public members) are nominated by RC-specic nominating organizations, selected by vote of the members of the
RCFM, and conrmed by the ACGME Board of Directors.
In family medicine, the nominating organizations include
the American Academy of Family Physicians (AAFP),
ABFM, AOA and AMA.The RCFM is composed of three
appointees from each of these four organizations, plus the
resident and public members, for a total of 14 voting
members.
The RCFM solicits nominations for physician members
from the four nominating organizations. The RCFM ED will
contact the nominating organizations with sufcient notice
to allow identication, vetting and submission of the names
of at least two candidates for each vacancy to the committee’s executive director at least 12months before the date of
the appointment. In the case of the public member, a call will
go out from the ACGME to solicit self-nominations for consideration. In the case of the resident member, the ED will
solicit nominations from the leadership of the resident section of the AAFP.The names of potential nominees may be
submitted by other FM organizations to the nominating organizations. For example, the Association of Family Medicine
Residency Directors (AFMRD) and Society of Teachers of
Family Medicine (STFM) may submit names to the AAFP
for consideration. Self-nominations are allowed. The RCFM
applies principles of diversity, equity, and inclusion when
considering candidates. The RCFM does not consider nominees from the same institution or the same city/metropolitan
areas of current members at the time of appointment.
The ACGME helps to promote new member solicitations
through its e-Communication program to the GME community, the ACGME website and through social media.
Nominees must submit specic materials, such as a curriculum vitae and letters of recommendation, to be considered by
the RCFM. Members are selected based on professional
qualications, geographic location, expertise needs of the
RCFM, and racial, ethnic, and community diversity. Once
the RCFM has selected a nominee, the ACGME Board of
Directors must conrm the nomination.
The physicians and public member serve a 6-year term.
The resident member is appointed for a 2-year term, must be
enrolled in a family medicine residency program at the time
of their appointment, must be endorsed by their Program
9 Family Medicine Residency Accreditation
49
Director (PD) and may not serve more than 1year beyond
the completion of their residency. A letter of support from
the nominee’s residency program director must ensure the
nominee will have sufcient time to dedicate to the role.
Upon completion of a 2-year term, the resident member may
not be appointed again to the same Review Committee.
Resident members should ideally not be from the same state
or institution as another current member of the RCFM.
As noted previously, in addition to the physician members, public member and resident member, the RCFM has
ex-ofcio non-voting members from the four nominating
organizations: AAFP, ABFM, AMA, and AOA. These
members serve to observe and report back to their respective organizations regarding the work of the RCFM as it
pertains to their constituents. The ex-ofcio members do
not vote on accreditation decisions and must recuse themselves from discussions if there is any conict of interest,
such as a discussion pertaining to an organization or individual who provides fee-based consultative services to the
ex-ofcio member’s institution. It should be noted, that
although the AMA is a founding appointing organization, it
has elected to not send an ex-ofcio member to RCFM
meetings in recent years unless it feels their presence is
warranted.
The Clinical Learning Environment Review (CLER)
The ACGME Clinical Learning Environment Review
(CLER) program promotes safety and quality of care by
focusing on six areas that include patient safety, healthcare
quality, teaming, appropriate resident supervision, wellbeing and professionalism.
The CLER visit is not tied to either a sponsoring institution or program accreditation status. Rather it is a “low
stakes” mechanism to enhance the quality improvement process of an institution’s educational learning environment.
The ACGME conducts CLER site visits at Sponsoring
Institutions. During the visit, CLER eld representatives
meet with groups of residents, faculty, PDs, and leaders of
the Sponsoring Institution. FM PDs may be included in
CLER site visits for their sponsoring institution. CLER
visitors obtain anonymous feedback from all relevant
stakeholders regarding the six areas mentioned above. A
report is then generated for the designated institutional
ofcial (DIO) highlighting areas for potential quality
improvement. It is then the responsibility of the designated
institutional ofcial (DIO) and graduate medical education
committee (GMEC) to address those areas of concern,
which will be subsequently reviewed at the next CLER
visit.
The Process ofAccreditation fromInitial
Application toContinued Accreditation
Family physicians continue to be the most sought-after medical specialty in part due to the varied and comprehensive
nature of the training experience. As a result, many hospitals
and institutions wish to establish family medicine residency
programs.
Accreditation ofaNew Program
Establishing a new program is a vast undertaking. The inherent complexity of family medicine programs calls for a
detailed business plan to ensure the successful initiation and
sustainability of the program. Essential factors to be dened
during the new program’s planning process include a startup
timeline, funding, ongoing operational costs, required afliation agreements, stakeholders, anticipated service area, the
Family Medicine Practice (FMP), faculty and above all a
motivated, capable, and qualied PD. The PD maintains
authority over all aspects of the program from the initial curriculum design to ensuring ongoing accreditation, engaging
stakeholders, and managing faculty, staff and residents while
executing the business plan.
Residency programs must operate under an accredited
Sponsoring Institution. The Sponsoring Institution must
have a Graduate Medical Education Committee (GMEC)
and a Designated Institutional Ofcial (DIO). The GMEC
must approve all appointed program directors. The DIO must
enter the name of the program director into ADS to notify the
ACGME and RCFM of the appointment. All PD changes
must be approved by the RCFM.PD responsibilities are outlined in detail in the SPRs.
To start a new program, the PD completes an initial application in which the detailed aspects of the proposed program
are explained. The application includes the program curriculum, rotations, evaluation systems, FMP data including
patient volume and demographics as well as the design of the
FMP, and all other elements pertinent to meeting accreditation requirements developed in preparation for accepting the
rst class of residents. Every element necessary for a successful residency program, as outlined in the CPRs and
SPRs, must be accounted for in the application. It is essential
to review the application with stakeholders and a trusted colleague for feasibility, accuracy, and readability.
The new program will be scheduled for a site visit.
Accreditation site visits are conducted by ACGME-employed
accreditation eld representatives who have extensive GME
experience and who are specically trained as site visitors.
Field representatives will communicate with the PD and
Program Coordinator (PC) to schedule the site visit which
50
G. S. Hoekzema et al.
may occur within 30days. The program will be asked to submit a limited number of “blackout dates” when essential program representatives may not be available to meet with the
eld representative.
Preparing fortheSite Visit
The eld representative’s objective is to meet with the PD,
PC, faculty, DIO, Family Medicine Department Chair, and
other applicable administrators such as the hospital CEO and
CFO who can best attest to institutional support for the program. The department chair may be the hospital family medicine chair or the medical school chair as applicable. The PD
should brief all stakeholders about questions they might
expect to be asked during the site visit.
The PD and PC will be provided with an interview day
schedule template to ll in with the selected individuals’
names and titles. Along with the scheduling directions, the
PD and PC will also receive a list of documents to complete
and submit electronically to the eld representative in preparation for the visit. Documents will include the application,
block rotation diagram, goals and objectives for each rotation which demonstrate progressive responsibility of
resident- physicians, Program Letters of Agreement (PLA),
sample evaluation tools for each of the required evaluations,
and the didactic curriculum outline among others. It is
important to ensure that the information provided in each
document meets the relevant program requirement(s). For
example, a PLA must be in place for every participating site
the program intends to have as a required assignment for all
residents and each PLA must be signed by the PD, DIO, and
site director. PLAs are not required for participating sites
under the governance of the program’s Sponsoring
Institution.
The Site Visit
and future plans for the program. Some institutions may
assume it is premature to have certain programmatic requirements in place such as a full complement of faculty, the FMP,
or signed PLAs, but this assumption is wrong and may lead to
citations and may delay or prevent accreditation. Although a
new program can only propose their planned curriculum and
participating sites, project the FMP volumes and demographics, and predict the anticipated program outcomes, it must
demonstrate substantial compliance with essential elements
to be considered for accreditation.
Family Medicine Review Committee
(RCFM)Initial Program Review (See Fig.9.2)
Two RCFM members are assigned to review each new program application. Reviewed materials include the program
application, site visit report and supplemental documents.
The two reviewers then compare and reconcile their ndings
in preparation for the RCFM meeting. The primary reviewer
presents their combined ndings at an RC meeting where the
committee applies peer judgment to issue one of three possible accreditation decisions: initial accreditation for 2years,
initial accreditation for 1 year or accreditation withheld.
Programs with high-quality proposals and few or no citations
are more likely to receive 2-year accreditation, whereas programs with less robust plans and more citations may receive
1year of accreditation before they are subject to another site
visit. Or the program may have accreditation withheld
entirely. RCFM meetings are held in January, April, and
October and the exact dates as well as deadlines for meeting
agendas can be found on the ACGME website. New program
PDs are encouraged to reach out to the RCFM Executive
Director for assistance with questions about the application
process and for support in order to achieve a timely review.
New programs generally require at least 1year of preparation before they apply for accreditation.
Site visits may be conducted virtually or in person. It goes
without saying that all scheduled interviewees must arrive
early. If the interview is to be conducted virtually, it should
be scheduled in a quiet space with reliable technology and
internet access.
The day starts out with a document review with the PD and
PC, is followed by interviews with all scheduled individuals,
and concludes with a wrap up with the PD and PC.The objective for the eld representative is to verify whether all program requirements are met and that plans will be executed
effectively by responsible interviewed stakeholders. The PD
must be familiar with the materials submitted and the ACGME
program requirements. It is helpful if the PC and faculty have
a basic understanding of the application, support materials,
Initial Accreditation Period
The initial accreditation period is the time during which programs can implement and ne tune their business plan while
collecting data to submit to the annual Accreditation Data
System (ADS) report. ADS is a web-based software system
managed by the ACGME to collect and maintain accreditation information. It also serves as a means of communication
between the ACGME and Sponsoring Institutions and
programs.
Programs with initial accreditation undergo another site
visit and RCFM review toward the end of their initial accreditation cycle. The potential outcomes of the second review
include continued accreditation, continued accreditation with
9 Family Medicine Residency Accreditation
51
Fig. 9.2 ACGME accreditation process owchart
warning and a site visit in 1year, or withdrawal of accreditation. This review is critical because the program can provide
data to support their application and residents are included in
the interview process. A very small percentage of programs
receive warnings or have accreditation withheld. Programs on
warning status are at risk of losing accreditation and typically
would benet from faculty development, enhanced resources,
and consultation to resolve citations. If accreditation is withheld, the program, with the approval of their DIO, has an
opportunity to appeal the decision and can do so by reaching
out to the ACGME Executive Director. Alternatively, these
programs may accept the decision or apply as a new program
after 2years and start the accreditation process anew.
Subspecialty Fellowship Application
The accreditation application and review process are similar
for subspecialty fellowship programs with the exception that
new fellowship applications do not require a site visit. The
review committee will preferentially assign a committee
member who is certied in the subspecialty as the primary
reviewer. If there is not a current committee member who
holds those subspecialty credentials, other committee members will conduct the review. Family Medicine currently
accredits subspecialty fellowships in sports medicine, geriatrics, hospice and palliative medicine, addiction medicine and
clinical informatics.
The Annual Program Review
Continued accreditation is maintained by ensuring compliance with ACGME program requirements as reported via
annual ADS submissions and as measured and reported via
the annual resident and faculty surveys. The RCFM monitors
program compliance through an annual review process. This
section will review the ACGME’s annual review process,
including a brief history of the process and the data collection process.
52
G. S. Hoekzema et al.
Brief History oftheAnnual Review Process
Prior to 2014, the ACGME accreditation process for family
medicine programs was organized in a very different manner. Program reviews were conducted every few years and
emphasized standardization. This older review process was
often described as an episodic “biopsy” model in which
compliance with program requirements was assessed based
on information submitted by the program and after a site
visit. Family medicine programs would be accredited for a
set accreditation cycle length. Programs in substantial compliance would aim for the longest cycle of accreditation,
which was 5years. Programs deemed to be struggling would
have a shorter accreditation cycle, sometimes as short as
1year. Programs would submit a large packet of information
about their program, called the program information form
(PIF), and have a scheduled site visit led by an ACGME eld
staff member. Organizing and collecting information to submit in the PIF was often considered one of the most timeintensive aspects of working in residency education
leadership. The PIF commonly contained 100 pages of documentation. Because programs were required to submit this
information every 4–5years, it required considerable work
within the program to locate and produce the data expected
in the PIF. Site visits were stressful for residency program
leadership as ACGME Field Staff would meet separately
with program leadership, faculty, residents, and institutional
leaders while verifying data submitted in the PIF and reported
in Annual Resident and Faculty ACGME surveys. Program
directors would often feel that the purpose of site visits was
to nd problems, and an environment of “gotcha” was frustrating to programs that were overall high-functioning, meeting program requirements, and graduating competent
residents. Field staff would generate a Site Review Report
which, along with the PIF, resident and faculty survey data,
and prior accreditation decisions, would be reviewed by the
RCFM to arrive at an accreditation decision and determine if
citations were indicated [8].
The Next Accreditation System Annual Review Process
The current review process, termed the Next Accreditation
System (NAS), focuses on continuous ongoing assessment
and improvement of residency programs based on specialty
requirements. This has been a move away from the “biopsy”
style of program evaluation. In the NAS, the ACGME conducts annual program reviews based on information collected by their data reporting systems, including the
electronic Accreditation Data System (ADS) and resident
and faculty ACGME surveys. Some specialties require procedure case log reporting. Family medicine does not yet use
this system of case logs but may pilot a modied version of
it in the near future.
Accreditation Data System (ADS)
ADS is a proprietary web-based software system through
which the ACGME collects and organizes information for
the purposes of accreditation, recognition, and the advancement of graduate medical education (GME). It also serves as
a communication mechanism between the ACGME and
accredited Sponsoring Institutions and programs. Information
collected assists the RCFM and ACGME eld representatives in conducting accreditation and recognition activities.
ADS facilitates annual data collection efforts, including the
Annual Update, Milestones and Case Logs. Inputting accurate and concise information into the annual ADS update is
of critical importance. It can be used to describe major
changes in the program and gives the program a chance to
explain how they are in compliance with program requirements. The major outcome elements that have been traditionally tracked in family medicine include resident continuity
visit numbers, data on family medicine practice volume and
demographics, total deliveries by residents upon graduation,
and average daily inpatient encounters.
Key sections of the ADS annual update include program
information questions, a resident/fellow roster and a faculty
roster. The specic information requested is meant to reect
program requirements. As a result of the major program
requirement changes effective July of 2023, the family
medicine- specic ADS data collection format has undergone
revision to align with the new program requirements.
ADS includes a combination of narrative, yes-no, numeric
and checklist questions. In 2020, ADS underwent an update
to reduce the total number of questions and allow for all
items except resident and faculty scholarly activity to autopopulate from the information entered the prior academic
year. On occasion, the question items in ADS will change to
collect new and additional information. An example of this
were questions added during the pandemic to understand the
impact COVID-19 had on resident education, the residency
curriculum, resident telehealth visits and resident and faculty
member well-being. Questions related to COVID-19 were
removed in 2023.
During 2023, the ACGME began a process to update ADS
and modernize its data collection system. As the program
requirements in family medicine evolve into more
competency- based expectations, the data collected in ADS
will also change. For example, asking programs to report the
top 10 diagnoses across hospital sites where residents rotate
has been removed. There will be an increased emphasis on
FMP patient panels and continuity as measured from the perspective of the patient and the resident. Not all numeric
9 Family Medicine Residency Accreditation
53
reporting will be removed from ADS despite the elimination
of some numerical patient encounter requirements. An
example of this is that while it is no longer a requirement that
each resident complete 1650 encounters with patients from
the FMP, programs will still be asked to report the number of
FMP patient encounters completed annually by the residents.
This will allow the RCFM to have a sense of the program’s
ability to provide residents’ clinical experiences, monitor the
impact of requirement changes and take trends into consideration for future program accreditation requirement revisions.
The ADS system can also serve to support PDs and programs
in advocating for the resources and support needed to train
residents.
An example of how the RCFM uses ADS data to monitor
the impact of changes in program requirements is with the
data collected about resident delivery numbers. Even though
specic numeric requirement for deliveries was removed
from the FM program requirements (in response to residency
program feedback and citation trends), it was still expected
that programs report this data in ADS annually. The RCFM
monitored this data for trends and, recognizing a decline in
deliveries, made the decision to reinstate an adjusted numeric
requirement for resident deliveries in the 2023 FM program
requirements.
ACGME eld representatives use ADS for accreditation
and recognition site visit scheduling and housing site visit
reports for submission to the Review and Recognition
Committees. Programs use ADS to evaluate ACGME accreditation eld representatives. The Clinical Learning
Environment Review (CLER) Program uses ADS to schedule CLER site visits and manage additional details of the
CLER process.
The ACGME has an online Help Center that explains
ADS, offers step-by-step guides for entering data into ADS
and provides a schedule of important due dates [9].
ACGME Resident/Fellow andFaculty Surveys
Annual ACGME Resident/Fellow and Faculty Surveys are
conducted using a web-based software system that preserves
anonymity and protects condentiality of survey takers.
These surveys collect critical information from residents/fellows and faculty members to assist in the accreditation
review process. ACGME surveys can only be completed by
designated participants during a specic timeframe each academic year. These survey administration periods are communicated directly to Sponsoring Institutions and programs
via email. All accredited programs must meet a minimum
level of participation compliance with the Resident/Fellow
and the Faculty Surveys. Program directors should emphasize the importance of completing the survey to both residents and faculty, so as to collect important feedback that can
be used for program improvement and to avoid potential
citations for poor participation. However, PD’s may not
coach residents or faculty on how to answer the survey
questions.
The Resident/Fellow Surveys contain general questions
pertinent to Common Program Requirements, resident wellbeing, and specialty-specic questions. The RCFM monitors
for compliance trends in the Resident/Fellow and Faculty
Surveys. Signicant areas of non-compliance on the surveys
may prompt the RCFM to request a Site Visit to better understand areas of non-compliance.
Programs can enhance survey completion by creating a
supportive environment, annually reviewing survey results
with residents and faculty and by implementing appropriate
changes in response to feedback. Survey response rates may
also increase when PDs and/or PCs send reminders via ADS
to residents and faculty who have not completed the survey
during the survey period.
Programs receive their individual results with accompanying national data for all FM programs. Areas of noncompliance are highlighted. Programs should compare their
mean scores to national mean scores to guide internal program improvement efforts. It is, unfortunately, not statistically possible to provide a standard deviation calculation due
to the nature of the statistical data. Interpretation of the survey
may also be complicated because program size may have an
outsized impact on the mean program score. The responses of
one or two residents in a small program may “tip the scales”.
Spotre
Spotre is a software program used for advanced analytics and
data visualization. The annual data submitted by the program
in ADS is processed and analyzed through Spotre. Several
indicators are used to interpret this data set [10]. The RCFM
and ACGME set parameters to ag program indicators as outliers when reported data fall outside an acceptable accreditation standard. Parameters can be discrete, such as an individual
resident graduate who did not meet a minimum clinical experience requirement, to those that are based on a normative distribution, such as faculty scholarship that falls below the fth
percentile of all family medicine residency programs. If an
indicator is agged as a data outlier, that program is pulled for
review by the RCFM.Being pulled for review does not necessarily mean a program will receive a citation.
Spotre Indicators include the following:
• Major changes in program indicators (such as a PD turn-
over or faculty attrition)
• Resident attrition
• Clinical experiences (e.g., number of FMP visits)
• Faculty and resident scholarly activity
54
G. S. Hoekzema et al.
• ABFM/AOBFP aggregate 5-year pass rate
• Resident annual survey results
• Faculty annual survey results
• Evidence of Milestone completion
The Program Evaluation Committee
andAnnual Program Evaluation
All family medicine programs are required to have a mission
statement that is aligned with the sponsoring institution’s
mission. Each program is required to have a Program
Evaluation Committee (PEC) whose purpose is to evaluate
the program’s effectiveness at meeting the program’s mission. The PEC is appointed by the program director. The program director is usually, but is not required to be, a member
of the PEC.The PEC must include members of the faculty,
including at least one core faculty member, as well as resident representatives, and it must be comprised of at least
three members.
At least yearly, the PEC conducts an Annual Program
Evaluation (APE) to document progress as part of the program’s continuous improvement process. The PEC considers
the program’s mission and aims, analyzes results from previous APEs and conducts an analysis to identify program
strengths, areas for improvement, opportunities and threats.
The Self-Study Process and10-Year Accreditation
Site Visits
The ACGME’s self-study process was intended for programs
to conduct a comprehensive, longitudinal, and objective selfevaluation with a goal of making program improvements. In
the past, the self-study occurred prior to the 10-year accreditation site visit as a discrete process though programs were
encouraged to embrace a mindset of continuous improvement within the program. A self-study document to guide
program improvement was created at the conclusion of the
self-study process and was reviewed with key stakeholders.
As a result of the COVID-19 pandemic, the ACGME suspended the self-study process. In November 2023, the
ACGME ofcially discontinued the 10-Year Accreditation
Site Visits. Site visits will continue for programs with initial
accreditation, those with adverse accreditation status and
select others.
In each of these situations, one or two RCFM members
independently review the program materials and determine
whether the program has failed to comply with any program
requirements. If the situation warrants two reviewers, then
those reviewers reconcile their reviews and present one
agreed upon set of recommendations and any proposed citations or areas for improvement to the RCFM. Committee
members may ask clarifying questions or provide additional
insights.
Citations
The ACGME denes a citation as “a nding of a Review or
Recognition Committee that a Sponsoring Institution or program has failed to comply substantially with a particular
accreditation or recognition requirement” [11]. Historically,
the most common citations in family medicine have centered
on inadequate or inconsistent educational experiences such
as resident FMP visits, delivery experience, and experience
caring for ill children in the emergency or hospital settings.
More recently, the lack of faculty role models who perform
deliveries or care for hospitalized children and adults have
been citation trends. Citation trends may change as the
ACGME has more information from the national data analyzed by Spotre software. Programs that are cited in multiple areas deemed critical to family medicine education are
more likely to receive an adverse accreditation decision
(such as a warning or probation). For example, a program
that has no core faculty who role-model the scope of family
medicine outside of the ambulatory setting or does not provide residents with enough clinical volume in multiple settings will likely receive an adverse decision.
PDs are expected to provide clear, detailed, and updated
responses to citations in ADS.The citation response section
in ADS provides an opportunity to demonstrate the program’s efforts to make improvements and address deciencies. It is best to avoid utilizing the same response for
multiple citations. Citation-specic answers demonstrate the
PD’s understanding of the program requirements and engender condence that matters are being addressed and are taken
seriously.
Areas forImprovement
Citations andAreas forImprovement
andAccreditation Status
Programs undergo RCFM review for three main reasons: initial or continued accreditation review, areas of concern identied during review of the ADS and/or the resident/faculty
survey, or if a complaint is led against the program.
At times, reviewers may identify an aspect of the program
that would benet from additional attention or educational
resources and these are communicated to the program as an
Area for Improvement (AFI).
AFIs are vetted by the RCFM in the same way as citations
to ensure that feedback is appropriate, helpful, and consistent across programs. A commonly issued AFI is faculty