Accreditation Overview
The ACGME utilizes a continuous accreditation model that emphasizes process to outcomes, and GMEC oversight of outcome measures and program quality improvement.
Two important processes 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 CLER (Clinical Learning in Environment Review) Program focuses on the hospitals, medical centers, and ambulatory care practices where residents and fellows train. This is separate from the accreditation process and is linked to accreditation only in that every institution must undergo a site visit once notified by the CLER Field Representative. 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), teaming, supervision, 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, 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 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. More information can be found on the Self Study page on the ACGME website: http://www.acgme.org/What-We-Do/Accreditation/Self-Study
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.
ACGME conducts accreditation site visits for programs with Continued Accreditation. These programs are selected through a randomized process equating to about 1-2% of programs nationally for about a total of 150 site visits conducted each year. Responsibility of subspecialty programs has been added to core programs and the sponsoring institution. More information on site visits can be found on the Site Visits page of the ACGME website.
ACGME may also perform discretionary site visits on an as needed basis due to ACGME survey results, reported complaints, etc., to assess potential problems.