Reasons for Data-Prompted Site Visits: Field Staff Findings and Review Committee Decisions

Abstract

Background A major component of the ACGME’s Next Accreditation System (NAS) is the annual review of key performance indicators by each review committee (RC) for all programs under its oversight. The RC may request a site visit that is dataprompted for either a full review of all common and specialty-specific program requirements or a focused review of specific concerns for programs identified as underperforming. Objective The aims of this study were to: (1) identify the reasons that RCs requested data-prompted site visits; (2) describe the findings by accreditation field representatives as reflected in their site visit reports; and (3) summarize the accreditation decisions of RCs that followed the data-prompted site visits (DPSVs). Methods RC letters to programs informing them of a DPSV, site visit reports, and RC letters with accreditation decisions were reviewed for all programs having DPSVs from 2015 to 2020. Results DPSVs were performed in 312 programs, including 59 hospital-based, 122 medical-based, and 131 surgery-based programs; 214 programs had a single DPSV, and 98 programs had repeat DPSV. The most frequent reason that RCs requested a DPSV was noncompliance on the annual ACGME Resident/Fellow Survey. Notification of a DPSV prompted a change in program director in 7% of programs in the single DPSVs group and 57% of programs in the repeat DPSVs group. Surgery-based programs in the single and repeat DPSVs groups were more likely to receive an unfavorable accreditation status. The majority of programs in the single DPSVs group (78%) and repeat DPSVs group (70%) had a status of continued accreditation as of March 2020. Conclusions Noncompliance on the Resident/Fellow survey was the most frequent reason that RCs requested a DPSV. The majority of programs in the single and repeat DPSV groups achieved a favorable accreditation status.