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

Area of Science:

• Medical Education Accreditation
• Graduate Medical Education
• Program Evaluation

Background:

• The Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System (NAS) mandates annual reviews of program key performance indicators.
• Review Committees (RCs) can initiate data-prompted site visits (DPSVs) for comprehensive or focused reviews of underperforming programs.

Purpose of the Study:

• To identify primary reasons for RCs initiating DPSVs.
• To characterize findings from accreditation field representatives' site visit reports.
• To summarize RC accreditation decisions post-DPSV.

Main Methods:

• Analysis of RC letters initiating DPSVs, site visit reports, and accreditation decision letters.
• Data collected for all programs undergoing DPSVs between 2015 and 2020.

Main Results:

• 312 programs underwent DPSVs (59 hospital-based, 122 medical-based, 131 surgery-based).
• Noncompliance with the ACGME Resident/Fellow Survey was the leading cause for DPSVs.
• Repeat DPSVs led to program director changes in 57% of cases, compared to 7% for single DPSVs.
• Surgery-based programs faced higher rates of unfavorable accreditation status, though most programs ultimately achieved continued accreditation.

Conclusions:

• Noncompliance on the Resident/Fellow Survey frequently triggers DPSVs.
• Most programs reviewed via DPSVs, both single and repeat, ultimately secured continued accreditation.