Preparing for the New ACGME Policy and Procedures

| July 23, 2013

In dealing with institutional, common program and specialty requirements, we in GME often forget about the global ACGME policies and procedures manual. With the implementation of NAS, the ACGME has made some major changes to the policies and procedures applicable to programs and sponsoring institutions. These changes go into effect July 1, 2013. Today, we’ll highlight a few.

The updated ACGME Policy and Procedure Manual can be found here: http://acgme.org/acgmeweb/Portals/0/PDFs/ab_ACGMEPoliciesProcedures.pdf

  1. No new independent subspecialty programs will be accredited after July 1, 2013. To remain ACGME accredited, n independent subspecialty program which was ACGME-accredited as of June 11, 2012 must, by July 1, 2015, meet one of the following conditions to retain accreditation:
    a) an independent subspecialty program within an institution without an associated core residency program in the specialty must operate under the oversight of a sponsoring institution accredited by ACGME and should be geographically proximate, or
    b) an independent subspecialty program sponsored by an ACGME accredited institution with an associated core residency program must function as a dependent subspecialty program to the associated core residency program.
  2. There will no longer be a distinction between a single program sponsoring institution and a multiple program sponsoring institution. Each sponsoring institution must achieve and maintain institutional accreditation in order to sponsor one or more ACGME-accredited programs.
  3. The revised policies include addition of the CLER (Clinical Learning Environment Review) site visit. The CLER visit will assess programs’ and institutions’ effectiveness in six focus areas related to patient safety and quality improvement, and are expected to occur every 18 months.
  4. There are four types of site visits, as of July 1, 2013:
    1. Focused site visit. Used to evaluate specific areas of concern.
    2. Full site visit. Used to review an application for a new sponsoring institution or program, at the end of initial accreditation period, to explore broad concerns or issues, and for any serious conditions or situations at the discretion of a review committee.
    3. Self-Study visit. A form a full site visit used at the end of the 10-year accreditation period.
    4. Alleged egregious violations. The ACGME may conduct a site visit, at any time, if an alleged egregious violation is identified.
  5. All programs will be reviewed annually through the annual data review of each program. Accreditation decisions are conferred based upon satisfactory ongoing performance of the program.
  6. The following is a list of accreditation statuses that may be granted to programs and institutions:
    1. Accreditation Withheld
    2. Initial Accreditation
    3. Initial Accreditation with Warning
    4. Continued Accreditation
    5. Continued Accreditation with Warning
    6. Probationary Accreditation
    7. Withdrawal of Accreditation
    8. Voluntary Withdrawal of Accreditation
    9. Administrative Withdrawal of Accreditation by the Board of Directors
  7. The ACGME has changed the name of the disaster policy to be an Extraordinary Circumstances policy. Extraordinary circumstances include abrupt hospital closures, natural disasters, or a catastrophic loss of funding.