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Instructions for composing a progress report for the ACGME

Residency Program Connection, October 7, 2008

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Editor’s Note: The following  information is an excerpt from Insider’s Guide to the ACGME Site Visit, Second Edition, by Kathryn Andolsek, MD, MPH and Shepard Cohen, published by HCPro, Inc.

If your RRC asks you to write a progress report with corrections to citations issued from your previous site visit, pay particular attention to the instructions accompanying the request.

In some instances, the RRC wants to receive the progress report within a few months of the request. Other times, the RRC wants to receive the report a year or two after the initial request. In either case, it is important that you comply with the deadline.

Take the following steps when composing your progress report:

1. Check the due date and make sure you submit it by then. Missing the deadline implies that your program does not take the RRC’s concerns seriously and neglects such concerns.
2. Discuss with your designated institutional official (DIO) and GMEC about conducting an abbreviated internal review midway between the RRC site visit and the date of the progress report deadline. (This is in addition to the ACGME-required site visit at the midpoint of the accreditation cycle)
3. Confirm when your DIO and GMEC will review and approve the progress report before sending it to the RRC. When you are developing the timeline for completing the progress report, be sure to build in time for the DIO to review the document.
4. Address each issue identified by the RRC separately in a paragraph or bullet format.
5. Make sure the progress report is succinct.
6. Restate the citation or concern the RRC outlined in their report. Briefly describe your position and argument.
7. Include data or document that supports your position.
8. Show evidence of your remediation efforts after the RRC cites your program for failure to meet a requirement. Focus on how your program is using the citation to develop a plan for continuous quality improvement.
9. If you can choose when to submit the progress report, allow sufficient time to pass to allow for real improvement. You may be tempted to respond with a quick rebuttal. However, the wiser course of action is to implement necessary changes; allow time to pass so that improvements are measurable.
10. Keep the file on hand for next year’s annual program review. This can be an excellent opportunity to track your progress and document improvement with progress reports.

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