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Focus on previous citations, concerns, and comments during site visit preparation

Residency Program Connection, December 2, 2008

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

When preparing for a site visit, first focus on the review committee’s (RC) previous citations and your program’s responses. Site visitors and RC members look at these elements first. They want to be assured that you accepted their previous letters seriously and have been aggressive in implementing corrective actions. This information will help you anticipate the site visitor’s first concerns. However, your improvements can’t stop there. Don’t simply fix past citations. Demonstrate substantial compliance with all the other requirements. Turn some of these into “best practices.”

Second, focus on the results of your own annual self-review program evaluations. What were the major one or two concerns you identified each year? How did you analyze the issues, create action plans and timelines, and use these to improve that area within your residency program. How have you measured your success? What has been your progress in those areas?

This information will allow you to demonstrate that your program leaders identified weaknesses leading to steps to strengthen those areas. For issues that you have not yet addressed, you can anticipate the site visitor’s questions and can then demonstrate your program’s commitment to making the necessary improvements. It is better that you identify a concern, rather than the site visitor finding it from reading the PIF or from interviews.

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