Tips for preparing the institutional review document

Residency Program Insider, December 29, 2009

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The following column was submitted by Shepard Cohen, GME consultant with Excellence in Graduate Medical Education. You may contact Shepard at


Attachment 1A/B and the companion Attachment 2 are two of the most important components of an ACGME Institutional Review Document (IRD) because their content will have a significant  impact on the outcome of any ACGME Institutional Review. Attachments 1A/B and 2 provide information relative to four of the ACGME’s institutional requirements:

  • ACGME Institutional Requirement 1 A. 2. which states that both the institution and all sponsored programs must be in compliance with the organizations Institutional, Common Program , and specialty/subspecialty-Specific Program  Requirements.
  • ACGME Institutional Requirement I. B. 5, which states that sponsoring institutions must make resources available so that programs can comply with all of the ACGME’s requirements.   
  • ACGME Institutional Requirement III. B. s, which outlines the GMEC’s oversight responsibilities, including  education and work environment
  • ACGME Institutional Requirement IV A. 4, which sets forth the purposes of the internal review

Attachment 1A/B is actually completed and kept current by the ACGME, and it is available on each sponsoring institution’s Accreditation Data System (WebADS) institutional page. Enter the system, click “Site Visit Documents”, then “IRD Part 1”, and then “Attachments.”

Attachment 1A, “Program-Specific Citation Category Summary,” is a three-column chart, first listing 37 program citation categories in six major categories:

  • Institutional support
  • Resident appointment issues
  • Faculty
  • The education program
  • Evaluation
  • Experimentation and innovation

The second column shows the number of the institution’s residency and fellowship programs that have a current, or most recent, RRC citation in each category. The third column identifies specialty or subspecialty programs receiving these citations.

For example, for one of the 37 categories, “on-call rooms,” if both internal medicine and general surgery each received a citation in this category, the second column in the on-call row would simply show “2” and the third column would list “IM’ and “GS.” The ACGME updates this attachment as each of the institution’s programs receives their RRC accreditation result letter.

Attachment 1B corresponds to Attachment B by stating the actual program citation as it is contained in each program’s RRC letter. Using the same example, under the on-call category, Attachment B would again identify specialty programs, e.g. internal medicine and general surgery, the date of the RRC meeting at which the RRC reviewed each program, and then the citation itself, e.g., “Inadequate numbers of on-call rooms.”

Again, Attachment 1A and B are always available and current on ACGME’s webADS.

Attachment 2, “Response to Program-specific Citation Category Summary” is generated by the institution (i.e., by the “author of the IRD) by simply creating a new blank document. Following the citation categories as listed in Attachment 1, the institutional and program leadership should provide a concise but specific description of the action plans and  actual corrections to each citation as developed and implemented in collaboration between the institution and the individual program cited, as well as  any appropriate, available outcome measures.

Most of the responses to the citations should have already been documented in one or more documents, such as: the program’s annual self-evaluation report, progress reports to the RRC, progress report to or other discussions at a GME Committee, and an internal review report. In a few cases, mostly in very recent citations or in the absence of any existing documentation of corrections, new information might need to be collected.
Most importantly, just as the ACGME keeps Attachment 1 current, then too should the DIO and the GME Office keep Attachment 2 current. Accreditation is not about accreditation, it is about quality improvement.  A highly effective , collaborative,  sustainable and efficient method for institutions and programs to meet QI objectives is to document corrections to RRC citations,  Once Attachment 2 is drafted, it should be distributed to each involved program director for any corrections, additions, or updates.

There are two critical “red flags” that will most likely draw the attention of the Institutional Review Committee. The first is a high number of citations, whether in one or two programs or in many programs, and second is a failure to respond in a timely and complete manner to each citation. The Institutional Review Committee will understandably penalize an institution if its GMEC does not monitor programs, primarily through internal reviews, and support programs so as to avoid program citations. The Institutional Review Committee will also understandably cite institutions that appear to fail to work with its programs to correct citations.

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