Checklist for Applying for a New Program or Accreditation of an Existing Program

During the past seven years, the education staff, faculty, and hospital administration at Mount Sinai Medical Center in Miami Beach, Florida, have started five new residencies, launched two new fellowship programs, and expanded two existing residency programs.

All are Accreditation Council for Graduate Medical Education (ACGME) accredited. We have had three accreditation site visits and one ACGME Clinical Learning Environment Review (CLER) visit in the past two years. The application and accreditation process are complex and require significant work to be successful. This is a step-wise process and one with many people involved. Using a checklist helps us be efficient and successful. I hope this checklist helps others with their application and accreditation visits.

Applying for a New Residency or Fellowship Program

Get Institutional Approval

1. Assess the need of the program for:

   1. Community

   2. Patients

   3. Institution

   4. Faculty

   5. Learners

2. Identify education champions

   1. Eager and committed to establish the program

   2. Respected clinician

   3. Respected educator

   4. Experienced educator

   5. Facile with ACGME.org and Microsoft applications

3. Review ACGME website for requirements to be sure we have all we need in place or have easy and excellent associated programs that can fulfill all requirements.

4. Present proposal to designated institutional official (DIO).

5. Present proposal to director of education.

6. DIO to present proposal to chief executive officer for review and approval.

In collaboration with DIO:

1. Determine if program champion is to be program director (PD). If not, appoint program director.

2. Appoint program coordinator (PC).

3. Develop a budget, taking into consideration:

   1. Learners’ salary and benefits and learner support such as books, information technology, food, travel, board course, white coat, beeper

   2. Faculty salary support and cost of time away from clinical activity (lost RVU billing).

   3. Education department expenses for coordinator, space, and information technology.

4. Present proposal and budget to CFO for financial review and approval of budget.

5. Get approval of department chair.

6. Get approval of other program director, if necessary, such as fellowship under internal medicine.

7. Get approval of chair of Graduate Medical Education Committee (GMEC).

8. Get approval of GMEC.

After Institutional Approval, Secure ACGME Approval

1. DIO logs into ACGME Accreditation Data System (ADS) website to enter information about application, PD, PC, and department chair.

2. Review ACGME application requirements. Involve PD, PC, GME leader, and DIO.

3. Check dates for residency committee meeting and application deadline and be sure everyone is informed and has a timeline.

4. PD calls ACGME residency program leader to get input about application for focus or suggestions.

5. Develop checklist of documents needed or work from ACGME application summary — typically 13–14 documents. www.acgme.org

6. Implement a shared drive with a unique folder for each document to save latest versions and avoid having everyone working on different versions.

7. Meet with program director, coordinator, and director of education weekly until application is complete and submitted to review progress.

8. PD and PC meet weekly to review documents and discuss plans for completing the application.

9. Review ACGME online ADS questions and input regularly.

10. Answer questions, directly and completely — no “fluff.”

    1. Consider copying the question with edits into the answer box

    2. Provide no more than what is asked for; if one example is requested, do not provide two.

    3. Watch word count when limited by ADS.

11. Complete the application.

    1. PD and DIO ensure all institutional resources are included as well as specifics of the program.

    2. Note ACGME requirements for months of training for specific rotations.

    3. Be sure application numbers for rotations are same as block diagram.

12. Provide faculty list.

    1. Check number of required core faculty and be sure this number is included; no need to have more.

    2. Get curriculum vitae of each faculty member with current scholarly activity for past year.

13. Provide scholarly activity.

    1. Upload scholarly activity in ADS for all faculty and in application for those requested.

14. Provide Program Letter of Agreement (PLA). Discuss need for outside sponsoring institution rotations. If needed:

    1. DIO contacts DIO, chief medical officer, or education office of outside sponsoring institution so they are aware.

    2. PD contacts outside PD to discuss need and opportunities.

    3. PD reviews standard AAMC PLA and signs.

    4. DIO signs PLA.

    5. PD sends to PD at outside institution.

    6. Discuss PLAs weekly at team meeting to be sure these are signed and returned early.

    7. Once all PLAs are signed by all, save in one PDF to be submitted. Label each with ADS assigned site number (Site 1, Site 2, etc.).

15. Outline evaluations.

    1. Use your electronic residency data program if possible.

    2. Be sure to include Milestones and Procedures if appropriate.

    3. Have semiannual, final, 360 feedback, as well as resident and faculty evaluations as listed on application list.

16. Provide Block Diagram. Be sure it is clear, no frills, and has 12 months of rotations each year. Use ACGME template.

17. Have a faculty member from a different program who is experienced with ACGME requirements review ADS and key documents as a program consultant. Consider chair of GMEC or other faculty member familiar with ACGME requirements.

18. Review Moonlighting and decide if permitted or not.

19. PD, PC, DIO, and education manager review all application and documents a few days prior to submission date.

20. Submit at least one day before due date.

21. Call review committee to be sure submission was received.

22. If site visit planned, get bio of reviewer from ACGME.org .

After Date of Accreditation Visit Is Set, Prepare for Visit for Accreditation

1. PD, PC, GME leader, and DIO review ACGME program-specific and common program requirements. www.acgme.org

2. Review bio of reviewer. www.acgme.org

3. Confirm date needed to update ADS and upload all documents.

   1. Typically 14 documents.

   2. Typically two weeks before the site visit.

   3. Use one day before required date as planned deadline.

4. Confirm what documents to email to the reviewer and by what date.

5. Develop specific checklist of documents needed based on ACGME letter.

6. Implement a shared drive with a unique folder for each document.

   1. One folder for application, one for documents to email to reviewer, and another for documents to upload.

   2. Save latest versions and avoid working on different versions of documents.

7. Meet with program director, coordinator, and director of education weekly until documents are complete and submitted to review progress.

8. PD and PC meet weekly to discuss application and documents.

9. Review last two years of anonymous survey of residents and faculty and be prepared for questions about weak areas, including Common Program Requirements Section VI questions about duty hours, wellbeing, and patient safety.

10. Review ADS questions and input once or twice a week.

11. Block Diagram: Be sure it is clear, no frills, and has 12 months of rotations each year.

    1. Confirm all rotation requirements for the program are met.

    2. Use ACGME template.

12. Update Major Changes to the Program.

13. Update Mission and Aims.

14. Update application with current and future activities:

    1. PD and DIO ensure all institutional resources are included as well as specifics of the program.

    2. Be sure of ACGME requirements for months of training for specific rotations.

    3. Confirm that application rotation months match the block diagram.

15. Answer questions, directly and completely, no “fluff.”

    1. Consider copying the question with edits into the answer box

    2. Provide no more than what is asked for; if one example is requested, do not provide two.

    3. Watch word count when limited by ADS

16. Faculty list

    1. Check number of required core faculty and be sure this number is included, and no more.

    2. Get CV of each faculty with current scholarly activity for past year.

17. Scholarly activity

    1. Upload scholarly activity in ADS for all faculty and in application for those requested.

18. Program Letter of Agreement (PLA)

    1. Double check signatures, including DIO, on each PLA.

    2. Confirm dates of PLA approval.

    3. Discuss PLAs weekly at team meeting to be sure these are returned and signed early.

    4. Once all PLAs are signed and confirmed by all, save in one PDF to be submitted. Label each with ADS assigned site number (Site 1, Site 2, etc.).

19. Citations:

    1. Be sure all are addressed in a comprehensive manner.

20. Evaluations:

    1. Use your electronic residency data program if possible.

    2. Be sure to include Milestones and Procedures if appropriate.

    3. Have semiannual, final, 360 feedback as well as resident and faculty evaluations as listed on application list.

21. Have a non-program faculty member review ADS and key documents as a program consultant. Consider chair of GMEC or other faculty member familiar with ACGME requirements.

22. Review Moonlighting and decide if permitted or not.

23. PD, PC, DIO, and education manager review all application and documents a few days before submission date to ensure:

    1. All questions are answered.

    2. No spelling or grammar errors appear.

    3. Questions are answered directly.

    4. Word counts where required are followed.

24. Submit at least one day before due date.

    1. PD submits and DIO approves.

    2. Documents and information in ADS.

    3. Email to reviewer.

25. Submit a list of PD, PC, institutional education coordinator, and DIO to reviewer. Include name, email, and mobile phone number.

26. Call/email reviewer to be sure submission received.

27. Meet with residents and faculty in advance of site visit at least once each and then once as a group.

    1. Be sure all are aware of importance of the review — the program accreditation is at stake.

    2. Stress it is not a complaints session; PD should be available always.

    3. Review citations so all are aware of improvements.

    4. Address any questions.

    5. Consider a practice site visit with an outside reviewer.

Next Steps:

We use our checklists for many activities. This checklist includes steps for applying for new education programs and preparing for an accreditation visit. The ACGME is helpful for applicants and programs and provides excellent information on its website. The people at the ACGME are also helpful in answering questions and providing suggestions. I recommend using those resources.