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The first task of the self-study group is a discussion of program aims. Aims are program and institutional leaders’ views of key expectations for the program, and how it differentiates itself from other programs in the same specialty/subspecialty. Aims may focus on the types of trainees recruited into the program, training for particular careers (clinical practice, academics, research, primary/generalist care), and other objectives, such as care for underserved patients, health policy or advocacy, population health, or generating new knowledge. Aims may also include other objectives, such as care for underserved patients, health policy or advocacy, population health, or generating new knowledge.

• Review this brief slide presentation on how to set and validate program aims.

Program aims should generally be vetted with program and institutional leadership, and in some institutions, setting aims will be an institution-level initiative. In setting aims, programs should generally take a longer-term strategic view. However, aims may change over time. Factors such as a shift in program focus initiated by institutional or department leadership, changes in local or national demand for a resident workforce with certain capabilities, or new opportunities to train residents and fellows in a different setting may prompt revision of program aims.

The central data for the Self-Study is information from a successive Annual Program Evaluations, with a focus on program strengths and self-identified areas for improvement; how improvements are prioritized, selected, and implemented; and follow-up to assess whether interventions were effective. 

Added data for the Self-Study should relate to ongoing improvement activities and the perspectives of program stakeholders, such as results of the annual ACGME Resident and Faculty Surveys, and relevant departmental or institutional data.

• Review a list of high-value data suggested for use in the Annual Program Evaluation and the Self-Study.

Data aggregation and evaluation should (1) address any active citations and areas for improvement from the program's most recent review; (2) identify any additional areas where the program may not be in compliance with ACGME requirements; and (3) focus on improvement that goes beyond compliance with requirements, with particular attention to improvements relevant to the program's aims.

• Click here for a single year's Annual Program Evaluation template
• Click here for tracking improvement longitudinally across multiple Annual Program Evaluations

The next step in the Self-Study process is to conduct an assessment of the program’s environment. The rationale for examining opportunities for and threats facing the program is to provide context for the self-study.

Opportunities: Opportunities are external factors that are not entirely under the control of the program, but if acted upon, will help the program flourish. Opportunities take many forms, such as access to expanded populations for ambulatory care at a local health center, partnering with an institution with a simulation center, or availability of new clinical or educational technology through agreements with external parties.

Threats: Threats also are largely beyond the program's control and come in many forms. They could result from a change in support for resident/fellow education at the national level, from changing priorities at the institutional or state levels, or from local factors, such as erosion of a primary ambulatory system based on voluntary faculty. The benefit of assessing program threats is that plans can be developed to mitigate their effect.

•  Review this resource for how to conduct a SWOT analysis (an environmental assessment)

These data should be confirmed and augmented by information from program stakeholders (residents/fellows, faculty members, others as relevant). In some cases, important information may include the perceptions of representatives from other specialties who interact with the program's residents or fellows.

To collect this information, the program may use surveys, conduct meetings with residents/fellows, or organize a retreat. Feedback from recent graduates could also provide useful data on the program's educational effectiveness. The only circumstance that may impact accreditation is if the program does not conduct a Self-Study.

Engagement of stakeholders (faculty members, residents, and others, as determined by program leaders) in ongoing conversations about what does and does not work in the program is a critical component of the Self Study. Stakeholders should also be engaged in a discussion of program aims and an assessment of program context, either as part of the Self-Study or Annual Program Evaluation, or as a stand-alone activity to jumpstart the program's improvement process.

• See this Guidance for the Plan-Do-Study-Act (PDSA) process for critical questions to ask at the four phases of the process.

Program leaders, the program coordinator, and others as needed, should assemble a "program improvement" file from prior Annual Program Evaluations and past action plans to use as a starting point for this program improvement effort.

The next step is to interpret the aggregated data from the Self-Study. Specific elements will include:

1. establish a working set of program aims
2. list key program strengths
3. prioritize among the self-identified areas for improvement to select those for active follow-up, and to help define the specific improvement activities
4. discuss opportunities that may enhance the program, and developing plans to take advantage of them
5. discuss threats identified in the Self-Study, and developing plans to mitigate their impact
6. conduct a five-year look-back using the data from Annual Program Evaluations
7. conduct a five-year look forward that also seeks to answer the question, "What will take this program to the next level?"
8. describe any learning that occurred during the Self-Study

The Self-Study findings from the five-year look forward and the vision for the program should be shared with faculty members and residents/fellows. This step should validate the findings and improvement priorities identified by the Self-Study group with these key stakeholders.

For a specialty program with dependent subspecialty programs, there should be a discussion about any common strengths, areas for improvement, and shared opportunities and threats for some or all of the dependent subspecialties. These may be important priorities for improvements, particularly those requiring institutional resources. Programs should maintain a list of strengths, areas for improvement, and opportunities and threats shared among some or all of the dependent subspecialties.