Full ACGME Site Visit Documentation

Sponsoring and Participating Institutions

  1. Current, signed Program Letters of Agreement (PLA), Resident Appointments and Evaluations

Resident Appointment and Evaluations

2. Files of current house officers and recent program graduates

3. If applicable, files of house officers who have transferred into the program (including documentation of previous experiences and competency-based evaluations)

4. If applicable, files of house officers who have transferred to other programs

5. Evaluations of the house officers at the completion of each rotation or assignment

6. Evaluations showing use of multiple evaluators (faculty, peers, patients, self and other staff - 360 degree evaluation)

7. Documentation of house officers' semi-annual evaluations of performance

8. Final or Summative Evaluation of house officers, documenting performance during the final period of education and verifying that the house officer has demonstrated competence to enter practice

9. Completed annual written Confidential Evaluations of faculty by house officers

Educational Program

10. Overall educational program goals

11. A sample of competency-based goals and objectives for one assignment at each educational level

12. Didactic and conference schedule for each year of training

Program Evaluation

13. Written description of the program's Clinical Competency Committee (membership, semi-annual resident evaluation process, reporting of Milestones evaluation to the ACGME, CCC advising on resident progress including promotion, remediation and dismissal)

14. Written description of the program's Program Evaluation Committee (membership, evaluation and tracking protocols, development of written Annual Program Evaluations, and improvement action plans resulting from the APE)

Duty Hours and the Learning Environment

15. Policy for supervision of residents/fellows (addressing progressive responsibilities for patient care, and faculty responsibility for supervision) including protocols defining common circumstances requiring faculty envolvement

16. Program policies and procedures for residents'/fellows' duty hours and work environment including the /wiki/spaces/OLD/pages/32928

17. Sample documents for episodes when residents/fellows remain on duty beyond scheduled hours

18. Resident Duty Hour Compliance Report (exceptions)

Quality Improvement

19. Sample QI Project Documentation offering evidence of resident/fellow participation in quality and safety improvement projects

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