Steps to Conducting a Self-Study

The Self-Study Group Participants: The members of the Program Evaluation Committee (PEC) are the ideal group for the self-study group, as they are familiar with the Annual Program Evaluation process and the resulting action plans and improvement efforts. Including the Program Coordinator is also recommended.

Additional Participants: The ACGME does not require additional participants in the self-study process, it may be beneficial to have other individuals to offer their perspective. This might include department leadership, a clerkship director, chief residents (both in the accredited years of training and beyond), or experts in education, curriculum design, or assessment. These individuals should be included if program leaders think their contributions would be beneficial. The DIO may be able to give suggestions for institutional experts to include.

CCC Representative: It may be beneficial to include a member of the Clinical Competency Committee (CCC) in the self-study group. The CCC possesses educational outcome data, which could provide key input into Self-Study discussions.

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.

Programs should maintain a document for their own records that lists the strengths and areas of improvement identified during the Self-Study process in a "program improvement" file.

The next step for the Self-Study group, or an individual designated by the group, is to compile a succinct Self-Study document that describes the process and key findings in the areas of program aims, threats and opportunities assessment, and program strengths and areas for improvement. 

• Click here for a sample Self-Study template

Ideally, the role of data collection, aggregation, and tracking of progress for these areas should be assigned to an individual or to a small group (with each individual responsible for a particular area of improvement).

Conducting the self-study for a dependent sub-specialty program

The ACGME has placed added responsibility for oversight of sub-specialty programs on the core program and sponsoring institution.

The self-study group for the core program should try to coordinate activities with the self-study groups for any dependent sub-specialty programs, to take advantage of common dimensions, explore potential synergies, and reduce the burden that may be associated with conducting an independent self-assessment.

The 10-year site visits for sub-specialty programs will be coordinated with the visit of their respective core program.

A test of a voluntary self-study pilot visit

The ACGME initiated a pilot study for any program in the seven Phase I specialties (Diagnostic Radiology, Emergency Medicine, Internal Medicine, Pediatrics, Neurological Surgery, Orthopaedic Surgery, and Urology) with its initial 10-year site visit scheduled between April 2015 and January 2017 (note that the interval for the pilot was recently extended from the original end date of July 2016). The objective is to assess if an added site visit to review the self-study will accelerate program improvement. In this pilot, following the program’s self-study, a special (non-accreditation) visit for guided discussion and feedback would be conducted by a group of field representatives with added training in self-study review. Programs volunteer to be part of this pilot.

The self-study pilot visit will not be an accreditation visit, and data shared by programs will not be used to assess compliance with requirements. Twelve to 18 months after the self-study pilot visit, the program would have its scheduled 10-year site visit. Additional detailed information about the self-study pilot visit is provided in a memorandum by ACGME Chief Executive Officer Thomas J. Nasca, MD, MACP.

Click here to review the memorandum

Review Committee evaluation of programs with early 10-year site visits

For a program with an early 10-year site visit, the Review Committee’s evaluation of the self-study will not have any accreditation impact. The ACGME will conduct an extensive program evaluation of these early 10-year site visits, focusing in particular on collecting best practice information for conducting the self-study. This information will be disseminated via the ACGME website and the Journal of Graduate Medical Education.