Common Terms
A web-based software system to collect, organize, and
maintain information for accreditation and recognition purposes, and a means of communication
between the ACGME and Sponsoring Institutions and programs.
Accreditation Data System (ADS)
There must be a program letter of agreement (PLA) between the
program and each participating site that governs the relationship
between the program and the participating site providing a required
assignment. How often must the PLA be renewed?
10 years
All Sponsoring Institutions and programs undergo a full accreditation site
visit every ________ years
10
The individual who, in collaboration with a Graduate Medical Education Committee (GMEC), must have authority and responsibility for the oversight and administration of each of the Sponsoring Institution’s ACGME accredited programs, as well as for ensuring compliance with the ACGME Institutional, Common, and specialty-/subspecialty specific Program Requirements
DIO- Designated Institutional Official
the organization or entity that assumes the
ultimate financial and academic responsibility for a program of graduate
medical education consistent with the ACGME Institutional Requirements.
Sponsoring Institution
The single identifiable physician ultimately responsible and accountable
for an individual patient’s care, who may or may not be responsible for supervising residents or
fellows.
Attending physician
At each participating site there must be _____ faculty member,
designated by the program director as the site director, who
is accountable for resident education at that site, in
collaboration with the program director
One
Our study guide describes 8 steps to prepare for the site visit- name 1 of these 8 steps that are discussed
-Reassemble the Annual Program Evaluation/Self-Study Group to "Harvest” the Data in Areas for Improvement Identified in the Self-Study
-Discuss Improvements Made as a Result of the Self-Study with Stakeholders
-Reassess Program Aims and Other Elements of the Program's Strategic Assessment (Strengths, Opportunities, and Threats)
-Discuss Program Aims, Improvements Achieved, and Other Elements of the Program's Strategic Assessment with Program Stakeholders
-Complete and Submit the Summary of Achievements
-Update Data in the Accreditation Data System {ADS) Ahead of the 10-Year Accreditation Site Visit
-Ensure Timely Data Submission Prior to the 10-Year Accreditation Site Visit
-Set and Confirm Logistics for the 10-Year Accreditation Site Visit
The GMEC must demonstrate effective oversight of underperforming program(s) through a _________ ___________ process
Special Review
Fellows should contribute to the ___________ of residents in core
programs, if present.
Education
Specific knowledge, skills, behaviors, and attitudes in the following domains:
patient care and procedural skills; medical knowledge; practice-based learning and
improvement; interpersonal and communication skills; professionalism; and systems-based
practice.
Competencies
The sponsoring institution's _________ must approve a change in program director.
Final approval of the program director resides with the _______ __________
GMEC
Review Committee
Who conducts the accreditation site visit?
Accreditation Field Representatives
The Sponsoring Institution must maintain a policy which states
that neither the Sponsoring Institution nor any of its ACGME-accredited programs
will require a resident/fellow to sign a non-competition guarantee or restrictive
covenant. What is this referring to?
Non-competition
The program’s aims must be made available to program
applicants, fellows, and faculty members.
True/False
True
The process of determining whether a Sponsoring Institution offering
graduate medical education programs is in substantial compliance with the Institutional
Requirements.
Institutional review
The program must demonstrate evidence of scholarly activities consistent with its __________ and ________.
Mission and aims
How much notice (approx) does program leadership receive ahead of the accreditation site visit?
Approx 30 days
Voluntary, compensated, medically-related work performed beyond a resident’s
or fellow’s clinical experience and education hours and additional to the work required for
successful completion of the program.
Moonlighting
For block rotations of greater than _______ months in
duration, evaluation must be documented at least
every _______ months.
Three
Three
An event or situation that did not produce patient injury, but only because of
chance
Near miss
At a minimum, the Clinical Competency Committee must
include __________ members of the program faculty, at least ___________ of
whom is a core faculty member
One
A site visit can be _______ or __________
full or focused
Who designates core faculty members?
Program Director
At least ___________(how often), there must be a summative evaluation of
each fellow that includes their readiness to progress to the
next year of the program, if applicable.
Annually