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Accreditation Requirements 

Program Administrators play an integral role in ensuring that Graduate Medical Education accreditation standards are in place for their program. Tasks will include yearly updates of program information such as site details, changes, clinical experience and evaluation methods, update of scholarly activity for faculty and residents, update of faculty and resident rosters, gathering data in preparation for meetings and ensuring exit evaluations and summative evaluations are completed.

Responsibilities regarding maintenance and accreditation

  • Attendance of all GME Committee (GMEC) meetings, which must take place on a quarterly basis, keeping meeting minutes
  • Maintenance and tracking resident evaluation committee meetings
  • Maintenance and tracking Clinical Competency Committee (CCC) meetings
  • Attendance of the GME Annual Conference
  • Ensuring accreditation requirements are met for the Council on Podiatric Medical Education (CPME)
  • Completion of the Accreditation Data System (ADS) Annual Update
  • The ability to provide letters of accreditation from previous ACGME reviews and documentation that assures processes for selection, evaluation and promotion of residents and establishment and implementation of fair institutional policies
  • Proof of compliance regarding accreditation of patient care, quality assurance, residency eligibility and selection, supervision, work environment, etc.
  • Please refer to specialty guidelines for additional information

The ADS update is due in July, CCC Meeting in September, ACGME Annual Conference takes place in February or March.

Resources for accreditation

Additional details regarding specific accreditation requirements


Program Administrators must ensure that program information including curriculum, scholarly activity, certifications, publications, and presentations are entered into the ACGME web-based portal for faculty, as well as policies, goals & objectives.

Enter data after July 1.

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ACGME Milestones evaluate resident progress throughout their training and ensures that residents are aware of expectations and understand how they will be evaluated during their training. Program Administrators must ensure residents receive a copy of the ACGME Milestones upon entering the program and compile milestones data prior to Clinical Competency Committee (CCC) meetings.

Milestone reporting to ACGME is twice per year, November to January & May to June.

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Clinical Competency Committee (CCC) 

Milestones are a set of competencies that are expected for achievement by residents throughout their training. Milestone evaluations assist programs in determining if a resident is “on track” or should be at different points in their training. A subgroup of faculty that are selected by the Program Director comprise the Clinical Competency Committee (CCC), who complete semi-annual performance evaluations for each resident. As a requirement by the ACGME, Milestone evaluations must be reported twice a year and each resident must meet with their program director at the end of the training program to ensure that clinical competency has been met in the milestones for their specialty. The GME Program Administrator will perform the following tasks in preparation for the CCC meetings:

  • Compile and synthesize information into the performance evaluation prior to the CCC meeting
  • Locate and save a copy of rotation evaluations, in-service exam scores, procedure numbers and other valuable data which can be found in Medtrics
  • Send the meeting invitation to attendees and CCC committee members
  • Prepare the meeting agenda
  • Take notes during the meeting which may include performance improvement plans
  • Observe meeting dynamics & provide feedback if needed
  • Report milestone progress to ACGME via WebADS

CCC Meetings will take place in November and April.

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Semi-Annual and/or Quarterly Evaluations

Resident evaluations will be conducted on a semi-annual or quarterly basis, dependent on each site’s preference. Resident self-assessment data and learning plans will be collected, evaluation summaries, any conference attendance information, and 360-degree evaluations will be reviewed by each program director. The Program Administrator will perform the following:

  • Download and prepare data for quarterly or semi-annual resident evaluations.
  • Share results with the program director.
  • Schedule meetings as necessary for each specialty.
  • Begin planning in August for semi-annual evaluation which typically occurs in December.

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ACGME Survey for Faculty, Residents and Fellows

Prepare active residents and fellows for the annual ACGME “State of the Residency” survey. Send notification with access and survey link by logging into ADS, click the “Surveys” tab and click “View/Remind Takers” and follow instructions to send an email reminder. Also include a reminder to complete program-specific questions. This survey contains questions about clinical and educational experiences within each program.

This required survey is available from January to April and a summary of results will be available annually in ADS.

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Program Evaluations for Faculty, Residents and Fellows, and GME Survey for Residents/Fellows

Prepare active residents and fellows for the GME Program evaluation by Resident and Faculty and Resident evaluation of faculty. Notify and send a reminder with all survey links to participants and be prepared to share results with the program director and specialty program director. The Program evaluation by Resident and Faculty and the Resident evaluation of Faculty is administered once a year, in April.

The GME staff survey is administered yearly, between October and November.

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Final Evaluations

A final (summative) evaluation must be completed by the program director to provide a final evaluation for each Resident and/or Fellow. Required components of the evaluation include demonstrated knowledge, behaviors, and skills necessary to enter unsupervised practice and should consider recommendations from the CCC committee. The final evaluation will become part of the resident or fellow’s permanent record maintained by the institution and must be shared with the Resident/Fellow. The Program Administrator will be responsible for ensuring surveys are entered into Medtrics, meetings are scheduled with the program director and resident or fellow and ensure that the final evaluation is signed by the Program Director.

The final evaluation should take place in May.

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Resident Evaluation Committee/Annual Program Evaluation (APE)

The Annual Program Evaluation (APE) survey is used to collect aggregate information from a single year. Questions should include number of learners, program changes in the past, plans for upcoming changes, faculty development, graduate performance, and key findings and action plan. The Program Administrator will collect all final APE documentation by the program director and upload to Medtrics by July.

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Work Hours

Program Administrators must ensure that Residents and Fellows are following ACGME common program requirements that respond to work-life balance. Common program requirements maintain that residents should not exceed an 80-hour work limit, must be off for one day in a 7-day period, and clinical work periods must not exceed 24 hours of continuous scheduled clinical assignment. Program Administrators will set up each trainee profile accordingly, in Medtrics, enter schedules for each trainee and set up their administrative profile to receive reminders. Residents and Fellows will provide feedback such as time off or vacation prospectively.

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Site Visit

GME programs must be prepared for periodic on-site visits to assess compliance with Institutional and Program Requirements. Accreditation and recognition site visits will be conducted by ACGME Accreditation field representatives using remote technology; however, sponsoring institutions and programs will be notified when a site visit should be conducted in person. There are several types of GME site visits and include the following:

  • Program Applicants
  • Sponsoring Institutions and Programs with Initial Accreditation
  • Continued Accreditation: Annual Data Review Site Visit
  • Continued Accreditation: 10-Year Accreditation Site Visit
  • Probationary Accreditation
  • Complaint
  • Other Site Visits, (such as JCAHO) upon request

For a full list of site visit requirements and types, see:

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With the goal of achieving overall program improvement, the ACGME Self-Study is a comprehensive evaluation of each residency or fellowship program. Using a SWOT (strengths, weaknesses, opportunities, threats) analysis, programs will measure effectiveness before the 10-year ACGME Accreditation site visit.
The Program Administrator will work with the Program Director to perform the following:

  • Assemble the self-study group
  • Engage program leaders in discussions regarding program aims
  • Synthesize data from annual program evaluations
  • Create a longitudinal assessment of program strengths and areas for improvement
  • Examine opportunities and threats within the program
  • Obtain stakeholder input on strengths and areas for improvement
  • Maintain meeting minutes
  • Complete the summary of achievements

This is performed once, per 10-year cycle.

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The purpose of the Clinical Learning Environment Review (CLER) site visit is to provide GME and hospital leaders, and clinical staff with formative feedback aimed at improving patient care. To prepare sites for the CLER site visit and provide a tool that can be used for self-assessment, a Regional GME CLER Report Card and user guide have been created. The purpose of the report card is to provide material for our GME leaders, such as DMEs, to do a high-level self-assessment of the entire clinical learning environment (CLE) at their respective medical center. Not just in preparation of a site visit, but more importantly, for continuous improvement efforts. Program Directors, residents/fellows, and GME staff can be asked to join CLER discussions based on what their GME team is doing.
With a focus on six key areas, (patient safety, healthcare quality, teaming, supervision, well-being, and professionalism), clinical sites will be able to optimize on the delivery of consistently safe, high-quality patient care. Working closely with the GME Program Director, the Program Administrator will perform the following:

  • Schedule planning meetings with program directors and hospital leaders
  • Maintain meeting minutes
  • Update organizational chart for the hospital and/or site and GME department
  • Update accreditation site documents pertaining to patient safety, healthcare quality, teaming, supervision, well-being, and professionalism

The CLER accreditation site visit takes place approximately every 18-30 months for each GME site.

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