Criteria for Excellence | Chapter 7: Program Accreditation

Key members of the residency administration include the program director (PD), associate PD, administrator, and coordinator. Appropriate recruitment, education, and retention are essential. Recruitment of appropriate staff depends on the organization’s human resources/recruiting staff’s understanding of the unique attributes of commonly hired positions relative to the educational needs of the program (e.g., information technology [IT] staff) and the positions unique to residency programs (e.g., residency coordinators and/or managers).

1. The residency coordinator and/or manager is an essential part of every
   residency program’s administration. Their many roles include providing essential accreditation system organization, supporting the PD and faculty, and supporting residents and fellows. They can provide an early warning to the PD about areas in which compliance lags to help monitor resident engagement, provision of information by the residents, work-hour compliance, and proactive scheduling. They are also core personnel that can help identify areas for process improvement.
2. The residency program or sponsor’s IT staff must be responsible for and responsive to data collection and processing of information essential to the accreditation process. The residency coordinator also plays a key role in helping to monitor data collection and progress toward resident goals by ensuring the flow of ongoing, accurate, and current data from IT and from residents documenting experiences.
   

Core faculty must be thoroughly educated in the accreditation requirements, including the need to monitor residents’ acquisition of required experiences. The faculty advisor role is essential for monitoring the successful outcome of individual resident’s educational needs to ensure graduates’ success and keep the program in full compliance.

Programs can identify areas of curricular weakness by conducting an annual review of curriculum to determine compliance with the Review Committee for Family Medicine (RC-FM) requirement for accreditation and by using In-Training Examination (ITE) scores. An active and engaged Program Evaluation
Committee (PEC), with support staff to assist in gathering data and monitoring and tracking interventions and recommendations, is key to ongoing assessment and improvement. To proactively ensure quality, programs may seek external validation of innovations and programmatic compliance (e.g., through a formal external program review).

The Common Program Requirements and the Institutional Requirements are in rapid evolution, as are their interpretation and best practices for their implementation. Program leadership must actively participate in continuous learning about application, interpretation, and best practices through attendance at appropriate educational conferences and other activities. Leadership and faculty should be encouraged to innovate and to present their curricular innovations at national educational forums.

Community and health system concerns may impede the program’s achievement of some of the ACGME requirements for accreditation. Sponsoring institutions (SIs), hospitals, and clinical systems also have priorities that could be viewed as conflicting with a residency program’s educational mission and requirements. Actively engaging hospital and clinical administration in the educational process with the PD is essential to gain understanding and support for required activities and to promote appropriate participation by the larger physician community. In partnership with the SI or other physician leadership, the PD must identify and directly address productivity pressure on the clinical system, data “protection” in the
system, institutionalized and/or historical community standards, and scopes of
practice. Program requirements specific to family physicians who provide maternity care, inpatient adult and pediatric care, and procedural care must be recognized as mandatory, and residents must be able to acquire these skills in a supportive environment.

A Program of Excellence has resources for residents who need academic support (e.g., test-taking skills, remediation of deficits in clinical reasoning and/or understanding of core knowledge content). It also offers confidential employee assistance programs and other resources to address behavioral health concerns and needs. The standard curriculum is structured, documented, and tracked to guarantee each resident has the learning experiences necessary to meet each core requirement, and the program can redirect residents’ work if they fall behind.