Preparing for Accreditation Council for Graduate Medical Education–International accreditation: exploring approaches, insights and learning experiences through accreditation journey of residency program

1. Introduction

Preventive and Community Medicine Residency Program (PCMRP) was launched in Qatar in 2004 by Hamad Medical Corporation in collaboration with Primary Health Care Corporation. The program aims to enhance residents’ competency in community health through diverse academic, clinical, and population-based experiences. The PCMRP is a 48-month residency program and is accredited by the Arab Board Specialty. After implementing structured residency program for 15 years, PCMRP leadership thought, it was the time to explore international accreditation opportunities. The residency programs in other specialties in the region were already moving towards Accreditation Council for Graduate Medical Education–International (ACGME-I) due to its advantages in enhancing medical education with international standards [1].

The article explores successful journey of accreditation including multiple activities, challenges, and learning experiences. The practical approaches to integrate ACGME-I requirements and existing structure of residency program was restructured to overcome challenges. These insights may be beneficial for policy makers to understand unique features of ACGME-I site visits and to identify ways to prepare for the accreditation process.

2. Phase-wise preparation for ACGME-I accreditation

The accreditation preparation journey was implemented at PCMRP, Department of Family and Community Medicine, Doha, Qatar.

1) Phase I: Situational analysis, groundwork, and planning

a. Step 1: Formation of ACGME-I accreditation working group

The ACGME-I accreditation working group (AWG) was formed with program director (PD), associate program director (APD), core faculty, and residents. The roles, action plans, and schedule of meetings were prepared and shared.

b. Step 2: Situational analysis and planning

The accreditation preparation process was executed through AWG. A comprehensive understanding of program requirements and documents was ensured by members. This helped us to comprehend the critical differences between the ACGME-I and Arab Board standards and what needs to be changed in the existing program.

c. Step 3: Creation of accreditation WhatsApp group and shared folder

To facilitate smooth functioning of accreditation work, WhatsApp group named “ACGME-I group” was formed to share related resources and updates. “ACGME-I accreditation shared folder” was created so that members could access and share resource material from different locations. WhatsApp platform was proved to be beneficial in sharing and discussing resource material especially during COVID-19 (coronavirus disease 2019) pandemic with restricted in-person interactions. It fostered collaborative learning, improved communication skills and enhanced knowledge about ACGME-I work. Similar experiences were reported in other studies [2,3].

d. Step 4: Getting advice and support

We contacted stakeholders from different levels for their inputs to strengthen accreditation preparation process. The guidance about accreditation application and requirements was acquired from other speciality programs who had already successfully navigated the transition to ACGME accreditation. In-person meetings were scheduled with Designated Institutional Official, department chair and training site officials for their orientation, perspectives, and feedback about ACGME aligned program. However, “open informal discussions” between PCMRP leaders and stakeholders was observed to be the most effective strategy to involve stakeholders actively in the accreditation process. Al-Bualy et al. [1] also reported similar findings in their study about stakeholder’s involvement. Whenever required, ACGME staff was also guided using Microsoft Teams, especially for video conferencing and sharing large document files.

2) Phase II: Prominent activities

a. Step 1: Milestone mapping

Milestones mapping was most complex tasks in the preparation process. Initially, AWG reviewed program requirements, certification examination outlines, and blueprints, and developed consensus towards aligning milestones that could provide a narrative description of competencies and sub-competencies along a developmental continuum. The weekly interactive sessions were conducted over a 6-month period and each core faculty presented pre-assigned mapped curriculum component in every session.

b. Step 2: Review and up gradation of documents

Several face-to-face group meetings were organized to revise documents including program letters of agreement (PLAs), evaluation forms, didactics, block diagrams, and so forth.

c. Step 3: ACGME-I sensitization workshops for residents

In the literature, there is a dearth of information on resident perceptions towards ACGME. The limited interaction between residents and ACGME can jeopardize the quality of information from residents and its value to ACGME [4]. Along with regular scheduled meetings, six interactive full day workshops were designed for all residents of PCMRP. The workshops intended to both introduce an ACGME-I aligned curriculum and retrieve constructive feedback for its improvement. These workshops were planned mostly on weekly “academic day” (regular educational activity). Each workshop focused on multiple elements of ACGME-I and were presented by faculty and residents (Table 1). Each member presented and discussed pre-assigned topic during workshops (Table 1). The validated quizzes for each topic were prepared and presented by volunteer residents. The emerging suggestions from the workshops were beneficial in revising the program curriculum.

Table 1.

Workshop on ACGME-I Accreditation

Time	Title of topic	Presenter
7.30 AM to 9 AM	Policies summary and discussion
	GME 1015: Oversight policy for GME programs	Resident A
	GME 1013: Leave policy for residents	Resident B
9 AM to 9.15 AM	Quizzes on policies	Resident C
9.15 AM to 9.45 AM	Break
9.45 AM to 11 AM	Policies summary and discussion
	GME 1019: Graduate medical education policy	Resident D
	GME 1036: Clinical attachment policy	Resident E
11 AM to 11.15 AM	Quizzes on policies	Resident C
11.15 AM to 11.30 AM	Break
11.30 AM to 1.30 PM	Program orientation	Faculty A
	Promotion criteria
	How to get ready for CCC evaluation
1.30 PM to 1.45 PM	Quizzes on program orientation	Resident C
1.45 PM to 2 PM	Summary, take home message, and wrap up	Resident C

ACGME-I: Accreditation Council for Graduate Medical Education–International, GME: Graduate Medical Education, CCC: Clinical Competence Committee.

d. Step 4: Creation of question bank by residents and faculty

All members were encouraged to prepare possible topic-wise questions with detailed answers related to ACGME accreditation. The question bank was circulated on WhatsApp groups for further reading and preparation. In addition to a significant improvement in knowledge regarding the ACGME-I accreditation process, this activity also enhanced group dynamics, self-directed, and collaborative learning among residents.

e. Step 5: Capacity building initiatives

Program members were motivated to participate in ACGME related academic events to enhance their skills in areas like competencies-based assessment, milestone mapping, curriculum design, and so forth. The exposure to these activities led to a noticeable increase in knowledge of ACGME components among members.

3) Phase III: Final preparation

a. Step 1: Pre-Mock Program Site Visit

PCMRP decided to conduct an initial program mock visit before proceeding to the actual mock visit by the internal review committee (IRC) of the sponsoring institution. It was intended to ensure consistency of required documents, identify preparedness gaps, and increase self-confidence among members. The pre-mock visit was facilitated by PD, APD, and senior faculty of the program. This initiative provided an opportunity to rectify unwanted citations, to reduce preparation gaps, and offered additional insights for better preparation for a mock visit by IRC. Therefore, it is strongly recommended to have a pre-mock visit at the program level before IRC mock reviews. The idea of organizing “pre-mock visits” before actual mock visits is not a widely reported or recognized concept in the current literature. Although the concept of mock visits, used for practice and training purposes, is established, the notion of a preliminary “pre-mock” step seems to be a novel strategy.

b. Step 2: Internal review committee mock reviews

Our preliminary robust pre-mock reviews received positive feedback and minimal citations from IRC during actual mock visits. However, the suggestions in areas like program evaluations, teaching-learning methods, and faculty development provided by IRC were useful for strengthening program documentation and standards.

3. Strengths, challenges, and lessons learned

1) Strengths

Our successful accreditation journey involved a multifaceted approach. An open-door policy, robust partnerships, active resident engagement, and extensive reviews were key elements (Table 2). They worked together to build a conducive environment, ensured diverse perspectives, and enabled continuous improvement.

Table 2.

Top 10 Practical Tips to Facilitate ACGME-I Accreditation Process

No.	10 Practical tips
1.	Ensure minimum/no citations during pre-mock visit at department level before IRC mock reviews.
2.	Conduct interactive workshops for residents for ACGME-I sensitization and involve all residents rather than selecting only nominated residents.
3.	Obtain extensive inputs from multiple stakeholders prior to accreditation preparation journey.
4.	Ensure strong coalitions with partners from participating sites.
5.	Encourage faculty and residents to actively participate in multiple ACGMEI related educational events like workshops, webinars, conferences, seminars, and so forth.
6.	Utilize weekly academic day to train residents about ACGME-I with least disruption of their routine professional work.
7.	Ensure appropriate process documentation throughout accreditation journey.
8.	Ensure the shared understanding of residents about goals, work, and program requirements of ACGME.
9.	Involve all residents in accreditation process rather than focusing on selected/nominated residents.
10.	An open-door communication strategy with faculty and residents must be encouraged.

ACGME-I: Accreditation Council for Graduate Medical Education–International, IRC: Institutional Review Committee.

2) Challenges

The primary challenge for PCMRP is that it provides oversight training to residents at various centers which are not under PCMRP jurisdiction. The routine operations and quality standards were initially managed by program evaluation committee (PEC). However, during the accreditation preparation process, the standards were revised by PEC and AWG after discussing with training site partners.

Making the necessary structural modifications in the program was one of the hurdles faced by PCMRP. Similar experience was also perceived by Oman Medical Specialty Board [1], and they overcame this challenge mainly through coalitions of stakeholders and multiple meetings. However, along with networking and partnerships, additionally, we conducted several pre-mock visits, extensive sensitization workshops with residents, and smart use of social media platforms to conquer this challenge.

Trainee perspectives are essential in accreditation because they bridge the gap between patient care experiences and the academic program’s effectiveness [5,6]. However, introducing the newly implemented ACGME-I aligned curriculum to residents was difficult as many residents were vaguely familiar with ACGME and had mixed perceptions about it. Initially, many residents perceived ACGME as burdensome and disconnected move towards existing program curriculum. Similar findings were also documented in another study [7]. However, workshops and individual meetings improved their views towards ACGME. The majority of residents acknowledged positive interactions, welcomed curriculum changes, and provided suggestions for improvement. Al-Mohammed et al. [8] also reported progressive improvement in resident performance in Qatar after restructuring the program through ACGME accreditation.

Completing ACGME documents like block diagrams, millstone mapping, and PLAs were time-consuming tasks, but they were addressed through extensive reviews and personal interactions. Implementing milestone-based assessment practices needed a comprehensive revision to ensure that they are explicitly linked to milestones. However, strategies like rethinking sources of assessment data, enhancing faculty assessments, and revising assessment tools made the process smooth and improved the program curriculum.

3) Lessons learned

Strong alliances with participating sites are indispensable for the eventual success of the accreditation process. Residents’ contributions are greatly influential in recognizing and addressing barriers specific to the residency program [9]. Actively involving residents in decision-making and promoting their leadership skills can transform them into catalysts for innovation and quality improvement. Similar opinions are also supported by Elkhaled et al. [9]. Frequent meetings and workshops are effective not only in ascertaining expectations and perspectives but also in facilitating better interpersonal relationships between faculty and residents. This finding is congruent with other studies [1,9].