Templates/ACGME Self-Study

ACGME Self-Study Template

Stop starting from scratch. Start with a framework that surveyors recognize.

The ACGME self-study process intimidates most programs because there's no official template — ACGME describes what the process should accomplish without prescribing exactly how to run it. This template was built from years of running self-studies across programs at HCA Healthcare and Vanderbilt, and refined based on what surveyors actually look for during site visits. It gives your program a concrete starting point while leaving room for the program-specific content that makes your self-study genuine.

What's included

  • →Gap analysis worksheet — map your program against current ACGME requirements by section
  • →Evidence tracker — organize your compliance documentation by requirement area
  • →Self-study narrative outline — structure your written self-study with surveyor-tested section headers
  • →PEC meeting framework — agendas, documentation templates, and action plan tracker
  • →Site visit preparation checklist — 45-point checklist for the 90 days before your visit
  • →Sample completed sections — annotated examples of strong self-study narrative writing

Who this is for

  • ✓Programs preparing for an upcoming ACGME site visit
  • ✓Programs building their first structured self-study process
  • ✓New program directors who inherited a program without a self-study infrastructure
  • ✓GME offices standardizing self-study processes across multiple programs

Preview

Gap Analysis Worksheet — Sample Row

The gap analysis maps each ACGME requirement to your current compliance status and evidence.

Requirement: The program must have a Program Evaluation Committee (PEC) that includes at least one resident. | Status: ✓ Met / ⚠ Partial / ✗ Not Met | Evidence on file: PEC charter, meeting minutes (last 12 months) | Evidence needed: Resident member documentation | Owner: Program Coordinator | Target date: [date] | Notes: Current resident member term expires [date] — need to confirm successor

Self-Study Narrative Outline — Section Headers

The narrative outline provides the structure for your written self-study document.

1. Program Overview and Mission | 2. Self-Study Process Description (how you ran the process, who was involved, timeline) | 3. Areas of Strength (with evidence) | 4. Areas for Improvement — Identified Problems (specific, honest) | 5. Action Plans (completed actions with dates and evidence; ongoing actions with timelines) | 6. Outcomes and Evaluation (what changed as a result of your actions) | 7. Continuous Improvement Cycle (demonstrate ongoing self-study, not just pre-visit preparation)

PEC Meeting Action Plan Tracker — Sample

Track identified problems, actions taken, and outcomes in a format surveyors can follow.

Problem identified: Resident satisfaction with feedback scores declined from 78% to 64% between 2023 and 2024 APE surveys | Date identified: October 2024 APE | Root cause: Faculty not completing end-of-rotation evaluations within required timeframe | Action taken: Program director sent individual emails to non-compliant faculty; evaluation completion now tracked monthly | Date completed: November 2024 | Outcome measurement: Evaluation completion rate increased from 61% to 89% by December 2024 | Follow-up: Monthly tracking continues; will re-survey residents in April 2025 APE

How to use this template

  1. 1Start with the gap analysis worksheet — complete one row per ACGME requirement section before doing anything else
  2. 2Use the evidence tracker to inventory what you already have versus what you need to gather
  3. 3Schedule PEC meetings using the meeting framework — don't write the narrative until you've run the process
  4. 4Draft the narrative using the outline after your PEC has completed its analysis
  5. 5Use the site visit checklist in the 90 days before your visit to make sure nothing falls through the cracks
Glossary: self studyExamples: ACGME Self-Study

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