Preparing for accreditation involves months of planning, heaps of documentation, and multiple meetings with stakeholders. The groundwork may vary according to the program and local context; however, the fundamentals remain the same.1
Until April 2020, the Oman Medical Specialty Board (OMSB), the sponsoring institution for graduate medical education (GME) in the Sultanate of Oman, had undergone traditional face-to-face site visits. With COVID-19 on the rise, conducting the site visits in the traditional way was unfeasible due to the enforcement of travel restrictions, implementation of social distancing regulations, and an increased involvement of stakeholders in the hospitals. Thus, the modality of site visits at OMSB had to change to a remote option.
As the first international organization to undergo remote accreditation site visits by the Accreditation Council for Graduate Medical Education International (ACGME-I), we have outlined our experience and provided thoughts on why and how this experience may be the way forward for accreditation and review processes. We have also outlined the feasibility of the experience and advocated for the move toward remote accreditation site visits and internal reviews in the future.
Background
Site visits for institutional and program-specific accreditation purposes were organized at OMSB between 2014 and 2019 by ACGME-I, which had accredited 16 training programs to date. These visits were performed traditionally in a face-to-face manner involving an ACGME-I field representatives traveling from the United States to the Sultanate of Oman to conduct meetings, tour facilities, and gather information related to the implementation of GME.
As COVID-19 cases increased, the program site visits scheduled for April 2020 were uncertain. With international travel restrictions, a heavy workload on the physicians, and no end to the pandemic in sight, OMSB, in coordination with ACGME-I, opted to proceed with a remote site visit.
Transition From Traditional to Remote Site Visits
To prepare for the transition to a remote site visit, it was important to study how much of the original site visit schedule could be preserved and to initiate the various new levels of coordination and management. For example, mock site visits were conducted remotely as opposed to in person, and participants were required to log in individually instead of in a group setting. Additionally, an increased involvement of the information technology department was needed. A comparison between traditional and remote site visit requirements is outlined in the Table. Also, a description of the various steps considered in the remote site visit is depicted in the online supplementary data.
Benefits and Challenges
As with any change in systems and processes, remote accreditation comes with its own pros and cons. Considering accreditation is an important public health safeguard,2 a key benefit to a remote site visit is the timely review of the program, compared to a traditional accreditation visit postponed to an unknown date. Additionally, logistics behind the day of the visit were noticeably reduced. The remote visit eliminated many tasks related to the traditional visit (Table) and resulted in a reduced number of staff required to assist with the visit day.
Remote site visits, which use electronic documents and don't require air travel, are also environmentally friendly and less expensive to conduct. With traditional visits, the organization incurs costs related to international travel, accommodation, local transportation, and refreshments on the day of the visit. Saving these costs may lead to a reduction in accreditation fees.2
Another benefit for participants is the reduced disruption of a busy clinical environment. Faculty and residents saved travel time and expenditure required to attend meetings, efficiently logged in to the meeting from their respective locations, and resumed their clinical duties immediately after the meetings.
Finally, having gone through the remote site visit, the administrative burden was less compared to a traditional site visit. OMSB staff and program leadership have adjusted to provide data in a format closer to the Next Accreditation System–International (NAS-I) requirement, which was announced by ACGME-I in 2020 for implementation on all ACGME-I-accredited institutions.
For the ACGME-I, a challenge to having remote site visits may be the time difference due to geographic locations of the field representatives and the sponsoring institutions.
Another challenge with remote site visits is the lack of an actual tour of facilities. Field representatives do not get the opportunity to experience and observe how the training sites function. Though many of the details are described in the application forms, having a physical walk-through of the facilities may contribute to a better understanding of the program and its local context.
Technology-related challenges may arise. The selection of the software used for remote meetings and sharing data and documents needs to be carefully considered. Nevertheless, despite the challenges, lessons learned are described in the Box.
Box Lessons Learned From Conducting Remote Site Visits
Prior to Visit
Involving information technology (IT) personnel is crucial. They played an important role in online setup, training residents and program faculty, and troubleshooting when necessary.
Mock remote meetings helped with familiarizing participants to the software and sharing important guidelines on conduct and “housekeeping notes” during the actual visit.
Ensuring a secure sharing platform is available to electronically share documents with the field representative needs to be taken into consideration.
Day of Visit
Busy faculty and residents saved a lot of travel time to and from traditional meeting locations.
Participants were more alert and prepared for the meetings.
Participants saved precious time for clinical responsibilities, especially during the pandemic.
The Future
The ACGME-I has recently announced the move to the NAS-I.3 The NAS-I aims to reduce administrative burden related to maintenance of accreditation and provide a continuous accreditation model. Considering the benefits of remote site visits, we encourage its incorporation in NAS-I.
From our reflection, the challenges of remote site visits may be easily overcome considering the benefits gained in return. In our case, the COVID-19 pandemic expedited the process from traditional to remote site visits. With this in mind, and considering the presence of the ACGME-I in several international countries,4 it may be a good time to recruit and train international field representatives. Having field representatives in multiple locations around the world could ameliorate the difficulty experienced with conducting remote site visits at unconventional hours. In addition, traditional site tours may be replaced in the future with live remote walk-throughs. Alternatively, a prerecorded narrated tour of the facilities may be considered. Early selection of the software as well as training and guidance for all participants will allow for a smoother implementation of remote site visits.
Local meetings and site visits have been arranged and conducted successfully using remote modalities, which included the internal reviews and annual program evaluation activities. Coupled with our most recent experience with remote accreditation, we believe that with appropriate leadership, buy-in from stakeholders, and adequate preparation, remote accreditation site visits may be the way forward, not only for international accreditation, but also for local internal reviews.
