Addressing Citations in an ACGME-I Psychiatry Residency Program: From Probationary to Continued Accreditation Within 13 Months Open Access

In May 2022, the psychiatry residency program at Hamad Medical Corporation, the primary and largest health care institution in the state of Qatar, was placed on probationary accreditation following a site visit conducted by Accreditation Council for Graduate Medical Education International (ACGME-I) representatives. This decision was precipitated by a progressive decline in residents’ ACGME-I annual survey scores, coupled with the accumulation of 9 citations over the preceding years (online supplementary data Table). Citations from the ACGME-I indicate areas of concern that require prompt attention for compliance with the accreditation standards.¹  In this perspective, we explore the strategies we adopted to effectively and rapidly tackle citations, transform deficiencies into strengths, and successfully regain full accreditation within a 13-month period. We hope to provide insights and strategies for other training programs facing similar challenges in their journey towards academic excellence and continued accreditation.

Residents’ contributions are instrumental in identifying and addressing challenges specific to the residency program. By actively involving them in decision-making and nurturing their leadership skills, residents become catalysts for innovation and quality improvement.²  Following placement of probationary status, program leadership swiftly established well-structured, resident-led committees in which all residents worked collaboratively with the chief resident and program director (PD) to improve the program. In addition to expanding leadership opportunities for residents, this initiative comprehensively oversees a range of program components, from enriching educational experiences to ensuring the overall well-being of residents (Figure). Numerous accomplishments, including the introduction of a residency handbook, establishment of online educational resources, and coordination of social activities, were made possible through resident contributions in resident-led committees.

While programs frequently give precedence to addressing citations in order to successfully overcome probation, it is equally imperative to follow the ACGME’s guideline of refraining from acquiring new citations throughout the probationary period.³  Therefore, our approach focused on enhancing the program holistically, to extend beyond the correction of citations and encompass other program areas. For instance, during the probationary period, we introduced a lactation room, updated the learning objectives and goals for all rotations, and introduced new clinical rotations; none of these areas were cited as areas of noncompliance by the ACGME-I (online supplementary data Table).

Regularly highlighting program accomplishments through official communication platforms, such as newsletters, serves as a powerful tool to showcase program successes and cultivate positive perceptions internally and externally.⁴  After being placed on probation, we started a monthly program newsletter, which highlights program updates, achievements, innovations, awards, publications by residents, and social events. Moreover, the newsletter was effective for tracking and highlighting our progress towards addressing ACGME-I citations. During the probationary period, our psychiatry residency program won the Best Learning Environment Award from the medical education department of our institution. Additionally, 2 of our faculty members were granted the Best Teacher Award, while 2 of our trainees were recognized with the Best Resident and Fellow Award.

The ACGME mandates that sponsoring institutions conduct internal reviews to systematically and comprehensively review their programs.⁵  We closely collaborated with our graduate medical education office in conducting a mock site visit mirroring the ACGME-I process. Additionally in October 2022, midway through the academic year, we conducted our first comprehensive anonymous program evaluation survey, which included residents and faculty. This survey incorporated questions similar to those in the ACGME-I annual survey. The mock site visit and program surveys were valuable in assessing progress, identifying deficiencies, and implementing corrective measures before the actual ACGME-I site visit.

Feedback is a valuable tool for indicating whether things are going in the right direction or whether redirection is required.⁶  In addition to monthly meetings between residents and the PD, we circulated monthly anonymous feedback forms to gather insights from residents about their clinical rotations, educational programs, and recommended improvements. Simultaneously, the PD conducted regular presentations and discussions about progress, with the director of medical education, during Graduate Medical Education Committee meetings. Furthermore, we fostered communication channels among residents, faculty, and executive management, by regularly inviting class representatives to attend meetings with the chairman and chief executive officer, alongside the PD. This proactive approach brought residents into direct contact with decision-makers, which facilitated open dialogue related to residency training.

To ensure compliance to work hours, we assigned resident class representatives the responsibility of monthly audits to confirm peers’ work hour submissions. The audit results were shared with the PD each month, to swiftly address potential noncompliance. As residents occasionally overlook submitting work hours, conducting routine audits is instrumental to ensure compliance and timeliness in work hour reports.

Drawing lessons from other programs that have encountered similar setbacks can play a pivotal role in effectively addressing citations. Program leadership connected with educators and PDs from ACGME residency programs who had prior challenging experiences with probation. This engagement proved instrumental in gaining valuable insights, advice, and the opportunity to learn from others’ experiences. In partnership with our graduate medical education team, we collaborated with external educators to develop workshops for faculty that focused on supervision, teaching, and leadership.

The probationary status shifted us towards a continuous quality improvement (CQI) process, to consistently evaluate and enhance the program. This involved the following:

• Collecting data using surveys to identify resident and faculty feedback (recommendations 1, 4, 5, and 6)

• Acting on the data collected (recommendations 1 and 3)

• Conveying to involved stakeholders the measures that were put into effect (recommendations 3 and 5)

• Executing these actions in a proactive way (recommendation 2)

The ACGME mandates that institutions and residency programs demonstrate a commitment to continuous improvement.⁷  Adopting a CQI process can assist programs in meeting these requirements and sustaining accreditation. One study concluded that, by utilizing CQI methods, the clarity and timeline for achieving institutional and program goals were enhanced.⁸  In our case, to foster a culture of continuous improvement, we designated a 2-hour weekly slot for residents to participate in committee meetings (Figure). Furthermore, we reinforced the administrative support for our program coordinators by freeing them from tasks unrelated to the residency program. Similarly, we reduced the clinical responsibilities of the PD and assistant program director (APD), to guarantee that they dedicate at least 50 percent of their time (20 hours per week) to focus on the program. These steps not only accelerated our response to the citations but are fundamental in sustaining a culture of continuous improvement for the future. For instance, the first citation highlighted a lapse in Accreditation Data System (ADS) monitoring. Through redefined coordinator roles and consistent PD and APD supervision, we maintained regular ADS updates. The second citation highlighted residents’ incomplete working hours entries and insufficient oversight. By designating class representatives to oversee their peers’ working hours and consistent guidance from our coordinators and PD/APD, we achieved swift compliance.

The ACGME-I Review Committee conducted our program site visit in May 2023. We received the ACGME-I report in June 2023, which confirmed successful restoration of our program to continued accreditation status. In the process of restoring accreditation, we effectively resolved the main citations, and no new instances of noncompliance were identified. This success was further supported by positive feedback in the recent ACGME-I resident survey. Moving forward, we are dedicated to continuously improving our program, with active participation from residents and faculty. Initiatives such as resident-led committees are now integral to our program curriculum and reflect a culture committed to continuous review and lasting advancement through CQI, rather than short-term fixes. By involving residents in leadership, surpassing accreditation criteria, showcasing achievements, conducting thorough reviews, maintaining regular audits, and learning from experienced educators, we established a solid foundation for ongoing excellence. These steps, while sparked by necessity, laid the groundwork for a sustainable model of CQI that can serve as a guide for programs seeking to enhance training quality and maintain accreditation. The probationary period, while challenging, reinforced the idea that accreditation is not just about meeting standards but consistently striving to exceed them.

The authors would like to thank Dr. Carma L. Bylund for her advisory role and program coordinators Shane Carpio, Fathima Pallikal, and Kathrina Jabay for their immense contribution during the ACGME-I accreditation process.

The supplementary data for this article contains ACGME-I citations and sample implemented improvements from the study.