Graduate Medical Education Program Achieves Citation-Free ACGME Accreditation for 10th Year

March 1, 2023 by

Susan E. Kirk, MD

Susan E. Kirk, MD

For the 10th consecutive year, UVA’s Graduate Medical Education (GME) program has been re-accredited by the Accreditation Council for Graduate Medical Education (ACGME) without a single citation. “To receive re-accreditation, unblemished, with no areas for improvement or continuing trends over 10 years — that is pretty unusual,” says Associate Dean for Graduate Medical Education and Associate Professor of Endocrinology, Susan Kirk, MD.

It may be unusual. But it’s not surprising if you consider the enormous effort that’s gone into improving our training environment over the past decade.

We asked Dr. Kirk to share more about the significance of this designation and her hopes for the program going forward as she prepares to retire and pass the torch.

Why is this accreditation important?

Kirk: I think it’s a testament to the collective effort that goes into making sure that all of our residents and fellows are not only adequately trained, but also that we are doing what we can to preserve their wellbeing. I know we have some important work to do in that latter area as it is equally as important as the education they receive.

What are some of the areas evaluated by the ACGME during this accreditation process? 

Kirk: So much of it is administrative, like having the right policy or the right membership on our GME committee. Other areas of concern would be if our residents were exceeding their work hour limits. That’s a big one. If we didn’t have adequate resources for them, such as call rooms, education space or computers. And the other thing is that, we’re not only responsible for the compliance of the institution, but also the compliance of all of our 82 programs. We have to have oversight and support for all of these programs because if there were even a couple of programs that had adverse accreditation decisions, that would reflect poorly on the institution.

Who is involved in making sure that our GME program is up to par?

Kirk: This is not a one-person job. This is, literally, the work of a couple thousand people when you look at all the residents, program coordinators and others. I would like to recognize the GME Committee and subcommittees that do a lot of the heavy lifting. There’s the Education Subcommittee, Policy Subcommittee, and then our annual Oversight Committee, which is chaired by Dr. Brad Kessler. They do an enormous amount of work to make sure that we’ve got all the I’s dotted and all the T’s crossed. Without the hard work of the GME staff, none of this would be possible.

We meet every month and go over in very granular detail the health and wellness of all of our programs. If any are struggling, we develop a team to go in and do a thorough investigation of where the problems might be. We come up with an action plan and then monitor them to make sure they’re being corrected. Because we’re doing that work internally, we can fix any issues before they rise to the level that the ACGME would feel that they need to take action.

How does the ACGME assess our GME program?

Kirk: We provide data electronically to the ACGME. But they also look at some data that they pull on their own. A really important one is that, every year, the ACGME sends an anonymous survey to all the residents and fellows, and all the faculty who are involved with graduate medical education. And if they sense any negative areas on that survey, we would then move into a higher level of scrutiny. They also look at things like how many of your graduates passed certifying boards. So there are things that they can pull outside of the information that I’m submitting to them each summer. If they’re concerned, they will send a site visitor to get a closer look.

There are also cyclical site visits, where they come and everything is on the table for review. Every single one of our requirements will be scrutinized to make sure that we’re meeting those. That is supposed to happen every 10 years. We should have had our site visit in 2020. But because of the pandemic, everything was delayed. So our site visit — the big one, the make-or-break one — is scheduled tentatively for Sept. 1. It’s great that we’re going into that 10-year accreditation visit with such a clean track record because they should come here not looking for trouble, but just affirming that we’re actually doing a good job.

As you approach retirement and look back at your leadership of the GME program, what are you most proud of?

Kirk: I’m pretty proud that we have now gotten to a point where we’re held up as an example of an institution that has done things really well for a number of years. That doesn’t mean that there aren’t still things that we could do better. But in terms of making sure that we’re compliant, I’m really proud of that. I also think I’m more proud of the fact that I’ve been able to mentor a lot of people through all of this, not just residents and fellows, but program directors. Hopefully, I have encouraged a number of them to come into graduate medical education or make careers out of graduate medical education. That’s probably even more important to me. That extends to my staff as well. I mean, I am lucky to have the best staff in the country in terms of graduate medical education. They’re just fantastic.

A you prepare to pass the torch to the next dean, what are your hopes for the future of the program?

Kirk: Well, my goal is to leave the institution in the absolute best shape possible, so that whoever comes in can really work to expand things that maybe we haven’t done, but that we would have liked to do. I want to make sure that they feel like they are inheriting a program without problems. And then they’ll have the space and the freedom to pursue their own goals. Ideally, this will be somebody who really brings fresh energy and fresh ideas, so that GME as a whole continues to grow.

Filed Under: Education, Honors & Awards