What does achieving a “Ten Year” Accreditation look like?

April 13, 2021

James Kruer, MD, Internal Medicine Program Director

How does a program become accredited?

The Northeast Georgia Medical Center (NGMC) Internal Medicine Residency Program has received the initial “10 year” accreditation. How did this milestone actually happen? Let’s explore!


Programs with a status of continued accreditation have an annual review of data by the Accreditation Council for Graduate Medical Education (ACGME). This includes review of resident and faculty survey reports by the internal medicine review committee of the ACGME; information on scholarly activity for residents and faculty members; resident and faculty member attrition and transitions in program leadership. The accreditation status is then updated based on the review annually. Every ten years the program undergoes a self-study and a site visit from the ACGME to review the goals and objectives of each year.

A Timeline of Accreditation

  • Sept 1, 2017: A new program application was submitted to the ACGME
  • October 6, 2017: First program site visit. The ACGME surveyor visited Northeast Georgia Medical Center in Gainesville to verify and clarify the application documents which described the resources of the program and how it would comply with the Internal Medicine (IM) program requirements. The Reviewer submits a supplemental report along with the program document (166 pages of plan and supporting documents).
  • January 2018: The ACGME IM resident review committee (RRC) made the decision to grant the program initial accreditation based on the site visit and application.
  • Initial accreditation lasts one to three years before a site visit happens after residents have been on site. All ACGME programs undergo a site visit at the end of the initial accreditation period and prior to the RRC’s decision to confer the status of continued accreditation.
  • March 18, 2020: The second site visit by the ACGME was scheduled but cancelled one week before due to the beginning of the COVID-19 pandemic. Travel was restricted and the ACGME had to develop a new method for site visits.
  • September 2, 2020: The program had its second site visit to determine accreditation status. This site visit was conducted via Zoom with two site visitors who met with the program director, program coordinator, a representative sample of program faculty, a representative sample of residents, the chair of medicine and the designated institutional official.
  • January 22, 2021: The Internal Medicine Residency Review Committee reviewed the site visitors report along with documents submitted to illustrate compliance with all the core program requirements. The program was granted continued accreditation with a “10 year self-study” target. There were no citations issued which is a remarkable outcome for a new start up residency.
  • September 1, 2028: Approximate due date of the Self Study report to the ACGME. At the ten-year mark, the program will complete a ACGME self-study. The self-study is an objective, comprehensive evaluation of the program with the goal of improving it in advance of the ten-year accreditation site visit.
  • September 1, 2030: Approximate next site visit from the ACGME. All programs undergo a site visit following the self-study process.

A few thoughts from Dr. Kruer

It is a great honor to work with the many community physicians, healthcare practitioners and supportive staff as we collaborate as one community to train the next generation of physician leaders. One of the reasons that I chose Northeast Georgia Medical Center was because the mission, vision and values were well thought out. It was evident that every employee from all departments had built a culture of caring for patients first and improving the health of the community in all that they were doing. When I learned further about the Quest for Excellence journey that had begun in 2015, I knew that the perfect foundation had been hardwired within the organization to train physician leaders in quality, safety and continuous improvement. The residents would learn that culture and fall in love with it. I was so excited about this that I asked for a second day of interviewing to get a personal walkthrough of the Four-Tiered Huddle system and Daily Visual Management Process. I came to fully understand how the Quest for Excellence system was designed – to help hardwire the organization for continued success, adaptability and growth while staying focused on its “True North” pillars for achieving excellence.

Thanks to the northeast Georgia community, who embraced the idea that we could train the best doctors, we have built a state-of-the-art training program complete with advance simulation technology, online learning support, telehealth and teleconferencing capability, a top notch electronic medical record system and the latest tools such as bedside ultrasound training.

Thanks to all those who have opened their doors and came together to build the infrastructure and processes needed to train doctors in the “thinking specialty” which is IM.

“We are always teaching residents to be “Sherlock Holmes” detectives – encouraging them to figure out difficult diagnoses and design evidence-based treatment plans. Our Internal Medicine graduates are able to take care of patients from adolescence to the end-of-life, while living our four core values of respectful compassion, deep interdependence, passion for excellence, and fiscal responsibility.”

James Kruer, MD – Program Director, Internal Medicine Residency Program at NGMC

Most of all, I would like my extend deepest appreciation to the patients and our northeast Georgia community. They have trusted our resident physicians and faculty to provide them an extra level of thinking and care. Having more eyes on your care can be a big advantage when it comes to safety. Having doctors that are up-to-date on the latest guidelines and evidence means that you will get top notch care right here in our beautiful communities of northeast Georgia.

It’s a humble honor to be able to help achieve this ten-year accreditation status for the community and for all those who have been my wing-men and wing-women! You all have helped make the dream come to life!

To learn more about our residency program, visit our website.