When No One is Looking: Annual Institutional Reviews and the Quiet Work of Accreditation
“Accreditation isn’t just about being ready for a visit. It’s about being honest with yourself when no one else is knocking.”
Some institutions live with a constant sense of scrutiny- regular ACGME visits, institutional reviews, detailed follow-ups. On paper, they check all the boxes, submit what’s required, and received continued accreditation.
That was true for the institution I recently supported.
They had periodic ACGME oversight and consistently provided the basic information needed. The reports highlighted ares where executive leadership could strengthen resident and fellow engagement in key domains- patient safety, quality, supervision, professionalism, and wellbeing.
But here’s the tension I’ve seen over and over again:
During these visits, residents, fellows, and even faculty are often on their best behavior. They may downplay issues, soften their language, or try to “explain away” concerns out of loyalty, fear of repercussions, or simply not wanting to make trouble.
So on the surface, everything looks intact. Beneath it, small misalignments and unresolved issues quietly accumulate.
I recently finished writing the Annual Institutional Review (AIR) fr this hospital, and what became clear was not a lack of contact with ACGME, but a lack of deeper engagement with the feedback those visits generated. Over time, one program drifted enough to receive accreditation with warning.
Not because people didn’t care, but because systems weren’t built for sustained, proactive oversight.
This is where the AIR matters more than most people realize.
The AIR as a Mirror, Not a Form
The Annual Institutional Review is often seen as a compliance tool, a document that has to be completed, submitted and filed away.
But at its best, the AIR is a mirror:
It asks:
What is really happening within our programs?
How are we supporting residents and fellows, formally and informally?
Where are the gaps we’ve learned to live with?
What patterns are hiding in plain sight: recruitment, retention, burnout, complaints, citations, outcomes?
For some institutions, the AIR may be one of the only structured moments where leadership steps back and takes an honest look at the big picture.
If that moment is rushed or treated like a formality, the institution loses one of its best tools for self-correction.
Flying Under the Radar is Not the Same as Being Okay
Even when an institution has periodic external review, it’s easy to slip into assumptions like:
“If there was a serious problem, we’d have heard about it.”
“We’re getting continued accreditation, so we must be fine.”
“We submitted what was asked for, what more is there to do?”
But accrediting bodies can only respond to what they see and what they’re told in a limited window of time.
In reality, institutional context can mask:
Underdeveloped infrastructure (informal CCC processes, limited faculty development, gaps in institutional oversight).
Thin administrative support, where one or two people are trying to hold everything together.
Program drift, where requirements are met “enough” but not consistently or intentionally.
Residents feeling unheard, especially if they don’t feel safe naming concerns or worry about being “the problem” if they speak up.
In these settings, the temptation is to do the minimum.
The opportunity is to do the opposite.
The AIR as a Leadership Tool
For institutional and GME leaders, the Annual Institutional Review can become more than a report, it can be a strategic conversation.
A well-done AIR allows you to:
Identify trends early, long before they escalate into citations or warnings.
Spot vulnerable programs, especially those with small faculty cores, leadership turnover, or limited administrative support.
Advocate for resources, using real data and themes (workload, evaluation gaps, duty hours, wellness, DEI).
Align reality with the story you want to be able to tell when an accreditor does show up.
Most importantly, it reinforces one quiet but powerful message:
“We are committed to integrity, even when no one is watching.”
Maintaining Integrity Between Visits
Whether an institution is visited frequently or not, the responsibility is the same: sustain the quality and safety of training.
That means:
Treating the AIR like an internal site visit.
Invite key voices. Ask hard questions. Don’t just celebrate strengths, name the gaps.
Bringing program leaders into the process.
Program Directors, coordinators, and residents should see the AIR as something that reflects their reality, not just a top-down exercise.
Closing the loop.
If the AIR reveals issues, evaluations delays, faculty shortages, wellness concerns; document not just the problem, but the plan an the follow-up.
Resisting complacency.
“We haven’t head anything” should never be mistaken for “We’re doing fine.”
When a Program Receives a Warning
When a program receives accreditation with warning, it can feel alarming, personal, or even shameful.
But it’s also a signal.
It tells us that something in the system isn’t lining up- resources, leadership, structure, support, or follow-through.
In the institution i’m working with now, that warning became a turning point. It forced a deeper look at institutional oversight, communication between leadership and programs, and how seriously the organization took its responsibility to its learners.
The AIR in that context became less about:
“What do we have to submit?”
and more about:
“What do we want to be true about our learning environment, whether the ACGME is here or not?”
Closing Reflection
In medical education, accreditation is often thought of as something that happens to us. A visit, a letter, a citation, a decision.
But some of the most important accreditation works happens quietly:
in the drafting of an Annual Institutional Review,
in the honesty of internal conversations,
in the choices we make when no one from the outside is asking.
The AIR is not just a requirement.
It’s an act of stewardship.
Because at the end of the day, the question is bigger than:
“Are we in good standing with the ACGME?”
The real question is:
Are we in good standing with the learners and communities who trust us to get this right, even when no one else is checking?