Improvement in Context: Exploring Aims, Improvement Priorities, and Environmental Considerations in a National Sample of Programs Using "Small Data".

Background: In 2013, the Accreditation Council for Graduate Medical Education (ACGME) transitioned into a new accreditation system to reduce burden, focus on outcomes, and promote innovation and improvement. One component is a self-study that includes aims, an environmental assessment, and setting improvement priorities. The ACGME initiated voluntary site visits following the self-study.

Objective: We explored common themes in program aims and assessment of their environment.

Methods: Using grounded theory, inductive and deductive qualitative methods, and truth grounding, we analyzed data from voluntary site visits of 396 core and subspecialty programs between June 2015 and September 2017, with a focus on common themes.

Results: We report common themes for aims and the dimensions of the environmental assessment. Themes for strengths include a collegial, supportive learning environment; responsive leaders; and experiences that prepare residents for unsupervised practice. Improvement priorities encompass low learner engagement and "content mismatch" in didactic education, balancing education and service at a time of growing clinical volumes, and improving the utility of assessment systems. Common opportunities encompass collaborations that improve education, involving alumni and harnessing technology to enrich education, while threats include an unsustainable effort for many program leaders, clinical pressures on faculty, and loss of external sites important for education. Linked dimensions of the environmental assessment suggest benefit in a growing focus on learners, and approaches to ensure a humanistic learning environment that allows for growth, self-determination, and inclusion.

Conclusions: The findings highlight actionable themes for the environmental assessment. We discuss implications for programs, institutions, and the ACGME.