• Purpose of Graduate Medical Education
• Institutional Responsibilities
• Institutional Responsibilities for Residents
• Graduate Medical Education Committee (GMEC)
• Internal Review

Purpose of Graduate Medical Education (GME)

The purpose of GME is to provide an organized educational program with guidance and supervision of the resident, facilitating the resident's ethical, professional and personal development while ensuring safe and appropriate care for patients.

Sponsoring Institution

ACGME-accredited GME programs must operate under the authority and control of a Sponsoring Institution (see definition of "Sponsoring Institution" in the Glossary under "Institution").

A Sponsoring Institution must be appropriately organized for the conduct of GME in a scholarly environment and must be committed to excellence in both medical education and patient care.

Compliance with ACGME Requirements, Policies and Procedures

A Sponsoring Institution must be in substantial compliance with the Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements and must ensure that its ACGME- accredited programs are in substantial compliance with the Institutional, common and specialty-specific Program Requirements.

A Sponsoring Institution's failure to comply substantially with the Institutional Requirements may jeopardize the accreditation of all of its sponsored ACGME-accredited programs.

A Sponsoring Institution and its ACGME-accredited programs must be in substantial compliance with the ACGME Manual of Policies and Procedures for GME Review Committees (ACGME Web site, www.acgme.org). Of particular note are those policies and procedures that govern "Administrative Withdrawal," an action that could result in the closure of a Sponsoring Institution's ACGME-accredited program(s) and cannot be appealed.

INSTITUTIONAL RESPONSIBILITIES

Commitment to GME

The commitment of the Sponsoring Institution to GME is exhibited by the provision of leadership, organizational structure, and resources to enable the institution to achieve substantial compliance with the Institutional Requirements and to enable its ACGME-accredited programs to achieve substantial compliance with Program Requirements. This includes providing an ethical, professional, and educational environment in which the curricular requirements as well as the applicable requirements for scholarly activity and the general competencies can be met. The regular assessment of the quality of the GME programs, the performance of their residents, and the use of outcome assessment results for program improvement are essential components of this commitment.

There must be a written statement of institutional commitment to GME that is dated and signed within two years of the next institutional review and indicates the support of the governing authority, the administration, and the GME leadership of the Sponsoring Institution. This statement must specify, at a minimum, a commitment to providing the necessary educational, financial, and human resources to support GME.

There must be an organized administrative system, which includes a graduate medical education committee (GMEC) as described in Section IV, to oversee all ACGME-accredited programs of the Sponsoring Institution.

There must be a Designated Institutional Official (DIO) who has the authority and responsibility for the oversight and administration of the Sponsoring Institution's ACGME-accredited programs and who is responsible for assuring compliance with ACGME Institutional Requirements.

The DIO is to establish and implement procedures to ensure that s/he, or a designee in the absence of the DIO, reviews and cosigns all program information forms and any correspondence or document submitted to the ACGME by the program directors that either addresses program citations or requests changes in the programs that would have significant impact, including financial, on the program or institution.

The DIO and/or the Chair of the GMEC shall present an annual report to the Organized Medical Staff(s) (OMS) and the governing body(s) of the major participating JCAHO-accredited hospitals in which the GME programs of the Sponsoring Institution are conducted. This annual report will review the activities of the GMEC during the past year with attention to resident supervision, resident responsibilities, resident evaluation, and the Sponsoring Institution's participating hospitals' and programs' compliance with the duty-hour standards. The GMEC should receive concerns of the OMS related to the items listed above. The GMEC and the OMS should regularly communicate about the safety and quality of patient care provided by the residents.

The Sponsoring Institution must provide sufficient institutional resources, to include GME staff, space, equipment, supplies, and time to allow for effective oversight of its ACGME-accredited programs. In addition, there must be sufficient institutional resources to ensure the effective implementation and development of the ACGME-accredited programs in compliance with the Program and Institutional Requirements.

The DIO, GME staff and personnel, program directors, faculty and residents must have access to adequate communication resources and technological support. This should include, at a minimum, computers and access to the Internet.

Institutional Agreements

The Sponsoring Institution retains responsibility for the quality of GME even when resident education occurs in other institutions.

Current institutional agreements (ie, master affiliation agreements) must exist between the Sponsoring Institution and all of its major participating institutions.

The Sponsoring Institution must assure that each of its ACGME-accredited programs has established program letters of agreement (or memoranda of understanding) with its participating institutions in compliance with the specialty's Program Requirements.

Accreditation for Patient Care

Institutions sponsoring or participating in ACGME-accredited programs should be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), if such institutions are eligible.

If a sponsoring or participating institution is eligible for JCAHO accreditation and chooses not to undergo such accreditation, then the institution should be reviewed by and meet the standards of another recognized body with reasonably equivalent standards.

If a sponsoring or participating institution is not accredited by JCAHO, it must provide a satisfactory explanation of why accreditation has not been either granted or sought.

If an institution loses its JCAHO accreditation or recognition by another appropriate body, the Institutional Review Committee (IRC) must be notified in writing with an explanation.

Quality Assurance

Sponsoring Institutions must ensure that formal quality-assurance programs are conducted and that there is a review of complications and deaths. To the degree possible and in conformance with state law, residents should participate in appropriate components of the institution's performance improvement program.

INSTITUTIONAL RESPONSIBILITIES FOR RESIDENTS

Eligibility and Selection of Residents

The Sponsoring Institution must assure that all enrolled residents are eligible as defined below. Institutions and ACGME-accredited programs that enroll noneligible residents will be subject to administrative withdrawal. The Sponsoring Institution must have written policies and procedures for the recruitment and appointment of residents that comply with the following requirements and must monitor each program for compliance:

Resident eligibility:

Applicants with one of the following qualifications are eligible for appointment to ACGME-accredited programs:

Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME).

Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA).

Graduates of medical schools outside the United States and Canada who meet one of the following qualifications:

Have received a currently valid certificate from the Educational Commission for Foreign Medical Graduates prior to appointment or

Have a full and unrestricted license to practice medicine in a US licensing jurisdiction in which they are in training.

Graduates of medical schools outside the United States who have completed a Fifth Pathway* program provided by an LCME-accredited medical school.

Resident selection:

The Sponsoring Institution must ensure that its ACGME-accredited programs select from among eligible applicants on the basis of their preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity. ACGME-accredited programs must not discriminate with regard to sex, race, age, religion, color, national origin, disability, or veteran status.

In selecting from among qualified applicants, it is strongly suggested that the Sponsoring Institution and all of its ACGME-accredited programs participate in an organized matching program, such as the National Resident Matching Program (NRMP), where such is available.

Financial Support for Residents

Sponsoring and participating institutions should provide all residents with appropriate financial support and benefits to ensure that residents are able to fulfill the responsibilities of their educational programs.

Benefits and Conditions of Appointment

Candidates for ACGME-accredited programs (applicants who are invited for an interview) must be informed, in writing or by electronic means, of the terms, conditions, and benefits of appointment, including financial support; vacations; parental, sick, and other leaves of absence; professional liability, hospitalization, health, disability and other insurance provided for the residents and their families; and the conditions under which living quarters, meals, laundry services, or their equivalents are to be provided.

Agreement of Appointment

The Sponsoring Institution must assure that residents are provided with a written agreement of appointment or contract outlining the terms and conditions of their appointment to an ACGME-accredited program, and the institution must monitor the implementation of these terms and conditions by the program directors. Sponsoring Institutions and program directors must ensure that residents adhere to established practices, policies, and procedures in all institutions to which residents are assigned. The agreement must contain or provide a reference to at least the following:

• Residents' responsibilities;
• Duration of appointment;
• Financial support;
• Conditions under which living quarters, meals, and laundry services or their equivalents are provided;
• Conditions for reappointment;

Nonrenewal of agreement of appointment:

The Sponsoring Institution must provide a written institutional policy that conforms to the following: In instances where a resident's agreement is not going to be renewed, the Sponsoring Institution must ensure that its ACGME-accredited programs provide the resident(s) with a written notice of intent not to renew a resident's agreement no later than four months prior to the end of the resident's current agreement . However, if the primary reason(s) for the nonrenewal occurs within the four months prior to the end of the agreement, the Sponsoring Institution must ensure that its ACGME-accredited programs provide the residents with as much written notice of the intent not to renew as the circumstances will reasonably allow, prior to the end of the agreement.

Residents must be allowed to implement the institution's grievance procedures as addressed below if they have received a written notice of intent not to renew their agreements.

Grievance procedures and due process: The Sponsoring Institution must provide residents with fair and reasonable written institutional policies on and procedures for grievance and due process. These policies and procedures must address academic or other disciplinary actions taken against residents that could result in dismissal, nonrenewal of a resident's agreement or other actions that could significantly threaten a resident's intended career development; and, adjudication of resident complaints and grievances related to the work environment or issues related to the program or faculty.

Professional liability insurance:

The Sponsoring Institution must ensure that residents in ACGME-accredited programs are provided with professional liability coverage for the duration of training. Such coverage must provide legal defense and protection against awards from claims reported or filed after the completion of the ACGME-accredited program if the alleged acts or omissions of the residents are within the scope of the ACGME-accredited program.

The professional liability coverage should be consistent with the Sponsoring Institution's coverage for other medical/professional practitioners.

Current residents in ACGME-accredited programs must be provided with the details of the institution's professional liability coverage for residents.

Health and disability insurance: The Sponsoring Institution must provide hospital and health insurance benefits for the residents and their families. The Sponsoring Institution must also provide access to insurance to all residents for disabilities resulting from activities that are part of the educational program.

Leaves of absence:

The Sponsoring Institution must provide written institutional policies on residents' vacation and other leaves of absence (with or without pay) to include parental and sick leave; these policies must comply with applicable laws.

The Sponsoring Institution must ensure that each program provides its residents with a written policy in compliance with its Program Requirements concerning the effect of leaves of absence, for any reason, on satisfying the criteria for completion of the residency program.

Duty Hours:

The Sponsoring Institution is responsible for promoting patient safety and education through carefully constructed duty-hour assignments and faculty availability.

The institution must have formal written policies and procedures governing resident duty hours that support the physical and emotional well-being of the resident, promote an educational environment, and facilitate patient care.

Moonlighting:

Professional and patient care activities that are external to the educational program are called moonlighting. Moonlighting activities, whether internal or external, may be inconsistent with sufficient time for rest and restoration to promote the residents' educational experience and safe patient care. Therefore, institutions and program directors must closely monitor all moonlighting activities.

The Sponsoring Institution must have a written policy that addresses moonlighting. The policy must specify that residents must not be required to engage in moonlighting; require a prospective, written statement of permission from the program director that is made part of the resident's file; and, state that the residents' performance will be monitored for the effect of these activities upon performance and that adverse effects may lead to withdrawal of permission.

Counseling services:

The Sponsoring Institution should facilitate residents' access to appropriate and confidential counseling, medical, and psychological support services.

Physician impairment: The Sponsoring Institution must have written policies that describe how physician impairment, including that due to substance abuse, will be handled.

Sexual harassment: The Sponsoring Institution must have written policies covering sexual and other forms of harassment.

Residency Closure/Reduction: The Sponsoring Institution must have a written policy that addresses a reduction in size or closure of a residency program. The policy must specify that if the Sponsoring Institution intends to reduce the size of an ACGME-accredited program or close a residency program, the Sponsoring Institution must inform the residents as early as possible; and, that in the event of such a reduction or closure, the Sponsoring Institution must either allow residents already in the program to complete their education or assist the residents in enrolling in an ACGME-accredited program in which they can continue their education.

Restrictive Covenants:

ACGME-accredited programs must not require residents to sign a noncompetition guarantee.

Resident Participation in Educational and Professional Activities

The Sponsoring Institution must ensure that each ACGME-accredited program defines, in accordance with its Program Requirements, the specific knowledge, skills, attitudes, and educational experiences required in order for their residents to demonstrate the following:

• Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
• Medical knowledge about established and evolving biomedical, clinical, and cognate (eg, epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
• Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
• Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals.
• Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
• Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value.

In addition, the Sponsoring Institution must ensure that residents

• develop a personal program of learning to foster continued professional growth with guidance from the teaching staff;
• participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents and students;
• have the opportunity to participate on appropriate institutional and departmental committees and councils whose actions affect their education and /or patient care;
• participate in an educational program regarding physician impairment, including substance abuse.
• The Sponsoring Institution must ensure that residents submit to the program director or to the DIO at least annually confidential written evaluations of the faculty and of the educational experiences.

Resident Work Environment

The Sponsoring Institution and its ACGME-accredited programs must provide an educational and work environment in which residents may raise and resolve issues without fear of intimidation or retaliation. This includes the following:

• Provision of an organizational system for residents to communicate and exchange information on their work environment and their ACGME-accredited programs. This may be accomplished through a resident organization or other forums in which to address resident issues.
• A process by which individual residents can address concerns in a confidential and protected manner.
• The Sponsoring Institution must provide services and develop systems to minimize the work of residents that is extraneous to their GME programs and ensure that the following conditions are met:
• Food services: Residents on duty must have access to adequate and appropriate food services 24 hours a day in all institutions.
• Call rooms: Residents on call must be provided with adequate and appropriate sleeping quarters.
• Support services: Patient support services, such as intravenous services, phlebotomy services, and laboratory services, as well as messenger and transporter services, must be provided in a manner appropriate to and consistent with educational objectives and patient care.
• Laboratory/pathology/radiology services: There must be appropriate laboratory, pathology, and radiology services to support timely and quality patient care in the ACGME-accredited programs. This must include effective laboratory, pathology, and radiologic information systems.
• Medical records: A medical records system that documents the course of each patient's illness and care must be available at all times and must be adequate to support quality patient care, the education of residents, quality assurance activities, and provide a resource for scholarly activity.
• Security/safety: Appropriate security and personal safety measures must be provided to residents at all locations including but not limited to parking facilities, on-call quarters, hospital and institutional grounds, and related clinical facilities (eg, medical office building).

GRADUATE MEDICAL EDUCATION COMMITTEE (GMEC)

GMEC Composition and Meetings

The Sponsoring Institution must have a GMEC that has the responsibility for monitoring and advising on all aspects of residency education. Voting membership on the committee must include residents nominated by their peers. It must also include appropriate program directors, administrators, the accountable DIO, and may include other members of the faculty.

The committee must meet at least quarterly, and maintain written minutes documenting fulfillment of the committee's responsibilities.

GMEC Responsibilities

The GMEC must:

establish and implement policies and procedures regarding the quality of education and the work environment for the residents in all ACGME-accredited programs.

review annually and make recommendations to the Sponsoring Institution on resident stipends, benefits, and funding for resident positions to assure that these are reasonable and fair.

establish and maintain appropriate oversight of and liaison with program directors and assure that program directors establish and maintain proper oversight of and liaison with appropriate personnel of other institutions participating in the ACGME-accredited programs of the Sponsoring Institution.

establish and implement formal written policies and procedures governing resident duty hours in compliance with the Institutional and Program Requirements. The GMEC must assure that the following requirements are met:

Each ACGME-accredited program must establish formal written policies governing resident duty hours that are consistent with the Institutional and Program Requirements. These formal policies must apply to all participating institutions used by the residents and must address the following requirements:

The educational goals of the program and learning objectives of residents must not be compromised by excessive reliance on residents to fulfill institutional service obligations. Duty-hours and call schedules must be monitored by both the Sponsoring Institution and programs and adjustments made as necessary to address excessive service demands and/or resident fatigue. Duty hours, however, must reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. ACGME-accredited programs must ensure that residents are provided appropriate backup support when patient care responsibilities are especially difficult or prolonged; and,

Resident duty hours and on-call time periods must be in compliance with the Institutional and Program Requirements. The structuring of duty hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident.

The GMEC must develop and implement procedures to regularly monitor resident duty hours for compliance with the Sponsoring Institution's policies and the Institutional and Program Requirements.

The GMEC must develop and implement written procedures to review and endorse requests from programs prior to submission to an RRC for exceptions in the weekly limit on duty hours up to 10 percent or up to a maximum of 88 hours. All exceptions requested must be based on a sound educational rationale. The procedures must outline the process for endorsing an exception in compliance with the ACGME policies and procedures for duty-hour exceptions. The procedures and their application, if the institution has utilized them, will be assessed during the institutional review.

assure that ACGME-accredited programs provide appropriate supervision for all residents that is consistent with proper patient care, the educational needs of residents, and the applicable Program Requirements. Supervision of residents must address the following:

Residents must be supervised by teaching staff in such a way that the residents assume progressively increasing responsibility according to their level of education, ability, and experience.

On-call schedules for teaching staff must be structured to ensure that supervision is readily available to residents on duty.

The teaching staff must determine the level of responsibility accorded to each resident.

assure that each program provides a curriculum and an evaluation system to ensure that residents demonstrate achievement of the six general competencies listed in Section III.E and as defined in each set of Program Requirements.

establish and implement formal written institutional policies for the selection, evaluation, promotion, and dismissal of residents in compliance with the Institutional and Program Requirements.

regularly review all ACGME program accreditation letters and monitor action plans for the correction of concerns and areas of noncompliance.

regularly review the Sponsoring Institution's Letter of Report from the IRC and develop and monitor action plans for the correction of concerns and areas of noncompliance.

review and approve prior to submission to the ACGME

all applications for ACGME accreditation of new programs and subspecialties;

changes in resident complement;

major changes in program structure or length of training

additions and deletions of participating institutions used in a program;

appointments of new program directors;

progress reports requested by any Review Committee;

responses to all proposed adverse actions;

requests for increases or any change in resident duty hours

requests for "inactive status" or to reactivate a program;

voluntary withdrawals of ACGME-accredited programs;

requests for an appeal of an adverse action; and,

appeal presentations to a Board of Appeal or the ACGME.

conduct internal reviews of all ACGME-accredited programs including subspecialty programs to assess their compliance with the Institutional Requirements and the Program Requirements of the ACGME Residency Review Committees in accordance with the guidelines in Section V.

INTERNAL REVIEW

Process

The GMEC is responsible for the development, implementation and oversight of the internal review process. The internal review process must comply with the following:

The GMEC must designate an internal review committee(s) to review each ACGME-accredited program in the Sponsoring Institution. The internal review committee must include faculty, residents, and administrators from within the institution but from GME programs other than the one that is being reviewed. External reviewers may also be included on the committee as determined by the GMEC.

The review must follow a written protocol approved by the GMEC that incorporates, at a minimum, the requirements in this section (Section V).

Reviews must be conducted at approximately the midpoint between the ACGME program surveys.

Although departmental annual reports are often important sources of information about a residency program, they do not meet the requirement for a periodic internal review.

While assessing the residency program's compliance with each of the program standards, the review should also appraise

• the educational objectives of each program;
• the effectiveness of each program in meeting its objectives;
• the adequacy of available educational and financial resources to support the program;
• the effectiveness of each program in addressing areas of noncompliance and concerns in previous ACGME accreditation letters and previous internal reviews;
• the effectiveness of each program in defining, in accordance with the Program and Institutional Requirements ( Section III.E), the specific knowledge, skills, attitudes, and educational experiences required for the residents to achieve competence in the following: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice;
• the effectiveness of each program in using evaluation tools developed to assess a resident's level of competence in each of the six general areas listed above;
• the effectiveness of each program in using dependable outcome measures developed for each of the six general competencies listed above; and,
• the effectiveness of each program in implementing a process that links educational outcomes with program improvement.
• Materials and data to be used in the review process must include

Institutional and Program Requirements for the specialties and subspecialties of the ACGME RRCs from the Essentials of Accredited Residency Programs;

• accreditation letters from previous ACGME reviews and progress reports sent to the RRC; and,
• reports from previous internal reviews of the program.

The internal review committee must conduct interviews with the program director, faculty, peer-selected residents from each level of training in the program, and other individuals deemed appropriate by the committee.

Program inactivity: ACGME-accredited programs and subspecialties that have applied for and received RRC approval for "inactive" status do not need internal reviews. However, an internal review must be conducted prior to requesting RRC approval for reactivation.

Internal Review Report

There must be a written report of the internal review for each ACGME-accredited specialty and subspecialty program that contains, at a minimum, the following:

• the name of the program or subspecialty program reviewed and the date of the review;
• the names and titles of the internal review committee members to include the resident(s);
• a brief description of how the internal review process was carried out, including the list of the groups/individuals who were interviewed;
• sufficient documentation or discussion of the specialty's or the subspecialty's Program Requirements and the Institutional Requirements to demonstrate that a comprehensive review was conducted and was based on the GMEC's internal review protocol;
• a list of the areas of noncompliance or any concerns or comments from the previous ACGME accreditation letter with a summary of how the program and /or institution addressed each one.

The written report of each internal review must be presented to and reviewed by the GMEC to monitor the areas of noncompliance and recommend appropriate action.

Reports from internal reviews are required to be shown to the ACGME site visitor for the institutional review and must be included in the Institutional Review Document submitted to the IRC. During the review of individual programs, these reports must not be shown to the ACGME site visitor or specialist site visitors, who only will ascertain that an internal review was completed in the interval since the program's previous site visit.

Approved by ACGME February 11, 2003; Effective: July 1, 2003