The purpose of GME is to provide an organized educational program with guidance and supervision of the house officer, facilitating the house officer's professional and personal development, while ensuring safe and appropriate care for patients. Sponsoring institutions, therefore, must be appropriately organized for the conduct of GME in a scholarly environment and be committed to excellence in both education and medical care. This commitment is exhibited by the provision of leadership and resources to enable the institution to achieve substantial compliance with the Institutional Requirements. This includes providing an ethical and professional environment in which the educational curricular requirements, as well as the applicable requirements for scholarly activity, can be met. The regular assessment of the quality of the educational programs is an essential component of this commitment.
A. Sponsoring Institution
A residency program must operate under the authority and control of a sponsoring institution.
There must be a written statement of institutional commitment to GME that is supported by the governing authority, the administration, and the teaching staff.
Sponsoring institutions must be in substantial compliance with the Institutional Requirements and must ensure that their ACGME-accredited programs are in substantial compliance with the Program Requirements.
An institution's failure to comply substantially with the Institutional Requirements may jeopardize the accreditation of all of its sponsored residency programs.
B. Educational Administration
There must be an organized administrative system to oversee all residency programs sponsored by an institution. In addition, there must be a designated institutional official who has the authority and the responsibility for the over sight and administration of the GME programs.
Institutions must have a GME Committee (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, appropriate program directors, other members of the faculty, and the accountable institutional official or his or her designee.
The committee must meet at least quarterly; minutes must be kept and be available for inspection by accreditation personnel.
The responsibilities of the committee must include:
a.
establishment and implementation of policies that affect all residency programs regarding the quality of education and the work environment for the residents in each program.
b.
establishment and maintenance of appropriate oversight of and liaison with program directors and assurance that program directors establish and maintain proper oversight of and liaison with appropriate personnel of other institutions participating in programs sponsored by the institutions.
c.
regular review of all residency programs to assess their compliance with both the Institutional Requirements and Program Requirements of the relevant ACGME RRCs. See Internal Review Policy in this document
d.
Assurance that each residency program establishes and implements formal written criteria and processes for the selection, evaluation, promotion, and dismissal of residents in compliance with both the Institutional and relevant Program Requirements.
e.
Assurance of an educational environment in which residents may raise and resolve issues without fear of intimidation or retaliation. This includes:
Provision of an organizational system for residents to communicate and exchange information on their working environment and their educational 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.
Establishment and implementation of fair institutional policies and procedures for academic or other disciplinary actions taken against residents.
Establishment and implementation of fair institutional policies and procedures for adjudication of resident complaints and grievances related to actions that could result in dismissal or could significantly threaten a resident's intended career development.
f.
Collecting of intra-institutional information and making recommendations on the appropriate funding for resident positions, including benefits and support services.
g.
Monitoring of the programs in establishing an appropriate work environment and the duty hours of residents.
h.
Assurance that the residents' curriculum provides a regular review of ethical, socioeconomic, medical/legal, and cost-containment issues that affect GME and medical practice. The curriculum must also provide an appropriate introduction to communication skills and to research design, statistics, and critical review of the literature necessary for acquiring skills for lifelong learning. There must be appropriate resident participation in departmental scholarly activity, as set forth in the applicable Program Requirements.
C. Institutional Agreement
When resident education occurs in a participating institution, the sponsoring institution continues to have responsibility for the quality of that educational experience and must retain authority over the resident's activities.
Therefore, current inter-institutional agreements must exist with all of its major participating institutions.
The sponsoring institution must ensure that for each accredited program, appropriate letters of agreement exist between the sponsoring institution and the participating institution. These agreements should:
identify the officials at the participating institution or faculty who will assume administrative, educational, and supervisory responsibility for the resident(s)
outline the educational goals and objectives to be attained within the participating institutions
specify the period of assignment of the residents to the participating institution, the financial arrangements, and the details for insurance and benefits
determine the participating institution's responsibilities for teaching, supervision, and formal evaluation of the resident's performances; and
establish with the participating institution the policies and procedures that govern the residents' education while rotating to the participating institution.
D. Accreditation for Patient Care
Institutions sponsoring or participating in GME programs should be accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), if such institutions are eligible. If an 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 the institution is not accredited, it must provide a satisfactory explanation of why accreditation has not been either granted or sought.
E. Quality Assurance
Institutions participating in GME must conduct formal quality-assurance programs and review complications and deaths.
All residents should receive instruction in quality-assurance/performed improvement. To the degree possible and in conformance with state law, residents should participate in appropriate components of the institution's performance improvement program.
As part of the educational program, it is important that autopsies be performed whenever possible and appropriate. A sufficient number of autopsies representing an adequately diverse spectrum of diseases should be performed to provide an adequate educational experience and to enhance the quality of patient care.
Institutions participating in GME must have a medical record system that is available at all times and documents the course of each patient's illness and care. The medical records system must be adequate to support the education of residents and quality-assurance activities and provide a resource for scholarly activity.
F. Compliance with ACGME Policies and Procedures
Sponsoring institutions must ensure that their ACGME-accredited programs are in substantial compliance with ACGME policies and procedures as defines in the ACGME Manuel of Policies and Procedures for Graduate Medical Education Review Committees. Of particular note are those policies and procedures that govern "Administrative Withdrawal of Accreditation", an action that is not subject to the appeals process:
A program may be deemed to have voluntarily withdrawn from the ACGME accreditation process, and an RRC may withdraw accreditation, if the program is not in substantial compliance with:
a.
site visit and program review policies and procedures
b.
directives associated with an accreditation action or
c.
requests by the RRC for information
A program that is judged to be delinquent in payment of fees is not eligible for review and will be notified by certified mail, return receipt requested, of the effective date of the withdrawal of accreditation. On that date, the program will be removed from the list of ACGME-accredited programs.
Internal Review Policy
Policy: The internal review process is a principal function of the Hospital Graduate Education Committee. Each ACGME accredited department is to have an internal review that must occur at the mid point between ACGME program reviews to ensure compliance with ACGME program requirements and continued accreditation. Participation in the internal review process is a requirement for GMEC membership.
Procedure:
Notification for internal reviews will be the responsibility of the Medical Education Department. The Medical Education Department will keep an accurate database which will include the date of the ACGME Letter of Report for each accredited program. The internal review date will be determined based on the effective date and the length of accreditation specified in the Letter of Report.
A listing of all internal reviews for upcoming year (s) with space for team sign up will be distributed at the October GMEC Meeting. If additional internal reviews are added, the list will be presented at the next regularly scheduled GMEC meeting.
Internal review teams are comprised of a GMEC Team Leader, a second GMEC member, one House Officer, an Administrative representative, and the Director of Instructional Design or designee.
All members of the GMEC are expected to participate in internal reviews. Lack of volunteers will necessitate assignment by the DIO, based on past participation of each member.
All programs are eligible to request a pre-review. A pre-review may be scheduled prior to the ACGME RRC Review as a means of assisting a department in preparing for the RRC review. Programs must contact Medical Education to schedule a pre-review. Requests must be made in a timely manner to allow review volunteers to schedule the time to participate. Generally, GMEC members must have a 90 day advance notice of a request for participation in a review in order to schedule time away from clinical duties.
Internal reviews must be presented at a GMEC meeting. The presentation should take place within two GMEC meeting dates from the occurrence of the review.
Reporting of the internal review at the GMEC meeting must be by the Team Leader faculty member of the review team. The Program Director (or Associate Program Director if PD cannot attend) of the program that was reviewed must be on hand to respond.
After deliberation the GMEC may choose to accept the report as it is, request more information from the program, or ask for a progress report outlining the response(s) to concerns raised during discussion.
The Medical Education Department will maintain electronic and hard copies of the internal review report, as well as any comments made at the GMEC meeting when the report was presented, in a program binder within the Medical Education Department. Follow up progress reports, if requested, will be filed as well.
Residents
A. Resident Eligibility and Selection
The sponsoring institution must have written policies and procedures for the recruitment and appointment of residents that comply with the requirements listed below, and it must monitor the compliance of each program with these procedures.
1. Resident Eligibility
Applicants with one of the following qualifications are eligible for appointment to accredited residency programs:
a.
Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME).
b.
Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA).
c.
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 or
have a full and unrestricted license to practice medicine in a U.S. licensing jurisdiction
d.
Graduates of medical schools outside the United States who have completed a Fifth Pathway program provided by an LCME-accredited medical school. Note: A Fifth Pathway program is an academic year of supervised clinical education provided by an LCME-accredited medical school to students who meet the following conditions:
have completed, in an accredited college or university in the United States, undergraduate premedical education of the quality acceptable for matriculation in an accredited United States medical school
have studied at a medical school outside the United States and Canada but listed in the World Health Organization Directory of Medical Schools
have completed all of the formal requirements of the foreign medical school except internship and / or social service
have attained a score satisfactory to the sponsoring medical school on a screening examination and
have passed Steps 1 and 2 of the United States Medical Licensing Examination (USMLE).
2. Resident Selection
The sponsoring institution must ensure that 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.
When selecting among qualified applicants, it is strongly suggested that institutions and all of their sponsored programs participate in an organized matching program, where available, such as the National Resident Matching Program (NRMP).
3. Enrollment of Non-eligible Residents
The enrollment of non-eligible residents may be a cause for withdrawal of accreditation of the involved program.
B. Resident Participation in Educational Activities
develop a personal program of learning to foster continued professional growth with guidance from the teaching staff
participate in safe, effective, and compassionate patient care, under supervision, commensurate with their level of advancement and responsibility
participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents and students
participate as appropriate in institutional programs and medical staff activities and adhere to established practices, procedures, and policies of the institution
participate on appropriate institutional committees and councils whose actions affect their education and/or patient care
submit to the program director or to a designate institution official at least annually confidential written evaluations of the faculty and of the educational experiences
C. Resident Support, Benefits, and Conditions of Employment
Sponsoring and participating institutions should provide all residents with appropriate financial support and benefits. Compensation of residents and distribution of resources for the support of education should be carried out with the advice of the GMEC.
Financial Support: Adequate financial support of residents is necessary to ensure that residents are able to fulfill the responsibilities of their educational programs
Applicants: Applicants for GME programs must be informed in writing of the terms and conditions of employment and benefits including financial support, vacations, professional leave, parental leave, sick leave, professional liability insurance, hospital and health insurance, disability insurance, and other insurance benefits for the residents and their family, and the conditions under which living quarters, meals and laundry or their equivalents are to be provided
Contracts: Sponsoring institutions must provide residents with a written agreement or contract outlining the terms and conditions of their appointment to an educational program, and the institutions must monitor the implementation of these terms and conditions by the program director. The agreement must contain or reference at least the following:
a.
Financial support
b.
Vacation policies
c.
Professional liability insurance in conformity with C.5 below
d.
Disability insurance and other hospital and health insurance benefits for the residents and their family in conformity with C.6 below
e.
Professional, parental, and sick-leave benefits in conformity with C.7 below
f.
Conditions under which living quarters, meals, and laundry or their equivalents are to be provided
g.
Counseling, medical, psychological, and other support services in conformity with C.8 and 9 below
h.
Institutional policies covering sexual and other forms of harassment
The agreement must also delineate or reference specific policies regarding
a.
resident's responsibilities
b.
duration of appointment and conditions for reappointment
c.
professional activities outside the education program
c.
grievance procedures
Liability Insurance: Residents in GME must be 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 GME if the alleged acts or omissions of the residents are within the scope of the education program. The coverage to be provided should be consistent with the institution's coverage for other medical/professional practitioners. Each institution must provide current residents and applicants for residency with the details of the institution's professional liability coverage for residents.
Disability Insurance: Institutions sponsoring GME must provide access to insurance, where available, to all residents for disabilities resulting from activities that are part of the education program.
Leave of Absence: There must be a written policy on leave (with or without pay) for residents that comply with applicable laws. The institution must provide resident with a written policy concerning the effect of leaves of absence, for any reason, on satisfying the criteria for completion of a residency program.
Counseling Services: GME places increasing responsibilities on residents and requires sustained intellectual and physical effort. Therefore, institutions should facilitate resident access to appropriate and confidential counseling, medical and psychological support services.
Physician Impairment: Institutions must have written policies that describe how physician impairment, including that due to substance abuse, will be handled. In addition, institutions should provide an educational program for residents regarding physician impairment, including substance abuse.
Residency Closure / Reduction: If an institution intends to reduce the size of a residency program or to close a residency program, the institution must inform the residents as soon as possible. In the event of such a reduction or closure, institutions must allow residents already in the program to complete their education or assists the residents in enrolling in an ACGME accredited program in which they can continue their education.
Restrictive Covenants: ACGME accredited residencies must not require residents to sign a non-competition guarantee.
D. Resident Supervision, Duty Hours, and Work Environment
Institutions must ensure that their GME programs provide appropriate supervision for all residents, as well as a duty hour schedule and a work environment that is consistent with proper patient care, the educational needs of residents, and the applicable Program Requirements.
Supervision: There must be sufficient institutional oversight to assure that residents are appropriately supervised. 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 level of responsibility accorded to each resident must be determined by the teaching staff
Duty Hours: The sponsoring institution must ensure that each residency program established formal policies governing resident duty hours that foster resident education and facilitate the care of patients.
a.
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, however, must reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. Programs must ensure that residents are provided appropriate backup support when patient care responsibilities are especially difficult or prolonged.
b.
Resident duty hours and on-call time periods must not be excessive. 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. Duty hours must be consistent with the Institutional and Program Requirements that apply to each program.
Work Environment: Sponsoring institutions must provide services and develop systems to minimize the work of residents that is extraneous to their educational programs, ensuring that the following conditions are met:
a.
Resident on duty in the hospital must be provided adequate and appropriate food services and sleeping quarters.
b.
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.
c.
An effective laboratory, medical records, and radiologic information retrieval system must be in place to provide for appropriate conduct of the educational programs and quality and timely patient care.
d.
Appropriate security and personal safety measures must be provided to residents in all locations including but not limited to parking facilities, on-call quarters, hospital and institutional grounds, and related clinical facilities (e.g., medical office building).
