Appendix II: ACGME Institutional Requirements (Addition of General Competencies: ACGME Approved 6/12/01, Effective 7/1/02)

doi:10.1016/S1076-6332(03)80161-7

Other| Volume 10, ISSUE 1, SUPPLEMENT , S109-S115, January 2003

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Appendix II

ACGME Institutional Requirements (Addition of General Competencies: ACGME Approved 6/12/01, Effective 7/1/02)

DOI:https://doi.org/10.1016/S1076-6332(03)80161-7

I
Institutional Organization and Commitment
The purpose of graduate medical education 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 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 and to enable the educational 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 educational programs, the performance of its residents, and the use of outcome assessment results for program improvement are essential components of this commitment.
- A
  Sponsoring Institution
  - 1
    A residency program must operate under the authority and control of a sponsoring institution (see definition for sponsoring institution in the Glossary under “Institution”).
  - 2
    There must be a written statement of institutional commitment to GME that is supported by the governing authority, the administration, and the teaching staff.
  - 3
    Sponsoring institutions must be in substantial compliance with the Institutional Requirements and must ensure that their Accreditation Council for Graduate Medical Education (ACGME) accredited programs are in substantial compliance with the Program Requirements and the applicable Institutional Requirements.
  - 4
    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 oversight and administration of the GME programs. Institutional officials, administrators of GME, program directors, faculty, and residents must have access to adequate communication technologies and technological support to include at least computers and access to the Internet.
  - 1
    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.
  - 2
    The committee must meet at least quarterly; minutes must be kept and be available for inspection by accreditation personnel.
  - 3
    The responsibilities of the committee must include the following:
    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 ACGME letters of accreditation and the monitoring of action plans for the correction of areas of noncompliance
    d
    Regular 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
    1)
    The review must be conducted by the GMEC, or a body designated by the GMEC, which must include faculty, residents, and administrators, from within the institution but from programs other than the one that is being reviewed. External reviewers may also be included on the review body as determined by the GMEC. The review must follow a written protocol approved by the GMEC.
    2)
    Reviews must be conducted at approximately the midpoint between the ACGME program surveys.
    3)
    While assessing the residency program's compliance with each of the program standards, the review should also appraise
    a)
    the educational objectives of each program;
    b)
    the adequacy of available educational and financial resources to meet these objectives;
    c)
    the effectiveness of each program in meeting its objectives; and
    d)
    the effectiveness in addressing citations from previous ACGME letters of accreditation and previous internal reviews.
    e)
    the use of dependable measures to assess residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice as defined in section II.B, and in the Program Requirements; and
    f)
    the effectiveness of each program in implementing a process that links educational outcomes with program improvement.
    4)
    Materials and data to be used in the review process must include
    a)
    Institutional and Program Requirements for the specialties and subspecialties of the ACGME RRCs from the
    b)
    letters of accreditation from previous ACGME reviews;
    c)
    reports from previous internal reviews of the program; and
    d)
    interviews with the program director, faculty, and residents in the program and individuals outside the program deemed appropriate by the committee.
    5)
    There must be a written report of each internal review that is presented to and reviewed by the GMEC for the monitoring of areas of noncompliance and appropriate action. In addition, this report or a succinct summary of each report is required as part of the ACGME institutional review document.
    6)
    Although departmental annual reports are often important sources of information about a residency program, they do not in themselves necessarily meet the requirement for a periodic review.
    e
    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 the Institutional and Program Requirements for the specialties and subspecialties of the ACGME RRCs
    f
    Assurance of an educational environment in which residents may raise and resolve issues without fear of intimidation or retaliation. This includes the following:
    1)
    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.
    2)
    A process by which individual residents can address concerns in a confidential and protected manner.
    3)
    Establishment and implementation of fair institutional policies and procedures for academic or other disciplinary actions taken against residents.
    4)
    Establishment and implementation of fair institutional policies and procedures for adjudication of resident complaints and grievances related to actions that could result in dismissal, nonrenewal of a resident's contract, or other actions that could significantly threaten a resident's intended career development.
    g
    Collecting of intrainstitutional information and making recommendations on the appropriate funding for resident positions, including benefits and support services
    h
    Monitoring of the programs in establishing an appropriate work environment and the duty hours of residents
    i
    Assurance that each program provides a curriculum and an evaluation system to ensure that residents demonstrate competence in the general areas listed in section II.B, and as defined in each set of Program Requirements.
  - C
    Institutional Agreements
    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 residents' activities. Therefore, current institutional agreements (ie, master affiliation agreements) must exist with all of its major participating institutions. Institutional agreements generally govern all GME programs that use the major participating institutions for educational experiences.
  - 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 ensure that formal quality-assurance programs are conducted and that there is a review of complications and deaths.
    1
    All residents should receive instruction in quality-assurance/performance improvement. To the degree possible and in conformance with state law, residents should participate in appropriate components of the institution's performance improvement program.
    2
    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.
  - 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 defined in the Manual of Policies and Procedures for ACGME Residency 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:
    1
    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.
    2
    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.
- II
  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:
    (1)
    Have received a currently valid certificate from the Educational Commission for Foreign Medical Graduates or
    (2)
    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
    ¹
    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: (1) 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; (2) have studied at a medical school outside the United States and Canada but listed in the World Health Organization Directory of Medical Schools; (3) have completed all of the formal requirements of the foreign medical school except internship and/or social service; (4) have attained a score satisfactory to the sponsoring medical school on a screening examination; and (5) have passed either the foreign Medical Graduate Examination in the Medical Sciences, Parts I and II of the examination of the National Board of Medical Examiners, or Steps 1 and 2 of the United States Medical Licensing Examination (USMLE).
    program provided by an LCME-accredited medical school.
    1A 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: (1) 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; (2) have studied at a medical school outside the United States and Canada but listed in the World Health Organization Directory of Medical Schools; (3) have completed all of the formal requirements of the foreign medical school except internship and/or social service; (4) have attained a score satisfactory to the sponsoring medical school on a screening examination; and (5) have passed either the foreign Medical Graduate Examination in the Medical Sciences, Parts I and II of the examination of the National Board of Medical Examiners, or Steps 1 and 2 of the United States Medical Licensing Examination (USMLE).
    2
    Resident selection
    a
    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. Programs must not discriminate with regard to sex, race, age, religion, color, national origin, disability, or veteran status.
    b
    In selecting from among qualified applicants, it is strongly suggested that institutions and all of their sponsored programs participate in an organized matching program, such as the National Resident Matching Program (NRMP), where such is available.
    3
    Enrollment of noneligibles
    The enrollment of noneligible residents may be a cause for withdrawal of accreditation of the involved program.
  - B
    Resident Participation in Educational and Professional Activities
    1
    Institutions must ensure that each program has defined, in accordance with the Program Requirements, the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate the following:
    a
    Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
    b
    Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
    c
    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
    d
    Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals
    e
    Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population and
    f
    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.
    2
    In addition, institutions must ensure that residents achieve the following:
    a
    Develop a personal program of learning to foster continued professional growth with guidance from the teaching staff
    b
    Participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents and students
    c
    Participate in appropriate institutional committees and councils whose actions affect their education and /or patient care
    d
    Submit to the program director or to a designated institutional 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.
    1
    : Adequate financial support of residents is necessary to ensure that residents are able to fulfill the responsibilities of their educational programs.
    2
    : Applicants for GME programs must be informed in writing of the terms and conditions of employment and benefits including financial support; vacations; professional, parental, and sick leave; professional liability, hospital, health, disability, and other insurance benefits for the residents and their families; and the conditions under which living quarters, meals, and laundry services or their equivalents are to be provided.
    3
    : 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 directors. Institutions must ensure that residents adhere to established practices, procedures, and policies of the institution.
    a
    The contract must contain or reference at least the following:
    1)
    Financial support
    2)
    Vacation policies
    3)
    Professional liability insurance in conformity with II.C.5 below
    4)
    Disability insurance and other hospital and health insurance benefits for the residents and their families in conformity with II.C.6 below
    5)
    Professional, parental, and sick-leave benefits in conformity with II.C.7 below
    6)
    Conditions under which living quarters, meals, and laundry services or their equivalents are to be provided
    7)
    Counseling, medical, psychological, and other support services in conformity with II.C.8 and 9 below
    8)
    Institutional policies covering sexual and other forms of harassment
    b
    The contract must also delineate or reference specific policies as follows:
    1)
    Resident's responsibilities
    2)
    Duration of appointment and conditions for reappointment
    3)
    Professional activities outside the educational program in conformity with II.C.11
    4)
    Grievance procedures in conformity with I.B.3.f.4
    4
    : Institutions must ensure that programs provide their residents with a written notice of intent not to renew a resident's contract no later than four months prior to the end of the resident's current contract. However if the primary reason(s) for the nonrenewal occurs within the four months prior to the end of the contract, institutions must ensure that programs provide their residents with as much written notice of the intent not to renew as the circumstances will reasonably allow, prior to the end of the contract. Residents must be allowed to implement the institution's grievance procedures as addressed in section I.B.3.f.4, when they have received a written notice of intent not to renew their contracts.
    5
    : 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.
    6
    : Institutions sponsoring GME must provide access to insurance, where available, to all residents for disabilities resulting from activities that are part of the educational program.
    7
    : There must be a written institutional policy on leave (with or without pay) for residents that complies with applicable laws. The institution must provide residents with a written policy concerning the effect of leaves of absence, for any reason, on satisfying the criteria for completion of a residency program.
    8
    : 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.
    9
    : 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.
    10
    : All sponsoring institutions must have a written policy that addresses a reduction in size or closure of a residency program. The policy must specify that 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 assist the residents in enrolling in an ACGME-accredited program in which they can continue their education.
    11
    : All sponsoring institutions must have a written policy that addresses professional activities outside the educational program to include moonlighting. The policy must specify that residents must not be required to engage in “moonlighting.” All residents engaged in moonlighting must be licensed for unsupervised medical practice in the state where the moonlighting occurs. It is the responsibility of the institution hiring the resident to moonlight to determine whether such licensure is in place, whether adequate liability coverage is provided, and whether the resident has the appropriate training and skills to carry out assigned duties. The sponsoring institution must ensure that the program director acknowledges in writing that she/he is aware that the resident is moonlighting, and that this information is made part of the resident's folder.
    12
    : ACGME-accredited residencies must not require residents to sign a noncompetition 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.
    1
    There must be sufficient institutional oversight to ensure 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.
    2
    : The sponsoring institution must ensure that each residency program establishes formal written policies governing resident duty hours that foster resident education and facilitate the care of patients. Duty hours must be consistent with the Institutional and Program Requirements of the specialties and subspecialties that apply to each program. These formal policies must apply to all institutions to which a resident rotates.
    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.
    3
    : 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
    Residents 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 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
    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 the education of residents, support quality-assurance activities, and provide a resource for scholarly activity.
    e
    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 (eg, medical office building).

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ACGME: 6/12/01

Effective Date: 7/1/02

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☆Reprinted with permission of the Accreditation Council for Graduate Medical Education, 515 N State St, Suite 2000, Chicago, IL 60610-4322

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DOI: https://doi.org/10.1016/S1076-6332(03)80161-7

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