I.
Up one level to ACGME Institutional Requirements 2018
| I. | Structure for Educational Oversight | |||||||||
| I.A. | Sponsoring Institution | |||||||||
| I.A.1. | Residency and fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) must function under the ultimate authority and oversight of one Sponsoring Institution. Oversight of resident/fellow assignments and of the quality of the learning and working environment by the Sponsoring Institution extends to all participating sites. | (Core) | ||||||||
| I.A.2. | The Sponsoring Institution must be in substantial compliance with the ACGME Institutional Requirements and must ensure that each of its ACGME-accredited programs is in substantial compliance with the ACGME Institutional, Common, and specialty-/subspecialty-specific Program Requirements, as well as with ACGME Policies and Procedures. | (Outcome) | ||||||||
| I.A.3. | The Sponsoring Institution must maintain its ACGME institutional accreditation. Failure to do so will result in loss of accreditation for its ACGME-accredited program(s). | (Outcome) | ||||||||
| I.A.4. | The Sponsoring Institution and each of its ACGME-accredited programs must only assign residents/fellows to learning and working environments that facilitate patient safety and health care quality. | (Outcome) | ||||||||
| I.A.5. | The Sponsoring Institution must identify a designated institutional official (DIO). | |||||||||
| I.A.5.a) | This individual who, in collaboration with a Graduate Medical Education Committee (GMEC), must have authority and responsibility for the oversight and administration of each of the Sponsoring Institution’s ACGME-accredited programs, as well as for ensuring compliance with the ACGME Institutional, Common, and specialty-/subspecialty-specific Program, and Recognition Requirements. | (Core) | ||||||||
| I.A.5.b) | The DIO must: | (Core) | ||||||||
| I.A.6. | A written statement must document the Sponsoring Institution’s commitment to GME by providing the necessary financial support for administrative, educational, and clinical resources, including personnel, and which must be reviewed, dated, and signed at least once every five years by the DIO, a representative of the Sponsoring Institution’s senior administration, and a representative of the Governing Body. | (Core) | ||||||||
| I.A.7. | Any Sponsoring Institution or participating site that is a hospital must | |||||||||
| I.A.7.a) | Accreditation for patient care must be provided by: | |||||||||
| I.A.7.a).(1) | REMOVED | |||||||||
| I.A.7.a).(2) | an entity granted “deeming authority” for participation in Medicare under federal regulations; or, | (Core) | ||||||||
| I.A.7.a).(3) | an entity certified as complying with the conditions of participation in Medicare under federal regulations. | (Core) | ||||||||
| I.A.8. | When a Sponsoring Institution or major participating site that is a hospital loses its accreditation for patient care, the Sponsoring Institution must notify and provide a plan for its response to the Institutional Review Committee (IRC) within 30 days of such loss. Based on the particular circumstances, the ACGME may invoke its procedures related to alleged egregious and/or catastrophic events. | (Core) | ||||||||
| I.A.9. | When a Sponsoring Institution’s or participating site’s license is denied, suspended, or revoked, or when a Sponsoring Institution or participating site is required to curtail activities, or is otherwise restricted, the Sponsoring Institution must notify and provide a plan for its response to the IRC within 30 days of such loss or restriction. Based on the particular circumstances, the ACGME may invoke its procedures related to alleged egregious and/or catastrophic events. | (Core) | ||||||||
| I.B. | GMEC | |||||||||
| I.B.1. | Membership | |||||||||
| I.B.1.a) | A Sponsoring Institution with multiple ACGME-accredited programs must have a GMEC that includes at least the following voting members: | (Core) | ||||||||
| I.B.1.a).(1) | the DIO; | (Core) | ||||||||
| I.B.1.a).(2) | a representative sample of program directors (minimum of two) from its ACGME-accredited programs; | (Core) | ||||||||
| I.B.1.a).(3) | a minimum of two peer-selected residents/fellows from among its ACGME-accredited programs; and, | (Core) | ||||||||
| I.B.1.a).(4) | a quality improvement or patient safety officer or designee. | (Core) | ||||||||
| I.B.1.b) | A Sponsoring Institution with one program must have a GMEC that includes at least the following voting members: | |||||||||
| I.B.1.b).(2) | the program director when the program director is not the DIO; | (Core) | ||||||||
| I.B.1.b).(3) | a minimum of two peer-selected residents/fellows from its ACGME-accredited program or the only resident/fellow if the program includes only one resident/fellow; | (Core) | ||||||||
| I.B.1.b).(4) | the individual or designee responsible for monitoring quality improvement or patient safety if this individual is not the DIO or program director; and, | (Core) | ||||||||
| I.B.1.b).(5) | one or more individuals from a different department than that of the program specialty (and other than the quality improvement or patient safety member), within or from outside the Sponsoring Institution, at least one of whom is actively involved in graduate medical education. | (Core) | ||||||||
| I.B.2. | Additional GMEC members and subcommittees: In order to carry out portions of the GMEC’s responsibilities, additional GMEC membership may include others as determined by the GMEC. | (Detail) | ||||||||
| I.B.2.a) | Subcommittees that address required GMEC responsibilities must include a peer-selected resident/fellow. | (Detail) | ||||||||
| I.B.2.b) | Subcommittee actions that address required GMEC responsibilities must be reviewed and approved by the GMEC. | (Detail) | ||||||||
| I.B.3. | Meetings and Attendance: The GMEC must meet a minimum of once every quarter during each academic year. | (Core) | ||||||||
| I.B.3.a) | Each meeting of the GMEC must include attendance by at least one resident/fellow member. | (Core) | ||||||||
| I.B.3.b) | The GMEC must maintain meeting minutes that document execution of all required GMEC functions and responsibilities. | (Core) | ||||||||
| I.B.4. | Responsibilities: GMEC responsibilities must include: | |||||||||
| I.B.4.a) | Oversight of: | |||||||||
| I.B.4.a).(1) | the ACGME accreditation status of the Sponsoring Institution and each of its ACGME-accredited programs; | (Outcome) | ||||||||
| I.B.4.a).(2) | the quality of the GME learning and working environment within the Sponsoring Institution, each of its ACGME- accredited programs, and its participating sites; | (Outcome) | ||||||||
| I.B.4.a).(3) | the quality of educational experiences in each ACGME-accredited program that lead to measurable achievement of educational outcomes as identified in the ACGME Common and specialty-/subspecialty-specific Program Requirements; | (Outcome) | ||||||||
| I.B.4.a).(4) | the ACGME-accredited program(s)’ annual program evaluations and self-studies; and, | (Core) | ||||||||
| I.B.4.a).(5) | all processes related to reductions and closures of individual ACGME-accredited programs, major participating sites, and the Sponsoring Institution. | (Core) | ||||||||
| I.B.4.a).(6) | the provision of summary information of patient safety reports by participating sites to residents, fellows, faculty members, and other clinical staff members. At a minimum, this oversight must include verification that such summary information is being provided by participating sites. | (Detail) | ||||||||
| I.B.4.b) | review and approval of: | |||||||||
| I.B.4.b).(1) | institutional GME policies and procedures; | (Core) | ||||||||
| I.B.4.b).(2) | annual recommendations to the Sponsoring Institution’s administration regarding resident/fellow stipends and benefits; | (Core) | ||||||||
| I.B.4.b).(3) | applications for ACGME accreditation of new programs; | (Core) | ||||||||
| I.B.4.b).(4) | requests for permanent changes in resident/fellow complement; | (Core) | ||||||||
| I.B.4.b).(5) | major changes in each of its ACGME-accredited programs’ structure or duration of education; | (Core) | ||||||||
| I.B.4.b).(6) | additions and deletions of each of its ACGME-accredited programs’ participating sites; | (Core) | ||||||||
| I.B.4.b).(7) | appointment of new program directors; | (Core) | ||||||||
| I.B.4.b).(8) | progress reports requested by a Review Committee; | (Core) | ||||||||
| I.B.4.b).(9) | responses to Clinical Learning Environment Review (CLER) reports; | (Core) | ||||||||
| I.B.4.b).(10) | requests for exceptions to clinical and educational work hour requirements; | (Core) | ||||||||
| I.B.4.b).(11) | voluntary withdrawal of ACGME program accreditation; | (Core) | ||||||||
| I.B.4.b).(12) | requests for appeal of an adverse action by a Review Committee; and, | (Core) | ||||||||
| I.B.4.b).(13) | appeal presentations to an ACGME Appeals Panel. | (Core) | ||||||||
| I.B.5. | The GMEC must demonstrate effective oversight of the Sponsoring Institution’s accreditation through an Annual Institutional Review (AIR). | (Outcome) | ||||||||
| I.B.5.a) | The GMEC must identify institutional performance indicators for the AIR, to include, at a minimum: | (Core) | ||||||||
| I.B.5.a).(1) | the most recent ACGME institutional letter of notification; | (Core) | ||||||||
| I.B.5.a).(2) | results of ACGME surveys of residents/fellows and core faculty members; and, | (Core) | ||||||||
| I.B.5.a).(3) | each of its ACGME-accredited programs’ ACGME accreditation information, including accreditation statuses and citations. | (Core) | ||||||||
| I.B.5.b) | REMOVED | |||||||||
| I.B.5.c) | The DIO must annually submit a written executive summary of the AIR to the Sponsoring Institution’s Governing Body. The written executive summary must include: | (Core) | ||||||||
| I.B.5.c).(1) | a summary of institutional performance on indicators for the AIR; and, | (Core) | ||||||||
| I.B.5.c).(2) | action plans and performance monitoring procedures resulting from the AIR. | (Core) | ||||||||
| I.B.6. | The GMEC must demonstrate effective oversight of underperforming program(s) through a Special Review process. | (Core) | ||||||||
| I.B.6.a) | The Special Review process must include a protocol that: | (Core) | ||||||||
| I.B.6.a).(1) | establishes criteria for identifying underperformance; and, | (Core) | ||||||||
| I.B.6.a).(2) | results in a report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes. | (Core) | ||||||||
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