IV.

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Last updated: Nov 21, 2017
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Up one level to ACGME Institutional Requirements 2018

IV.

Institutional GME Policies and Procedures

IV.A.
Resident/Fellow Recruitment

IV.A.1.
Eligibility and Selection of Residents/Fellows: The Sponsoring Institution must have written policies and procedures for resident/fellow recruitment and appointment, and must monitor each of its ACGME-accredited programs for compliance.
(Core)

IV.A.2.
An applicant must meet one of the following qualifications to be eligible for appointment to an ACGME-accredited program:
(Core)

IV.A.2.a)
graduation from a medical school in the United States or Canada, accredited by the Liaison Committee on Medical Education (LCME); or,
(Core)

IV.A.2.b)
graduation from a college of osteopathic medicine in the United States, accredited by the American Osteopathic Association (AOA); or,
(Core)

IV.A.2.c)
graduation from a medical school outside of the United States or Canada, and meeting one of the following additional qualifications:
(Core)

IV.A.2.c).(1)
holds a currently-valid certificate from the Educational Commission for Foreign Medical Graduates prior to appointment; or,
(Core)

IV.A.2.c).(2)
holds a full and unrestricted license to practice medicine in a United States licensing jurisdiction in his or her current ACGME specialty-/subspecialty program; or,
(Core)

IV.A.2.c).(3)
has graduated from a medical school outside the United States and has completed a Fifth Pathway** program provided by an LCME-accredited medical school.
(Core)

IV.A.3.
An applicant invited to interview for a resident/fellow position must be informed, in writing or by electronic means, of the terms, conditions, and benefits of appointment to the ACGME-accredited program, either in effect at the time of the interview or that will be in effect at the time of his or her eventual appointment.
(Core)

IV.A.3.a)
Information that is provided must include: financial support; vacations; parental, sick, and other leaves of absence; and professional liability, hospitalization, health, disability and other insurance accessible to residents/fellows and their eligible dependents.
(Core)

IV.B.
Agreement of Appointment/Contract

IV.B.1.
The Sponsoring Institution must ensure that residents/fellows are provided with a written agreement of appointment/contract outlining the terms and conditions of their appointment to a program. The Sponsoring Institution must monitor each of its programs with regard to implementation of terms and conditions of appointment.
(Core)

IV.B.2.
The contract/agreement of appointment must directly contain or provide a reference to the following items:
(Core)

IV.B.2.a)
resident/fellow responsibilities;
(Core)

IV.B.2.b)
duration of appointment;
(Core)

IV.B.2.c)
financial support for residents/fellows;
(Core)

IV.B.2.d)
conditions for reappointment and promotion to a subsequent PGY level;
(Core)

IV.B.2.e)
grievance and due process;
(Core)

IV.B.2.f)
professional liability insurance, including a summary of pertinent information regarding coverage;
(Core)

IV.B.2.g)
hospital and health insurance benefits for residents/fellows and their eligible dependents;
(Core)

IV.B.2.h)
disability insurance for residents/fellows;
(Core)

IV.B.2.i)
vacation, parental, sick, and other leave(s) for residents/fellows, compliant with applicable laws;
(Core)

IV.B.2.j)
timely notice of the effect of leave(s) on the ability of residents/fellows to satisfy requirements for program completion;
(Core)

IV.B.2.k)
information related to eligibility for specialty board examinations; and,
(Core)

IV.B.2.l)
institutional policies and procedures regarding resident/fellow clinical and educational work hours and moonlighting.
(Core)

IV.C.
Promotion, Appointment Renewal and Dismissal

IV.C.1.
The Sponsoring Institution must have a policy that requires each of its ACGME-accredited programs to determine the criteria for promotion and/or renewal of a resident’s/fellow’s appointment.
(Core)

IV.C.1.a)
The Sponsoring Institution must ensure that each of its programs provides a resident/fellow with a written notice of intent when that resident’s/fellow’s agreement will not be renewed, when that resident/fellow will not be promoted to the next level of training, or when that resident/fellow will be dismissed.
(Core)

IV.C.1.b)
The Sponsoring Institution must have a policy that provides residents/fellows with due process relating to the following actions regardless of when the action is taken during the appointment period: suspension, non-renewal, non-promotion; or dismissal.
(Core)

IV.D.
Grievances: The Sponsoring Institution must have a policy that outlines the procedures for submitting and processing resident/fellow grievances at the program and institutional level and that minimizes conflicts of interest.
(Core)

IV.E.
Professional Liability Insurance

IV.E.1.
The Sponsoring Institution must provide residents/fellows with professional liability coverage, including legal defense and protection against awards from claims reported or filed during participation in each of its ACGME-accredited programs, or after completion of the program(s) if the alleged acts or omissions of a resident/fellow are within the scope of the program(s).
(Core)

IV.E.2.
The Sponsoring Institution must provide official documentation of the details of liability coverage upon request of the individual.
(Core)

IV.F.
Health and Disability Insurance

IV.F.1.
The Sponsoring Institution must provide health insurance benefits for residents/fellows and their eligible dependents beginning on the first day of insurance eligibility.
(Core)

IV.F.1.a)
If the first day of health insurance eligibility is not the first day that residents/fellows are required to report, then the residents/fellows must be given advanced access to information regarding interim coverage so that they can purchase coverage if desired.
(Core)

IV.F.2.
The Sponsoring Institution must provide disability insurance benefits for residents/fellows beginning on the first day of disability insurance eligibility.
(Core)

IV.F.2.a)
If the first day of disability insurance eligibility is not the first day that residents/fellows are required to report, then the residents/fellows must be given advanced access to information regarding interim coverage so that they can purchase coverage if desired.
(Core)

IV.G.
Vacation and Leaves of Absence

IV.G.1.
The Sponsoring Institution must have a policy for vacation and other leaves of absence, consistent with applicable laws.
(Core)

IV.G.2.
This policy must ensure that each of its ACGME-accredited programs provides its residents/fellows with accurate information regarding the impact of an extended leave of absence upon the criteria for satisfactory completion of the program and upon a resident’s/fellow’s eligibility to participate in examinations by the relevant certifying board(s).
(Core)

IV.H.
Resident Services

IV.H.1.
Behavioral Health: The Sponsoring Institution must provide residents/fellows with access to confidential counseling and behavioral health services.
(Core)

IV.H.2.
Physician Impairment: The Sponsoring Institution must have a policy, not necessarily GME-specific, which addresses physician impairment.
(Core)

IV.H.3.
Harassment: The Sponsoring Institution must have a policy, not necessarily GME-specific, covering sexual and other forms of harassment, that allows residents/fellows access to processes to raise and resolve complaints in a safe and non-punitive environment consistent with applicable laws and regulations.
(Core)

IV.H.4.
Accommodation for Disabilities: The Sponsoring Institution must have a policy, not necessarily GME-specific, regarding accommodations for disabilities consistent with all applicable laws and regulations.
(Core)

IV.I.
Supervision

IV.I.1.
The Sponsoring Institution must maintain an institutional policy regarding supervision of residents/fellows.
(Core)

IV.I.2.
The Sponsoring Institution must ensure that each of its ACGME- accredited programs establishes a written program-specific supervision policy consistent with the institutional policy and the respective ACGME Common and specialty-/subspecialty-specific Program Requirements.
(Core)

IV.J.
Clinical and Educational Work Hours: The Sponsoring Institution must maintain a clinical and educational work hour policy that ensures effective oversight of institutional and program-level compliance with ACGME clinical and educational work hour requirements.
(Core)

IV.J.1.
Moonlighting: The Sponsoring Institution must maintain a policy on moonlighting that includes the following:

IV.J.1.a)
residents/fellows must not be required to engage in moonlighting;
(Core)

IV.J.1.b)
residents/fellows must have written permission from their program director to moonlight;
(Core)

IV.J.1.c)
an ACGME-accredited program will monitor the effect of moonlighting activities on a resident’s/fellow’s performance in the program, including that adverse effects may lead to withdrawal of permission to moonlight; and,
(Core)

IV.J.1.d)
the Sponsoring Institution or individual ACGME-accredited programs may prohibit moonlighting by residents/fellows.
(Core)

IV.K.
Vendors: The Sponsoring Institution must maintain a policy that addresses interactions between vendor representatives/corporations and residents/fellows and each of its ACGME-accredited programs.
(Core)

IV.L.
Non-competition: The Sponsoring Institution must maintain a policy which states that neither the Sponsoring Institution nor any of its ACGME-accredited programs will require a resident/fellow to sign a non-competition guarantee or restrictive covenant.
(Core)

IV.M.
Disasters: The Sponsoring Institution must maintain a policy consistent with ACGME Policies and Procedures that addresses administrative support for each of its ACGME-accredited programs and residents/fellows in the event of a disaster or interruption in patient care.
(Core)

IV.M.1.
This policy should include information about assistance for continuation of salary, benefits, and resident/fellow assignments.
(Core)

IV.N.
Closures and Reductions: The Sponsoring Institution must maintain a policy that addresses GMEC oversight of reductions in size or closure of each of its ACGME-accredited programs, or closure of the Sponsoring Institution that includes the following:
(Core)

IV.N.1.
the Sponsoring Institution must inform the GMEC, DIO, and affected residents/fellows as soon as possible when it intends to reduce the size of or close one or more ACGME-accredited programs, or when the Sponsoring Institution intends to close; and,
(Core)

IV.N.2.
the Sponsoring Institution must allow residents/fellows already in an affected ACGME-accredited program(s) to complete their education at the Sponsoring Institution, or assist them in enrolling in (an)other ACGME- accredited program(s) in which they can continue their education.
(Core)
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