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Graduate Medical Education Committee

GMEC Responsibilities (ACGME Institutional Requirements, Sect IV, B)

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 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.

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San Francisco, CA 94143-0474
Telephone: (415) 476-4562
Fax: (415) 502-4166
www.medschool.ucsf.edu/gme