Guide to the Common Program Requirements (Residency)

Accreditation Council for Graduate Medical Education

Guide to the

Common Program Requirements

(

Residency)

(Version 4.1; updated March 2024)

Accreditation Council for Graduate Medical Education

ACGME Mission

The Mission of the ACGME is to improve health care and population health by assessing and

enhancing the quality of resident and fellow physicians’ education through advancements in

accreditation and education.

ACGME Vision

We envision a health care system in which the Quadruple Aim* has been realized. We aspire to

advance a transformed system of graduate medical education with global reach that is:

• Compet

ency-based with customized professional development and identity formation for

all physicians;

• Led by inspirational faculty role models overseeing supervised, humanistic, clinical

educational experiences;

• Immersed in evidence-based, data-driven, clinical learning and care environments

defined by excellence in clinical care, safety, cost-effectiveness, professionalism, and

diversity, equity, and inclusion;

• Located in health care delivery systems equitably meeting local and regional community

needs; and,

• Graduating residents and fellows who strive for continuous mastery and altruistic

professionalism throughout their careers, placing the needs of patients and their

communities first.

* The Quad

ruple Aim simultaneously improves patient experience of care, population health,

and health care practitioner work life, while lowering per capita cost.

ACGME Values

• Honesty and Integrity

• Accountability and Transparency

• Equity and Fairness

• Diversity and Inclusion

• Excellence and Innovation

• Stewardship and Service

• Leadership and Collaboration

• Engagement of Stakeholders

Int.A, B and C Introduction 6

I.A. and I.A.1. Oversight and Sponsoring Institution 9

I.B.1. Participating Sites 11

I.B.2. and I.B.3. Program Letters of Agreement with AAMC Template 14

I.B.4. Participating Sites Addition and Deletion 18

I.C. Diversity and Inclusion in Workforce Recruitment and Retention 23

I.D.1. - I.D.3. Resources, Sleep Facilities, References, Security 27

I.E. Presence of Other Learners 30

II.A.1.a) and

II.A.1.a).(1)

Program Director Appointment 33

II.A.1.b) Program Director Continuity of Leadership 37

II.A.2. Program Director Support for Administration of Program 39

II.A.3. and

II.A.3.a) - c)

Qualifications of Program Director 42

II.A.4.a).(1) - (5)

Program Director Responsibilities - Professionalism and

Learning Environment

II.A.4.a).(6)

Program Director Responsibilities - Submit Accurate and

Complete Information

II.A.4.a).(7) -

(9).(a)

Program Director Responsibilities - Raising Concerns and

Sponsoring Institution Policies

II.A.4.a).(10) -

(11)

Program Director Documentation and Verification of Resident

Education/VGMET

II.A.4.a).(12) Resident Eligibility for Specialty Board Examination 68

II.B.1. and

II.B.2.a) - f)

Faculty Responsibilities 72

II.B.3.a) - b) Faculty Qualifications 76

II.B.4. Core Faculty 82

II.C. and II.D. Coordinator and Other Personnel 87

III.A.1. – III.A.3. Resident Appointments 91

III.B. Resident Complement 105

III.C. Resident Transfers 108

IV.A.1. – IV.A.5. Educational Program Curriculum 112

IV.B. ACGME Competencies 118

IV.B.1.a) Professionalism 122

IV.B.1.b) Patient Care and Procedural Skills 126

IV.B.1.c) Medical Knowledge 128

IV.B.1.d) Practice-based Learning and Improvement 130

IV.B.1.e) Interpersonal and Communication Skills 133

IV.B.1.f) Systems-based Practice 137

IV.C. Curriculum Organization and Resident Experiences 141

IV.C.2. Pain Management and Substance Use Disorder 143

IV.D.1. Scholarship Program Responsibilities 147

IV.D.2. Faculty Scholarly Activity 151

IV.D.3. Resident Scholarly Activity 159

V.A.1.a) - f) Resident Evaluation 164

V.A.1.d).(2) Resident Individual Learning Plans 168

V.A.1.d).(3) Plans for Residents Failing to Progress 171

V.A.2.a).(1) Milestones and Sharing Externally 178

V.A.2.a).(2) Final Evaluation 180

V.A.3.a) - b) Clinical Competency Committee Composition and Role 182

V.B.1. - 3. Faculty Evaluation 184

V.C.1. The Program Evaluation Committee 188

V.C.2. Self-Study 197

V.C.3.a) - f) Board Pass Rates and Ultimate Board Certification 199

VI.A.1.a).(1) – (3) Patient Safety and Quality Metrics 205

VI.A.2. Supervision and Accountability 209

VI.B. Professionalism 215

VI.C. Well-Being 222

VI.D. Fatigue Mitigation 226

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care 229

VI.F. Clinical Experience and Education 232

Guide to the Common Program Requirements

(Residency)

The Guide to the Common Program Requirements is a living document that will be updated as

the Common Program Requirements change. In addition to this Residency version, the ACGME

has developed a Fellowship version.

This gui

de is available as a downloadable PDF version that can be printed. If referring to a

printed version, periodically check the website for any version updates.

The Guide

should serve as a resource, and the content within it is designed to serve as helpful

guidance and not to be interpreted as additional requirements. It is also not meant to be read

cover to cover in one sitting, but to be referenced as needed throughout the academic year.

If t

here are any conflicts between the Guide and the Common Program Requirements, as

interpreted and implemented by the Review Committees, the interpretation and

implementation of the Review Committees shall control.

Note:

Every set of specialty-specific Program Requirements includes content specific and

unique to the specialty. Specialty Program Requirements are not addressed in this Guide. The

specialty-specific FAQs and other resource documents provided by the respective Review

Committee should be consulted; these are available on the respective specialty section of the

ACGME website. Contact Review Committee staff members with specific questions.

Format

• Requirement text is included on the pages with a blue background.

o Italicized text provides philosophical background; these statements are not Program

Requirements and, therefore, are not citable by Review Committees.

o Text in boxes provides Background and Intent and is also not citable.

o Review Committees may further specify additional Program Requirements only

where bracketed notes indicate that the Review Committee may/must further specify.

• Guidance for understanding and applying individual Program Requirements is included

on the pages with a white background.

• Each entry in the Table of Contents is a link that can be used to jump to a specific topic

area in the Guide.

• The search function allows users to enter key words to quickly locate information.

• Where appropriate, screenshots of what data entry looks like within the ACGME’s

Accreditation Data System (ADS) are included. ADS screenshots may change as

system enhancements are made every month. The Guide will be updated periodically as

these changes occur.

The ACG

ME encourages feedback, comments, and questions about the Guide via this survey.

COMMON PROGRAM REQUIREMENTS

Where applicable, text in italics describes the underlying philosophy of the requirements

in that section. These philosophic statements are not program requirements and are

therefore not citable.

Note: Review Committees may further specify only where indicated by “The Review

Committee may/must further specify.”

Intr

oduction

Int.A

Definition of Graduate Medical Education

Graduate medical education is the crucial step of professional

development between medical school and autonomous clinical practice. It

is in this vital phase of the continuum of medical education that residents

learn to provide optimal patient care under the supervision of faculty

members who not only instruct, but serve as role models of excellence,

compassion, cultural sensitivity, professionalism, and scholarship.

Gradua

te medical education transforms medical students into physician

scholars who care for the patient, patient’s family, and a diverse

community; create and integrate new knowledge into practice; and educate

future generations of physicians to serve the public. Practice patterns

established during graduate medical education persist many years later.

Gradua

te medical education has as a core tenet the graded authority and

responsibility for patient care. The care of patients is undertaken with

appropriate faculty supervision and conditional independence, allowing

residents to attain the knowledge, skills, attitudes, judgement, and empathy

required for autonomous practice. Graduate medical education develops

physicians who focus on excellence in delivery of safe, equitable,

affordable, quality care; and the health of the populations they serve.

Graduate medical education values the strength that a diverse group of

physicians brings to medical care, and the importance of inclusive and

psychologically safe learning environments

Graduate medical education occurs in clinical settings that establish the

foundation for practice-based and lifelong learning. The professional

development of the physician, begun in medical school, continues through

faculty modeling of the effacement of self-interest in a humanistic

environment that emphasizes joy in curiosity, problem-solving, academic

rigor, and discovery. This transformation is often physically, emotionally,

and intellectually demanding and occurs in a variety of clinical learning

environments committed to graduate medical education and the well-being

of patients, residents, fellows, faculty members, students, and all members

of the health care team.

Int.B

. Definition of Specialty

[The

Review Committee must further specify]

Int.C

. Length of educational program

[The

Review Committee must further specify]

GUIDANCE

Introduction A (Int.A.) is not a requirement but is a philosophic statement that embodies the

meaning and purpose of graduate medical education (GME). It describes why GME is important

and why programs must ensure that residents are provided with the best education possible.

Introduction B (Int.B.) and Introduction C (Int.C.) address the definition of a specialty and the

length of the educational program for that specialty. These requirements must be further

specified in the specialty-specific Program Requirements.

To revi

ew the specialty-specific Program Requirements:

1. Go to

https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the subspecialty Program Requirements currently in effect.

For exam

ple, to locate the Program Requirements for Orthopaedic Surgery:

1. Go to: https://www.acgme.org/specialties/

2. Select Orthopaedic Surgery.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Access a P

DF version of the current “Program Requirements for Orthopaedic Surgery”

by selecting the “Program Requirements Effective [current date]” file in the box labeled

“Orthopaedic Surgery.”

As Progr

am Requirements are revised and approved by the ACGME Board of Directors,

Program Requirements that are approved but not yet effective can be found on that same page,

labeled “Future Effective Date.”

Some s

pecialties have also developed an FAQ document, which complements the specialty

Program Requirements and can be found below the specialty-specific Program Requirements.

COMMON PROGRAM REQUIREMENTS

I. Oversight

I.A. Sponsoring Institution

The Sponsoring Institution is the organization or entity that assumes the

ultimate financial and academic responsibility for a program of graduate

medical education, consistent with the ACGME Institutional Requirements.

When th

e Sponsoring Institution is not a rotation site for the program, the

most commonly utilized site of clinical activity for the program is the

primary clinical site.

Background and Intent: Participating sites will reflect the healthcare needs of the

community and the educational needs of the residents. A wide variety of organizations

may provide a robust educational experience and, thus, Sponsoring Institutions and

participating sites may encompass inpatient and outpatient settings including, but not

limited to a university, a medical school, a teaching hospital, a nursing home, a school

of public health, a health department, a public health agency, an organized health care

delivery system, a medical examiner’s office, an educational consortium, a teaching

health center, a physician group practice, federally qualified health center, or an

educational foundation.

I.A.1

. The program must be sponsored by one ACGME-accredited

Sponsoring Institution.

(Core)

GUIDANCE

Sponsorship and Sponsoring Institution accreditation

Common Program Requirement I.A.1. corresponds with Institutional Requirement I.A.1.:

“Residency and fellowship programs accredited by the 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.”

Sponsor

ship of a program includes responsibility for oversight of the Sponsoring Institution’s

and all accredited programs’ compliance with the applicable ACGME requirements, and the

assurance of the resources necessary for graduate medical education.

The ACG

ME Board of Directors delegates authority for accrediting Sponsoring Institutions to the

Institutional Review Committee. The ACGME’s primary point of contact with each Sponsoring

Institution is the designated institutional official (DIO).

For mor

e information about Sponsoring Institutions, refer to the ACGME Institutional

Requirements and Frequently Asked Questions.

COMMON PROGRAM REQUIREMENTS

I.B. Participating Sites

A participating site is an organization providing educational experiences or

educational assignments/rotations for residents.

I.B.1. The pr

ogram, with approval of its Sponsoring Institution, must designate a

primary clinical site.

(Core)

[The Review Committee may specify which other specialties/programs

must be present at the primary clinical site]

GUIDANCE

I.B.1. Primary clinical site designations and Sponsoring Institution approval

The philosophic statement preceding Common Program Requirement I.A defines a program’s

primary clinical site as “the most commonly utilized site of clinical activity for the program.” A

program should follow its Sponsoring Institution’s methods for identifying the primary clinical

site. Typically, the “most commonly utilized” participating site is that which has the highest count

of resident full-time equivalents (FTEs) in a program over an academic year, assuming a full

and evenly distributed resident complement.

ADS screenshot: primary clinical site

In a program’s Accreditation Data System (ADS) profile, the designated primary clinical site can

be found in the “Sites” tab. It is marked as “Primary” in the list of participating sites (# column), is

shaded in yellow, and appears first on the list.

ADS screenshot: identifying the primary clinical site in applications

In applications for ACGME accreditation, when adding participating sites, programs are directed

to identify one of the participating sites as the primary clinical site. Only one site can be

identified as the primary clinical site.

Part

icipating site information listed in ADS, including the designation of the primary clinical site,

implies the Sponsoring Institution’s approval. The ACGME does not provide a standardized

format for documenting institutional approval of these designations. Refer to

specialty-specific

Program Requirements for additional information.

[The Review Committee may specify which other specialties/programs must be

present at the primary clinical site]

Since Review Committees may specify which other specialties/programs must be present at the

primary clinical site, programs must review the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

Quest

ions about specialty Program Requirements or expectations for the primary clinical site

should be directed to specialty Review Committee staff members. Programs can also access

the Common Program Requirements FAQs

for additional information on participating sites.

COMMON PROGRAM REQUIREMENTS

I.B. Participating Sites

I.B.2.

here must be a program letter of agreement (PLA) between the program

and each participating site that governs the relationship between the

program and the participating site providing a required assignm

ent.

(Core)

I.B.2.a

) The PLA must:

I.B.2.a

).(1) be renewed at least every 10 years; and,

(Core)

I.B.2.a

).(2) be approved by the designated institutional official (DIO).

(Core)

I.B.3. T

he program must monitor the clinical learning and working environment

at all participating sites.

(Core)

I.B.3.a

) At each participating site there must be one faculty member,

designated by the program director as the site director, who is

accountable for resident education at that site, in collaboration with

the program director.

(Core)

Background and Intent: While all residency programs must be sponsored by a single ACGME-

accredited Sponsoring Institution, many programs will utilize other clinical settings to provide

required or elective education and training experiences. At times it is appropriate to utilize

community sites that are not owned by or affiliated with the Sponsoring Institution. Some of

these sites may be remote for geographic, transportation, or communication issues. When

utilizing such sites the program must ensure the quality of the educational experience.

Suggested el

ements to be considered in PLAs will be found in the Guide to the Common

Program Requirements. These include:

• Identifying the faculty members who will assume educational and supervisory

responsibility for residents

• Specifying the responsibilities for teaching, supervision, and formal evaluation of

residents

• Specifying the duration and content of the educational experience

• Stating the policies and procedures that will govern resident education during the

assignment

GUIDANCE

The PLA is a written document that addresses graduate medical education (GME)

responsibilities between a program and a participating site at which residents have required

educational experiences.

The As

sociation of American Medical Colleges (AAMC) has developed a PLA

template whic

programs can use and modify according to their specific needs.

Note:

• Program directors are responsible for PLAs. Designated institutional officials (DIOs) are

required to review and approve all PLAs.

• A change in program director or DIO does not require updating a PLA with new

signatures.

• PLAs must be updated and renewed at least every 10 years.

• PLAs are required only for sites providing required educational experiences.

• Although the ACGME does not require PLAs for sites providing elective rotations, an

institution or GME office may require a PLA for those sites.

• PLAs are between a program and the participating site and include all rotations taking

place at that participating site.

• PLAs are not required for participating sites under the governance of the Sponsoring

Institution.

The purpose of a PLA is to ensure a shared understanding of expectations for the educational

experience, the nature of the experience, and the responsibilities of the program and the

participating site.

As specified in the Background and Intent under Common Program Requirement I.B.3.a),

suggested elements for a PLA include:

• identifying the faculty members who will assume educational and supervisory

responsibility for residents;

• specifying the responsibilities for teaching, supervision, and formal evaluation of

residents;

• specifying the duration and content of the educational experience (e.g., rotation name,

educational objectives) and

• stating the policies and procedures that will govern resident education during the

assignment.

Addit

ional considerations for PLAs that may be further clarified in specialty-specific FAQs

include:

• the site director may be the program director in some cases, but the program director is

not usually the site director at all participating sites; and

• if the site is distant, the program should consider providing the residents with

accommodation proximate to the participating site.

The ACG

ME requires copies of PLAs to be uploaded in the Accreditation Data System (ADS)

for new program applications and updated applications. Accreditation Field Staff request copies

of and verify PLAs during site visits for applications, initial accreditation, and other types of site

visits. For programs with a status of Continued Accreditation, the PLA is not requested when a

new

participating site is added in ADS. However, the program must provide confirmation that a

PLA is in place and list the effective date. If the effective date is not available, the signature date

may be documented as the effective date.

ADS screenshot: adding a participating site and PLA details

When entering a new participating site in ADS, programs are asked to confirm that a PLA exists

and provide its effective date.

Examples of rotations that require a PLA

• one-month required rotation in a pediatric inpatient unit in a children’s hospital in a family

medicine program

• one-month required rotation in rheumatology in an internal medicine program

• two-month required rotation in an emergency department with a Level 1 trauma center at

a site that is not the Sponsoring Institution

• required osteopathic neuromusculoskeletal medicine inpatient rotation

• longitudinal required geriatric experience in a long-term care facility in a family medicine

program

• four-week required retina rotation with a community physician who is not a member of

the medical staff of one of the participating sites in an ophthalmology program

Potential areas for improvement (AFIs) or citations

• failure to have a PLA signed by the DIO, the program director, and the site director for

each site at which residents rotate for a required educational experience

• failure to renew a PLA every 10 years

• incorrect/incomplete participating site information in ADS

In addi

tion to the guidance included here, the Common Program Requirements FAQs

address

multiple questions from the GME community about PLAs

Com

mon Program Requirement I.B.3. requires that the program must monitor the clinical

learning and working environment at all participating sites. The Background and Intent further

explains the rationale for this requirement and is worth repeating: “While all residency programs

must be sponsored by a single ACGME-accredited Sponsoring Institution, many programs will

utilize other clinical settings to provide required or elective education and training experiences.

At times it is appropriate to utilize community sites that are not owned by or affiliated with the

Sponsoring Institution. Some of these sites may be remote for geographic, transportation, or

communication issues. When utilizing such sites the program must ensure the quality of the

educational experience.” Examples of how programs can monitor the experience at all

participating sites include but are not limited to:

• resident evaluations of rotations at each participating site;

• participation of the site director in faculty meetings; and

• inclusion of the site director on the Clinical Competency Committee (CCC), and/or on the

Program Evaluation Committee (PEC).

COMMON PROGRAM REQUIREMENTS

I.B. Participating Sites

A participating site is an organization providing educational experiences or

educational assignments/rotations for residents.

I.B.4. The program director must submit any additions or deletions of

participating sites routinely providing an educational experience, required

for all residents, of one month full time equivalent (FTE) or more through

the ACGME’s Accreditation Data System (ADS).

(Core)

[The Review Committee may further specify]

GUIDANCE

The philosophic statement preceding Common Program Requirement I.B. defines a

participating site as “an organization providing educational experiences or educational

assignments/rotations for residents.” In addition to the primary clinical site, per Common

Program Requirement I.B.4. the program director must add all participating sites routinely

providing a required educational experience of one month or more in ADS.

When applying for accreditation or recognition of a new program, or when a change occurs in

the educational structure of a program and a new participating site at which a required

educational experience of one month or more will occur, the program director must add the new

site in ADS. All sites added in ADS will be visible to both the program and the Review

Committee.

Adding participating sites in ADS that provide elective experiences and/or experiences shorter

than one month in length is not required by the ACGME but may be helpful for some specialties.

[The Review Committee may further specify]

Since Review Committees may specify other requirements related to participating sites,

programs must review the specialty-specific Program Requirements:

• Go to https://www.acgme.org/specialties/

• Select the applicable specialty.

• Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

• Select the specialty Program Requirements currently in effect.

Questions about specialty-specific Program Requirements related to participating sites should

be directed to specialty Review Committee staff. Programs can also access the

Common

Program Requirements FAQs for additional information on participating sites.

ADS screenshot: adding a participating site

To add a site in ADS, log into the program’s ADS profile, then go to the Sites tab on the top

navigation bar and click the “Add Site” blue button.

ADS screenshot: instructions for adding participating sites

For instructions on the participating sites to add into ADS, on the “Sites” tab, click the arrow on

the “Instructions” blue bar to expand it.

ADS screenshot: participating site definition

For the definition of a participating site, click the arrow on the “Participating Site Definition” blue

bar to expand it. (See accompanying screenshot which follows on the next page.)

ADS screenshot: adding participating site details

On the “Add Site” screen, the program will select a site name from the pre-populated dropdown

menu. If the site is not on the list, contact the designated institutional official to have the site

added. Programs may only enter sites that the Sponsoring Institution has approved and added

to ADS. Complete all other information and click the “Save Site” button. (See accompanying

screenshot which follows on the next page.)

NOTE: Programs should complete all requested information. The ACGME may request

additional information from the program if the information submitted is incomplete or inaccurate.

For example:

• Rotation months for each post-graduate year listed for that participating site do not align

with the rotation months on the block diagram.

• The description of the content of the educational experience does not include a rationale

for the addition of the site, faculty coverage, volume/variety of clinical experience, site

support, and/or educational impact.

While copies of Program Letters of Agreement (PLAs) are not required when adding a new

participating site, programs should ensure that a PLA is in place. A copy may be requested by

the ACGME during a site visit or as needed.

ADS screenshot: deleting a participating site

If the program no longer uses a participating site, the site should be removed from their list of

sites in ADS. To remove a site, on the Sites tab hover over the site in the list of participating

sites and click the “X” button.

Once all participating sites have been added to or deleted from ADS, programs should review

the list of participating sites and ensure that they are ordered based on the number of months

residents spend at each site, with the most-used site listed as primary and all other sites listed

in descending order. Programs should also ensure that the number of months for each year of

training totals 12. If the number of months for each year of education and training do not total

12, the “Comments” box should be used to provide an explanation to the Review Committee.

Lastly, programs should ensure that the participating sites listed in ADS match the participating

sites listed on the block diagram, including the number of months residents rotate at each site.

This is a common discrepancy identified by Review Committees.

Review Committee approval of participating site additions and deletions

Once a site is added to or removed from ADS, the Review Committee staff members are

notified of the change. The change is reviewed per the Review Committee process and

programs will receive notification of approval or follow-up from the Review Committee staff.

Common areas for improvement (AFIs) or citations

Some of the most common areas for which programs receive an AFI or citation include:

• the listing of participating sites in ADS does not match information on the block diagram;

• the number of months for each year of education and training listed for each participating

site in ADS is different from the block diagram;

• the number of months for each year of education and training does not total 12 and the

program does not provide an explanation; and

• a site director is not identified or is incorrectly identified on the participating site profile in

ADS and/or the PLA.

COMMON PROGRAM REQUIREMENTS

I.C. Workforce Recruitment and Retention

The program, in partnership with its Sponsoring Institution, must engage in

practices that focus on mission-driven, ongoing, systematic recruitment and

retention of a diverse and inclusive workforce of residents, fellows (if present),

faculty members, senior administrative staff members, and other relevant

members of its academic community.

(Core)

Background and Intent: It is expected that the Sponsoring Institution has, and

programs implement, policies and procedures related to recruitment and retention of

individuals underrepresented in medicine and medical leadership in accordance with

the Sponsoring Institution’s mission and aims.

GUIDANCE

The ACGME is interested in the diversity of the physician workforce because it is essential to

addressing health care access and health equity. While most, if not all, Sponsoring Institutions

have mission statements pertaining to diversity and policies regarding diversity, these serve as

a starting point, and there are aspects of this requirement that may take considerable time to

produce quantifiable results. Common Program Requirement I.C. states that programs must

engage in mission-driven, ongoing, systematic efforts to recruit and retain individuals of diverse

backgrounds as residents, fellows, and faculty. It is important to also consider that the ability to

alter the number of such individuals appreciably will require years of effort to expand the pool of

diverse graduate medical education (GME) applicants. This will require cooperative efforts

among programs within Sponsoring Institutions, cities, and specialties. Therefore, the initial

emphasis is on process, not numerical outcomes.

On June 29, 2023, the United States Supreme Court issued its decisions in Students for Fair

Admissions, Inc. v. President and Fellows of Harvard College, University of North Carolina

addressing the consideration of race-based affirmative action in university admissions. The

ACGME reaffirms its commitment to its requirements as a way to help eliminate health care

inequities and disparities, to assist Sponsoring Institutions and programs in achievement of their

mission, and to develop a diverse physician workforce to provide care that meets the needs of

marginalized patients in particular, and all patients in general. It is important to note that the

ACGME standards do not require race-based affirmative action to achieve diversity, and this

decision does not require programs and institutions to change their resident selection practices.

The definition of diversity is intended to parallel that of the Association of American Medical

Colleges’ (AAMC) philosophy on Underrepresented in Medicine

, which permits flexibility in

defining the target groups for diversity based on the service demographics of the program that is

underrepresented relative to the workforce for a given role. The population of individuals

considered underrepresented in medicine will include racial and ethnic minority individuals

reflective of the program’s service area, but may also include others the program deems

underrepresented in medicine in the service area, or in the discipline in general. As noted in the

Background and Intent section of Common Program Requirement V.C.1.c) data to be

considered for assessment may include workforce diversity as a core element of a program’s

annual evaluation. Evaluation of workforce diversity should include an assessment of the

demographic population in the area served by the program and the program’s efforts to recruit

and retain a diverse workforce of individuals who are underrepresented in medicine, reflective of

the service area population, and in the roles clarified in Common Program Requirement I.C. i.e.,

residents, fellows, faculty members, senior GME administrative staff members, and other

relevant members of the program’s academic community.

Eac

h program is asked to present the demographic information for all GME learners on the

Resident Roster in the ACGME’s Accreditation Data System (ADS). This information provides

important baseline data on the number of individuals as a function of race/ethnicity and gender.

With time, as efforts to enhance the pool of diverse learners lead to improvements, ACGME

assessment may shift to include the actual increase in the number of diverse learners. To

assess meaningful change, it is essential to track these numbers annually to reveal continued

progress.

It i

s important that the best possible data are entered in the Resident Roster. The gold standard

for obtaining the race and ethnicity for each resident is for the program staff to have a

conversation about the subject and to ask directly how each resident would choose to be

represented on the Roster. An alternative approach for obtaining this information is to transfer

the race/ethnicity and gender information from the electronic application used at the time of

residency selection. This is primary data supplied by the residents themselves and transfer of

this information is perhaps the most efficient way of supplying it to the ACGME.

In 2020, the ACGME introduced the Resident/Fellow Portal, providing residents and fellows

access to ADS. During their educational program, individual residents can use the Portal to

input their personal demographic information at their discretion. Access to the Portal is

automatically provided to individuals in specialties using the Case Log System but must be

requested by all other residents. Since not all residents are automatically granted access to the

Portal, the ACGME will continue to ask programs to provide this information on the Resident

Roster.

The demographic categories used by the ACGME reflect race/ethnicity as White, Black or

African American, Asian, Native Hawaiian or Pacific Islander, American Indian or Alaska Native;

and Hispanic, Latino, or of Spanish origin. Programs will select one of these categories. There

are three additional categories: Other, Unknown, and Prefer not to report. Since multiple races

cannot currently be selected, if a resident prefers to identify as multiracial, to the exclusion of a

single race choice, “Other” is the suggested category. If any residents truly do not know their

race/ethnicity (e.g., the resident was adopted or the child of an adopted individual, or the

program was not able to obtain any information pertaining to demographics), only then should

the “Unknown” category be selected.

For gender, the ACGME currently offers four options for programs to report on the Resident

Roster: Male, Female, Non-Binary, and Prefer not to report. For individuals who choose to

identify as male, select Male, and for those who choose to identify as female, select Female.

Those who choose not to identify as solely male or female should select Non-Binary.

Programs are encouraged to describe in detail the specific efforts being made to advance

diversity, equity, and inclusion (DEI) to increase the number of diverse residents and other

individuals participating in the program (e.g., faculty members and administrative personnel),

consistent with existing law. Evidence-based strategies and success stories illustrating these

efforts are strongly recommended. Examples should include affiliated medical schools or

Sponsoring Institution efforts only if done in partnership with the program. This is an opportunity

to describe practices instituted in the program to result in a diverse recruitment and retention

strategy and an inclusive learning environment. Do not simply copy and paste general diversity

policies and statements. Any numerical data supporting the success of these DEI efforts (e.g.,

number of students involved, success of students after participation) should be included. The

goal is for programs to outline the concrete steps they are taking to foster DEI among early

learners, residents, and other individuals participating in the program rather than broad,

philosophical policies.

Furthermore, ACGME asks programs to quantify efforts to increase the diversity of residents

and individuals participating in the program to provide a baseline to determine the effectiveness

of such measures in the future. Common Program Requirement I.C. focuses on ongoing,

systematic recruitment and retention of a diverse workforce. Programs are encouraged to

continue recruiting diverse classes as they currently do, consistent with existing law. The

requi

rement encourages programs and institutions to engage learners earlier and farther

upstream in the career pathway to provide equitable opportunities, such as by developing

programs for early medical students that introduce specialties; providing research, mentoring,

and shadowing for college and post-baccalaureate students; and/or partnering with local STEM

programs to encourage biomedical careers for high school and elementary school students. For

programs with such efforts already in place, the request for numerical impact will provide a

baseline to track progress. Numerical data that supports the success of these efforts can

include, but is not limited to, measures of practical outcomes, numbers of participants in a given

activity or approach, and any metrics that can be determined to measure how well a program is

achieving diversity in the recruitment and retention of residents and other individuals

participating in the program. It is hoped that this will help assess and accelerate the

effectiveness of equitable opportunities and diversity efforts. Programs may wish to include

numerical data on faculty members and other academic individuals in the program in response

to the question on efforts to increase diversity through faculty recruitment and retention as this

information is not collected elsewhere.

The ACGME has designed a new initiative, ACGME Equity Matters

, to assist programs in

enhancing their diversity, equity, and inclusion. Among other resources, it includes a toolkit of

approaches that address many of the barriers diverse individuals face in the GME environment.

Some ideas employed by the most inclusive programs include having a chief diversity officer

position; creating and supporting a diversity committee; and actively engaging minoritized

individuals in the learning environment to help eliminate barriers to success in recruitment and

retention.

COMMON PROGRAM REQUIREMENTS

I.D Resources

I.D.1 The program, in partnership with its Sponsoring Institution, must ensure

the availability of adequate resources for resident education.

(Core)

[The Review Committee must further specify]

I.D.2. The program, in partnership with its Sponsoring Institution, must ensure

healthy and safe learning and working environments that promote resident

well-being and provide for:

(Core)

I.D.2.a) access to food while on duty;

(Core)

I.D.2.b) safe, quiet, clean, and private sleep/rest facilities available and

accessible for residents with proximity appropriate for safe patient

care;

(Core)

Background and Intent: Care of patients within a hospital or health system occurs

continually through the day and night. Such care requires that residents function at

their peak abilities, which requires the work environment to provide them with the

ability to meet their basic needs within proximity of their clinical responsibilities.

Access to food and rest are examples of these basic needs, which must be met while

residents are working. Residents should have access to refrigeration where food may

be stored. Food should be available when residents are required to be in the hospital

overnight. Rest facilities are necessary, even when overnight call is not required, to

accommodate the fatigued resident.

I.D.2.c) clean and private facilities for lactation that have refrigeration capabilities,

with proximity appropriate for safe patient care;

(Core)

Background and Intent: Sites must provide private and clean locations where residents

may lactate and store the milk within a refrigerator. These locations should be in close

proximity to clinical responsibilities. It would be helpful to have additional support

within these locations that may assist the resident with the continued care of patients,

such as a computer and a phone. While space is important, the time required for

lactation is also critical for the well-being of the resident and the resident’s family as

outlined in VI.C.1.d).

I.D.2.d) security and safety measures appropriate to the participating site;

and,

(Core)

I.D.2.e) accommodations for residents with disabilities consistent with the

Sponsoring Institution’s policy.

(Core)

I.D.3. Residents must have ready access to specialty-specific and other

appropriate reference material in print or electronic format. This must

include access to electronic medical literature databases with full text

capabilities.

(Core)

GUIDANCE

I.D.1. Availability of adequate resources for resident education

[The Review Committee must further specify]

Since Common Program Requirement I.D.1. requires that Review Committees further specify

about the “availability of adequate resources,” programs must review the specialty-specific

Program Requirements:

1. Go to https://www.acgme.org/specialties/

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

The ACGME monitors compliance with requirements in Common Program Requirements I.D.2.-

I.D.3 in various ways, including:

• questions answered by program leadership as part of an application or during the ADS

Annual Update;

• questions answered by residents and faculty members as part of the annual

Resident/Fellow and Faculty Surveys; and

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

The Resident and Faculty Surveys include several questions that address the Program

Requirements in section I.D. Two resource documents, the Resident/Fellow Survey-Common

Program Requirements Crosswalk and the Faculty Survey-Common Program Requirements

Crosswalk, provide additional information for programs on the key areas addressed by the

survey questions and how they map to the ACGME Common Program Requirements. These

documents can be found at

https://www.acgme.org/data-sys

tems-technical-support/resident-

fellow-and-faculty-surveys/.

I.D.2.a) and I.D.2.b) Access to food and sleep/rest facilities

Programs are expected to partner with their Sponsoring Institutions to ensure residents have

adequate access to food and sleep/rest facilities at all participating sites. Interpretations of the

requirements for space may depend on the attributes of a participating site and the needs of

residents when they are assigned to that site.

Depending on the type of participating site and the type of educational experience (e.g.,

overnight call, outpatient clinic) occurring at that site, there may be differences in the types of

resources provided. Because of site-, program-, and resident-specific factors, the ACGME does

not provide uniform specifications for access to food and the physical space of sleep/rest

facilities beyond the qualities indicated in the requirements and the guidance in the associated

Background and Intent. It is important for Sponsoring Institutions and programs to obtain

resident input when evaluating these aspects of clinical learning environments.

I.D.2.c) Access to lactation facilities

It is critical to acknowledge that the timing of residency often overlaps with the timing of starting

and raising families. Therefore, residents must have access to lactation facilities.

Rooms for lactation must be clean, provide privacy and refrigeration, and be close enough to

the clinical setting to be of use for residents who need them. Simply using a restroom as a

facility for lactation or for medication administration would not meet the standard of cleanliness.

Refrigeration capabilities are essential for storage. In addition, the availability of a computer and

telephone will allow residents, if necessary, to provide continued attention to patient care while

attending to their personal health care needs.

Interpretation of the requirement for “proximity appropriate for safe patient care” is left to the

program and the Sponsoring Institution. The requirements do not dictate a specific distance or a

time element for the resident to get from the lactation facility or room for personal health care

needs to the clinical location. Instead, institutions and programs are urged to consider the

circumstances. For example, a busy, high-intensity clinical location, such as the intensive care

unit, might require that the lactation room is in a location that allows immediate access to the

patient care area, whereas a clinical location that is less busy or intense will not require such

proximity. In addition, it is not necessary for the lactation facility to be solely dedicated to

resident use.

I.D.2.e) Accommodations for residents with disabilities

Programs must work with their Sponsoring Institutions to ensure compliance with institutional

policies related to resident requests for accommodation of disabilities. Common Program

Requirements I.D.2. and I.D.2.e) are companions of Institutional Requirement IV.I.4., which

states, “The Sponsoring Institution must have a policy, not necessarily GME-specific, regarding

accommodations for disabilities consistent with all applicable laws and regulations.”

Laws

and regulations concerning requests for accommodation of disabilities include Title I of the

Americans with Disabilities Act and related enforcement guidance published by the US Equal

Employment Opportunity Commission. Other federal, state, and local laws and regulations may

also apply. It is common for program directors, coordinators, residents, faculty members, and

designated institutional officials to collaborate with their institution’s human resources and legal

departments and/or institutional officers/committees to manage requests for accommodation.

I.D.3. Reference Material

Sponsoring Institutions and programs must ensure that residents have access to medical

literature that supports their clinical and educational work. Common Program Requirement

I.D.3. is parallel to ACGME Institutional Requirement II.E.2., which states, “Faculty members

and residents/fellows must have ready access to electronic medical literature databases and

specialty-/subspecialty-specific and other appropriate full-text reference material in print or

electronic format.”

Rev

iew Committee members are aware that the availability of a computer or mobile device with

internet access alone may provide access to a wide range of relevant reference material. Many

Sponsoring Institutions and programs purchase subscriptions to information resources and

services to supplement open access materials. As with other programmatic resources,

interpretation of the requirement may depend on unique circumstances of participating sites,

programs, faculty members, and residents. Residents and faculty members may provide

valuable input to Sponsoring Institutions and programs regarding the adequacy of available

medical literature resources.

COMMON PROGRAM REQUIREMENTS

I.E. Other Learners and Health Care Personnel

The presence of other learners and other health care personnel, including,

but not limited to residents from other programs, subspecialty fellows, and

advanced practice providers, must not negatively impact the appointed

residents’ education.

(Core)

[The Review Committee may further specify]

Background and Intent: The clinical learning environment has become increasingly

complex and often includes care providers, students, and post-graduate residents and

fellows from multiple disciplines. The presence of these practitioners and their

learners enriches the learning environment. Programs have a responsibility to monitor

the learning environment to ensure that residents’ education is not compromised by

the presence of other providers and learners.

GUIDANCE

Although other learners and other health care personnel can, and frequently do, enhance

resident education, there are certainly circumstances in which they negatively impact that

process. Examples include:

• interference of a subspecialty fellow or another care provider in the communication

between a faculty member and the resident (or resident team) in such a manner that the

resident does not gain the educational benefit of direct communication with the faculty

member;

• a fellow repeatedly performing procedures in which the resident is expected to develop

competence when there is a limited pool of procedures available;

• too many learners for the amount of educational experience or excessive rotators (e.g.,

medical students, residents from other specialties, advanced practice provider students);

• lack of opportunity for peer teaching (e.g., senior resident to junior resident, PGY-1 to

medical student); and

• certified registered nurse anesthetists (CRNAs) or CRNA students interfering with

residents performing and gaining competence in certain procedures.

Situations of this type frequently involve a degree of intra- or inter-departmental disagreement

on educational responsibilities and priorities. In the case of other health care personnel, they

may also impact decisions made by the administration of the clinical site. The designated

institutional official and Graduate Medical Education Committee (GMEC) may be very helpful in

supporting the program(s) and in arriving at equitable and mutually beneficial solutions.

The ACGME monitors compliance with Common Program Requirement I.E. in various ways,

including:

• questions answered by program leadership as part of an application or during the

Accreditation Data System (ADS) Annual Update;

• questions answered by residents and faculty members as part of the annual

Resident/Fellow and Faculty Surveys; and

• questions asked by the Accreditation Field Staff during site visits of the program at

various stages of accreditation.

The Resident/Fellow and Faculty Surveys include several questions that address the Program

Requirements in section I.D. The ACGME has prepared two documents, a Resident/Fellow

Survey-Common Program Requirements Crosswalk and a Faculty Survey-Common Program

Requirements Crosswalk, to provide additional information for programs on the key areas

addressed by the survey questions and how they map to the ACGME Common Program

Requirements. These documents can be found at

https://www.acgme.org/data-systems-

technical-support/resident-fellow-and-faculty-surveys/.

Programs are encouraged to monitor any concerns identified in the Resident/Fellow Survey and

address them proactively in the major changes section in ADS as part of their ADS Annual

Update or in preparation for a site visit.

ADS screenshot: presence of other learners

The question below is part of the program ADS Annual Update Questionnaire.

COMMON PROGRAM REQUIREMENTS

II. Personnel

II.A. Program Director

II.A.1. There must be one faculty member appointed as program director

with authority and accountability for the overall program, including

compliance with all applicable program requirements.

(Core)

II.A.1.a) The Sponsoring Institution’s GMEC must approve a change in

program director and must verify the program director’s

licensure and clinical appointment.

(Core)

II.A.1.a).(1) Final approval of the program director resides with the

Review Committee.

(Core)

[For specialties that require Review Committee

approval of the program director, the Review

Committee may further specify.

This requirement will be deleted for those specialties

that do not require Review Committee approval of the

program director.]

Background and Intent: While the ACGME recognizes the value of input from numerous

individuals in the management of a residency, a single individual must be designated as

program director and have overall responsibility for the program. The program

director’s nomination is reviewed and approved by the GMEC.

GUIDANCE

II.A.1. One faculty member must be appointed as program director with authority

and accountability for the overall program.

This requirement specifies that each program must have one faculty member appointed as

program director. The program director is responsible for all aspects of the program and is

accountable for compliance with all applicable program requirements. For new programs, the

program director is identified in the Accreditation Data System (ADS) by the designated

institutional official (DIO). For existing programs, the program director is already designated and

appears first on the faculty roster.

II.A.1.a) The Graduate Medical Education Committee (GMEC) must approve a

program director change and verify the program director’s licensure and clinical

appointment.

A new program director can be designated for a program at any time through a program director

change request initiated by the DIO in ADS. For appointment of a new program director, the

GMEC must verify that the program director meets the qualifications outlined in Common

Program Requirement II.A.3. as well as verify that the program director has an active medical

license and a current clinical appointment and privileges before approving the change.

Following GMEC approval, the DIO will enter the recommendation into ADS via a new program

director request.

ADS steps and screenshots for initiating a new program director request:

The DIO must log into the Sponsoring Institution’s ADS account and complete the following

steps:

1. Select the Sponsored Programs tab and locate the program for which the program

director will change.

2. On the Program tab, select New Program Director.

3. Read the instructions carefully and select one of two options: Choose Program Faculty

or Search/Add New Person.

4. The DIO must complete two key sections: DIO questions and Director Profile

Information, including the rationale for the change. (See accompanying screenshots

which follow on the next page.)

5. When the DIO submits the change, the old program director’s ADS access will

be immediately disabled and the new program director will receive an email

notification with the username and password (if new to ADS) and a notification

to review the change. The new contact information is immediately reflected in ADS

and on the public ACGME website.

6. Once the new program director logs into ADS, the change request will be

available on the Overview tab toward the bottom of the page for review, completion

of any missing information, and submission. The program director change is not

complete until submitted by the new program director.

NOTE: The new program director or a designee must complete all required fields on

both the “Profile and Certifications” and “CV” tabs associated with the request.

Fields that require information or updates will be marked in red. This action will reduce

the need for ACGME staff members to seek updated information from programs and will

ensure timely review and approval by Review Committees.

7. Once the new program director submits the completed request, an email notification will

be generated in ADS to the ACGME, the DIO, and the institutional coordinator(s).

8. Rev

iew Committee staff members will reach out to programs with questions or requests

for additional information as needed if the new program director change request is

incomplete. Programs will be notified through ADS if a request is denied.

II.A.1.a).(1). Final approval of the program director resides with the Review Committee.

This requirement is included in the specialty Program Requirements only if the Review

Committee with oversight for a particular specialty has elected to establish the approval of

program director changes by the Review Committee as one of its processes. Not all Review

Committees or specialties/subspecialties have the same processes for reviewing program

director changes. Programs should review the resources on the applicable specialty section of

the website for more information, and can contact Review Committee staff members to verify

the program director change process for their specialty.

COMMON PROGRAM REQUIREMENTS

II. Personnel

II.A. Program Director

II.A.1. There must be one faculty member appointed as program director

with authority and accountability for the overall program, including

compliance with all applicable program requirements.

(Core)

II.A.1.b) The program must demonstrate retention of the program

director for a length of time adequate to maintain continuity

of leadership and program stability.

(Core)

[The Review Committee may further specify]

Background and Intent: The success of residency programs is generally enhanced by

continuity in the program director position. The professional activities required of a

program director are unique and complex and take time to master. All programs are

encouraged to undertake succession planning to facilitate program stability when

there is necessary turnover in the program director position.

GUIDANCE

II.A.1.b) Program director retention

The program director has many important responsibilities in a residency program. It can take

years for individuals to understand and reach a level of expertise in the role and develop

effective working relationships with all the individuals they must interact, including the

designated institutional official, program faculty members, faculty members and leaders in

related educational programs, administrators at the clinical sites to which residents rotate,

community leaders, and others. For these reasons, continuity in the program director role is

critical to ensure and maintain program stability and it is often associated with success of the

program.

[The Review Committee may further specify]

Common Program Requirement II.A.1.b) allows specialties to further specify. Currently, only a

few specialties have added a requirement that further specifies the minimum amount of time a

program director should serve in their role. To review the specialty-specific Program

Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

The Background and Intent associated with this requirement encourages programs “to

undertake succession planning to facilitate program stability when there is necessary turnover in

the program director position.” While having a formal succession planning process at the

program or Sponsoring Institution level would be ideal, there are many ways programs can think

about succession planning. In larger programs, having one or more assistant/associate program

directors may be a good option for ensuring continuity of leadership in the program in case of a

program director change. In other cases, having a faculty mentoring process to identify faculty

members with an interest in a graduate medical education leadership career path and

supporting them in achieving various leadership competencies would also be a way to develop

talent for a program director or assistant/associate program director role.

COMMON PROGRAM REQUIREMENTS

II.A. Program Director

II.A.2. The program director and, as applicable, the program’s leadership

team, must be provided with support adequate for administration of

the program based upon its size and configuration.

(Core)

[The Review Committee must further specify minimum dedicated

time for program administration and will determine whether

program leadership refers to the program director or both the

program director and associate/assistant program director(s).]

Background and Intent: To achieve successful graduate medical education, individuals

serving as education and administrative leaders of residency programs, as well as

those significantly engaged in the education, supervision, evaluation, and mentoring

of residents, must have sufficient dedicated professional time to perform the vital

activities required to sustain an accredited program.

The ultimate outcome of graduate medical education is excellence in resident

education and patient care.

The program director and, as applicable, the program leadership team, devote a

portion of their professional effort to the oversight and management of the residency

program, as defined in II.A.4.-II.A.4.a).(16). Both provision of support for the time

required for the leadership effort and flexibility regarding how this support is provided

are important. Programs, in partnership with their Sponsoring Institutions, may

provide support for this time in a variety of ways. Examples of support may include,

but are not limited to, salary support, supplemental compensation, educational value

units, or relief of time from other professional duties.

Program directors and, as applicable, members of the program leadership team who

are new to the role, may need to devote additional time to program oversight and

management initially as they learn and become proficient in administering the

program. It is suggested that during this initial period the support described above be

increased as needed.

In addition, it is important to remember that the dedicated time and support

requirement for ACGME activities is a minimum, recognizing that, depending on the

unique needs of the program, additional support may be warranted. The need to

ensure adequate resources, including adequate support and dedicated time for the

program director is also addressed in Institutional Requirement II.B.1. The amount of

support and dedicated time needed for individual programs will vary based on a

number of factors and may exceed the minimum specified in the applicable specialty

specific program requirements. It is expected that the Sponsoring Institution, in

partnership with its accredited programs, will ensure support for program directors,

core faculty members, and program coordinators to fulfill their program

responsibilities effectively.

GUIDANCE

II.A.2. The program director and, as applicable, the program’s leadership team,

must be provided with support adequate for administration of the program based

upon its size and configuration.

The Background and Intent associated with this requirement further explains the rationale,

provides various examples of what may constitute program director support, and identifies

instances in which minimum support may need to be increased.

It is important to note that Review Committees consider approved resident complement rather

than filled resident complement when assessing program director or program leadership support

for administration of the program.

This requirement is closely linked to Institutional Requirements II.B.-II.B.4

. A Sponsoring

Institution is not necessarily the entity that provides compensation directly to a program director,

and, in many cases, a program director’s employer is not the Sponsoring Institution. However,

each accredited Sponsoring Institution is accountable to the ACGME’s Institutional Review

Committee for ensuring that program directors receive support and dedicated time in substantial

compliance with this requirement.

[The Review Committee must further specify minimum dedicated time for

program administration and will determine whether program leadership refers to

the program director or both the program director and associate/assistant

program director(s).]

Since Review Committees must specify minimum dedicated time for the program director or

program leadership, programs must review the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of specialty

section.

4. Select the specialty Program Requirements currently in effect.

The Program Leadership Dedicated Time

summary document included as an institutional

resource on the ACGME website also provides a snapshot of program director dedicated time

and support across all ACGME-accredited specialties and subspecialties.

Accr

editation Data System (ADS) screenshot: program director support

The program director must answer or update the following questions as part of the ADS Annual

Update regarding support adequate for the administration of the program based on its size and

configuration. Programs are strongly encouraged to verify the specialty-specific Program

Requirements each year to ensure at least the minimum required level of support is provided.

(See accompanying screenshot which follows on the next page.)

COMMON PROGRAM REQUIREMENTS

II.A.3. Qualifications of the program director:

II.A.3.a) must include specialty expertise and at least three years of

documented educational and/or administrative experience, or

qualifications acceptable to the Review Committee;

(Core)

Background and Intent: Leading a program requires knowledge and skills that are

established during residency and subsequently further developed. The time period

from completion of residency until assuming the role of program director allows the

individual to cultivate leadership abilities while becoming professionally established.

The three-year period is intended for the individual's professional maturation.

The broad allowance for educational and/or administrative experience recognizes that

strong leaders arise through diverse pathways. These areas of expertise are important

when identifying and appointing a program director. The choice of a program director

should be informed by the mission of the program and the needs of the community.

In certain circumstances, the program and Sponsoring Institution may propose and the

Review Committee may accept a candidate for program director who fulfills these

goals but does not meet the three-year minimum.

II.A.3.b) must include current certification in the specialty for which

they are the program director by the American Board of _____

or by the American Osteopathic Board of _____, or specialty

qualifications that are acceptable to the Review Committee;

and,

(Core)

[The Review Committee may further specify acceptable

specialty qualifications or that only ABMS and AOA

certification will be considered acceptable]

II.A.3.c) must include ongoing clinical activity.

(Core)

Background and Intent: A program director is a role model for faculty members and

residents. The program director must participate in clinical activity consistent with the

specialty. This activity will allow the program director to role model the Core

Competencies for the faculty members and residents.

[The Review Committee may further specify additional program director

qualifications]

GUIDANCE

II.A.3.a) Specialty expertise and at least three years of documented educational

and/or administrative experience, or qualifications acceptable to the Review

Committee.

The Background and Intent that follows this requirement helps explain the rationale behind the

requirement. Graduate medical education leaders require knowledge and skills that are

established during residency and must be subsequently further developed and cultivated over a

minimum of three years as an individual becomes professionally established. This requirement

also broadly allows for educational and/or administrative experience, recognizing that strong

leaders arise through diverse pathways. Lastly, the requirement acknowledges that the mission

of the program and the needs of its community should inform the selection of a program

director.

The Background and Intent also allows for potential exceptions, in certain circumstances, to the

three-year minimum educational or administrative experience requirement. The program and

Sponsoring Institution may propose, and the Review Committee may accept, a candidate for

program director who fulfills all other qualification requirements but does not meet the three-year

minimum.

Program director education and training, clinical and administrative experience and expertise,

and other demographic information are captured on the program director profile and curriculum

vitae (CV) in the Accreditation Data System (ADS). Programs should complete all required

information when adding a new program director into ADS as part of an application or when

submitting a program director change for an existing program. It is also important to carefully

review and update all the program director information if a profile for that individual already

exists in ADS.

ADS screenshots: program director profile and CV (See accompanying screenshots

on the next pages.)

II.A.3.b) Current certification in the specialty for which they are the program

director or specialty qualifications that are acceptable to the Review Committee.

[The Review Committee may further specify acceptable specialty qualifications or

that only ABMS and AOA certification will be considered acceptable]

Some Review Committees will accept only certification in the appropriate specialty by an

American Board of Medical Specialties (ABMS) member board or American Osteopathic

Association (AOA) certifying board for the program director. Other Review Committees will

accept other qualifications for the program director. Programs are encouraged to refer to the

specialty-specific Program Requirements

for more information on t

his requirement.

The ACGME automatically populates data received from the ABMS and the AOA for the

program director on their individual ADS profile page, where data are available. Program

director board certification data will be matched to the ABMS and AOA datasets based on

National Provider Identifier (NPI) number, as well as name, date of birth, and medical school

graduation year. Program directors who are newly entered into ADS will have their certification

information matched and populated within 24 hours.

Programs are only required to provide a manual entry for the program director’s specialty

certification under the following circumstances:

• No ABMS/AOA board certification data is displayed in ADS or it is incorrect. In this case,

a manual entry for “ABMS missing/inaccurate data” or “AOA missing/inaccurate data”

should be added on the program director’s profile with a duration type, initial certification

year, certification name, and an explanation for Review Committee consideration.

• The program director is not certified by the ABMS/AOA. Add a manual entry of “Not

Board Certified” and an explanation.

• The program director is board eligible but has not yet achieved board certification. Add a

manual entry of “Board eligible” and provide an explanation.

• The program director is certified by another certifying body. Some Review Committees

allow other acceptable specialty qualifications and therefore a manual entry of “Other

Certifying Body” can provide that information.

ADS screenshot: specialty certification – manual entries

Common issues related to the ABMS and AOA data not auto-populating on the program

director’s profile and in the faculty roster include:

• the NPI number in ADS is incorrect or does not match the NPI number in the

ABMS/AOA dataset; and

• a lag in when updated board certification data are received by the ACGME from the

ABMS and AOA.

II.A.3.c).Ongoing clinical activity

This requirement is self explanatory. The expectation is that program directors are clinically

active in their specialty and are involved in working with residents.

Common citations regarding program director qualifications include:

• no or not enough previous experience in the specialty;

• no or not enough previous educational/administrative experience;

• board certifications that are lapsed; and

• no board certification information entered at all.

[The Review Committee may further specify additional program director

qualifications]

The ACGME Review Committees want to help programs succeed. One essential element of

program success is having a qualified individual as program director. Based on years of

cumulative experience with both programs that are successful and those that are not as

successful, many Review Committees have developed minimal qualifications for program

directors in each specialty. Review Committees may specify other requirements related to

additional qualifications and clarifications for appointment, so programs must review the

specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

Questions about specialty-specific Program Requirements related to program director

qualifications should be directed to respective specialty Review Committee staff.

COMMON PROGRAM REQUIREMENTS

II.A.4. Program Director Responsibilities

The pr

ogram director must have responsibility, authority, and

accountability for: administration and operations; teaching and scholarly

activity; resident recruitment and selection, evaluation, and promotion of

residents, and disciplinary action; supervision of residents; and resident

education in the context of patient care

. (Core)

II.A.4

.a) The program director must:

II.A.4

.a).(1) be a role model of professionalism;

(Core)

Background and Intent: The program director, as the leader of the program, must serve

as a role model to residents in addition to fulfilling the technical aspects of the role. As

residents are expected to demonstrate compassion, integrity, and respect for others,

they must be able to look to the program director as an exemplar. It is of utmost

importance, therefore, that the program director model outstanding professionalism,

high quality patient care, educational excellence, and a scholarly approach to work.

The program director creates an environment where respectful discussion is welcome,

with the goal of continued improvement of the educational experience.

II.A.4

.a).(2) design and conduct the program in a fashion consistent with

the needs of the community, the mission(s) of the Sponsoring

Institution, and the mission(s) of the program;

(Core)

Background and Intent: The mission of institutions participating in graduate medical

education is to improve the health of the public. Each community has health needs that

vary based upon location and demographics. Programs must understand the structural

and social determinants of health of the populations they serve and incorporate them

in the design and implementation of the program curriculum, with the ultimate goal of

addressing these needs and eliminating health disparities.

II.A.4

.a).(3) administer and maintain a learning environment conducive to

educating the residents in each of the ACGME Competency

domains;

(Core)

Background and Intent: The program director may establish a leadership team to

Assist in the accomplishment of program goals. Residency programs can be highly

complex. In a complex organization, the leader typically has the ability to delegate

authority to others, yet remains accountable. The leadership team may include

physician and non-physician personnel with varying levels of education, training, and

experience.

II.A.4

.a).(4) have the authority to approve or remove physicians and non-

physicians

as faculty members at all participating sites,

including the designation of core faculty members, and must

develop and oversee a process to evaluate candidates prior

to approval;

(Core)

Background and Intent: The provision of optimal and safe patient care requires a team

approach. The education of residents by non-physician educators may enable the

resident to better manage patient care and provides valuable advancement of the

residents’ knowledge. Furthermore, other individuals contribute to the education of

residents in the basic science of the specialty or in research methodology. If the

program director determines that the contribution of a non-physician individual is

significant to the education of the residents, the program director may designate the

individual as a program faculty member or a program core faculty member.

II.A.4.a).(5) have the authority to remove residents from supervising

interactions and/or learning environments that do not meet

the standards of the program;

(Core)

Background and Intent: The program director has the responsibility to ensure that all

who educate residents effectively role model the Core Competencies. Working with a

resident is a privilege that is earned through effective teaching and professional role

modeling. This privilege may be removed by the program director when the standards

of the clinical learning environment are not met.

There may be faculty in a department who are not part of the educational program, and

the program director controls who is teaching the residents.

GUIDANCE

Simply put, the program director is the person who is ultimately responsible for the program.

II.A.4.a).(1) and II.A.4.a).(3) [The program director must:] be a role model of

professionalism; and administer and maintain a learning environment conducive

to educating the residents in each of the ACGME Competency domains.

The purpose of this section is to emphasize the importance of the program director and faculty

leadership as noted in the Background and Intent, including role modeling of professionalism,

high-quality patient care, educational excellence, and scholarly approach to work. While the

guidance below is related to Common Program Requirements II.A.4.a).(1) and II.A.4.a).(3), it

does not constitute actual requirements. Although this section is not tied to a specific

requirement, program directors are urged to consult some or all the references for inspiration

related to mentorship, humanism, and leadership.

Leadership

The concepts of program director and faculty leadership take many forms and are important,

regardless of program size. The designation of faculty leadership can be a formal or informal

process, but what is most important is the composition of such a group. The group can be

composed of physicians and non-physicians who know the residents well, have frequent

interactions with them, and most importantly, can serve as role models in clinical care,

professionalism, and scholarship. In addition, they can serve as a sounding board for the

program director and help in shaping the program.

ACGME President and Chief Executive Officer Dr. Thomas J. Nasca provides the context for

understanding the professionalism that underlies leadership in medicine:

The philosophical roots of professionalism include the Hippocratic tradition of medicine

as a moral enterprise; the transition of medicine from guild to profession with a

commitment to competence, altruism, and public trust; and the responsibility of the

profession to prepare the next generation of physicians to serve the public. (Nasca 2015;

emphasis added)

Nasca 2015

Mentorship

While there are many articles that define and describe mentoring and mentorship, there are

several characteristics that constitute this relationship. Mentorship is a long-term relationship

between a more senior person (mentor) and a less experienced person (mentee). While both

benefit from the relationship, it is generally established for the betterment of the mentee.

According to Sambunjak, Dario, and Marušić (2009), mentorship includes three components:

helping mentees acquire and integrate new learning; managing a personal aspect of transitional

states; and maximizing the mentee’s potential to become a fulfilled and achieving practitioner.

Mentorship therefore helps

physicians uphold the responsibility to educate the next generation

of physicians to serve patients.

Tjan (2017) interviewed scores of leaders and concluded that successful mentors have four

characteristics: 1) they put the relationship before the mentorship; 2) they focus on character

rather than competence and on shaping character, values, self-awareness, empathy, and

capacity for respect; 3) they shout loudly with optimism and keep quiet with cynicism; and 4)

they are more loyal to their mentees than to their companies.

References

• Lacombe, Michael A. 1990. “Recent Advances.” The American Journal of Medicine

88(4), 407–8. https://doi.org/10.1016/0002-9343(90)90497-2

• Nasca, Thomas J. 2015. “Professionalism and Its Implications for Governance and

Accountability of Graduate Medical Education in the United States.” JAMA 313(18):

1801. Graphic available at https://doi.org/10.1001/jama.2015.3738

• Sambunjak, Dario, Sharon E. Straus, and Ana Marušić. 2006. “Mentoring in Academic

Medicine.” JAMA 296(9): 1103. https://doi.org/10.1001/jama.296.9.1103.

• Sambunjak, Dario, and Ana Marušić. 2009. “Mentoring.” JAMA 302(23): 2591.

https://doi.org/10.1001/jama.2009.1858.

• Tjan, Anthony K. “What the Best Mentors Do.” Harvard Business Review, 2017(2).

https://hbr.org/2017/02/what-the-best-mentors-do.

Humanism

Humanism in health care is characterized by a respectful and compassionate relationship

between physicians and their patients. It reflects attitudes and behaviors that are sensitive to the

values and the cultural and ethnic backgrounds of others. The humanistic health care

professional has two key attributes: altruism and empathy. Chou et al. (2014) stated that

“Humanism in medicine combines scientific knowledge and skills with respectful, compassionate

care that is sensitive to the values, autonomy and cultural backgrounds of patients and their

families.”

Evidence demonstrates that compassion and empathy are critical components of good

medicine. When provided with humanistic care, patients are more likely to adhere to their

treatment regimens, and this adherence makes it more likely that they adhere to preventive

practices and may heal more quickly. Studies indicate that the characteristics of humanism can

be taught. While Chou et al. (2014) acknowledged this fact, they sought to determine how

humanism can be maintained in a world of increasing demands and technologies. They

interviewed faculty members in internal medicine who had been identified by the residents to be

excellent role models for humanism. The authors found three themes: attitudes needed to

sustain humanism included humility, curiosity, standard of behavior (“I treat patients the way I

would want to be treated”), importance for the patient, importance for the physician (joy in caring

for patients), and more than just the disease (“my role is being there with and for the patient”);

habits included self-reflection, seeking a connection with the patients, teaching/role modeling

(“knowing that I’m responsible not just for the patients in front of me, but modeling how my

students and residents are going to treat their patients”), balance, and mindfulness and spiritual

practices; and humanism and maintenance of humanism in medical practice takes effort. Many

of the physicians interviewed noted that humanism takes deliberate, intentional work, and

identified the need for environmental support. While one may conclude that the work that goes

into deliberative practice of humanism imposes additional workload on physicians that leads to

burnout, the physicians in the study believed that humanism, as represented by the joy in caring

for patients and educating residents, actually was a deterrent to burnout.

References

• Chou, Carol M., Katherine Kellom, and Judy A. Shea. 2014. “Attitudes and Habits of

Highly Humanistic Physicians.” Academic Medicine 89(9): 1252–58.

https://doi.org/10.1097/acm.0000000000000405.

• Montgomery, Lynda L., Sana Loue, and Kurt C. Stange. 2017. “Linking the Heart and the

Head: Humanism and Professionalism in Medical Education and Practice.” Family

Medicine 49(5): 378–83. https://www.ncbi.nlm.nih.gov/pubmed/28535319

II.A.4.a).(2) [The program director must:] design and conduct the program in a

fashion consistent with the needs of the community, the mission(s) of the

Sponsoring Institution, and the mission(s) of the program.

This requirement is intended to bring intentionality to the development, design, and

implementation of each residency program in consideration of the needs and desires of its

stakeholders. Programs are encouraged to develop and clearly articulate their mission with the

input of the communities they serve, their residents, their Sponsoring Institution, and

participating sites, and others. Although the process may prove to be time consuming,

developing this foundation will likely prove rewarding for all involved. Once developed, the

mission of the program should periodically be re-evaluated for potential improvement, again

incorporating input from stakeholders.

II.A.4.a).(4) [The program director must:] have the authority to approve or remove

faculty for participation in the residency program education at all sites and

oversee a process to evaluate candidates prior to approval.

This requirement applies to faculty members at the primary clinical site and at any participating

sites used by the program. It is important that the faculty members who participate in the

education of residents are interested in and dedicated to the educational program.

The program director must have the authority to approve or remove a faculty member from the

teaching service. For example, if a faculty member is consistently reported as being unable or

refusing to teach, berating the residents, and generally being unavailable for educational

activities, the program director may decide to remove the faculty member from the teaching

service. However, the faculty member may still continue with other clinical and administrative

responsibilities within the department.

II.A.4.a).(5) [The program director must:] have the authority to remove residents

from supervising interactions and/or learning environments that do not meet the

standards of the program.

For example, residents might be assigned to a participating site for a one-month rotation and

residents report that their role is only to provide service. Faculty members at the site do not

provide supervision, evaluation, or education and are not available to the residents. The

program director may choose to discontinue the rotation and have the residents rotate to

another participating site that can provide the appropriate an educational experience.

COMMON PROGRAM REQUIREMENTS

II. Personnel

II.A. Program Director

II.A.4. Program Director Responsibilities

II.A.4.a) The program director must:

II.A.4.a).(6)

submit accurate and complete information required

and requested by the DIO, GMEC, and ACGME;

(Core)

Background and Intent: This includes providing information in the form and format

requested by the ACGME and obtaining requisite sign-off by the DIO.

GUIDANCE

II.A.4.a).(6). It is the responsibility of the program director to submit accurate and

complete information required and requested by the DIO, GMEC, and ACGME.

The submission of incomplete and/or inaccurate information by a program is one of the most

common citations given by the Review Committees. Programs are required to submit specific

information as part of an application, annually during the Accreditation Data System (ADS)

Annual Update process, as part of preparing for a program site visit, or for other types of

requests submitted to the ACGME. The program director is responsible for the accuracy and

completeness of information submitted to the ACGME.

This requirement captures a broad array of information and Review Committees will issue

citations related to this requirement if there are consistent gaps in data submitted to the

ACGME. Some examples include:

• An application or updated application had significant gaps in data required by the

ACGME, the data was submitted in a format that is hard to understand for the Review

Committee, or there are a lot of discrepancies between various parts of the application

or updated application.

• The program’s Annual Update was not completed, not approved by the designated

institutional official (DIO), or has significant gaps in data required by the ACGME.

• For an application or updated application, required attachment documents were not

provided, are missing key information, or do not meet common and specialty-specific

requirements. For example:

o program letter(s) of agreement (PLA) not submitted, outdated, lacking the

appropriate components, or lacking requisite signatures (see I.B.2.a) and I.B.3.);

o block diagram not submitted, does not capture all required clinical experiences, or

includes participating sites that do not align with the participating sites listed in ADS;

o goals and objectives not provided, are not competency based, or are not level- or

rotation-specific; and

o the supervision policy does not reflect appropriate levels of supervision (see

Common Program Requirements VI.A.2.b) through VI.A.2.b).(3)).

• Responses to previous citations were not provided or were inadequate, if applicable.

• Program director and faculty qualifications were missing or outdated

residency/fellowship training, as well as academic appointments, licensure, and board

certification information.

• Program director and faculty curriculum vitae (CV) were incomplete or outdated

scholarly activity was included.

• Faculty and resident scholarly activity information were not submitted as part of the

Annual Update.

• ACGME Case Log or patient numeric data were not submitted or were incomplete.

• The Accreditation Field Staff spent a significant amount of time during the site visit

needing to make clarifications, corrections, and looking for missing information.

The ACGME created three brief videos available here

to help with av

oiding common errors in

the data submitted to the ACGME:

• creating a block diagram (N

OTE: some specialties require a specialty-specific block

diagram, so programs must check ADS for instructions on whether the common block

diagram instructions or specialty-specific instructions apply)

• responding to citations

• providing information on scholarly activity

ADS Annual Update

The ACGME will conduct an annual review of programs that achieve a status of Initial or

Continued Accreditation and provide an accreditation decision. As part of this annual review,

programs must complete the ADS Annual Update process each academic year between July

and September. The exact date varies by specialty. The program director and program

coordinator will receive a notification in ADS with a reminder to perform the required program

ADS Annual Update and a deadline. Program directors are responsible for ensuring that all

program information is updated in ADS, that the Annual Update is submitted by the program’s

due date, and that it is approved by the DIO.

Key data to be reviewed and updated during the ADS Annual Update

• Program information

o program details

o Common Program Requirements questions, clinical and educational work section,

overall evaluations methods section, etc.

o responses to current citations, if applicable

o major changes and other program updates section

o The sites tab and added, deleted, or updated information for each participating site

o current block diagram, if applicable

• Faculty information

o the program director’s profile and CV, if applicable

o all physician and non-physician faculty members’ profiles and CVs (if applicable)

 accuracy of all information and dates

 number limitations for current professional activities, selected bibliography,

review articles, chapters, and/or textbooks

 removal of program director and faculty scholarly activities which occurred more

than five years ago

 For the physician and non-physician faculty rosters, accuracy of information,

including board certification, identification of an individual as a core faculty

member, and time spent in the program

o Faculty scholarly activity for the previous academic year

• Resident information

o resident profiles; identification of new residents to the program, confirmation or

updating of PGY level, and identification of graduating residents

o resident ultimate certification status for graduates from seven years prior.

o resident scholarly activity for the previous academic year

ADS screenshot: program annual update checklist

When logging into ADS, on the Program Overview tab, the program director and/or program

coordinator can see a checklist of all information that should be reviewed and updated during

the Annual Update. (See accompanying screenshots which follow on the next page.)

Block diagrams

When completing an application for accreditation of a new program in ADS, instructions are

provided for completing a block diagram. Subsequently, the block diagram may need to be

updated during the ADS Annual Update to reflect changes in the program.

ADS screenshot: common block diagram instructions

ADS screenshot: specialty-specific block diagram instructions

Some Review Committees have created specialty-specific block diagrams and do not accept

the common block diagram. For these specialties, the program will not see the sample block

diagram in ADS, but rather a link to the specialty instructions on the ACGME specialty-specific

web page.

Review Committees use block diagrams:

• to review rotation length(s);

• to get a summary of time spent at each participating site; and

• to get a summary of time spent on each rotation type

The block diagram must clearly illustrate the length of rotations in a program. Rotation length

has educational implications since longer rotations provide more opportunities for the educators

on that rotation to observe and assess the residents, providing more accurate evaluations and

increased opportunities to provide feedback. Rotation length also has clinical implications in that

short rotations increase the number of team turnovers. The block diagram also provides a

summary of the types of clinical experiences and the time spent at each participating site. An

accurate block diagram therefore illustrates how much cumulative time a resident spends in a

particular clinical experience or subspecialty area at all of the participating sites used by the

program.

Programs may use the block diagram:

• to ensure that Program Requirements are met (by documenting the participating site and

the program year during which required experiences take place, the block diagram helps

programs ensure that the Program Requirements are being met);

• to ensure that certifying board requirements are met (many certifying boards require that

candidates fulfill certain chronological educational requirements);

• in recruitment of residents (an accurate and complete block diagram may provide

potential applicants a quick yet detailed snapshot of what they can expect each year in

the program); and

• when a program is contemplating or requesting a permanent increase of its resident

complement (block diagrams for each of the years anticipated for the transition to the

new full complement are extremely useful to—and required by—the Review Committee,

allowing the program to ensure that each rotation and participating site will have an

appropriate number of residents at any time during the transition).

NOTE: Rotation schedules for individual residents are important for use by the residents, faculty

members, and other personnel involved in a program, but rotation schedules are NOT block

diagrams, and are not required by the ACGME. A block diagram is not a depiction of the rotation

schedule of an individual resident.

A block diagram:

• depicts the rotations assigned in each program year (a block diagram shows each of the

rotations a resident will typically be assigned in each year of the program, the amount of

time that a resident spends on each of these rotations, and the participating sites the

rotations occur at);

• is flexible in defining rotation lengths (a block diagram can show rotations as short as

one week or as long as several months) and

• provides other important information, such as

o inpatient time on a rotation;

o outpatient time on a rotation;

o research time on a rotation; and

o rotation(s) offering particular required experience(s).

Tips for completing the block diagram

• Show program name and number.

• Clearly identify each clinical site.

• Use participating site numbers from ADS.

• Clearly explain any abbreviations.

• Clearly explain any local jargon.

• Differentiate rotations with the same name.

• Identify rotations for key clinical experience.

COMMON PROGRAM REQUIREMENTS

II. Personnel

II.A Program Director

II.A.4. Program Director Responsibilities

II.A.4.a) The program director must:

II.A.4.a).(7)

provide a learning and working environment in which

residents have the opportunity to raise concerns, report

mistreatment, and provide feedback in a confidential manner

as appropriate, without fear of intimidation or retaliation;

(Core)

II.A.4.a).(8)

ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures related to grievances

and due process, including when action is taken to suspend

or dismiss, or not to promote or renew the appointment of a

resident;

(Core)

Background and Intent: A program does not operate independently of its Sponsoring

Institution. It is expected that the program director will be aware of the Sponsoring

Institution’s policies and procedures and will ensure they are followed by the

program’s leadership, faculty members, support personnel, and residents.

II.A.4.a).(9) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures on employment and

non-discrimination;

(Core)

II.A.4.a).(9).(a) Residents must not be required to sign a non-

competition guarantee or restrictive covenant.

(Core)

GUIDANCE

II.A.4.a).(7) Raising concerns, providing feedback, and submitting grievances

There must be both institutional and programmatic processes that support residents in raising

concerns, reporting mistreatment, and providing feedback confidentially and without fear of

retaliation. Residents should first attempt to address concerns within their programs. In some

programs, chief residents, junior faculty members, or administrators facilitate communication

between residents and program leaders by conveying residents’ concerns and feedback in a

confidential manner. Programs may solicit residents’ concerns and feedback confidentially using

program evaluations, rotation evaluations, class or program meetings, and other means.

If attempts to address concerns within the program are ineffective, residents must be able to

raise concerns, report mistreatment, or provide feedback confidentially and without fear of

retaliation through institutional mechanisms (see Institutional Requirement III.A.

), which m

include specific, confidential reporting processes related to patient safety events, supervision

concerns, or professionalism issues. Avenues to raise concerns and provide feedback outside

of the program may involve the designated institutional official (DIO), other institutional officers,

and/or groups, such as resident/fellow forums or the Graduate Medical Education Committee

(GMEC).

stated in Institutional Requirement IV.E.: “The S

ponsoring 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.” This requirement ensures there

are formal processes through which residents can address concerns about their education or

the clinical learning environment. Sponsoring Institutions and programs must manage conflicts

of interest of individuals or groups who make decisions in grievance processes. Program

directors should contact the DIO if they have questions about the Sponsoring Institution’s or

program’s grievance procedures or policies.

For p

rograms applying or re-applying for accreditation and accredited programs with a status of

Initial Accreditation and Initial Accreditation with Warning, the ACGME includes the following

question in the ADS Annual Update that programs must answer or update annually until they

move to a Continued Accreditation status.

ADS screenshot: Common Program Requirements question regarding the

process of reporting problems and concerns

The ACGME’s Institutional Review Committee and/or the specialty Review Committees may

investigate potential non-compliance with these requirements indicated by the results of the

annual ACGME Resident/Fellow and/or Faculty Surveys or by complaints or concerns submitted

to the ACGME.

II.A.4.a).(8) Actions against residents and due process

(See related Common Program Requirement V.A.1. on feedback and evaluation)

Each program must determine criteria for promotion and/or renewal of a resident’s appointment.

Sponsoring Institutions “must ensure that each [program] provides a resident/fellow with a

written notice of intent when that resident’s/fellow’s agreement [of appointment] 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.” (Institutional Requirement IV.D.1.a)

)

There must be an institutional policy that provides due process to any resident who is

suspended or dismissed from a program, who is not promoted to the next program year, or

whose residency appointment will not be renewed. Questions about institutional policy should

be directed to the Sponsoring Institution’s DIO. Sponsoring Institutions and programs are not

required to provide due process in the remediation of residents through probation, warning, or

other locally defined disciplinary or academic actions that are not identified in the requirement.

It is common for program directors, coordinators, residents, fellows, faculty members, and DIOs

to collaborate with their local human resources or legal departments, and/or with institutional

officers/committees to ensure compliance with institutional policy related to actions against

residents and the provision of due process.

II.A.4.a).(9) Employment and discrimination

Laws and regulations concerning employment and discrimination include, but are not limited to,

those for which enforcement is overseen by the US Equal Employment Opportunity

Commission. Other federal, state, and local laws and regulations may also apply. It is common

for program directors, coordinators, residents, fellows, faculty members, and DIOs to collaborate

with their local human resources or legal departments and/or with institutional

officers/committees to ensure compliance with institutional policy related to employment and

discrimination. Sponsoring Institutions must have policies and procedures, not necessarily

GME-specific, prohibiting discrimination in employment and in the learning and working

environment, consistent with all applicable laws and regulations (

Institutional Requirement

IV.I.5.).

II.A.4.a).(9).(a) Non-competition guarantees and restrictive covenants

Sponsoring Institutions and programs must not require residents to enter into restrictive

covenants or non-competition guarantees. (See Institutional Requirement IV.M.) The

participation of residents in graduate medical education must not be contingent upon such

contractual provisions, which may limit residents’ professional options after completing their

programs.

COMMON PROGRAM REQUIREMENTS

II. Personnel

II.A. Program Director

II.A.4. Program Director Responsibilities

II.A.4.a) The program director must:

II.A.4.a).(10)

document verification of education for all residents

within 30 days of completion of or departure from the

program; and,

(Core)

II.A.4.a).(11)

provide verification of an individual resident’s

education upon the resident’s request, within 30 days

and,

(Core)

Background and Intent: Primary verification of graduate medical education is

important to credentialing of physicians for further training and practice. Such

verification must be accurate and timely. Sponsoring Institution and program policies

for record retention are important to facilitate timely documentation of residents who

have previously completed the program. Residents who leave the program prior to

completion also require timely documentation of their summative evaluation.

GUIDANCE

It is important to the resident, to the program itself, and to the Sponsoring Institution that

resident education be verified in a timely manner for all residents completing or departing from

the program. Such verification should be provided to residents upon their request, and to other

entities as needed. The ACGME does not specify exactly what must be included in such

verification, nor does it require that any particular format be used for such verification.

The Verification of Graduate Medical Education Training (VGMET) Form

Several organizations have collaborated to develop a Verification of Graduate Medical

Education Training (VGMET) Form that programs can use or adapt to their needs. The VGMET

Form was jointly developed by the American Hospital Association (AHA), the National

Association Medical Staff Services (NAMSS), the Organization of Program Director

Associations (OPDA), and the ACGME. It is designed to satisfy national credentialing

standards, and to be completed once (and only once) by the program director, and then copied

and reused in perpetuity.

Clarification

The VGMET Form was not designed or intended for applications for licensure or certification.

For licensure purposes, use this Federation Credentials Verification Service (FCVS) Form. The

FCVS Form can be used if the physician is using FCVS or is seeking licensure independently.

There i

s no time limit on a program’s obligation to continue providing verifications of residents’

graduate medical education appointments. Programs are accountable for ensuring timely

verifications for graduate medical education regardless of the location and control of the

relevant program records. When making major program changes or transferring program

sponsorship, program directors should work with the designated institutional official and others

to ensure that they are able to continue fulfilling their responsibility for timely verifications.

When a program closes and will no longer be accredited by the ACGME, program directors may

transfer responsibility for verifications to another party, such as the

Federation Credentials

Verification Service (FCVS) of the Federation of State Medical Boards (FSMB).

The verification of training should not be confused with the final evaluation described in the

Common Program Requirements V.A.2., which must include the specific elements outlined in

those requirements. Programs may use one form to meet both the requirement for verification

of training and final evaluation, but they must ensure that the final evaluation includes the

specific elements the ACGME requires.

Milestones information

The verification of training and education requirements do not indicate that programs should

share residents’ Milestones information with certifying bodies.

Milestones can and should be utilized in the determination by a program director that an

individual resident has satisfactorily completed the program and is able to engage in

autonomous practice of the specialty.

(See Common Program Requirement V.A.2.a).(1))

However, a resident’s attainment of a specific level on the Milestones should not be specified in

the program director’s verification of education or program completion. The Milestones were not

designed or intended for use in such high-stakes applications for credentialing, certification, and

licensure. The Milestones are designed as a formative judgment of progress at least twice a

year. Therefore, the ACGME actively discourages specification of Milestones achievement in

verification of education or program completion.

Milestones Resources

Programs are encouraged to visit the Milestones Resources section of the ACGME website to

review additional resources and tools.

COMMON PROGRAM REQUIREMENTS

II. Personnel

II.A. Program Director

II.A.4 Program Director Responsibilities

II.A.4.a) The program director must:

II.A.4.a).(12)

provide applicants who are offered an interview with

information related to the applicant’s eligibility for the

relevant specialty board examination(s);

(Core)

[This requirement may be omitted at the discretion of the

Review Committee]

GUIDANCE

While the transition to a single graduate medical education (GME) accreditation system that was

outlined in the Memorandum of Understanding among the ACGME, American Osteopathic

Association (AOA), and Association of American Colleges of Osteopathic Medicine (AACOM)

ended June 30, 2020, individuals who entered AOA-approved programs may be affected by the

transition for several years after 2020. Furthermore, the number of individuals completing

ACGME-accredited programs who will be eligible to be certified by AOA boards has increased

considerably. There are now many more permutations and combinations of educational

pathways and board-determined eligibility standards that may be confusing to sort out. The

following is an attempt to delineate some of those educational pathways and their effects on

board eligibility.

NOTE: Eligibility to enter an ACGME-accredited program is under ACGME purview and is

clearly delineated in the ACGME Institutional and Program Requirements. Eligibility for

certification in a specialty or subspecialty is individually determined by more than 40 different

American Board of Medical Specialties (ABMS) and AOA boards and can be changed at any

time by any of those boards. Accordingly, the ACGME cannot provide accurate, up-to-date

criteria for certification. It is the responsibility of the program director to ascertain and convey to

each applicant the pertinent eligibility criteria in any given specialty or subspecialty.

The following general guidance applies:

1. For a resident who enters residency directly from medical school, assuming acceptance

to and completion of the program, the individual should be eligible for specialty

certification.

o Allopathic and osteopathic physicians would be eligible for certification by an

ABMS member board.

o Osteopathic physicians would be eligible for certification by an AOA board.

Allopathic physicians in an ACGME-accredited program with Osteopathic

Recognition in a designated osteopathic position would be eligible for certification by

an AOA board. Allopathic physicians in an ACGME-accredited osteopathic

neuromusculoskeletal medicine program are also eligible for AOA board

certification in neuromusculoskeletal medicine.

2. For a resident who transfers from one program that has been accredited by the ACGME

throughout the resident’s tenure to another ACGME-accredited program, assuming

acceptance to and completion of the program, the individual should be eligible for

specialty certification.

o Allopathic and osteopathic physicians would be eligible for certification by an

ABMS member board.

o Osteopathic physicians would be eligible for certification by an AOA board.

Allopathic physicians in an ACGME-accredited program with Osteopathic

Recognition in a designated osteopathic position would be eligible for certification by

an AOA board. Allopathic physicians in an ACGME-accredited osteopathic

neuromusculoskeletal medicine program are also eligible for AOA board

certification in neuromusculoskeletal medicine.

3. For a

resident who transfers from an AOA-approved program to an ACGME-accredited

program, assuming acceptance to and completion of the program, the individual should

be eligible for specialty certification.

o The individual may be eligible for certification by an ABMS member board. The

program director should check with the applicable ABMS member board to

determine eligibility.

o The individual may be eligible for certification by an AOA board. The program

director should check with the applicable AOA specialty board to determine eligibility.

4. For a resident who transfers from a program that is currently accredited by the ACGME

but that was AOA-approved when the resident entered the program, assuming

acceptance to and completion of the program, the individual should be eligible for

specialty certification.

o The individual may be eligible for certification by an ABMS member board. The

program director should check with the applicable ABMS member board to

determine eligibility.

o The individual may be eligible for certification by an AOA board. The program

director should check with the applicable AOA specialty board to determine eligibility.

Program directors MUST make this clear to all applicants, as required in Common Program

Requirement II.A.4.a).(12): “The program director must provide applicants who are offered an

interview with information related to the applicant’s eligibility for the relevant specialty board

examination(s).” This requirement is closely linked to Common Program Requirement III.A. and

we encourage you to review that section of the guide as well. A sample letter the program

director can provide to applicants to comply with this requirement is provided on the following

page.

SAMPLE LETTER

Eligibility for Board Certification to Applicants to the Program

Date:

To: Residency Applicants

Re: Eligibility for Board Certification

Dear:

As part of your application and interview for a potential residency position in our program, this

letter is to notify you that this program is accredited by the Accreditation Council for Graduate

Medical Education (ACGME) and that you meet the ACGME requirements for matriculation in

our program.

Upon graduating from our program, most of our residency graduates seek board certification

from the American Board of _____ or the American Osteopathic Board of ________. Board

certification is a separate process from residency training and education and has additional

requirements. Some board organizations require that you complete all of your education in an

ACGME-accredited residency. If part of your residency education occurred in a non-ACGME-

accredited program, even if it was approved by the American Osteopathic Association or

accredited by the Royal College of Physicians and Surgeons of Canada, the College of Family

Physicians of Canada, or ACGME International (ACGME-I) with Advanced Specialty

Accreditation, there is a possibility that you may not be eligible for board certification upon

completion of your education.

It is important that you contact the appropriate certifying board to understand your eligibility for

board certification before you accept a position for residency (if offered) at our institution.

Please contact the American Board of _________________ at (website URL) or American

Osteopathic Board of ______________ at (website).

I have read this letter and understand the requirements for board certification.

____________________ ________________________

Applicant Name Applicant Signature/Date

____________________ _________________________

Program Director Name Program Director Signature/Date

COMMON PROGRAM REQUIREMENTS

II.B. Faculty

Faculty members are a foundational element of graduate medical education –

faculty members teach residents how to care for patients. Faculty members

provide an important bridge allowing residents to grow and become practice-

ready, ensuring that patients receive the highest quality of care. They are role

models for future generations of physicians by demonstrating compassion,

commitment to excellence in teaching and patient care, professionalism, and a

dedication to lifelong learning. Faculty members experience the pride and joy of

fostering the growth and development of future colleagues. The care they provide

is enhanced by the opportunity to teach and model exemplary behavior. By

employing a scholarly approach to patient care, faculty members, through the

graduate medical education system, improve the health of the individual and the

population.

Faculty members ensure that patients receive the level of care expected from a

specialist in the field. They recognize and respond to the needs of the patients,

residents, community, and institution. Faculty members provide appropriate

levels of supervision to residents to promote patient safety. Faculty members

create an effective learning environment by acting in a professional manner and

attending to the well-being of the residents and themselves.

Background and Intent: “Faculty” refers to the entire teaching force responsible for

educating residents. The term “faculty,” including “core faculty,” does not imply or

require an academic appointment.

II.B.1.

There must be a sufficient number of faculty members with competence to

instruct and supervise all residents.

(Core)

[The Review Committee may further specify]

II.B.2. Faculty members must:

II.B.2.a) be role models of professionalism;

(Core)

II.B.2.b)

demonstrate commitment to the delivery of safe, equitable, high-

quality, cost-effective, patient-centered care;

(Core)

II.B.2.c)

demonstrate a strong interest in the education of residents including

devoting sufficient time to the educational program to fulfill their

supervisory and teaching responsibilities;

(Core)

Background and Intent: Patients have the right to expect quality, cost-effective care

with patient safety at its core. The foundation for meeting this expectation is formed

during residency and fellowship. Faculty members model these goals and continually

strive for improvement in care and cost, embracing a commitment to the patient and

the community they serve.

II.B.2.d) administer and maintain an educational environment conducive to

educating residents;

(Core)

II.B.2.e) regularly participate in organized clinical discussions, rounds,

journal clubs, and conferences; and,

(Core)

II.B.2.f) pursue faculty development designed to enhance their skills at least

annually:

(Core)

Background and Intent: Faculty development is intended to describe structured

programming developed for the purpose of enhancing transference of knowledge, skill,

and behavior from the educator to the learner. Faculty development may occur in a

variety of configurations (lecture, workshop, etc.) using internal and/or external

resources. Programming is typically needs-based (individual or group) and may be

specific to the institution or the program. Faculty development programming is to be

reported for the residency program faculty in the aggregate.

II.B.2.f).(1)

as educators and evaluators;

(Detail)

II.B.2.f).(2)

in quality improvement, eliminating health inequities, and

patient safety;

(Detail)

II.B.2.f).(3)

in fostering their own and their residents’ well-being; and,

(Detail)

II.B.2.f).(4)

in patient care based on their practice-based learning and

improvement efforts.

(Detail)

Background and Intent: Practice-based learning serves as the foundation for the

practice of medicine. Through a systematic analysis of one’s practice and review of the

literature, one is able to make adjustments that improve patient outcomes and care.

Thoughtful consideration to practice-based analysis improves quality of care, as well

as patient safety. This allows faculty members to serve as role models for residents in

practice-based learning.

[The Review Committee may further specify additional faculty

responsibilities]

GUIDANCE

II.B. Faculty

As a foundational element of graduate medical education, faculty members have numerous

responsibilities in the education of residents. Selection of faculty members should be carefully

considered to ensure they fulfill the stated requirements that follow. In addition to providing

consistently high-quality patient care, faculty members must teach and supervise residents in

the provision of equivalent high-quality care and allow graded supervision that enables residents

to achieve readiness for autonomous practice at the end of their training and education. Non-

clinical faculty members should be similarly capable in their areas of expertise. Faculty

members should be effective in the provision of both formal and informal, written and oral

feedback and participate in faculty development activities to enhance their teaching and

evaluative skills. They should demonstrate a commitment to the education of residents and to

the privilege of training the next generation of physicians.

The Background and Intent for this requirement clarifies that the term “Faculty” refers to the

entire teaching force responsible for educating residents. The term “faculty,” including “core

faculty,” does not imply or require an academic appointment.

II.B.1. Need for a sufficient number of faculty members

The requirement is intended to ensure that there are enough competent faculty members to

teach and supervise residents at all participating sites. Participating sites cannot be selected

solely based on the availability of a specific procedure or a unique patient care experience in the

absence of faculty members with the interest, ability, and commitment to resident education.

[The Review Committee may further specify]

Programs should reference the specialty-specific Program Requirements to ensure they are

compliant with the minimum number of faculty members and/ or faculty-to-resident ratio

requirements of their particular specialty. Programs may also reference the Number of Facult

document available on the Institutional Application and Requirements page of the Institutional

Review Committee section of the ACGME website.

II.B.2.a)-c) Faculty Members as role models of professionalism, commitment to

delivery of safe, quality, cost-effective, patient-centered care

In addition to being role models, faculty members must also demonstrate a strong interest in the

education of residents. Residents learned the most about professionalism from observing

faculty member role models. (Brownell, A. Keith W., and Luc Côté. 2001. “Senior Residents’

Views on the Meaning of Professionalism and How They Learn about It.” Academic Medicine

76,(7): 734–37. https://doi.org/10.1097/00001888-200107000-00019

Faculty members must also have sufficient time to fulfill their responsibilities. Some faculty

members may need defined protected time to fulfill their responsibilities, while other faculty

members can supervise and teach within their defined assignments. Sufficient time for resident

education is a shared responsibility of individual faculty members and the department or

institution. Pressure for clinical productivity must not preclude sufficient time to teach and

supervise residents in the program.

II.B.2.d) Faculty members as part of administration and maintenance of an

educational environment conducive to educating residents

An educational environment includes more elements than the provision of patient care. An

environment geared toward resident education allows time for questions and discussions which

support evidence-based medical decision making. There should be appropriate discussions

about the evidence-based references, pathophysiology, and rationale of clinical decisions to a

sufficient degree to maintain an environment of continuous learning.

II.B.2.e) Faculty member participation in organized clinical discussion, rounds,

journal clubs, and conferences

Formal didactic educational activities should include experienced faculty members who can

provide commentary and clinical insights to augment the information being presented. All faculty

members do not need to participate in all didactic activities. However, it is inappropriate for

residents to consistently lead organized didactic experiences without a faculty presence.

II.B.2.f).(1)-(4) Faculty members pursuit of faculty development designed to

enhance skills as an educator, quality improvement and patient safety, well-

being, and patient care

Programs should ensure that there are opportunities for their faculty members to participate in

professional development activities designed to optimize their skills. Faculty members should

participate annually in faculty development activities in one of these four areas: as an educator,

quality improvement and patient safety, fostering their own and their residents’ well-being, and

patient care based on their practice-based learning and improvement efforts. This does not

preclude faculty development in other important areas such as clinical knowledge, leadership,

team building, communications, and patient relationships.

The Background and Intent states that faculty development is intended to describe structured

programming developed for the purpose of enhancing transference of knowledge, skill, and

behavior from the educator to the learner. Faculty development may occur in a variety of

configurations (lecture, workshop, etc.) using internal and/or external resources. Programming

is typically needs based (individual or group) and may be specific to the institution or the

program. Faculty development programming is to be reported for the residency program faculty

in the aggregate.

[The Review Committee may further specify additional faculty responsibilities]

Review Committees may specify other requirements related to additional faculty responsibilities,

so programs must review the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

Questions about specialty-specific Program Requirements related to program director

qualifications should be directed to specialty Review Committee staff.

COMMON PROGRAM REQUIREMENTS

II.B.3. Faculty Qualifications

II.B.3.a) Faculty members must have appropriate qualifications in their field

and hold appropriate institutional appointments.

(Core)

[The Review Committee may further specify]

II.B.3.b) Physician faculty members must:

II.B.3.b).(1) have current certification in the specialty by the American

Board of _____ or the American Osteopathic Board of _____,

or possess qualifications judged acceptable to the Review

Committee.

(Core)

[The Review Committee may further specify additional qualifications

and/or requirements regarding non-physician faculty]

GUIDANCE

II.B.3.a) Faculty members must have appropriate qualifications in their field and

hold appropriate institutional appointments.

Minimum faculty member qualifications include having specialty or subspecialty board

certification, a license to practice, and appropriate institutional appointment. Additional

qualifications include expertise in the field and skills as an educator. Faculty information is

captured in the faculty profile and curriculum vitae (CV) in the Accreditation Data System (ADS).

Programs should complete all required information when adding a new faculty member into

ADS. It is also important to carefully review and update all the faculty information if a profile for

that individual already exists in ADS and you are importing the profile into your program.

ADS screenshots: faculty profile and CV

II.B.3.b) Physician faculty members must have current certification in the

specialty by the ABMS or AOA, or possess qualifications judged acceptable to

the Review Committee.

Some Review Committees will accept only certification in the appropriate specialty by an

American Board of Medical Specialties (ABMS) member board or American Osteopathic

Association (AOA) certifying board for the program director. Other Review Committees will

accept other qualifications for the program director. Programs are encouraged to refer to the

specialty-specific Program Requirements

for more information on this requirement.

The ACGME automatically populates data received from the ABMS and the AOA for all faculty

members on their individual ADS faculty profile page, where data are available. Physician

faculty members’ board certification data will be matched to the ABMS and AOA datasets based

on National Provider Identifier (NPI) number, as well as name, date of birth, and medical school

graduation year. Faculty members who are newly entered into ADS will have their certification

information matched and populated within 24 hours.

Programs are only required to provide a manual entry for faculty members’ specialty certification

if:

• No ABMS/AOA board certification data is displayed in ADS or it is incorrect. In this case,

a manual entry for “ABMS missing/inaccurate data” or “AOA missing/inaccurate data”

should be added on the faculty’s profile with a duration type, initial certification year,

certification name, and an explanation for Review Committee consideration.

• The faculty member is not certified by the ABMS/AOA. Add a manual entry of “Not Board

Certified” and an explanation.

• The faculty member is board eligible but has not yet achieved board certification. Add a

manual entry of “Board eligible” and provide an explanation.

• The faculty member is certified by another certifying body. Some Review Committees

allow other acceptable specialty qualifications and therefore a manual entry of “Other

Certifying Body” can provide that information.

ADS screenshot: specialty certification – manual entries

Common issues related to the ABMS and AOA data not auto-populating on the faculty profile

and in the faculty roster include:

• The NPI number in ADS is incorrect or does not match the NPI number in the

ABMS/AOA dataset.

• A lag in when updated board certification data are received by the ACGME from the

ABMS and AOA.

Non-physicians are often important contributors to programs and warrant appointment to the

faculty. These individuals may bring specialized expertise in public health, patient safety,

laboratory science, pharmacology, basic science, research, a specific procedural skill, or other

important aspects of medicine. Non-physician educators may provide valuable contributions to

the residents’ knowledge and skills. If the program director determines that the contribution of a

non-physician individual is significant to the education of the residents, the program director

may designate the individual as a faculty member or a core faculty member.

ADS screenshot: non-physician faculty qualifications

[The Review Committee may further specify]

Review Committees may specify other requirements related to faculty qualifications, specialty

certification and non-physician faculty, so programs must review the specialty-specific Program

Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

Questions about specialty-specific Program Requirements related to faculty qualifications

should be directed to specialty Review Committee staff.

COMMON PROGRAM REQUIREMENTS

II.B.4. Core Faculty

Cor

e faculty members must have a significant role in the education and

supervision of residents and must devote a significant portion of their entire effort

to resident education and/or administration, and must, as a component of their

activities, teach, evaluate, and provide formative feedback to residents.

(Core)

Background and Intent: Core faculty members are critical to the success of resident

education. They support the program leadership in developing, implementing, and

assessing curriculum, mentoring residents, and assessing residents’ progress toward

achievement of competence in and the independent practice of the specialty. Core

faculty members should be selected for their broad knowledge of and involvement in

the program, permitting them to effectively evaluate the program. Core faculty

members may also be selected for their specific expertise and unique contribution to

the program. Core faculty members are engaged in a broad range of activities, which

may vary across programs and specialties. Core faculty members provide clinical

teaching and supervision of residents, and also participate in non-clinical activities

related to resident education and program administration. Examples of these non-

clinical activities include, but are not limited to, interviewing and selecting resident

applicants, providing didactic instruction, mentoring residents, simulation exercises,

completing the annual ACGME Faculty Survey, and participating on the program’s

Clinical Competency Committee, Program Evaluation Committee, and other GME

committees.

II.B

.4.a) Core faculty members must complete the annual ACGME Faculty

Survey.

(Core)

[The Review Committee must specify the minimum number of core

faculty and/or the core faculty-resident ratio]

[The Review Committee may further specify either:

1) requirements regarding dedicated time and support for core

faculty members’ non-clinical responsibilities related to

resident education and/or administration of the program, or]

2) requirements regarding the role and responsibilities of core

faculty members, inclusive of both clinical and non-clinical

activities, and the corresponding time commitment required

to meet those responsibilities.]

If the Review Committee adds requirements as described in number (1) above, the

Review Committee may choose to include background and intent as follows:

Background and Intent: Provision of support for the time required for the core

faculty members’ responsibilities related to resident education and/or

administration of the program, as well as flexibility regarding how this support

is provided, are important. Programs, in partnership with their Sponsoring

Institutions, may provide support for this time in a variety of ways. Examples of

support may include, but are not limited to, salary support, supplemental

compensation, educational value units, or relief of time from other professional

duties.

It is important to remember that the dedicated time and support requirement is a

minimum, recognizing that, depending on the unique needs of the program,

additional support may be warranted. The need to ensure adequate resources,

including adequate support and dedicated time for the core faculty members, is

also addressed in Institutional Requirement II.B.2. The amount of support and

dedicated time needed for individual programs will vary based on a number of

factors and may exceed the minimum specified in the applicable specialty-

/subspecialty-specific Program Requirements.

If the Review Committee adds requirements as described in number (2) above, the

following Background and Intent must be included:

Background and Intent: The core faculty time requirements address the role and

responsibilities of core faculty members, inclusive of both clinical and

nonclinical activities, and the corresponding time to meet those responsibilities.

The requirements do not address how this is accomplished, and do not

mandate dedicated or protected time for these activities. Programs, in

partnership with their Sponsoring Institutions, will determine how compliance

with the requirements is achieved.

[The

Review Committee may specify requirements specific to

associate program director(s)]

GUIDANCE

II.B.4. Core faculty

Core faculty members have responsibilities specific to the educational program. These

individuals may be associate/assistant program directors, participating site directors, conference

organizers, or subspecialty experts responsible for a segment of the curriculum. They may be

members of the Program Evaluation Committee and/or Clinical Competency Committee, have

expertise in medical education, or be health care professionals dedicated to the program who

are developing into future educational leaders.

As the Background and Intent for this requirement states, “Core faculty members are critical to

the success of resident education. They support the program leadership in developing,

implementing, and assessing curriculum, mentoring residents, and assessing residents’

progress toward achievement of competence in and the independent practice of the specialty.”

II.B.4.a) Core faculty members must complete the ACGME Faculty Survey.

Core faculty members are expected to complete the annual ACGME Faculty Survey, which is

one of the instruments used by specialty Review Committees to assess programs. Therefore,

core faculty members should be selected for their broad knowledge of and involvement in the

program, which provides them with the insight necessary to effectively evaluate the program.

[The Review Committee must specify the minimum number of core faculty and/or

the core faculty-resident ratio]

Since Review Committees must specify minimum number of core faculty, programs must review

the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

It is the responsibility of the program director to determine which members of the faculty best

meet the needs of the program and to designate those individuals as core faculty members in

the Accreditation Data System (ADS). As stated in the Background and Intent for this

requirement, “Core faculty members should be selected for their broad knowledge of and

involvement in the program, permitting them to effectively evaluate the program. Core faculty

members may also be selected for their specific expertise and unique contribution to the

program. Core faculty members are engaged in a broad range of activities, which may vary

across programs and specialties. Core faculty members provide clinical teaching and

supervision of residents, and also participate in non-clinical activities related to resident

education and program administration. Examples of these non-clinical activities include, but are

not limited to, interviewing and selecting resident applicants, providing didactic instruction,

mentoring residents, simulation exercises, completing the annual ACGME Faculty Survey, and

participating on the program’s Clinical Competency Committee, Program Evaluation Committee,

and other GME committees.”

ADS screenshots: designating core faculty in ADS

1. Programs can designate individual faculty members as core/non-core.

2. Programs can designate multiple faculty members as core/non-core at the

same time.

[The Review Committee may further specify requirements regarding dedicated

time and support for or the role and responsibilities of core faculty members]

The Core Faculty Dedicated Time summary document included on the ACGME website

provides a snapshot of the core faculty dedicated time and support across all ACGME-

accredited specialties.

ADS Screenshot: program resources – percent of FTE support – core faculty (if

applicable)

part of a new a program application as well as the Accreditation Data System (ADS) Annual

Update process, programs must provide the percent of FTE support allocated to core faculty, if

applicable for their specialty.

[The Review Committee may specify requirements specific to associate program

director(s)]

Programs should consult the specialty-specific Program Requirements for further specification.

ADS screenshot: program resources – percent of FTE support – associate

program director(s) (if applicable)

As part of a new program application as well as the Accreditation Data System (ADS) Annual

Update process, programs must provide the percent of FTE support allocated to associate

program director(s), if applicable for their specialty.

COMMON PROGRAM REQUIREMENTS

II.C. Program Coordinator

II.C

.1.

II.C

.2.

There must be a program coordinator.

(Core)

The program coordinator must be provided with dedicated time and

support adequate for administration of the program based upon its size

and configuration.

(Core)

[The Review Committee must further specify minimum dedicated time for

the program coordinator.]

Background and Intent: The requirement does not address the source of funding

required to provide the specified salary support.

Each pr

ogram requires a lead administrative person, frequently referred to as a

program coordinator, administrator, or as otherwise titled by the institution. This

person will frequently manage the day-to-day operations of the program and serve as

an important liaison and facilitator between the learners, faculty and other staff

members, and the ACGME. Individuals serving in this role are recognized as program

coordinators by the ACGME.

The

program coordinator is a key member of the leadership team and is critical to the

success of the program. As such, the program coordinator must possess skills in

leadership and personnel management appropriate to the complexity of the program.

Program coordinators are expected to develop in-depth knowledge of the ACGME and

Program Requirements, including policies and procedures. Program coordinators

assist the program director in meeting accreditation requirements, educational

programming, and support of residents.

ograms, in partnership with their Sponsoring Institutions, should encourage the

professional development of their program coordinators and avail them of

opportunities for both professional and personal growth. Programs with fewer

residents may not require a full-time coordinator; one coordinator may support more

than one program.

The

minimum required dedicated time and support specified in II.C.2.a) is inclusive of

activities directly related to administration of the accredited program. It is understood

that coordinators often have additional responsibilities, beyond those directly related

to program administration, including, but not limited to, departmental administrative

responsibilities, medical school clerkships, planning lectures that are not solely

intended for the accredited program, and mandatory reporting for entities other than

the ACGME. Assignment of these other responsibilities will necessitate consideration

of allocation of additional support so as not to preclude the coordinator from devoting

the time specified above solely to administrative activities that support the accredited

program.

In addition, it is important to remember that the dedicated time and support

requirement for ACGME activities is a minimum, recognizing that, depending on the

unique needs of the program, additional support may be warranted. The need to

ensure adequate resources, including adequate support and dedicated time for the

program coordinator, is also addressed in Institutional Requirement II.B.4. The amount

of support and dedicated time needed for individual programs will vary based on a

number of factors and may exceed the minimum specified in the applicable

specialty/subspecialty-specific Program Requirements. It is expected that the

Sponsoring Institution, in partnership with its accredited programs, will ensure support

for program coordinators to fulfill their program responsibilities effectively.

II.D. Other Program Personnel

The program, in partnership with its Sponsoring Institution, must jointly ensure

the availability of necessary personnel for the effective administration of the

program.

(Core)

[The Review Committee may further specify]

Background and Intent: Multiple personnel may be required to effectively administer a

program. These may include staff members with clerical skills, project managers,

education experts, and staff members to maintain electronic communication for the

program. These personnel may support more than one program in more than one

discipline.

GUIDANCE

II.C. Program coordinator

Common Program Requirement II.C.1. specifies that each program must have a program

coordinator. Requirement II.C.2. further specifies that the program coordinator must be provided

with dedicated time and support adequate for administration of the program based upon its size

and configuration.

[The Review Committee must further specify minimum dedicated time for the

program coordinator.]

Since Review Committees must specify minimum dedicated time for the program coordinator,

programs must review the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

The Coordinator Dedicated Time

summary document included as an institutional resource also

provides a snapshot of the program coordinator dedicated time and support across all ACGME-

accredited specialties.

The Bac

kground and Intent for Common Program Requirement II.C. explains that “each

program requires a lead administrative person, frequently referred to as a program coordinator,

administrator, or as otherwise titled by the institution. This person will frequently manage the

day-to-day operations of the program and serve as an important liaison and facilitator between

the learners, faculty and other staff members, and the ACGME. Individuals serving in this role

are recognized as program coordinators by the ACGME.” In that same section, the ACGME also

recognizes that “the program coordinator is a key member of the leadership team and is critical

to the success of the program. As such, the program coordinator must possess skills in

leadership and personnel management appropriate to the complexity of the program. Program

coordinators are expected to develop in-depth knowledge of the ACGME and Program

Requirements, including policies and procedures. Program coordinators assist the program

director in meeting accreditation requirements, educational programming, and support of

residents.”

Other important considerations described in the Background and Intent for this requirement

include the following:

• The source of funding for the specified salary support is not addressed.

• Programs, in partnership with their Sponsoring Institutions, should encourage the

professional development of their program coordinators.

• Programs with fewer residents may not require a full-time coordinator; one coordinator

may support more than one program so long as the individual’s total dedicated time

across programs does not exceed 100 percent FTE.

• The minimum required dedicated time and support specified in Common Program

Requirement II.C.2.a) is inclusive of activities directly related to administration of the

accredited program.

• Assignment of other responsibilities, beyond those directly related to program

administration, will necessitate consideration of allocation of additional support.

• The dedicated time and support requirement for ACGME activities is a minimum,

recognizing that, depending on the unique needs of the program, additional support may

be warranted.

The ACGME monitors compliance with requirements in section II.C. in various ways, including:

• questions answered by program leadership as part of an application or during the ADS

Annual Update; and

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

ADS screenshot: program resources – percent of FTE support – program

coordinators

As part of a new program application as well as the Accreditation Data System (ADS) Annual

Update process, programs must provide the percent of FTE support allocated to the program

coordinator(s).

II.D. Other program personnel

[The Review Committee may further specify]

Programs should review the specialty-specific Program Requirements for further specification, if

applicable.

The Background and Intent for this requirement explains that in addition to program

coordinators, there may be others needed to help in the administration of a program. These

individuals may include project managers, experts in education and/or communication, and

those with clerical skills. These individuals may provide support for more than one program in

more than one specialty.

COMMON PROGRAM REQUIREMENTS

III. Resident Appointments

III.A. Eligibility Requirements

III.A.1. An applicant must meet one of the following qualifications to be

eligible for appointment to an ACGME-accredited program:

(Core)

III.A.1.a) graduation from a medical school in the United States or

Canada, accredited by the Liaison Committee on Medical

Education (LCME) or graduation from a college of

osteopathic medicine in the United States, accredited by the

American Osteopathic Association Commission on

Osteopathic College Accreditation (AOACOCA); or,

(Core)

III.A.1.b) graduation from a medical school outside of the United

States or Canada, and meeting one of the following additional

qualifications:

(Core)

III.A.1.b).(1) holding a currently valid certificate from the

Educational Commission for Foreign Medical

Graduates (ECFMG) prior to appointment; or,

(Core)

III.A.1.b).(2) holding a full and unrestricted license to practice

medicine in the United States licensing jurisdiction in

which the ACGME-accredited program is located.

(Core)

III.A.2. All prerequisite post-graduate clinical education required for initial

entry or transfer into ACGME-accredited residency programs must

be completed in ACGME-accredited residency programs, AOA

approved residency programs, Royal College of Physicians and

Surgeons of Canada (RCPSC)-accredited or College of Family

Physicians of Canada (CFPC)-accredited residency programs

located in Canada, or in residency programs with ACGME

International (ACGME-I) Advanced Specialty Accreditation.

(Core)

III.A.2.a) Residency programs must receive verification of each

resident’s level of competency in the required clinical field

using ACGME, CanMEDS, or ACGME-I Milestones evaluations

from the prior training program upon matriculation.

(Core)

[The Review Committee may further specify prerequisite

postgraduate clinical education]

Background and Intent: Programs with ACGME-I Foundational Accreditation or from

institutions with ACGME-I accreditation do not qualify unless the program has also

achieved ACGME-I Advanced Specialty Accreditation. To ensure entrants into ACGME-

accredited programs from ACGME-I programs have attained the prerequisite

milestones for this training, they must be from programs that have ACGME-I Advanced

Specialty Accreditation.

III.A.3. Resident Eligibility Exception

The Review Committee for ______ will allow the following exception to the

resident eligibility requirements:

(Core)

[Note: A Review Committee may permit the eligibility exception if the

specialty requires completion of a prerequisite residency program prior to

admission. If the specialty-specific Program Requirements define multiple

program formats, the Review Committee may permit the exception only for

the format(s) that require completion of a prerequisite residency program

prior to admission. If this language is not applicable, this section will not

appear in the specialty-specific requirements.]

III.A.4.a) An ACGME-accredited residency program may accept an

exceptionally qualified international graduate applicant who does

not satisfy the eligibility requirements listed in III.A.1. - II.A.2., but

who does meet all of the following additional qualifications and

conditions:

(Core)

III.A.4.a).(1) evaluation by the program director and residency selection

committee of the applicant’s suitability to enter the program,

based on prior training and review of the summative

evaluations of this training; and,

(Core)

III.A.4.a).(2) review and approval of the applicant’s exceptional

qualifications by the GMEC; and,

(Core)

III.A.4.a).(3) verification of Educational Commission for Foreign Medical

Graduates (ECFMG) certification.

(Core)

III.A.4.b) Applicants accepted through this exception must have an evaluation

of their performance by the Clinical Competency Committee within

12 weeks of matriculation.

(Core)

GUIDANCE

In addition to the Common Program Requirements related to resident eligibility requirements,

program directors must comply with the policies and procedures of the Sponsoring Institution

and the ACGME Institutional Requirements for resident appointment. See Institutional

Requirements IV.B., IV.B.1., and IV.B.2. for additional information.

III.A.1. Eligibility Requirements

The following links provide helpful information about residency eligibility requirements:

• United States Doctor of Medicine (MD) graduates

−

Liaison Committee on Medical

Education (LCME)

• United States Doctor of Osteopathic Medicine (DO) graduates

−

American Osteopathic

Association (AOA) Commission on Osteopathic College Accreditation (AOA-COCA)

• Canada jointly with LCME Doctor of Medicine (MD) graduates

−

Committee on

Accreditation of Canadian Medical Schools (CACMS)

Residents who completed an AOA-approved program that became ACGME accredited during

the transition to a single graduate medical education (GME) accreditation system may be

eligible for American Board of Medical Specialties (ABMS) and/or AOA board certification.

While program accreditation is under the purview of the ACGME, individual board certification is

under the jurisdiction of the individual certifying boards. For individual specialty board qualifying

information, program directors and residents must communicate with the applicable certifying

board.

ADS screenshots: resident eligibility requirements

The ACGME collects information on each resident during the Accreditation Data System (ADS)

Annual Update process when programs input new residents into ADS and update their resident

roster. Information collected includes the type of medical school the resident graduated from,

the graduation date, and the Educational Commission for Foreign Medical Graduates (ECFMG)

certificate where applicable. (See accompanying screenshots which follow on the next pages.)

The table below provides definitions of the different resident statuses:

III.A.2. Prerequisite post-graduate clinical education required for initial entry or

transfer into ACGME-accredited residency programs

Prerequisite post-graduate clinical education must be obtained in the following types of

programs:

• ACGME-accredited residency programs

• AOA-approved residency programs

• Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of

Family Physicians of Canada (CFPC)-accredited residency programs located in Canada

• Residency programs with ACGME International (ACGME-I) Advanced Specialty

Accreditation

III.A.2.a) Verification of competence using Milestones evaluations in the required

clinical field

To verify the competence of each matriculating resident, all prerequisite post-graduate clinical

education required for initial entry or transfer into ACGME-accredited residency programs must

be verified by the program director using Milestones evaluations. Any one of the following three

evaluation tools may be used:

• ACGME Milestones evaluations

• ACGME-I Milestones evaluations

• CanMEDS Milestones evaluations

ADS screenshot: retrieving Milestones reports from a previous residency

program

Once a transfer resident is entered in ADS and starts in a new residency program, program

leadership can retrieve the Milestones report for that resident from the previous program by

following these steps:

1. Log into ADS.

2. Go to the Reports tab.

3. Select “Residency Milestones Retrieval” in the Reports section.

4. Select the academic year to view a list of current residents and, if available, the last

Milestone evaluation form completed by their most recent accredited core residency

program.

5. Select the “Summary Report” button for that particular resident.

NOTE: A report may be unavailable if the previous program has not updated that resident's

record in ADS or if the previous training and education could not be matched when entered on

your roster (based on name, date of birth, social security number, medical school, or some

combination of those elements). The resident may also have completed core residency training

and education in a program not accredited by the ACGME or completed training and education

prior to Milestones implementation. For residents that do not have a Milestone report on record,

contact the previous specialty program director to obtain the summative report or email

[email protected]

with questions. (

See accompanying screenshot which follows on the next

page.)

[The Review Committee may further specify prerequisite postgraduate clinical

education]

Since Review Committees may specify other requirements related to prerequisite postgraduate

clinical education, programs must review the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

Questions about specialty-specific Program Requirements should be directed to specialty

Review Committee staff.

Common Program Requirement III.A.3 describes exceptions to the general requirement in

Common Program Requirement III.A.2. It applies only to an individual who has graduated from

a residency in the same specialty. Residents should expect to enter at the PGY-1 level, but if

they are performing at a higher level that can be demonstrated through the Milestone

evaluation, they can be advanced to the PGY-2 level.

III.A.3. Resident eligibility exception

The Review Committee for ______ will allow the following exception to the

resident eligibility requirements:

(Core)

[NOTE: A Review Committee may permit the eligibility exception if the specialty

requires completion of a prerequisite residency program prior to admission. If

this language is not applicable, this section will not appear in the specialty-

specific requirements.]

Some specialties will allow exceptions to resident eligibility requirements. Review the

information in the document ACGME Review Committee Eligibility Decisions or refe

r to the

specialty-specific Program Requirements. Review Committees that allow exceptions require

completion of a prerequisite residency program prior to admission. Programs can also access

the Common Program Requirements FAQs for additional information on resident eligibility.

See the table below for information on eligibility for specialty certification by ABMS

member boards and AOA member boards during and following the transition period to a

single GME accreditation system based on training and program accreditation status.

Refer to the ABMS and AOA websites for most current information.

The A

OA provides a pathway for osteopathic physicians (whether they were educated in AOA-

approved or ACGME-accredited programs) to sit for AOA board examinations in the areas the

AOA certifies. Allopathic physicians who complete an ACGME-accredited program with

Osteopathic Recognition in a designated osteopathic position are also eligible for AOA board

certification. Allopathic physicians who complete an ACGME-accredited osteopathic

neuromusculoskeletal medicine program are eligible for AOA board certification in

neuromusculoskeletal medicine. For AOA programs that achieved ACGME accreditation during

the transition, all osteopathic residents in the program at the time it achieved ACGME

accreditation will receive AOA approval following completion of the program, which will satisfy

the AOA board eligibility requirements.

ABMS Board Certification

Requirements

AOA Board Certification

Requirements

Specialty

ABMS Member Board and

Training and Program

Accreditation Status

AOA Member Board and

Training Eligibility Criteria

for Specialty Certification

Allergy and

Immunology

American Board of Allergy and

Immunology (ABAI)

Two full years in an ACGME-

accredited allergy and immunology

program AND must be eligible to

take the certifying examination for

either the American Board of

Internal Medicine or the American

Board of Pediatrics. In 2016, the

Allergy and Immunology -

Joint Examination

Completed an AOA-

approved or ACGME-

accredited program

ABMS Board Certification

Requirements

AOA Board Certification

Requirements

Specialty

ABMS Member Board and

Training and Program

Accreditation Status

AOA Member Board and

Training Eligibility Criteria

for Specialty Certification

ACGME approved allergy and

immunology programs accredited

by the American Osteopathic

Association to be approved for dual

accreditation. Graduates of a dually

accredited program are now eligible

to apply for admission to the ABAI

Certification Examination in Allergy

and Immunology. Therefore,

candidates with one year of training

in an AOA-accredited program and

one year of training in an ACGME-

accredited program may be

considered for admission to the

allergy and immunology

examination. Candidates who

submit appropriate documentation

will be reviewed by the ABAI Ethics

and Professionalism Committee to

ensure their training meets the

requirements for admission to the

examination.

Anesthesiology

American Board of

Anesthesiology (ABA)

All three years of clinical anesthesia

(CA 1-3) training must occur in

programs that are accredited by the

ACGME for the entire period of

training. All physicians who

graduate from an AOA-approved

anesthesiology residency program

on or after the date the program

receives full ACGME accreditation

will receive ABA credit for the CA 1-

3 years of satisfactory training in

the newly accredited program.

American Osteopathic

Board of Anesthesiology

Completed an AOA-

approved or ACGME-

accredited program

Colon and Rectal

Surgery

American Board of Colon and

Rectal Surgery

Not applicable. There are no AOA-

approved programs.

N/A

Dermatology

American Board of Dermatology

Program must achieve ACGME

accreditation prior to completion.

American Osteopathic

Board of Dermatology

ABMS Board Certification

Requirements

AOA Board Certification

Requirements

Specialty

ABMS Member Board and

Training and Program

Accreditation Status

AOA Member Board and

Training Eligibility Criteria

for Specialty Certification

Completed an AOA-

approved or ACGME-

accredited program

Emergency Medicine

American Board of Emergency

Medicine

Program must achieve ACGME

accreditation prior to completion.

American Osteopathic

Board of Emergency

Medicine

Completed an AOA-

approved or ACGME-

accredited program

Family Medicine

American Board of Family

Medicine (ABFM)

A time-limited exemption during the

transition period will be offered to

allow osteopathic family physicians

who have completed three years of

an AOA-approved family medicine

residency program to be eligible for

ABFM specialty certification.

American Osteopathic

Board of Family

Physicians

Completed an AOA-

approved or ACGME-

accredited program

Internal Medicine

American Board of Internal

Medicine (ABIM)

Program must achieve ACGME

accreditation prior to resident’s

completion of the program. In

addition, the program director must

be certified by ABIM, or other

ABMS member board if applicable,

by the completion of the transition

period (2016-2023) to a single GME

accreditation system in order to

attest to ABIM initial eligibility

criteria. Beginning in 2024, only

graduates of programs with

program directors certified by ABIM,

or other ABMS board if applicable,

will be eligible for certification by

ABIM.

American Osteopathic

Board of Internal Medicine

Completed an AOA-

approved or ACGME-

accredited program

Medical Genetics and

Genomics

American Board of Medical

Genetics and Genomics

There are no AOA-approved

residency programs in medical

genetics and genomics. A minimum

of one year of GME training in

either an ACGME-accredited

program or a program in the

ACGME pre-accreditation phase

N/A

100

ABMS Board Certification

Requirements

AOA Board Certification

Requirements

Specialty

ABMS Member Board and

Training and Program

Accreditation Status

AOA Member Board and

Training Eligibility Criteria

for Specialty Certification

with 12 months of direct patient

care is required prior to beginning

the medical genetics and genomics

residency.

Neuromusculoskeletal

Medicine

N/A

American Osteopathic

Board of

Neuromusculoskeletal

Medicine

Completed an AOA-

approved or ACGME-

accredited program

Neurological Surgery

American Board of Neurological

Surgery (ABNS)

Neurological surgery training is 84

months in total. There are 54

months of “core" neurological

surgery training which must be

completed in an ACGME-accredited

program. For the 30 months of

research or elective time, there is

flexibility depending upon the

quality of the clinical or research

experience. It is not necessary for

this experience to be in an ACGME-

accredited program. However,

written approval from the ABNS is

required for any off-site elective

experiences. The ABNS works

collaboratively with the ACGME

when questions arise to ensure

high-quality training and education.

American Osteopathic

Board of Surgery:

Neurological Surgery

Completed an AOA-

approved or ACGME-

accredited program

Nuclear Medicine

American Board of Nuclear

Medicine

Not applicable. There are no AOA-

approved nuclear medicine

programs.

American Osteopathic

Board of Nuclear Medicine

Completed an AOA-

approved or ACGME-

accredited program

Obstetrics and

Gynecology

American Board of Obstetrics

and Gynecology

Program must have achieved

ACGME accreditation prior to

completion.

American Osteopathic

Board of Obstetrics and

Gynecology

Completed an AOA-

approved or ACGME-

accredited program

101

ABMS Board Certification

Requirements

AOA Board Certification

Requirements

Specialty

ABMS Member Board and

Training and Program

Accreditation Status

AOA Member Board and

Training Eligibility Criteria

for Specialty Certification

Ophthalmology

American Board of

Ophthalmology

All training must be in an ACGME-

accredited program.

American Osteopathic

Board of Ophthalmology

and Otolaryngology

Completed an AOA-

approved or ACGME-

accredited program

Orthopaedic Surgery

American Board of Orthopaedic

Surgery

All training must be in an ACGME-

accredited program.

American Osteopathic

Board of Orthopedic

Surgery

Completed an AOA-

approved or ACGME-

accredited program

Otolaryngology –

Head and Neck

Surgery

American Board of

Otolaryngology – Head and Neck

Surgery (ABOHNS)

All training must be in an ACGME-

accredited program.

Based on the timing of AOA-

approved residencies transitioning

to ACGME accreditation, ABOHNS

started seeing some applicants

from the traditional AOA-approved

residencies in 2021. This transition

will be completed with all residents

in newly ACGME-accredited

residency programs by 2025.

American Osteopathic

Board of Ophthalmology

and Otolaryngology

Completed an AOA-

approved or ACGME-

accredited program

Pathology

American Board of Pathology

Not applicable. There are no AOA-

approved programs in pathology.

American Osteopathic

Board of Pathology

Completed an AOA-

approved or ACGME-

accredited program

Pediatrics

American Board of Pediatrics

All residency training must be

completed in an ACGME- or

RCPSC-accredited program.

American Osteopathic

Board of Pediatrics

Completed an AOA-

approved or ACGME-

accredited program

Physical Medicine and

Rehabilitation

American Board of Physical

Medicine and Rehabilitation

(ABPMR)

Through June 30, 2020, the

ABPMR will recognize AOA-

approved training as acceptable

toward PGY-1-level physical

American Osteopathic

Board of Physical

Medicine and

Rehabilitation

102

ABMS Board Certification

Requirements

AOA Board Certification

Requirements

Specialty

ABMS Member Board and

Training and Program

Accreditation Status

AOA Member Board and

Training Eligibility Criteria

for Specialty Certification

medicine and rehabilitation

residency training. Due to the

impact of the transition to a single

GME accreditation system, the

ABPMR will recognize physicians

who completed at least 36 months

of AOA-approved physical medicine

and rehabilitation training as eligible

for certification in circumstances

where ACGME accreditation was

granted by the time of program

completion. Program completion

must have occurred July 1, 2015,

and forward to coincide with the

transition to a single GME

accreditation system.

Completed an AOA-

approved or ACGME-

accredited program

Plastic Surgery

American Board of Plastic

Surgery

All training must be in an ACGME-

accredited program.

American Osteopathic

Board of Surgery: Plastic

and Reconstructive

Surgery

Completed an AOA-

approved or ACGME-

accredited program

Preventive Medicine

American Board of Preventive

Medicine

PGY-1 year can take place in an

AOA-approved program. Years 2

and 3 must be in an ACGME-

accredited program.

American Osteopathic

Board of

Preventive Medicine

Completed an AOA-

approved or ACGME-

accredited program

Psychiatry and

Neurology

American Board of Psychiatry

and Neurology

Program must achieve ACGME

accreditation prior to completion.

American Osteopathic

Board of Neurology and

Psychiatry

Completed an AOA-

approved or ACGME-

accredited program

Radiology

American Board of Radiology

All residency training must be

completed in an ACGME- or

RCPSC-accredited program.

American Osteopathic

Board of Radiology

Completed an AOA-

approved or ACGME-

accredited program

Surgery

American Board of Surgery

The final three years of the basic

five-year surgery residency must be

in an ACGME-accredited program.

American Osteopathic

Board of Surgery

Completed an AOA-

approved or ACGME-

accredited program

103

ABMS Board Certification

Requirements

AOA Board Certification

Requirements

Specialty

ABMS Member Board and

Training and Program

Accreditation Status

AOA Member Board and

Training Eligibility Criteria

for Specialty Certification

Thoracic Surgery

American Board of Thoracic

Surgery

The last three years of a surgical

residency (PGY 3-5) must be

completed in an ACGME-accredited

program followed by completion of

an ACGME-accredited thoracic

surgical residency.

American Osteopathic

Board of Surgery:

Thoracic and

Cardiovascular Surgery

Completed an AOA-

approved or ACGME-

accredited program

Urology

American Board of Urology

All training must be in an ACGME-

or RCPSC-accredited program.

American Osteopathic

Board of Surgery:

Urological Surgery

Completed an AOA-

approved or ACGME-

accredited program

104

COMMON PROGRAM REQUIREMENTS

III. Resident Appointments

III.B. Resident Complement

The program director must not appoint more residents than approved by

the Review Committee.

(Core)

[The Review Committee may further specify minimum complement

numbers]

Background and Intent: Programs are required to request approval of all complement

changes, whether temporary or permanent, by the Review Committee through ADS.

Permanent increases require prior approval from the Review Committee and temporary

increases may also require approval. Specialty-specific instructions for requesting a

complement increase are found in the “Documents and Resources” page of the applicable

specialty section of the ACGME website.

105

GUIDANCE

III.B. Resident complement

Review Committees approve resident complement for a program at the time of an application

and the program director must not appoint more residents than approved by the Review

Committee. Some Review Committees approve complement by total while others approve

complement by both total and program year.

Complement increases can be permanent or temporary.

Permanent complement change requests

A program may request a permanent complement increase to expand its size. Programs can

also request a decrease in permanent complement if they need to decrease the size of the

program below the approved complement. All permanent complement increase requests must

be submitted through the Accreditation Data System (ADS) and require approval by the Review

Committee. Review Committees assess all requests for permanent complement increases

thoroughly, considering the clinical, educational, and other resources available to the program.

Additional information or a site visit may be requested for a permanent complement change

request, depending on the details of the request. Review Committees review permanent

increase requests at their scheduled meetings and therefore programs should check posted

meeting agenda closing dates on the applicable specialty

page of the ACGME website and plan

accordingly before submitting a request.

mporary complement change requests

A program may request a temporary complement increase for many reasons, including

remediation, resident well-being needs, medical, parental, or caregiver leave, and a resident

beginning the program off-cycle. Temporary complement increase requests of greater than 90

days must be submitted through ADS and require approval by the Review Committee, although

the submission and approval process differ by Review Committee and programs must consult

specialty-specific guidance referenced below in this document. All Review Committees allow

extensions of education and training of up to 90 days for residents in all specialties except one-

year programs without the need to submit a temporary complement increase request. This

change was implemented to reduce burden for the graduate medical education community and

better align with the Institutional Requirements related to Leaves of Absence (IV.H.1.a)).

Program directors are strongly encouraged to contact their graduate medical education office

and the applicable specialty certifying board for guidance on extending a resident’s education

and training, as the impact and requirements vary from one certifying board to another.

To initiate a request to change the program’s approved complement:

1. The program director must:

b. Log into ADS.

c. Under the “Program” tab, select “Complement Change” from the right panel

under “Requests.”

d. Select either “Temporary” or “Permanent” request.

e. Complete all required information and submit.

2. Once submitted, the request will be forwarded to the designated institutional official

(DIO) for approval.

3. Once approved by the DIO, the request will be forwarded to the specialty Review

Committee.

106

4. ACGME staff will notify the program of the Review Committee’s decision. The

notification time may vary based on the type of request and whether it needs to be

reviewed during a Review Committee meeting.

ADS screenshot: complement change requests

[The Review Committee may further specify minimum complement numbers]

For more information on resident complement and whether your specialty Review Committee

specifies minimum complement numbers, programs must review the specialty-specific Program

Requirements.

1. Go to https://www.acgme.org/specialties/

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

Each Review Committee also provides additional information on the specialty-specific process

to request a complement change in the Documents and Resources section of their specialty-

specific web page or in the specialty FAQs. Questions about specialty-specific Program

Requirements related to resident complement should be directed to specialty Review

Committee staff.

107

COMMON PROGRAM REQUIREMENTS

III. Resident Appointments

III.C. Resident Transfers

The program must obtain verification of previous educational experiences

and a summative competency-based performance evaluation prior to

acceptance of a transferring resident, and Milestones evaluations upon

matriculation.

(Core)

[The Review Committee may further specify]

108

GUIDANCE

III.C. Resident Transfers

Residents are considered transfer residents under several conditions, including:

• when moving from one program to another within the same or to a different Sponsoring

Institution;

• when moving from one program to another within the same or different specialty; and

• when entering as a PGY-2 in a program requiring a preliminary year, regardless of

whether the resident was accepted to the preliminary year and the specialty program as

part of the match (i.e., accepted to both the preliminary program and the specialty

program upon graduation from medical school).

The term does not apply to a resident who has successfully completed a residency and then is

accepted into a subsequent residency or fellowship program.

Before accepting a transferring resident, the “receiving” program director must obtain written or

electronic verification of prior educational experiences and performance by the program from

which the resident is seeking to transfer.

Documentation includes evaluations, rotations completed, procedural/operative

experience/Case Logs if applicable, and a summative competency-based performance

evaluation.

While a Milestones evaluation cannot be used in the decision to accept a transferring resident, a

Milestones evaluation must be obtained upon matriculation.

The ACGME monitors compliance with this requirement in various ways, including:

• resident-level questions answered by program leadership as part of an application or

during the Accreditation Data System (ADS) Annual Update when entering/updating

their resident roster; and

• questions asked and documentation reviewed by Accreditation Field Staff during site

visits of the program at various stages of accreditation.

ADS screenshot: identifying transfer residents

During the ADS Annual Update, programs update their resident roster and information on each

resident. On the resident Profile page, under the Resident Details section, programs are asked

to answer several questions regarding a transferring resident and confirm that documentation of

prior training and education has been obtained for a transfer resident(s). (See accompanying

screenshot which follows on the next page.)

109

ADS screenshot: retrieving Milestones reports from previous residency program

Once a transfer resident starts in a new residency program, program leadership can retrieve the

Milestones report for that resident from the previous program by following these steps:

1. Log into ADS.

2. Go to the Reports tab.

3. Select “Residency Milestones Retrieval” in the Reports section.

4. Select the academic year to view a list of current residents and, if available, the last

Milestone evaluation form completed by their most recent accredited core residency

program.

5. Select the “Summary Report” button for that particular resident.

NOTE: A report may be unavailable if the previous program has not updated that resident's

record in ADS or if the previous training and education could not be matched when entered on

that resident’s roster (based on name, date of birth, social security number, medical school, or

some combination of those elements). The resident may also have completed core residency

training and education in a program not accredited by the ACGME or completed training and

education prior to Milestones implementation. For residents that do not have a Milestone report

on record, contact the previous specialty program director to obtain the summative report or

email ADS@acgme.org

with questions.

110

[The Review Committee may further specify]

Since Review Committees may specify other requirements related to resident transfers,

programs must review the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the currently in effect specialty Program Requirements currently in effect.

Quest

ions about specialty-specific Program Requirements related to resident transfers should

be directed to specialty Review Committee staff.

Programs can also access the Common Program Requirements FAQs for additional information

on resident transfers and Milestones retrieval.

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COMMON PROGRAM REQUIREMENTS

IV. Educational Program

The ACG

ME accreditation system is designed to encourage excellence and

innovation in graduate medical education regardless of the organizational

affiliation, size, or location of the program.

The educational

program must support the development of knowledgeable, skillful

physicians who provide compassionate care.

It is

recognized that programs may place different emphasis on research,

leadership, public health, etc. It is expected that the program aims will reflect the

nuanced program-specific goals for it and its graduates; for example, it is

expected that a program aiming to prepare physician-scientists will have a

different curriculum from one focusing on community health.

IV.A

Educational Components

The cur

riculum must contain the following educational components:

IV.A

.1.

a set of program aims consistent with the Sponsoring Institution’s

ssion, the needs of the community it serves, and the desired

distinctive capabilities of its graduates, which must be made

available to program applicants, residents, and faculty members;

(Core)

IV.A

.2. competency-based goal

s and objectives for each educational

experience designed to promote progress on a trajectory to

independent practice. These must be distributed, reviewed, and

available to residents and faculty members;

(Core)

Background and Intent: The trajectory to autonomous practice is documented by

Milestones evaluations. Milestones are considered formative and should be used to

identify learning needs. Milestones data may lead to focused or general curricular

revision in any given program or to individualized learning plans for any specific

resident.

IV.A

.3. delineation of resident responsibilities for patient care, progressive

responsibility for patient management, and graded supervision;

(Core)

Background and Intent: These responsibilities may generally be described by PGY

level and specifically by Milestones progress as determined by the Clinical

Competency Committee. This approach encourages the transition to competency-

based education. An advanced learner may be granted more responsibility

independent of PGY level and a learner needing more time to accomplish a certain task

may do so in a focused rather than global manner.

IV.A

.4. a broad range of structured didactic activities; and,

(Core)

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IV.A.4.a) Residents must be provided with protected time to participate

in core didactic activities.

(Core)

Background and Intent: It is intended that residents will participate in structured

didactic activities. It is recognized that there may be circumstances in which this is not

possible. Programs should define core didactic activities for which time is protected

and the circumstances in which residents may be excused from these didactic

activities. Didactic activities may include, but are not limited to, lectures, conferences,

courses, labs, asynchronous learning, simulations, drills, case discussions, grand

rounds, didactic teaching, and education in critical appraisal of medical evidence.

IV.A

.5. formal educational activities that promote patient safety-rel

ated

goals, tools, and techniques.

(Core)

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GUIDANCE

The Common Program Requirements do not list detailed curricular elements for each specialty.

The overarching intent of the Common Program Requirements related to the educational

program is to ensure that programs provide a framework for:

• a comprehensive education for residents pertinent to the specific mission and aims of

the Sponsoring Institution, the program, and the community served; and

• the development of knowledgeable, skilled, and compassionate physicians capable of

autonomous practice.

IV.A.1. Program aims

Programs must develop aims to add context to the program’s expectations and focus on

aspects such as:

• tyles of residents being educated by the program

• residents’ future roles in the community

Having aims allows the program to construct curricular elements that address career options

(e.g., clinical practice, research, primary care, or health policy and advocacy). For example, a

program in a rural community might focus its resident education on issues relevant to that

community, while a program in an institution with a goal to produce physician-scientists might

want to provide more education in research. The Program Evaluation Committee (PEC) should

play a central role in the development of program aims and should ensure that the program is

working toward these aims.

Program aims should be vetted with program and institutional leaders, and in some institutions,

setting aims will be an institution-level initiative. In setting aims, programs should generally take

a longer-term strategic view. However, aims may change over time. Factors such as a shift in

program focus initiated by institutional or department leadership, changes in local or national

demand for a resident workforce with certain capabilities, or new opportunities to train and

educate residents in a different setting may prompt revision of program aims.

It bears re-emphasizing that while Common Program Requirement IV.A.1. requires that the

program develop a set of program aims consistent with its mission and the community it serves,

the Review Committees will not evaluate the specifics of the program aims for accreditation

purposes. What Review Committees will evaluate is that a program has defined its program

aims and that it has a process to share them with applicants to the program, residents, and

faculty members.

New programs submitting an application for accreditation and programs with a status of Initial

Accreditation or Initial Accreditation with Warning must provide or update their program aims in

the Accreditation Data System (ADS) as part of an application or the ADS Annual Update.

Accreditation Field Staff also verify that a program has identified program aims and that it has a

process in place to share those with program applicants, residents, and faculty members.

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ADS screenshot: program aims

IV.A.2. Goals and objectives

The program must design competency-based, level-specific goals and objectives for each

educational experience/rotation to promote progress on a trajectory to autonomous practice in

its subspecialty. These goals and objectives must be distributed, reviewed, and available to

residents and faculty members.

Defining goals and objectives

• A goal is an overarching principle that guides decision making.

• Objectives are specific, measurable steps that can be taken to meet a goal.

Developing goals and objectives

While the ACGME and the Review Committees do not endorse any single method for

developing goals and objectives, a number of resources are available to guide those entrusted

with constructing residency curricula. For example, among the most widely known approaches

is the “Theory of Bloom’s Taxonomy of Measurable Verbs.” (Bloom, 1956) Bloom based his

taxonomy on the premise that observable action levels can help explicitly define what a student

must do to demonstrate learning. He organized these action levels by using measurable verbs

to describe observable knowledge, skills, attitudes, behaviors, and abilities. In developing

residency curricula, these categories can be used to identify residents’ learning needs for each

rotation. Many iterations of the taxonomy are easily accessible on a variety of educational

websites.

Another

tool for guiding the development of goals and objectives is the SMART mnemonic

developed by Doran (1981). He simply states that goals and objectives should be:

• S − Specific

• M − Measurable

• A − Attainable

• R − Relevant

• T −Time-bound

Common mistakes in creating goals and objectives

• Using vague verbs and phrases that cannot be measured

a. words to avoid

• believe

• comprehend

• know

• perceive

• recognize

• understand

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b. phrases to avoid

• appreciation for

• capable of

• familiar with

• knowledge of

2. Creating goals and objectives that are not level-specific and/or competency-based

Goals

and objectives must be competency-based and level-specific. For example, a PGY-1

resident must demonstrate the ability to independently perform a complete history and physical

examination as part of the Patient Care Competency. As part of the same competency, a PGY-3

resident in a three-year program must demonstrate the ability to guide and supervise a PGY-1

resident in obtaining a complete history and physical examination and take an active role in the

formulation of diagnostic and treatment plans.

Goals

and objectives must be distributed, reviewed, and available to residents and faculty

members to ensure an understanding of learning expectations. New programs submitting an

application for accreditation and programs with a status of Initial Accreditation or Initial

Accreditation with Warning must answer the question shown in the screenshot below in ADS as

part of the application or during the ADS Annual Update process. Finally, Accreditation Field

Staff also verify during a site visit that the program has a process in place for informing

residents about goals and objectives for all educational assignments.

ADS screenshot: goals and objectives

IV.A.3. Resident responsibilities and graded supervision

Common Program Requirement IV.A.3. is closely related to the Common Program

Requirements in section VI.A.2. focused on supervision and accountability. Programs are

encouraged to review those requirements and associated guidance as well. The responsibilities

and supervision of residents must be clearly delineated. The ACGME assesses compliance with

this requirement in multiple ways, including:

• review of the supervision policy and answers to the question shown below for programs

submitting an application or during the Initial Accreditation stage; and

• verification of information Accreditation Field Staff related to this requirement during

accreditation site visits.

116

ADS screenshot: resident progressive authority and responsibilities in patient

care

Milestones evaluations can be helpful to Clinical Competency Committees which should review

them, be educated in Milestones assessment, and use this knowledge to delineate resident

responsibilities and determine levels of graded supervision in the program.

IV.A.4. Structured didactic activities

There are many forms of didactic activities, including lectures, workshops, courses, simulation

with feedback, case discussions, grand rounds, board review, and journal club. Faculty

members’ presence, participation, and leadership is key. In addition, residents must have the

opportunity to participate in didactic activities. While residents may occasionally miss didactic

activities because of priorities related to patient care, it is important that the program provide

protected time to allow their attendance. Residents on rotations at a distant site should be given

the opportunity to participate in didactic activities online, via recorded conferences, and through

other means as applicable.

Program l

eaders should conduct periodic reviews of the program’s curriculum to determine if

adjustments need to be made (e.g., new treatment protocols or concepts may need to be

incorporated). If Milestones evaluation and in-training examination results consistently indicate a

significant portion of residents are not performing well in a particular area, program leaders

should address that knowledge deficiency in the didactic curriculum.

117

COMMON PROGRAM REQUIREMENTS

IV.B. ACGME Competencies

Background and Intent: The Competencies provide a conceptual framework describing

the required domains for a trusted physician to enter autonomous practice. These

Competencies are core to the practice of all physicians, although the specifics are

further defined by each specialty. The developmental trajectories in each of the

Competencies are articulated through the Milestones for each specialty.

118

GUIDANCE

The ACGME and the American Board of Medical Specialties developed the six Core

Competencies necessary for a practicing physician:

• Patient Care and Procedural Skills

• Medical Knowledge

• Practice-Based Learning and Improvement

• Interpersonal and Communication Skills

• Professionalism

• Systems-Based Practice

The Core C

ompetencies provide a systematic framework to think about both curriculum and

assessment in medical education. Each specialty was tasked with crafting specific

milestones within each Competency.

The Mil

estones in graduate medical education (GME) provide narrative descriptions of the

Competencies and subcompetencies along a developmental continuum with varying degrees of

granularity. Simply stated, the Milestones describe performance levels residents are expected to

demonstrate for skills, knowledge, and behaviors in the six Core Competency domains. The

Milestones lay out a framework of observable behaviors and other attributes associated with a

resident’s development as a physician.

It i

s essential to recognize that milestones, based on the concept of stages of professional

development, are designed to be criterion-based and agnostic to the actual PGY level of the

resident. Programs should judge each resident based on the actual level of performance as

described in the Milestones, not in relation to peers or others.

The Mil

estones describe the learning trajectory within a subcompetency that takes the resident

from a beginner in the specialty to a highly proficient resident or resident expert. The Milestones

are different from many other assessments because there is an opportunity for the learner to

demonstrate the attainment of aspirational levels of the subcompetency. The Level 4 milestones

are designed as the graduation target but do not represent a graduation requirement. Making

decisions about readiness for graduation is the purview of the residency program director. (See

the Milestones FAQs

for further discussion of this issue: “Can a resident/fellow graduate if he or

she does not reach all of the milestones?”) The Milestones allow for a shared understanding of

the expectations for the learner.

It i

s also important to recognize what the Milestones are not. First and foremost, they do not

describe or represent a complete description of a clinical discipline. They represent the core of a

discipline, but programs will need to use good judgment to fill in the gaps in curriculum and

assessment. It is essential that the Milestones do not serve as curricula in and of themselves,

but rather guide a thoughtful analysis of curricula to identify strengths and gaps. Second, they

are not tools designed to affect program accreditation, and therefore Review Committees do not

see or review any individual resident Milestones ratings or aggregated Milestones data for a

particular program. The Milestones are intended for formative purposes to help learners, faculty

members, and programs.

119

General description of Milestone levels related to stage of education

Example of the basic Anatomy of a milestone

Several key aspects about the use of the Milestones deserve special attention. First, the

Milestones reported to the ACGME were not designed to be used as evaluation forms for

specific rotations or experiences. The Milestones are designed as a formative judgment of

progress at least twice a year. The language from the Milestones may be helpful as part of a

mapping exercise to determine which subcompetencies are best covered in specific rotations

and curricular experiences. The Milestones can also be used for guided self-assessment and

reflection by the resident in preparation for feedback sessions and in creating individual learning

plans. Residents should use the Milestones for self-assessment with input and feedback from a

faculty advisor, mentor, or program director. Residents should not judge themselves on the

Milestones in isolation. Milestones feedback is most effective when performed in dialogue

between a learner and a faculty advisor. The Milestones can be useful in faculty development

by helping faculty members recognize performance expectations of learners, more explicitly

assess the trajectory of skill progression in their specialty, and discern how to ideally assess a

120

learner’s perf

ormance. Finally, it is imperative that programs remember that the Milestones are

not inclusive of the broader curriculum and that limiting assessments to the Milestones could

leave many topics without proper and essential assessment and evaluation.

The Supplemental Guides are a tool to aid in the development of a shared mental model of the

Milestones for each specialty. The Milestones Supplemental Guide for each specialty includes

the overall intent of each subcompetency, examples for each individual milestone, ideas for

assessment methods, and other resources. An editable version of each Supplemental Guide is

available so that each program can identify what it expects to see at each level. It can also be

used to aid in mapping to curricula, rotations, and assessments. Many of the Supplemental

Guides include a map from Milestones 1.0 to 2.0 to show topics that were carried over and

those that were deleted or added. It is recommended that the Supplemental Guide be shared

with all learners and faculty. Milestones Supplemental Guides can be found on the Milestones

section of each specialty

section of the ACGME website.

Other Milestones resources

The ACGME provides many resources for residents, faculty members, and

program administration and leadership, and new resources are developed regularly.

The Milestones section of the ACGME website provides access to available resources and

tools at https://www.acgme.org/milestones/resources/.

The ACGME also offers courses designed to help faculty members and leaders achieve the

goals of competency-based assessment in graduate medical education. Visit the Developing

Faculty Competencies in Assessment course page for information on dates, fees, and

registration availability.

121

COMMON PROGRAM REQUIREMENTS

IV.B. ACGME Competencies

Background and Intent: The Competencies provide a conceptual framework describing

the required domains for a trusted physician to enter autonomous practice. These

Competencies are core to the practice of all physicians, although the specifics are

further defined by each specialty. The developmental trajectories in each of the

Competencies are articulated through the Milestones for each specialty.

IV.B.1. T

he program must integrate the following ACGME Competencies

into the curriculum:

(Core)

IV.B.1.a

) Professionalism

Residents

must demonstrate a commitment to

professionalism and an adherence to ethical principles.

(Core)

IV.B.1.a

).(1) Residents must demonstrate competence in:

IV.B.1.a

).(1).(a) compassion, integrity, and respect for others;

(Core)

IV.B.1.a

).(1).(b) responsiveness to patient needs that

supersedes self-interest;

(Core)

IV.B.1.a

).(1).(c) cultural humility;

(Core)

IV.B.1.a

).(1).(d) respect for patient privacy and autonomy;

(Core)

IV.B.1.a

).(1).(e) accountability to patients, society, and the

profession;

(Core)

IV.B.1.a

).(1).(f) respect and responsiveness to diverse patient

populations, including but not limited to

diversity in gender, age, culture, race, religion,

disabilities, national origin, socioeconomic

status, and sexual orientation;

(Core)

IV.B.1.a

).(1).(g) ability to recognize and develop a plan for one’s

own personal and professional well-being; and,

(Core)

IV.B.1.a

).(1).(h) appropriately disclosing and addressing

confli

ct or duality of interest.

(Core)

Background and Intent: This includes the recognition that under certain

circumstances, the interests of the patient may be best served by transitioning care to

another practitioner. Examples include fatigue, conflict or duality of interest, not

connecting well with a patient, or when another physician would be better for the

situation based on skill set or knowledge base.

122

GUIDANCE

Professionalism is at the core of being a physician, yet, teaching it can be difficult, and

evaluation of professionalism presents significant challenges. There are many factors that

influence the erosion of professionalism, including state control, corporate demands, and

overemphasis on income and power. Some argue that the loss of ethics and morals underlies

this erosion, and therefore propose that medical professionalism cannot be taught separately

from ethical principles, morality, and emotional intelligence.

ACGME President and Chief Executive Officer Thomas J. Nasca, MD, MACP uses the following

chart to summarize the traditions contributing to the American concept of professionalism.

Dr. Na

sca (2015) states: “The philosophical roots of professionalism include the Hippocratic

tradition of medicine as a moral enterprise; the transition of medicine from guild to profession

with a commitment to competence, altruism, and public trust; and the responsibility of the

profession to prepare the next generation of physicians to serve the public.” Often neglected in

this equation is physician well-being. A physician who is unwell may not be able to provide good

care to patients.

Element

s of professionalism must be addressed in the program curriculum. Programs have

reported more success with simulation, workshops, and case discussions. Some programs have

incorporated education on professionalism into morbidity and mortality conferences and other

case review conferences. More importantly, repeated sessions throughout the educational

program provide reminders of the elements of professionalism and keep residents on track to

Nasca 2015

123

develop a lifelong commitment to this critical aspect of being a physician. Since role modeling of

professionalism by faculty members is key to the professional behavior of residents, it is

important to incorporate professionalism into faculty development sessions. While good role

models and mentors are essential for the education of residents and fellows, there is no way to

guarantee their presence. In addition, role modeling as a method of teaching professionalism

has been criticized as imprecise and lacking structure.

References/Resources

• Nasca, Thomas J. 2015. “Professionalism and its Implications for Governance and

Accountability of Graduate Medical Education in the United States.” JAMA 313(18):

1801-1802. doi:10.1001/jama.2015.3738.

• The American Medical Association (AMA) and the American Osteopathic Association

(AO

A) have defined rules and guidelines for physician professional responsibility and

conduct; those resources are provided below:

o AMA Declaration of Professional Responsibility

o AOA Rules and Guidelines on Physicians’ Professional Conduct

• The May 12, 2015 issue of JAMA (https://jamanetwork.com/journals/jama/issue/313/18)

is a great resource for programs and takes a deep dive into professionalism, including

Viewpoints from scholars and academic leaders about the responsibility and

accountability of medicine to self-govern, self-regulate, and ensure the highest degree of

professionalism.

Related Requirements: II.A.4.a) and II.A.4.a).(1): The program director must be a

role model of professionalism.

Examples of linking professionalism values to specific behaviors:

Values

Behaviors

Responsibility

• Follows through on tasks

• Arrives on time

Maturity

• Accepts blame for failure

• Does not make inappropriate demands

• Is not abusive and critical in times of stress

Communication Skills

• Listens well

• Is not hostile, derogatory, sarcastic

• Is not loud or disruptive

Respect

• Maintains patient confidentiality

• Is patient

• Is sensitive to physical/emotional needs

• Is not biased/discriminatory

Reference

Kirk, Lynne M. 2007. “Professionalism in Medicine: Definitions and Considerations for

Teaching.” Proceedings (Baylor University. Medical Center) 20(1):13-16.

doi:10.1080/08998280.2007.11928225

124

To review specialty-specific Requirements for Professionalism:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

In addit

ion, the Milestones are used to assess the progression of a resident in specific

competencies and subcompetencies. To access a specialty’s Milestones:

1. Go to https://www.acgme.org/specialties

2. Select the applicable specialty.

3. Select “Milestones” at the top of the specialty section.

4. Select from the list of applicable Milestones.

Below

is an example of an Internal Medicine Milestones evaluation of Professionalism:

125

COMMON PROGRAM REQUIREMENTS

IV.B. ACGME Competencies

IV.B.1. The program must integrate the following ACGME Competencies

into the curriculum:

(Core)

IV.B.1.b) Patient Care and Procedural Skills

Background and Intent: Quality patient care is safe, effective, timely, efficient, patient-

centered, equitable, and designed to improve population health, while reducing per

capita costs. In addition, there should be a focus on improving the clinician’s well-

being as a means to improve patient care and reduce burnout among residents,

fellows, and practicing physicians.

IV.B.1.b).(1)

Residents must be able to provide patient care that is

patient- and family-centered is compassionate,

equitable, appropriate, and effective for the treatment

of health problems and the promotion of health.

(Core)

[The Review Committee must further specify]

IV.B.1.b).(2) Residents must be able to perform all medical,

diagnostic, and surgical procedures considered

essential for the area of practice.

(Core)

[The Review Committee may further specify]

126

GUIDANCE

To review the specialty-specific Program Requirements for Patient Care and Procedural Skills:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

In addit

ion, Milestones are used to assess the progression of a resident in specific

competencies and subcompetencies. To access a specialty’s Milestones:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select the “Milestones” at the top of the specialty section.

4. Select from the list of applicable Milestones.

Below

is an example of an Internal Medicine Milestones evaluation of Patient Care and

Procedural Skills:

127

COMMON PROGRAM REQUIREMENTS

IV.B. ACGME Competencies

IV.B.1

. The program must integrate the following ACGME Competencies

into the curriculum:

(Core)

IV.B.1

.c) Medical Knowledge

Resident

s must demonstrate knowledge of established and

evolving biomedical, clinical, epidemiological and social-

behavioral sciences, including scientific inquiry, as well as

the application of this knowledge to patient care.

(Core)

[The Review Committee must further specify]

128

GUIDANCE

To review the specialty-specific Program Requirements for Medical Knowledge:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” tab at the top of the

specialty section.

4. Select the specialty Program Requirements currently in effect.

In addit

ion, Milestones are used to assess the progression of a resident in specific

competencies and subcompetencies. To access a subspecialty’s Milestones:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Milestones” at the top of the specialty section.

4. Select from the list of applicable Milestones.

Below is an example of a Surgery Milestones evaluation of Medical Knowledge:

129

COMMON PROGRAM REQUIREMENTS

IV.B. ACGME Competencies

IV.B.1

. The program must integrate the following ACGME Competencies

into the curriculum:

(Core)

IV.B.1

.d) Practice-based Learning and Improvement

Resident

s must demonstrate the ability to investigate and

evaluate their care of patients, to appraise and assimilate

scientific evidence, and to continuously improve patient care

based on constant self-evaluation and lifelong learning.

(Core)

IV.B.1

.d).(1) Residents must demonstrate competence in:

IV.B.1.d).(1).(a) identifying strengths, deficiencies, and limits in

one’s knowledge and expertise;

(Core)

IV.B.1.d).(1).(b) setting learning and improvement goals;

(Core)

IV.B.1

.d).(1).(c) identifying and performing appropriate learning

activities;

(Core)

IV.B.1

.d).(1).(d)

systematically analyzing practice using quality

impr

ovement methods, including activities

aimed at reducing health care disparities, and

implementing changes with the goal of practice

improvement;

(Core)

IV.B.1

.d).(1).(e) incorporating feedback and formative

evaluation into daily practice; and,

(Core)

IV.B.1

.d).(1).(f) locating, appraising, and assimilating evidence

from scientific studies related to their patients’

health problems.

(Core)

[The

Review Committee may further specify by adding to the

list of sub-competencies]

130

GUIDANCE

Practice-based Learning and Improvement is best developed in an environment that provides

residents with enough information to investigate and evaluate the care of their patients. The

environment needs to support open and honest attempts to improve, and not punish errors or

mistakes as personal weakness.

To identi

fy strengths, deficiencies, and limitations, residents should learn to self-reflect to

answer the question: How can I improve care for my patients? This may include single patients,

such as at a case conference during which residents present individual patients they have cared

for and reflect on how they may improve on that care for a similar patient in the future. A more

systematic approach provides residents with information about the outcomes of their care for a

larger sample of their patients. This information may demonstrate a resident’s compliance with a

specific protocol or clinical guideline for a defined group of patients. Examples include the

number of patients who receive key elements of care in a sepsis bundle or the complication rate

for a certain procedure. It is not required that each resident have an individual project. Some

outcome measures will require institutional assistance to link the activity to a broader

departmental goal.

Learning and i

mprovement goals can be formulated after a resident determines what to improve

and may follow a deliberate process such as a “Plan-Do-Study-Act” cycle under the guidance of

a faculty member to systematically analyze the resident’s practice. This may be performed in

conjunction with the ongoing quality improvement efforts of the Sponsoring Institution.

Residents constantly receive feedback and suggestions. They may wish to target a certain

behavior for improvement, or try out suggestions for improvement, and consider how to analyze

and incorporate these improvements into practice.

Locati

ng and assimilating evidence may occur while a resident is preparing for upcoming case

presentations or during the actual care of a patient using a Cochrane Review or a PubMed

search or other clinical references. A resident may need to learn how an individual patient’s

circumstances fit into the larger knowledge base, and how to use published literature to fit the

scenario. This may incorporate activities such as literature review for case conferences or

journal club where a critical review of the literature is demonstrated and learned.

To revi

ew the specialty-specific Program Requirements for Practice-based Learning and

Improvement:

• Go to https://www.acgme.org/specialties/

• Select the applicable specialty.

• Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

• Select the subspecialty Program Requirements currently in effect.

In addit

ion, Milestones are used to assess the progression of a resident in specific

competencies and subcompetencies. To access a subspecialty’s Milestones:

1. Go to https://www.acgme.org/specialties

2. Select the applicable specialty.

3. Select “Milestones” at the top of the specialty section.

4. Select from the list of applicable Milestones.

131

Below is an example of a Pediatrics Milestones evaluation of Practice-Based Learning and

Improvement:

References

1. Bernabeo, Elizabeth, Sarah Hood, William Iobst, Eric Holmboe, and Kelly Caverzagie.

2013. “Optimizing the Implementation of Practice Improvement Modules in Training:

Lessons from Educators.” Journal of Graduate Medical Education 5(1): 74–80.

https://doi.org/10.4300/jgme-d-11-00281.1.

2. “Practice-Based Learning and Improvement: ACGME Core Competencies.” 2016. NEJM

Knowledge+. November 18. https://knowledgeplus.nejm.org/blog/practice-based-

learning-and-improvement/.

A description of why practice-based learning is important and how it fits into lifelong

learning.

3. “Practice-Based Learning - ACGME Competencies.” n.d. University of Maryland Medical

Center.

https://www.umms.org/ummc/pros/gme/acgme-com

petencies/practice-based-

learning.

Resources

An example of the resources compiled at one institution to address key components of Practice-

Based Learning and Improvement:

• life-long learning and practice improvement (self-reflection)

• appraisal and assimilation of scientific literature (EBM)

• ability to implement quality improvement

• actively participate in the education of others

132

COMMON PROGRAM REQUIREMENTS

IV.B. ACGME Competencies

IV.B.1

. The program must integrate the following ACGME Competencies

into the curriculum:

(Core)

IV.B.1

.e) Interpersonal and Communication Skills

Resident

s must demonstrate interpersonal and

communication skills that result in the effective exchange of

information and collaboration with patients, their families,

and health professionals.

(Core)

IV.B.1

.e).(1) Residents must demonstrate competence in:

IV.B.1.e).(1).(a)

communicating effectively with patients and

pati

ents’ families, as appropriate, across a

broad range of socioeconomic circumstances,

cultural backgrounds, and language

capabilities, learning to engage interpretive

services as required to provide appropriate care

to each patient;

(Core)

IV.B.1

.e).(1).(b) communicating effectively with physicians,

other health professionals, and health-related

agencies;

(Core)

IV.B.1

.e).(1).(c) working effectively as a member or leader of a

health care team or other professional group;

(Core)

IV.B.1

.e).(1).(d) educating patients, patients’ fami

lies, students,

other residents, and other health professionals;

(Core)

IV.B.1

.e).(1).(e)

acting in a consultative role to other physicians

and health pr

ofessionals;

(Core)

IV.B.1

.e).(1).(f) maintaining comprehensive, timely, and legible

health

care records, if applicable.

(Core)

IV.B.1

.e).(2) Residents must learn to communicate with patients

and patient

s’ families to partner with them to assess

their care goals, including, when appropriate, end-of-

life goals.

(Core)

[The

Review Committee may further specify by adding to the

list of sub-competencies]

133

GUIDANCE

The ability to communicate is one of the basic tenets of the physician-patient relationship, and

an important component of professionalism. Yet education related to communication skills is

frequently neglected. Apart from medical knowledge and the ability to provide good patient care,

physicians need communication skills in many aspects of their practice. Examples include:

• The physi

cian and the patient:

o history taking and physical examination — ability to elicit pertinent information, and

the capacity to listen attentively to what a patient/family member has to say

o explaining medical information, such as diagnosis, complications, and treatment

(surgical and medical)

o shared decision making regarding diagnostic and therapeutic interventions

o Instructions related to prescriptions — patients often take medications incorrectly

because of inadequate instructions

o delivering bad news

o discharge instructions

o sensitivity to different cultural and socioeconomic backgrounds

o respect for privacy and confidentiality

o obtaining informed consent for procedures or study participation

o end-of-life decisions

• Physician to physician or other health care providers:

o consultations

o sign-outs

o patient transfers

o leading and participating in team-based medical care

• Written and other communication

o medical records

o procedure notes

o consults

o transfers

o lectures and presentations

It i

s well known that good communication skills improve patient satisfaction and treatment

adherence and reduce medication errors. Modalities of communication skills include:

• skills-based − word usage, approach to patients and families;

• content-based − patient interviewing, obtaining informed consent;

• advanced encounters − delivering bad news, disclosing errors, shared decision making;

and

• interaction-focused − physician-patient and/or physician-family, interprofessional.

Techniques used to teach interpersonal and communication skills include:

• role play;

• standardized patients;

• simulation; and

• real-life experiences, such as during morbidity and mortality conference.

134

References

1. Bragard, Isabelle, Isabelle Merckaert, Yves Libert, Nicole Delvaux, Anne-Marie Etienne,

Serge Marchal, Christine Reynaert, et. al. 2012. “Communication Skills Training for

Residents: Which Variables Predict Learning of Skills?” Open J Med Psychol 1:68-75.

2. Peterson, Eleanor B., Kimberly A. Boland, Kristina A. Bryant, Tara F. McKinley, Melissa

B. Porter, Katherine E. Potter, and Aaron W. Calhoun. 2016. “Development of a

Comprehensive Communication Skills Curriculum for Pediatrics Residents.” Journal of

Graduate Medical Education 8(5): 739–46. https://doi.org/10.4300/jgme-d-15-00485.1

3. Sullivan, Amy M., Laura K. Rock, Nina M. Gadmer, Diana E. Norwich, and Richard M.

Schwartzstein. 2016. “The Impact of Resident Training on Communication with Families

in the ICU: Resident and Family Outcomes.” Annals of the American Thoracic Society.

https://doi.org/10.1513/annalsats.201508-495oc

4. Wild, Dorothea, Haq Nawaz, Saif Ullah, Christina Via, William Vance, and Paul Petraro.

2018. “Teaching Residents to Put Patients First: Creation and Evaluation of a

Comprehensive Curriculum in Patient-Centered Communication.” BMC Medical

Education 18(1). https://doi.org/10.1186/s12909-018-1371-3

Whil

e many of the efforts in teaching communication skills are successful, there is evidence that

success also depends on human variables. The ability to develop effective communication skills

is dependent on a number of human factors, including:

• individual characteristics, such as sociodemographics, professional and personal

experiences, health, burnout, depersonalization, ability to cope, psychological

characteristics, and technological demands;

• contextual characteristics, such as professional and personal environments; and

• pre-training communication skills.

Some ex

amples of patient comments regarding negative communication experiences include:

• “I wish he would face me instead of the computer.”

• “She seemed in a hurry and did not have time to listen to my fears about the surgery.”

• “He seemed to be hiding something when he told me about the medication mistake.”

• “I felt like I did not matter, my concerns were ignored.”

• “He seemed in a hurry to pull the plug on my dad so he could get on to the next task.”

To revi

ew the specialty-specific Program Requirements for Interpersonal and Communication

Skills:

• Go to https://www.acgme.org/specialties/

• Select the applicable specialty.

• Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

• Select the specialty Program Requirements currently in effect.

In addit

ion, Milestones are used to assess the progression of a resident in specific

competencies and subcompetencies. To access a specialty’s Milestones:

1. Go to https://www.acgme.org/specialties/

2. Select the applicable specialty.

3. Select “Milestones” at the top of the specialty section.

4. Select from the list of applicable Milestones.

135

Below is an example of an Obstetrics and Gynecology Milestones evaluation of Interpersonal

and Communication Skills:

136

COMMON PROGRAM REQUIREMENTS

IV.B. ACGME Competencies

IV.B.1

. The program must integrate the following ACGME Competencies

into the curriculum:

(Core)

IV.B.1

.f) Systems-based Practice

Resident

s must demonstrate an awareness of and

responsiveness to the larger context and system of health

care, including the structural and social determinants of

health, as well as the ability to call effectively on other

resources to provide optimal health care.

(Core)

Background and Intent: Medical practice occurs in the context of an increasingly

complex clinical care environment where optimal patient care requires attention to

compliance with external and internal administrative and regulatory requirements.

IV.B.1

.f).(1) Residents must demonstrate competence in:

IV.B.1.f).(1).(a) working effectively in various health care

delivery settings and systems relevant to their

clinical specialty;

(Core)

IV.B.1

.f).(1).(b) coordinating patient care across the health care

continuum and beyond as relevant to their

clinical specialty;

(Core)

Background and Intent: Every patient deserves to be treated as a whole person.

Therefore it is recognized that any one component of the health care system does not

meet the totality of the patient's needs. An appropriate transition plan requires

coordination and forethought by an interdisciplinary team. The patient benefits from

proper care and the system benefits from proper use of resources.

IV.B.1

.f).(1).(c) advocating for quality patient care and optimal

patien

t care systems;

(Core)

IV.B.1

.f).(1).(d) participating in identifying system errors and

implementing potential systems solutions;

(Core)

IV.B.1

.f).(1).(e) incorporating considerations of value, eq

uity,

cost awareness, delivery and payment, and

risk-benefit analysis in patient and/or

population-based care as appropriate; and,

(Core)

IV.B.1.f).(1).(f) understanding health care finances and its

impact on individual patients’ health decisions.

(Core)

137

V.B.1.f).(1).(g) using tools and techniques that promote patient

safety and disclosure of patient safety events

(real or simulated).

(Detail)

IV.B.1

.f).(2) Residents must learn to advocate for patients within

the heal

th care system to achieve the patient's and

patient’s family's care goals, including, when

appropriate, end-of-life goals.

(Core)

[The

Review Committee may further specify by adding to the

list of sub-competencies]

138

GUIDANCE

Physicians are increasingly dependent on the health care system to support their patients. At

the same time, they can significantly influence the health care system to ensure appropriate

support for patients and their families. Most residents work passively in these settings, but the

curriculum must provide education on how residents can actively and positively have such an

impact on the system in their future practice. Their education and training should prepare

residents to answer the question: How can I help to improve the system of care?

There are many ways residents can participate in specialty-specific didactics or discussions

regarding their practice environment through institution-wide, multi-specialty, or multi-

disciplinary discussions. Residents may participate in one or more institutional or program

committees seeking to address health care system issues. These learning activities can be

longitudinal or part of regularly scheduled workshops.

References/Resources

1. Johnson, Julie K., Stephen H. Miller, and Sheldon D. Horowitz. 2008. “Systems-Based

Practice: Improving the Safety and Quality of Patient Care by Recognizing and

Improving the Systems in Which We Work.” In Advances in Patient Safety: New

Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Vol. 2. Rockville,

MD: Agency for Healthcare Research and Quality (US).

https://www.ncbi.nlm.nih.gov/books/NBK43731/#_ncbi_dlg_citbx_NBK43731

2. Nabors, Christopher, Stephen J. Peterson, Roger Weems, Leanne Forman, Arif

Mumtaz, Randy Goldberg, Kausik Kar, et.al. 2011. “A Multidisciplinary Approach for

Teaching Systems-Based Practice to Internal Medicine Residents.” Journal of Graduate

Medical Education 3(1): 75-80. https://doi.org/10.4300/JGME-D-10-00037.1

3. “Systems-Based Practice: ACGME Core Competencies (Part 4 of 7).” 2016. NEJM

Knowledge. November 18. https://knowledgeplus.nejm.org/blog/acgme-core-

competencies-systems-based-practice/.

4. Wachtel, Ruth E. and Franklin Dexter. 2010. “Curriculum Providing Cognitive Knowledge

and Problem-Solving Skills for Anesthesia Systems-Based Practice.” Journal of

Graduate Medical Education 2(4): 624-632. https://doi.org/10.4300/JGME-D-10-00064.1.

To review the specialty-specific Program Requirements for Systems-based Practice

Competency,

1. Go to https://www.acgme.org/specialties.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

4. Select the specialty Program Requirements currently in effect.

In addit

ion, the Milestones are used to assess the progression of a resident in specific

competencies and subcompetencies. To access a specialty’s or subspecialty’s Milestones:

1. Go to https://www.acgme.org/specialties

2. Select the specialty.

3. Select “Milestones” at the top of the specialty section.

4. Select from the list of applicable Milestones.

139

Below is an example of an Emergency Medicine Milestones evaluation of Systems-based

Practice:

140

COMMON PROGRAM REQUIREMENTS

IV.C. Curriculum Organization and Resident Experiences

IV.C.1

The curriculum must be structured to optimize resident educational

experi

ences, the length of the experiences, and the supervisory

continuity. These educational experiences include an appropriate

blend of supervised patient care responsibilities, clinical teaching,

and didactic educational events.

(Core)

[The Review Committee must further specify]

Background and Intent: In some specialties, frequent rotational transitions, inadequate

continuity of faculty member supervision, and dispersed patient locations within the

hospital have adversely affected optimal resident education and effective team-based

care. The need for patient care continuity varies from specialty to specialty and by

clinical situation, and may be addressed by the individual Review Committee.

[The

Review Committee may specify required didactic and clinical

experiences]

141

GUIDANCE

[The Review Committee must further specify]

Common Program Requirement IV.C.1. requires programs to optimize all educational

experiences, the length of the experiences, and supervision continuity. Review Committees

must further specify additional requirements, therefore programs must review the specialty-

specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

• Select the applicable specialty.

• Select “Program Requirements and FAQs and Applications” at the top of the specialty

section.

• Select the specialty Program Requirements currently in effect.

Quest

ions about specialty requirements should be directed to specialty Review Committee staff

members.

[The Review Committee may specify required didactic and clinical experiences]

Common Program Requirement IV.C. allows Review Committees to specify required didactic

and clinical experiences, so programs should consult the specialty-specific Program

Requirements for additional information.

142

COMMON PROGRAM REQUIREMENTS

IV. Educational Program

IV.C. C

urriculum Organization and Resident Experiences

IV.C.2. The program must provide instruction and experience in pain

management if applicable for the specialty, including recognition of

the signs of substance use disorder.

(Core)

[The Review Committee may further specify]

[The

Review Committee may specify required didactic and clinical

experiences]

143

GUIDANCE

Common Program Requirement IV.C.2. directs programs to develop evidence-based

educational interventions to effectively teach residents how to:

• prevent substance use disorder wherever possible while effectively treating pain;

• recognize substance use disorder in its earliest stages;

• function effectively in systems of care for effective pain relief and substance use

disorder;

• use non-pharmacologic means wherever possible; and

• participate in clinical trials of new non-opioid pain relief customized to the needs of the

clinical disorders of the populations they serve.

The ACGM

E expects that the education of residents and faculty members regarding prescribing

opioids be integrated into graduate medical education and professional development, including,

but not limited to, didactic lectures, specific learning modules, chart reviews, and small-group

discussions about difficult patients.

Review Co

mmittees monitor compliance with Common Program Requirement IV.C.2. in various

ways, including:

• questions answered by program leadership as part of an application or during the

Accreditation Data System (ADS) Annual Update;

• questions answered by residents and faculty members as part of the annual ACGME

Resident/Fellow and Faculty Surveys; and

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

ADS screenshot: ADS Annual Update Common Program Requirements question

for applications and programs with statuses of Initial and Continued

Accreditation

The Resident/Fellow and Faculty Surveys include several questions that address the

requirements in Common Program Requirement IV.C.2. Two resource documents, the

“Resident/Fellow Survey-Common Program Requirements Crosswalk” and the “Faculty Survey-

Common Program Requirements Crosswalk,” provide additional information for programs on the

key areas addressed by the survey questions and how they map to the ACGME Common

144

Program Requirements. These documents can be found at https://www.acgme.org/data-

systems-technical-support/resident-fellow-and-faculty-surveys/.

GME Stakeholder Congress on Preparing Residents and Fellows to Manage Pain

and Substance Use Disorder

On March 30-31, 2021, the ACGME hosted a virtual graduate medical education (GME)

Stakeholder Congress on Preparing Residents and Fellows to Manage Pain and Substance Use

Disorder. The Congress brought together experts from across the medical education spectrum

with the goal of supporting programs in implementing Common Program Requirement IV.C.2.

by developing considerations for general and specialty-specific elements of a foundational

curriculum for the recognition and treatment of pain and substance use disorder. More

information about the Congress and a variety of resources are available on the ACGME website

at https://www.acgme.org/meetings-and-educational-activities/opioid-use-disorder/

National Academy of Medicine (NAM) Action Collaborative on Countering the US

Opioid Epidemic

The ACGME participates in and supports the NAM Action Collaborative on Countering the US

Opioid Epidemic.

Centers for Disease Control and Prevention (CDC) Guideline for Prescribing

Opioids for Chronic Pain

Improving the way opioids are prescribed through clinical practice guidelines can ensure

patients have access to safer, more effective chronic pain treatment while reducing the number

of people who misuse or overdose from these drugs.

The CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain

to provide recommendations for the prescribing of opioid pain medication for patients 18 and

older in primary care settings. Recommendations focus on the use of opioids in treating chronic

pain outside of active cancer treatment, palliative care, and end-of-life care.

The CDC has

also provided a number of Opioid Prescribing Guideline Resources that

complement and supplement the guideline, including clinical tools, practitioner FAQs, web-

based training for practitioner, and public educational videos.

Additional resources for pain management and substance use disorder

The following resources can be used to help programs and institutions identify solutions to meet

local needs. The ACGME does not endorse the use of any specific tool or resource.

• The ACGME-accredited multidisciplinary subspecialty of addiction medicine: The

ACGME Program Requirements for Addiction Medicine

(subspecialty) provide detailed

curricular elements related to medical knowledge and patient care that might be useful in

defining curricular and didactic substance use disorder experiences for residents and

fellows.

• ACP Pain Management Learning Series: The American College of Physicians provides

interactive modules, case studies, and videos supporting patient-centered pain

management, OUD identification, and OUD treatment. Content stresses communication

techniques and interdisciplinary team care. Modules can be viewed in a linear fashion or

independently. An X-Express buprenorphine waiver video supports implementation for

limited waiver applicants.

• FDA caution to avoid abrupt decrease or discontinuation of prescribed opioids: The US

145

Food and Drug Administration (FDA) identifies harm reported from sudden

discontinuation of opioid pain medicines, and requires label changes to guide

prescribers on gradual, individualized tapering. April 9, 2019.

• MAT Waivered Prescriber Support Initiative Presents: Medications for Opioid Use

Disorder: The purpose of this online training is to provide participants with a detailed

overview of medications that have been shown to be effective as a component of the

treatment of opioid use disorder.

• Medication-ass

isted treatment waiver training: Medication assisted treatment (MAT) of

substance use disorders involves a combination of medications that target the brain, and

psychosocial interventions (e.g., counseling, skills development) aimed at improving

treatment outcomes. Research shows that medications and therapy together may be

more successful than either treatment method alone.

• Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) 63.

SAMHSA: This guide provides a comprehensive overview and guidance on issues

related to Opioid Use Disorder: signs and symptoms; diagnostic criteria; co-occurrence

with other substance use disorders; and prevention and treatment, including opioid

withdrawal techniques, pharmacotherapies, tapering opioids, and non-pharmacologic

interventions.

• New England Journal of Medicine Knowledge + Pain Management and Opioids learning

module: The New England Journal of Medicine, in partnership with Boston University

School of Medicine’s SCOPE of Pain and Area9 Lyceum, has instated a learning module

to assist in furthering education regarding pain management, opioid prescribing, and

Opioid Use Disorder (OUD).

• References of par

ticular interest:

o Lembke, Anna, Keith Humphreys, and Jordan Newmark. “Weighing the Risks and

Benefits of Chronic Opioid Therapy.” American Family Physician 93, no. 12 (June 16,

2016): 982-90. https://www.ncbi.nlm.nih.gov/pubmed/27304767

o Salsitz, Edwin A. “Chronic Pain, Chronic Opioid Addiction: a Complex

Nexus.” Journal of Medical Toxicology 12, no. 1 (2015): 54-57.

https://doi.org/10.1007/s13181-015-0521-9.

What does this mean for GME?

• Current residents and fellows will prescribe opioids for the next 40 years.

• Everyone involved in GME must be part of the solution.

• Clinical learning environments must use protocols and procedures that are:

o evidence-based;

o customized to the needs of the clinical disorders of the populations served; and

o effective in teaching residents how to:

 treat pain while preventing substance use disorder;

 recognize substance use disorder in its earliest stages;

 function effectively in systems of care for effective pain relief and substance use

disorder treatment;

 use non-pharmacologic means wherever possible; and

 participate in clinical trials of new non-opioid pain relief.

146

COMMON PROGRAM REQUIREMENTS

IV.D. Scholarship

Medic

ine is both an art and a science. The physician is a humanistic

scientist who cares for patients. This requires the ability to think critically,

evaluate the literature, appropriately assimilate new knowledge, and

practice lifelong learning. The program and faculty must create an

environment that fosters the acquisition of such skills through resident

participation in scholarly activities. Scholarly activities may include

discovery, integration, application, and teaching.

The ACG

ME recognizes the diversity of residencies and anticipates that

programs prepare physicians for a variety of roles, including clinicians,

scientists, and educators. It is expected that the program’s scholarship will

reflect its mission(s) and aims, and the needs of the community it serves.

For example, some programs may concentrate their scholarly activity on

quality improvement, population health, and/or teaching, while other

programs might choose to utilize more classic forms of biomedical

research as the focus for scholarship.

IV.D.1

. Program Responsibilities

IV.D.1

.a) The program must demonstrate evidence of scholarly

activities consistent with its mission(s) and aims.

(Core)

IV.D.1.b) The program, in partnership with its Sponsoring Institution,

must allocate adequate resources to facilitate resident and

faculty involvement in scholarly activities.

(Core)

[The Review Committee may further specify]

IV.D.1

.c) The program must advance residents’ knowledge and

practice of the scholarly approach to evidence-based patient

care.

(Core)

147

GUIDANCE

IV.D.1. Program responsibilities related to scholarship

This section focuses on requirements for program responsibilities related to scholarship and is

closely linked to both Common Program Requirements IV.D.2. — faculty scholarly activity —

and IV.D.3. — resident scholarly activity. As the italicized philosophy states, physicians require

“the ability to think critically, evaluate the literature, appropriately assimilate new knowledge, and

practice lifelong learning. The program and faculty must create an environment that fosters the

acquisition of such skills through resident participation in scholarly activities. Scholarly activities

may include discovery, integration, application, and teaching.”

IV.D.1.a) The program must demonstrate evidence of scholarly activities

consistent with its mission(s) and aims.

As the italicized philosophy states, “the ACGME recognizes the diversity of residencies and

anticipates that programs prepare physicians for a variety of roles, including clinicians,

scientists, and educators. It is expected that the program’s scholarship will reflect its mission(s)

and aims, and the needs of the community it serves.” For example, a program located in a rural

environment may want to focus on meeting the needs of the community, and advance scholarly

efforts on quality improvement measures or projects that would benefit the people it serves,

while a large cancer center in an urban institution may want to recruit faculty members and

residents whose primary research focus is basic science.

IV.D.1.b) The program, in partnership with its Sponsoring Institution, must

allocate adequate resources to facilitate resident and faculty involvement in

scholarly activities.

Depending on the mission and aims of each program, the resources needed to support resident

and faculty involvement in scholarly activities may vary greatly. The work taking place in a basic

science laboratory or the conduct of large clinical trials may require significant personnel,

laboratory, and other resources. There are many other scholarly activities that may not require

such resources. A key universal resource requirement for scholarly activities is time. Faculty

members and residents may need protected time away from clinical activities to successfully

engage in and perform scholarly activity.

IV.D.1.c) The program must advance residents’ knowledge and practice of the

scholarly approach to evidence-based patient care.

The scholarly approach can be defined as a synthesis of teaching, learning, and research with

the aim of encouraging curiosity and critical thinking based on an understanding of physiology,

pathophysiology, differential diagnosis, treatments, treatment alternatives, efficiency of care,

and patient safety. While some faculty members are responsible for fulfilling the traditional

elements of scholarship through research, integration, and teaching, all faculty members are

responsible for advancing residents’ scholarly approach to patient care.

Elements of a scholarly approach to patient care include:

• asking meaningful questions to stimulate residents to utilize learning resources to create

a differential diagnosis, diagnostic algorithm, and treatment plan;

• challenging the evidence that the residents use to reach their medical decisions so that

they understand the benefits and limits of the medical literature;

148

• when appropriate, disseminating scholarly learning in a peer-reviewed manner

(publication or presentation); and,

• improving residents’ learning by encouraging them to teach using a scholarly approach.

The scholarly approach to patient care begins with curiosity, is grounded in the principles of

evidence-based medicine, expands the knowledge base through dissemination, and develops

the habits of lifelong learning by encouraging residents to be scholarly teachers.

The intent

is to create an environment of scholarship to encourage critical thinking in providing

patient care, e.g., discussing the rationale for a new and expensive therapeutic option;

discontinuing a “popular” treatment option based on evidence that it provides no benefits;

adapting an approach to early discontinuation of central venous catheters or bladder catheters

when these devices are no longer essential for the care of the patient; or the judicious use of

antibiotics. These scholarly approaches are all designed to instill curiosity and critical thinking in

patient care. There is evidence that fostering this mindset in residents during residency implants

lifelong habits that continue decades after graduation.

• An envi

ronment of scholarship:

o leads to the creation of new knowledge;

o encourages lifelong learning;

o creates a mindset of inquiry that

 might reduce “jumping on any bandwagon that comes along;” and

 develops mindful practice habits, e.g., antibiotic stewardship, infection control,

and careful consideration of new (and expensive) drugs before use.

• Boyer’s (1990) Models of Scholarship:

o The scholarship of DISCOVERY

 Traditional definition: research

 Search for new knowledge

 Discovery of new information and new models

 Sharing discoveries through scholarly publication

o The scholarship of INTEGRATION

 integrates knowledge from different sources

 presents overview of findings in a resource topic

 brings findings together from different disciplines to discover convergence

 Identifies trends and sees knowledge in new ways

o examples: professional development workshops, literature reviews, meta-

analysis, quality improvement projects

o The scholarship of APPLICATION

 discovers ways that new knowledge can be used to solve real-world problems

 identifies new intellectual problems that can arise out of the very act of

application

 examples: translational research, development of community activities that link

with academic work, development of centers for study or service, quality

improvement projects

o The scholarship of TEACHING

 searches for innovative approaches and best practices to develop skills and

disseminate knowledge

 examples: courses; innovative teaching materials; educational research;

instructional activities; publication of books or other teaching materials; quality

149

improvement projects; digital scholarship, including open education resources

(Massive Open Online Courses (MOOCs), Khan Academy, digital publishing, and

providing courses in Blackboard

, Bridge

, and Moodle

)

There are many ways to provide these curricular elements. Programs may wish to cover specific

topics at monthly sessions over a one-year period. These sessions do not need to be taught by

the program director; this is an opportunity for collaboration, where experts in the topic can be

invited to speak. There are many web-based curricula for teaching these topics as well.

Key t

o this process is faculty mentorship. While there may be some residents who begin the

program with specific research plans, many do not. They need guidance from faculty mentors

who can help them design and conduct a study, gather and analyze data, and write up results

for presentation or publication. Faculty members also need to be involved in, or even lead,

journal club and other scholarly activities.

An envi

ronment of scholarship is essential to ensuring residents continue applying the methods

of the scholarly approach in their own practice after completion of the program.

Reference

Boyer, Ernest L., 1990. Scholarship reconsidered: priorities of the professoriate, A

special report. The Carnegie Foundation for the Advancement of Teaching, Princeton

University Press.

150

COMMON PROGRAM REQUIREMENTS

IV. Educational Program

IV.D. Scholarship

Medicine is both an art and a science. The physician is a humanistic

scientist who cares for patients. This requires the ability to think critically,

evaluate the literature, appropriately assimilate new knowledge, and

practice lifelong learning. The program and faculty must create an

environment that fosters the acquisition of such skills through resident

participation in scholarly activities. Scholarly activities may include

discovery, integration, application, and teaching.

The ACG

ME recognizes the diversity of residencies and anticipates that

programs prepare physicians for a variety of roles, including clinicians,

scientists, and educators. It is expected that the program’s scholarship will

reflect its mission(s) and aims, and the needs of the community it serves.

For example, some programs may concentrate their scholarly activity on

quality improvement, population health, and/or teaching, while other

programs might choose to utilize more classic forms of biomedical

research as the focus for scholarship.

IV.D.2. Faculty Scholarly Activity

IV.D.2

.a) Among their scholarly activity, programs must demonstrate

accomplishments in at least three of the following domains:

(Core)

• Research i

n basic science, education, translational

science, patient care, or population health

• Peer-reviewed grants

• Quality improvement and/or patient safety initiatives

• Systematic reviews, meta-analyses, review articles,

chapters in medical textbooks, or case reports

• Creation of curricula, evaluation tools, didactic

educational activities, or electronic educational

materials

• Contribution to professional committees, educational

organizations, or editorial boards

• Innovations in education

IV.D.2.b) The program must demonstrate dissemination of scholarly

activity within and external to the program by the following

methods:

[Revi

ew Committee will choose to require either IV.D.2.b).(1)

or both IV.D.2.b).(1) and IV.D.2.b).(2)]

151

Background and Intent: For the purposes of education, metrics of scholarly activity

represent one of the surrogates for the program’s effectiveness in the creation of an

environment of inquiry that advances the residents’ scholarly approach to patient care.

The Review Committee will evaluate the dissemination of scholarship for the program

as a whole, not for individual faculty members, for a five-year interval, for both core

and non-core faculty members, with the goal of assessing the effectiveness of the

creation of such an environment. The ACGME recognizes that there may be differences

in scholarship requirements between different specialties and between residencies and

fellowships in the same specialty.

IV.D.2

.b).(1) faculty participation in grand rounds, posters,

workshops, quality improvement presentations,

podium presentations, grant leadership, non-peer-

reviewed print/electronic resources, articles or

publications, book chapters, textbooks, webinars,

service on professional committees, or serving as a

journal reviewer, journal editorial board member, or

editor;

(Outcome)

IV.D.2

.b).(2) peer-reviewed publication.

(Outcome)

152

GUIDANCE

The requirements for faculty scholarship in Common Program Requirement IV.D.2. are closely

linked to the program responsibility of ensuring that residents and faculty members are provided

with a scholarly environment as specified in Common Program Requirement IV.D.1. and

resident scholarly activity as specified in IV.D.3.

Facult

y scholarly activity demonstrates to the Review Committees that:

• Faculty members have the skills to analyze and utilize new knowledge.

• The program has the ability to teach those skills to residents.

• An environment of scholarship exists in the program.

While

the value of scholarly activity is undeniable, such as the publication of peer-reviewed

journal articles and the presentation of basic science research at national conferences, other

activities are equally valuable. Scholarship is not done only for its own sake, but also serves as

a proxy for the creation of a clinical learning environment that encourages an environment of

inquiry and an evidence-based, scholarly approach to patient care.

The phil

osophical statement associated with section IV.D. of the Common Program

Requirement on the previous page, bears repeating:

Medic

ine is both an art and a science. The physician is a humanistic scientist who cares for

patients. This requires the ability to think critically, evaluate the literature, appropriately

assimilate new knowledge, and practice lifelong learning. The program and faculty must

create an environment that fosters the acquisition of such skills through resident

participation in scholarly activities.

and

It is expected that the program’s scholarship will reflect its mission(s) and aims, and

the needs of the community it serves. For example, some programs may concentrate

their scholarly activity on quality improvement, population health, and/or teaching, while

others might use more classic forms of biomedical research as the focus for scholarship.

There is

wide variability in programs and the communities they serve. For example, a program

in a remote, rural community might focus on primary care education and training, and may not

want or have the resources to put together a million-dollar laboratory to study some

characteristics of a murine model of disease. Instead, it may emphasize improving vaccination

rates, increasing compliance with diabetes care, or determining how to deal with an opioid

epidemic in the community.

IV.D.2.a) Among their [faculty] scholarly activity, programs must demonstrate

accomplishments in at least three of the following domains:

• research in basic science, education, translational science, patient care, or population

health;

• peer-reviewed grants;

• quality improvement and/or patient safety initiatives;

• systematic reviews, meta-analyses, review articles, chapters in medical textbooks, or

case reports;

153

• creation of curricula, evaluation tools, didactic educational activities, or electronic

educational materials;

• contribution to professional committees, educational organizations, or editorial boards;

and

• innovations in education.

The program will be reviewed in aggregate. This requirement does not mean that each faculty

member must have activity in three domains.

IV.D.2.b) The program must demonstrate dissemination of scholarly activity

within and external to the program by the following methods:

IV.D.2.b).(1) faculty participation in grand rounds, posters, workshops, quality

improvement presentations, podium presentations, grant leadership, non-

peer-reviewed print/electronic resources, articles or publications, book

chapters, textbooks, webinars, service on professional committees, or

serving as a journal reviewer, journal editorial board member, or editor;

IV.D.2.b).(2) peer-reviewed publication.

The Review Committee will choose to require either Common Program Requirement

IV.D.2.b).(1) or both IV.D.2.b).(1) and IV.D.2.b).(2), so programs are encouraged to reference

the specialty-specific Program Requirements. This

ACGME Review Committee Faculty

Scholarly Activity Decisions document provides a synopsis of the faculty scholarly activity

requirement across all specialties and subspecialties. Some Review Committees also provide

further information on their interpretation of these requirements in associated specialty-specific

FAQs. These documents, for specialties that provide them, can be found on the Program

Requirements and FAQs and Applications section of the

specialty-specific w

eb pages.

Accreditation Data System (ADS) screenshots: faculty scholarly activity

instructions and data entry screens (see below)

1. Faculty scholarly activity instructions

2. The “Download Scholarly Activity Template” button in the screenshot

above will pull up an Excel spreadsheet to enter information. The purpose of

the spreadsheet is for programs to disseminate it to program faculty members to aid in

the collection of accurate scholarly activity data. The spreadsheet includes definitions of

the different types of scholarly activities.

154

3. The faculty scholarly activity summary provides a list of all faculty

members in the program and allows programs to update scholarly activity

information for each individual faculty member by adding it, copying

information another program has entered, or reporting “no activity.”

4. The columns on the faculty scholarly activity data entry screen have an

“information” button that expands to provide a more specific definition of

each type of scholarly activity. Those definitions are also provided in the

downloadable Excel template, and are included below.

• PubMed IDs (PMIDs)

The PMID is a unique number assigned to each PubMed record. This is

generally an eight-digit number. Enter up to four PMIDs (assigned by PubMed)

for articles published during the previous academic year. The PubMed Central

reference number (PMCID) is different from the PubMed reference number

(PMID). PubMed Central is an index of full-text papers, while PubMed is an index

of abstracts.

If this faculty is a designated osteopathic faculty, use the

checkboxes (if applicable) to indicate if an article integrated the application of

Osteopathic Principles and Practice (OPP).

• Non-PMI

D Peer Review Publications: Number of peer-reviewed publications

without a PMID, which are not recognized by the National Library of Medicine

during the previous academic year.

• Other Publications: Number of other articles/publications without PMIDs and

not peer reviewed. Examples include editorials, online magazines, or other

155

activities related to item-writing (e.g., board examination questions) during the

previous academic year.

• Conference Presentations: Number of abstracts, posters, and presentations at

international, national, state, or regional meetings during the previous academic

year.

• Other Presentations: Number of other presentations (e.g., grand rounds, invited

professorships), materials developed (e.g., computer-based modules) during the

previous academic year.

• Chapters/Textbooks: Number of chapters or textbooks published during the

previous academic year.

• Grant Leadership: Number of grants for which faculty member had a leadership

role (e.g., principal investigator [PI], co-PI, or site director) during the previous

academic year.

• Leadership or Peer-Review Role: Active leadership role (such as serving on

committees or governing boards) in international, national, state, or regional

medical organizations or served as reviewer or editorial board member for a

peer-reviewed journal during the previous academic year.

• Formal Courses: Responsible for seminars, conference series, or course

coordination (e.g., arrangement of presentations and speakers, organization of

materials). This includes developing training modules for medical students,

residents, fellows, and other health professionals (e.g., simulation). Program

didactics and/or conferences are not considered formal courses.

5. The legend at the bottom of the faculty scholarly activity data entry screen

provides the key domains for scholarly activity. These domains are also

available in the Excel template and on the individual faculty scholarly activity

entry screen.

156

6. The screenshots below depict the individual faculty scholarly activity data

entry.

157

Resources

The following presentation is available on the ACGME website and provides helpful tips for

entering scholarly activity in ADS as part of the ADS Annual Update and avoiding common

citations.

• Video: Av

oiding Common Errors in the ADS Annual Update - Entering Scholarly Activity

into ADS

158

COMMON PROGRAM REQUIREMENTS

IV. Educational Program

IV.D. Scholarship

Medicine is both an art and a science. The physician is a humanistic

scientist who cares for patients. This requires the ability to think critically,

evaluate the literature, appropriately assimilate new knowledge, and

practice lifelong learning. The program and faculty must create an

environment that fosters the acquisition of such skills through resident

participation in scholarly activities. Scholarly activities may include

discovery, integration, application, and teaching.

The ACG

ME recognizes the diversity of residencies and anticipates that

programs prepare physicians for a variety of roles, including clinicians,

scientists, and educators. It is expected that the program’s scholarship will

reflect its mission(s) and aims, and the needs of the community it serves.

For example, some programs may concentrate their scholarly activity on

quality improvement, population health, and/or teaching, while other

programs might choose to utilize more classic forms of biomedical

research as the focus for scholarship.

IV.D.3

. Resident Scholarly Activity

IV.D.3

.a) Residents must participate in scholarship

(Core)

[The Review Committee may further specify]

159

GUIDANCE

The requirement for resident participation in scholarship in Common Program Requirement

IV.D.3.a) is closely linked to the program responsibility of ensuring that the faculty members and

residents are provided with a scholarly environment as specified in Common Program

Requirement IV.D.1. and faculty scholarly activity as specified in Common Program

Requirement IV.D.2.

Resi

dent scholarly activity demonstrates to the Review Committees that the program can teach

scholarship skills to residents and that an environment of scholarship exists in the program.

[The Review Committee may further specify]

Since Review Committees may specify requirements for resident scholarly activity, programs

must review the specialty-specific Program Requirements:

1. Go to https://www.acgme.org/specialties/.

2. Select the applicable specialty.

3. Select “Program Requirements and FAQs and Applications” at the top of the specialty

page.

4. Select the specialty Program Requirements currently in effect.

Quest

ions about subspecialty Program Requirements related to resident scholarly activity

should be directed to specialty Review Committee staff members.

Review Committees consider the wide variability in programs and the communities they serve

when evaluating programs. For example, a program in a remote, rural community might focus

on primary care education and training and may not want or have the resources to put together

a million-dollar laboratory to study some characteristics of a murine model of disease. Instead, it

may emphasize improving vaccination rates, increasing compliance with diabetes care, or

determining how to deal with an opioid epidemic in the community.

Accreditation Data System (ADS) screenshots: resident scholarly activity

instructions and data entry screens

1. Resident scholarly activity instructions

160

2. The “Download Scholarly Activity Template” button in the screenshot

above will pull up an Excel spreadsheet to enter information. The purpose of

the spreadsheet is for programs to disseminate it to residents to aid in the collection of

accurate scholarly activity data. The spreadsheet includes definitions of the different

types of scholarly activities.

3. The resident scholarly activity summary provides a list of all residents in

the program and allows programs to update scholarly activity information

for each individual resident. NOTE: The information requested is for the previous

academic year only. First-year residents in the program will not appear on the list.

4. The columns on the resident scholarly activity data entry screen have an

“information” button that expands to provide a more specific definition of

each type of scholarly activity. Those definitions are also provided in the

downloadable Excel template and are included below.

• PubMed IDs (PMIDs):

The PMID is a unique number assigned to each PubMed record. This is generally an

eight-digit number. Enter up to four PMIDs

(assigned by PubMed) for articles

published during the previous academic year. The PubMed Central reference

number (PMCID) is different from the PubMed reference number (PMID). PubMed

Central is an index of full-text papers, while PubMed is an index of abstracts. If this

resident is a designated osteopathic resident, use the checkboxes (if applicable) to

161

indicate if an article integrated the application of Osteopathic Principles and Practice

(OPP).

• Other Publications: Number of articles without PMIDs, non-peer-reviewed

publications, peer-reviewed publications which are not recognized by the National

Library of Medicine, and activities related to item-writing (e.g., board examination

questions) during the previous academic year.

• Conference Presentations: Number of abstracts, posters, and presentations given

at international, national, or regional meetings during the previous academic year.

• Chapters/Textbooks: Number of chapters or textbooks published during the

previous academic year.

• Participated in Research: Participated in funded or non-funded basic science or

clinical outcomes research project during the previous academic year.

• Teaching Presentations: Lecture or presentation (such as grand rounds or case

presentations) of at least 30-minute duration within the Sponsoring Institution or

program during the previous academic year.

5. The screenshots below depict the individual resident scholarly activity data

entry.

162

If a program sends its residents to a one-month rotation at a participating site where faculty

members produce a large amount of scholarly activity, it would be improper for the program to

list all the scholarly activities at that participating site. Doing so does not meet substantial

compliance with the requirement to create an environment of scholarship. The idea behind this

requirement is that residents be “immersed” in an environment of scholarship and inquiry

throughout their educational programs.

Resources:

The following presentation is available on the ACGME website and provides helpful tips for

entering scholarly activity in ADS as part of the ADS Annual Update and avoiding common

citations.

• Video: Av

oiding Common Errors in the ADS Annual Update - Entering Scholarly Activity

into ADS

163

COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.A. Resident Evaluation

V.A.1. Feedback and Evaluation

Background and Intent: Feedback is ongoing information provided regarding aspects of one’s

performance, knowledge, or understanding. The faculty empower residents to provide much

of that feedback themselves in a spirit of continuous learning and self-reflection. Feedback

from faculty members in the context of routine clinical care should be frequent, and need not

always be formally documented.

Formative and summative evaluation have distinct definitions. Formative evaluation is

monitoring resident learning and providing ongoing feedback that can be used by residents

to improve their learning in the context of provision of patient care or other educational

opportunities. More specifically, formative evaluations help:

• residents identify their strengths and weaknesses and target areas that need work

• program directors and faculty members recognize where residents are struggling and

address problems immediately

Summative evaluation is evaluating a resident’s learning by comparing the residents against

the goals and objectives of the rotation and program, respectively. Summative evaluation is

utilized to make decisions about promotion to the next level of training, or program

completion.

End-of-rotation and end-of-year evaluations have both summative and formative components.

Information from a summative evaluation can be used formatively when residents or faculty

members use it to guide their efforts and activities in subsequent rotations and to

successfully complete the residency program.

Feedback, formative evaluation, and summative evaluation compare intentions with

accomplishments, enabling the transformation of a neophyte physician to one with growing

expertise.

V.A.1.a) Faculty members must directly observe, evaluate, and frequently

provide feedback on resident performance during each rotation or

similar educational assignment.

(Core)

Background and Intent: Faculty members should provide feedback frequently throughout the

course of each rotation. Residents require feedback from faculty members to reinforce well-

performed duties and tasks, as well as to correct deficiencies. This feedback will allow for the

development of the learner as they strive to achieve the Milestones. More frequent feedback is

strongly encouraged for residents who have deficiencies that may result in a poor final

rotation evaluation.

V.A.1.b) Evaluation must be documented at the completion of the

assignment.

(Core)

164

V.A.1.b).(1) For block rotations of greater than three months in duration,

evaluation must be documented at least every three months.

(Core)

V.A.1.b).(2) Longitudinal experiences, such as continuity clinic in the

context of other clinical responsibilities, must be evaluated at

least every three months and at completion.

(Core)

V.A.1.c) The program must provide an objective performance evaluation

based on the Competencies and the specialty-specific Milestones,

and must:

(Core)

V.A.1.c).(1) use multiple evaluators (e.g., faculty members, peers,

patients, self, and other professional staff members); and,

(Core)

V.A.1.c).(2) provide that information to the Clinical Competency

Committee for its synthesis of progressive resident

performance and improvement toward unsupervised practice.

(Core)

V.A.1.d) The program director or their designee, with input from the Clinical

Competency Committee, must:

V.A.1.d).(1) meet with and review with each resident their

documented semi-annual evaluation of performance,

including progress along the specialty-specific

Milestones;

(Core)

V.A.1.e) At least annually, there must be a summative evaluation of each

resident that includes their readiness to progress to the next year of

the program, if applicable.

(Core)

V.A.1.f) The evaluations of a resident’s performance must be accessible for

review by the resident.

(Core)

[The Review Committee may further specify under any requirement in

V.A.1.-V.A.1.f)]

165

GUIDANCE

The requirements included in this section are generally self-explanatory, including descriptions

of evaluation frequency and when they should be performed.

V.A.1.a) Faculty members must directly observe, evaluate, and frequently provide

feedback on resident performance during each rotation or similar educational

assignment.

Common Program Requirements V.A.1.a) is unequivocal in stating that direct observation is key

to the evaluation of resident performance and progress. The Background and Intent box further

emphasizes that “faculty members should provide feedback frequently throughout the course of

each rotation. Residents require feedback from faculty members to reinforce well-performed

duties and tasks, as well as to correct deficiencies. [This feedback will allow for development of

learners as they strive to achieve the Milestones.] More frequent feedback is strongly

encouraged for residents who have deficiencies that may result in a poor final rotation

evaluation.”

Evaluation and feedback can be provided during the provision of clinical care for any of the six

required Competency areas. Faculty members have many responsibilities that sometimes

require short clinical rotations of five days or less. It is important to note that continuity of

observation is just as important; even in short rotations, continuity allows faculty members to

know the resident and for the resident to observe the faculty members.

V.A.1.b) Evaluation must be documented at the completion of the assignment.

Timely faculty member completion of resident evaluation following completion of an assignment

is crucial to a resident’s development. Evaluation must address strengths and areas for

improvement. Requirements V.A.1.b).(1) and (2) further specify that for block rotations or

continuity experiences that are longer than three months in duration, an evaluation must be

documented at least every three months.

ADS screenshots: overall evaluation methods

Either as part of an application for accreditation or annually, as part of the ADS Annual Update,

the program director must answer or update the following question regarding end of rotation

evaluations.

V.A.1.c) The program must provide an objective performance evaluation based on

the Competencies and the specialty-specific Milestones, and must:

(Core)

V.A.1.c).(1) use multiple evaluators (e.g., faculty members, peers, patients, self,

and other professional staff members); and,

In addition to faculty members, residents interact with many other health providers, including

nurses, physician assistants, other physicians, residents, fellows, peers, and patients. The input

of the relevant individuals or groups is needed to provide an overall picture of resident

performance. Notably, residents asked to provide a self-evaluation using the Milestones have

been shown to develop a better perspective of their own performance.

166

V.A.1.c).(2) provide that information to the Clinical Competency Committee for its

synthesis of progressive resident performance and improvement toward

unsupervised practice.

V.A.1.d) The program director or their designee, with input from the Clinical

Competency Committee, must:

V.A.1.d).(1) meet with and review with each resident their documented semi-

annual evaluation of performance, including progress along the specialty-specific

Milestones;

(Core)

Although this requirement is self-explanatory, it is critical to note that the semi-annual evaluation

of performance must include a review of the resident’s progress on the specialty-specific

milestones. As the Background and Intent further states, “Learning is an active process that

requires effort from the teacher and the learner. Faculty members evaluate a resident's

performance at least at the end of each rotation. The program director or their designee will

review those evaluations, including their progress on the Milestones, at a minimum of every six

months. Residents should be encouraged to reflect upon the evaluation, using the information to

reinforce well-performed tasks or knowledge or to modify deficiencies in knowledge or practice.

Working together with the faculty members, residents should develop an individualized learning

plan.”

Accreditation Data System (ADS) screenshot: semi-annual evaluation

The program director must answer or update the following question as part of the ADS Annual

Update to acknowledge meeting with the residents to review their documented semi-annual

evaluation of performance, including progress along the specialty-specific milestones.

V.A.1.e) At least annually, there must be a summative evaluation of each resident

that includes their readiness to progress to the next year of the program, if

applicable.

The end-of-year, summative evaluation of each resident must include a specific statement about

the resident’s readiness to progress to the next year of the program and it should be discussed

by the Clinical Competency Committee.

V.A.1.f) The evaluations of a resident’s performance must be accessible for

review by the resident.

Residents must be able to access their performance evaluations, which could be in

electronic or hard copy format, depending on the system used by each program.

167

COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.A. R

esident Evaluation

V.A.1. Feedback and Evaluation

Background and Intent: Feedback is ongoing information provided regarding aspects

of one’s performance, knowledge, or understanding. The faculty empower residents to

provide much of that feedback themselves in a spirit of continuous learning and self-

reflection. Feedback from faculty members in the context of routine clinical care

should be frequent, and need not always be formally documented. Formative and

summative evaluation have distinct definitions. Formative evaluation is monitoring

resident learning and providing ongoing feedback that can be used by residents to

improve their learning in the context of provision of patient care or other educational

opportunities. More specifically, formative evaluations help:

• residents identify their strengths and weaknesses and target areas that need

work

• program directors and faculty members recognize where residents are

struggling and address problems immediately

Summative evaluation is evaluating a resident’s learning by comparing the residents

against the goals and objectives of the rotation and program, respectively. Summative

evaluation is utilized to make decisions about promotion to the next level of training, or

program completion. End-of-rotation and end-of-year evaluations have both summative

and formative components. Information from a summative evaluation can be used

formatively when residents or faculty members use it to guide their efforts and

activities in subsequent rotations and to successfully complete the residency program.

Feedback, formative evaluation, and summative evaluation compare intentions with

accomplishments, enabling the transformation of a neophyte physician to one with

growing expertise.

V.A.1

.d).(2) assist residents in developing individualized learning plans to

capitalize on their strengths and identify areas for growth;

and

(Core)

168

GUIDANCE

Common Program Requirement V.A.1.d).(2) was written with the intention of ensuring that the

program director and faculty members help residents to develop individualized learning plans

(ILPs) that capitalize on their strengths and identify any areas that need additional support or

effort.

General

ly, ILPs include self-assessment and reflection, career goals, development of plans to

achieve the goal(s), assessment of progress toward the goal(s), and revising/generating new

goals. An ILP is a living document that must be reviewed to ensure progress and refocus as

needed. Goals can be short term and/or long term. ILPs help residents learn the concepts of

lifelong learning and practice-based learning and improvement.

Barr

iers to successful implementation of an ILP (identified by residents)

• difficulty with self-reflection

• environmental strain: fatigue, time constraints

• competing demands: personal and work

• difficulty with goal generation

Dif

ficulties in developing a plan and plan implementation

• not seeing the patient population needed for clinical goals

• not having time to consistently review the plan with a mentor

• Lack of objective measures when goals that were created goals cannot be tracked

The ACGME has developed several resources for programs that include more information on

ILPs, including components of an ILP and what ILPs are and what they are not. The Clinical

Competency Committee Guidebook provides more insight on this requirement and ILPs.

Component

s of an ILP (Li and Burke, 2010)

• reflection on goals and self-assessment of strengths and weaknesses

• generation of specific learning goals and/or objectives

• specific plans or strategies to achieve each goal focused on what the learner will do to

improve

• mutual agreement on how the assessment of progress on each goal will be determined

• eventual revision of goals or creation of new goals based on performance

• expected timeline

ILPs are:

• formulated by the individual (resident/fellow) – made by the learner, for the learner;

• guided by a facilitator (faculty member, advisor, coach, or program director);

• an exercise in self-assessment and self-reflection;

• iterative;

• an ACGME core requirement; and

• an indicator of insight and ability to become an independent lifelong learner.

169

ILPs are not:

• set in stone – they can and should be revisited by both the learner and the facilitator;

• a portfolio;

• evaluations; or

• The sole or major responsibility of the program director (or faculty) or the program.

References/Resources

1. Li, Su-Ting T., and Ann E. Burke. 2010. “Individualized Learning Plans: Basics and

Beyond.” Academic Pediatrics 10(5): 289–92.

https://doi.org/10.1016/j.acap.2010.08.002.

2. Li, Su-Ting T., Debora A. Paterniti, John Patrick T. Co, and Daniel C. West. 2010.

“Successful Self-Directed Lifelong Learning in Medicine: A Conceptual Model Derived

From Qualitative Analysis of a National Survey of Pediatric Residents.” Academic

Medicine 85(7): 1229–36. https://doi.org/10.1097/acm.0b013e3181e1931c.

3. Li, Su-Ting T., Debora A. Paterniti, Daniel J. Tancredi, John Patrick T. Co, and Daniel C.

West. 2011. “Is Residents' Progress on Individualized Learning Plans Related to the

Type of Learning Goal Set?” Academic Medicine 86(10): 1293-1299.

doi:10.1097/ACM.0b013e31822be22b.

4. University of Washington Graduate Medical Education. “Resident and Fellow Education:

Individualized Learning Plan (ILP).” https://sites.uw.edu/uwgme/resident-evaluation/#ilp.

Accessed 2023.

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COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.A. R

esident Evaluation

V.A.1. Feedback and Evaluation

Background and Intent: Feedback is ongoing information provided regarding aspects

of one’s performance, knowledge, or understanding. The faculty empower residents to

provide much of that feedback themselves in a spirit of continuous learning and self-

reflection. Feedback from faculty members in the context of routine clinical care

should be frequent, and need not always be formally documented.

Format

ive and summative evaluation have distinct definitions. Formative evaluation is

monitoring resident learning and providing ongoing feedback that can be used by

residents to improve their learning in the context of provision of patient care or other

educational opportunities. More specifically, formative evaluations help:

• resident

s identify their strengths and weaknesses and target areas that need

work

• program directors and faculty members recognize where residents are

struggling and address problems immediately

Summ

ative evaluation is evaluating a resident’s learning by comparing the residents

against the goals and objectives of the rotation and program, respectively. Summative

evaluation is utilized to make decisions about promotion to the next level of training, or

program completion.

End-of-rot

ation and end-of-year evaluations have both summative and formative

components. Information from a summative evaluation can be used formatively when

residents or faculty members use it to guide their efforts and activities in subsequent

rotations and to successfully complete the residency program.

Feedback, formative evaluation, and summative evaluation compare intentions with

accomplishments, enabling the transformation of a neophyte physician to one with

growing expertise.

V.A.1

.d) The program director or their designee, with input from the Clinical

Competency Committee, must:

V.A.1.d).(3) develop plans for residents failing to progress, following

institutional policies and procedures.

(Core)

Background and Intent: Learning is an active process that requires effort from the

teacher and the learner. Faculty members evaluate a resident's performance at least at

the end of each rotation. The program director or their designee will review those

evaluations, including their progress on the Milestones, at a minimum of every six

months. Residents should be encouraged to reflect upon the evaluation, using the

information to reinforce well-performed tasks or knowledge or to modify deficiencies in

171

knowledge or practice. Working together with the faculty members, residents should

develop an individualized learning plan.

Residents who are experiencing difficulties with achieving progress along the

Milestones may require intervention to address specific deficiencies. Such intervention,

documented in an individual remediation plan developed by the program director or a

faculty mentor and the resident, will take a variety of forms based on the specific

learning needs of the resident. However, the ACGME recognizes that there are

situations which require more significant intervention that may alter the time course of

resident progression. To ensure due process, it is essential that the program director

follow institutional policies and procedures.

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GUIDANCE

V.A.1.d). and V.A.1.d).(3). The program director or their designee, with input from

the Clinical Competency Committee, must develop plans for residents failing to

progress, following institutional policies and procedures.

The Background and Intent reinforces the importance of institutional policies and procedures in

this process: “To ensure due process, it is essential that the program director follow institutional

policies and procedures.” It is, therefore, strongly encouraged that program directors work

closely with the designated institutional official (DIO) to ensure all applicable policies and

procedures are followed and the appropriate institutional departments are engaged in the

process of addressing residents failing to progress at the appropriate time. The goal of these

processes is to help residents in difficulty to succeed while also ensuring appropriate

documentation of resident performance and due process.

Mil

estones assessments and evaluations by the Clinical Competency Committee (CCC) are

essential to the early identification of residents in difficulty.

To assi

st with fulfilling this responsibility, the ACGME has developed a Remediation Toolkit

authored by experts from across the country. This free course consists of 11 modules covering

a range of essential topics related to remediation. These modules will equip educators and

administrators with a solid foundation for addressing the needs of struggling learners,

implementing effective remediation strategies, and fostering a supportive and conducive

learning environment in GME. The toolkit is available in

Learn at ACGME and is part of a suite

of materials to aid in faculty development, including the Improving Assessment Using Direct

Observation Toolkit and the Developing Faculty Competencies in Assessment Course.

The st

udies listed below address the issue of residents failing to progress.

1. Cosco, Dominique, Denise Dupras, Maggie So, Eugene Lee, Jason Schneider, and

Randall Edson. 2014. “Look on the Bright Side: Case Studies in Successful

Remediation of Problem Learners. Tools for Faculty and Staff/Remediation.”

Academic Medicine Insight 12(3): 8-11.

Cosco et al. studied cases in which remediation of problem learners was successful and

identified some key steps

o identification of the issue (competency-based)

o multiple sources of learner assessment

o early feedback and intervention

o resident reflection with buy-in

o specific remediation goals with outlined consequences for failure to meet goals

o frequent follow-up

o group effort

o thorough documentation

173

2. Dupras, Denise M., Randall S. Edson, Andrew J. Halvorsen, Robert H. Hopkins, and

Furman S. McDonald. 2012. “‘Problem Residents’: Prevalence, Problems and

Remediation in the Era of Core Competencies.” The American Journal of Medicine

125,(4): 421–25. https://doi.org/10.1016/j.amjmed.2011.12.008

The authors studied the prevalence of residents in difficulty, and the problems associated

with placing a resident in remediation. They suggested a change of terms from “problem

residents” to “residents in difficulty” (RID).

The authors conducted a survey of members of the Association of Program Directors in

Internal Medicine:

o 372 program directors were surveyed (97.1% of 383 US categorical internal

medicine programs).

o 268 program directors (72%) completed the survey.

o 197 program directors reported RID.

o 3.5% of residents were identified as RID (532 of 15,031 total residents with a mean

of 2.9 RIDs per program).

They noted

that factors that correlated with subsequent need for probation/remediation

included low scores on the Internal Medicine In-Training Examination and the US Medical

Licensing Examination Step 3.

Resi

dents in difficulty were most frequently identified by faculty member (#1). They were

also identified by supervising/chief residents, program directors, fellows, and nurses.

The most

common deficiencies of residents in difficulty identified in this study included:

o patient care (53%);

o medical knowledge (48%;)

o organization/prioritization, communication (40%;)

o professionalism (41%); and

o the majority (77%) had MULTIPLE deficiencies.

The most

common contributing factors to residents having difficulty in the study were:

o depression

o anxiety

o personality disorders

Less common contributing factors to residents having difficulty included:

o learning disability

o illness

o substance use disorder

o divorce

In t

his study, the authors noted that actions taken by program directors to address residents

in difficulty included:

o remediation (including repeating a rotation or an entire year)

o disciplinary action

o probation

o dismissal

In t

his study, only 34.5% of program directors retrospectively identified warning signs.

174

Conclusions:

o The majority of residents in difficulty have deficiencies in multiple competencies.

o Medical knowledge and patient care deficiencies are much easier to remediate.

o Deficiencies in professionalism are common (41%).

o Residents respond poorly to remediation.

o There is a concern that unprofessional behavior in residents is predictive of future

disciplinary action by specialty boards.

3. Lefebvre,

Cedric, Kelly Williamson, Peter Moffett, Angela Cummings, Beth

Gianopulos, Elizabeth Winters, and Mitchell Sokolosky. 2018. “Legal Considerations

in the Remediation and Dismissal of Graduate Medical Trainees.” Journal of Graduate

Medical Education 10,(3): 253–57. https://doi.org/10.4300/jgme-d-17-00813.1

Lefebvre et al. reviewed the legal considerations in placing residents in remediation or

dismissing them from the program, and have the following summary points:

o Sponsoring Institutions and their programs must provide residents with due process

in cases of contract non-renewal, non-promotion, suspension, or dismissal.

 Adherence to remediation policy, use of consistent remediation language, and

documentation of all phases of remediation are important to optimize outcomes

and limit legal liability when dismissal occurs.

 Programs are generally on solid legal ground when they exercise due process for

the remediated resident, when they take actions based on educational standards

and patient safety, and when they only disclose educational records to inquiring

parties in good faith.

 Courts have consistently declined to consider the tort of educational malpractice.

4. Papadakis,

Maxine A., Gerald K. Arnold, Linda L. Blank, Eric S. Holmboe, and

Rebecca S. Lipner. 2008. “Performance during Internal Medicine Residency Training

and Subsequent Disciplinary Action by State Licensing Boards.” Annals of Internal

Medicine 148,(11): 869. https://doi.org/10.7326/0003-4819-148-11-200806030-00009

Papadakis et al. evaluated the incidence of subsequent disciplinary action by state licensing

boards according to performance during residency and concluded that poor performance on

behavioral and cognitive measures during residency is associated with greater risk for state

licensing board actions against practicing physicians at every point on a performance

continuum. These findings support the ACGME standards for professionalism and cognitive

performance and the development of best practices to remediate these deficiencies.

5. Smith, Jessica, Monica Lypson, Mark Silverberg, Moshe Weizberg, Tiffany Murano,

Michael Lukela, and Sally Santen. 2017 “Defining Uniform Processes for Remediation,

Probation and Termination in Residency Training.” Western Journal of Emergency

Medicine 18,(1): 110–13. https://doi.org/10.5811/westjem.2016.10.31483

The authors state that: “It is important that residency programs identify trainees who

progress appropriately, as well as identify residents who fail to achieve educational

milestones as expected so they may be remediated. The process of remediation varies

greatly across training programs, due in part to the lack of standardized definitions for good

standing, remediation, probation and termination.”

The author

s provided standardized definitions for terms used in remediation, probation, and

termination related to residency education as listed below:

175

Informal Remediation: The first step in the process when warning signs of problems exist but

are not so significant that formal remediation is warranted. This is a critical time to start

documentation of the process to determine if there is an eventual need to escalate to a

formal remediation process. Many programs have developed documentation templates or

standard language, and completed forms or email notifications to the resident are placed in

the resident’s file. Some create confidential notes placed in “shadow files,” which are

destroyed once the remediation process is completed successfully.

It i

s important to engage the program director, CCC, and resident at this stage.

Formal

Remediation: The next step in the management of residents in difficulty. This step is

implemented when the resident fails to correct identified deficiencies during informal

remediation or when the deficiencies are so significant that the step of informal remediation

is skipped.

o Components of formal remediation:

 Document the need for formal remediation and inform the resident in writing. It is

important that the resident read and sign a formal document. The document must

also be signed by the program director.

 Provide the resident with program and institutional grievance and due process

policies.

 Determine the length of time of formal remediation, decided by the program

director and the CCC. Do not leave the date open-ended — there must be a

target date.

 Create a correction plan with expected outcomes — there must be specific

targets based on the deficiencies.

 Include a time frame for reassessment and the consequences of not meeting the

expected outcome within the time frame.

 Place all documentation in the resident’s file.

 Notify the graduate medical education (GME) office, including the DIO.

Probat

ion: Probation is initiated when a resident fails to correct deficiencies identified during

formal remediation. The program director and the CCC may place a resident on immediate

probation if major problems occur.

Some p

rograms set a limit of six months to the period of formal remediation. If there is no or

not enough improvement after six months of formal remediation, the resident is then placed

on probation.

Notes

related to probation:

o The period of probation must be definite, not open-ended.

o The program must follow due process, especially if non-renewal or termination is

being considered.

o The same points listed in formal remediation need to be followed: dates, target

outcome, consequences of not meeting the requirements, and documentation.

o The GME office must be involved. Other participants in the probation process include

the program director, the CCC, the department chair, and faculty members assigned

to remediate the resident.

o The legal department must be involved.

o Probation must be disclosed in the final Verification of Graduate Medical Education

Training (VGMET) Form, employment letters, and letters of references.

176

o If the resident does not meet the requirements outlined in the letter of probation, the

program may choose non-renewal of contract, or termination.

Termi

nation: A resident may be terminated if that resident fails to meet the terms of

probation. In some instances, a resident may be terminated immediately if the problem is

severe enough.

o Those involved in the process of probation must be involved in the termination

process. In addition, if there is a house officer/resident union, a representative of the

union needs to be involved.

o Termination must be disclosed in the final VGMET Form, employment letters, and

letters of references.

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COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.A. R

esident Evaluation

V.A.2. Final Evaluation

V.A.2.a) T

he program director must provide a final evaluation for each

resident upon completion of the program.

(Core)

V.A.2

.a).(1) The specialty-specific Milestones, and when

applicable, the specialty-specific Case Logs, must be

used as tools to ensure residents are able to engage in

autonomous practice upon completion of the program.

(Core)

178

GUIDANCE

As Com

mon Program Requirement V.A.2.a).(1) specifies, the program director must use the

specialty-specific Milestones, and when applicable, the specialty-specific Case Logs as tools to

ensure residents are able to engage in autonomous practice upon completion of the program.

However, the program director should consider a number of other items to make the

determination about a resident’s ability to engage in autonomous practice (e.g., semi-annual

and summative evaluations; recommendations from the Clinical Competency Committee).

Milestones

Milestones evaluation is an educational and formative assessment methodology designed to

help promote improvement in every specialty and subspecialty graduate medical education

(GME) program in the United States. The Milestones were not designed or intended for use by

external entities, such as state medical licensing boards or credentialing entities, to inform or to

make high-stakes decisions. The ACGME is concerned that GME programs may artificially

inflate individual Milestones assessment data if the Milestones are used for high-stakes

decisions. Their value would risk being lost as an honest and valuable assessment tool for

continuous improvement and professional development.

The Milestones are designed only for use in evaluation of residents in the context of their

participation in ACGME-accredited programs. The Milestones provide a framework for the

assessment of the development of the resident in key dimensions of the elements of physician

competence in a specialty. They neither represent the entirety of the dimensions of the six Core

Competency domains, nor are they designed to be relevant in any other context.

The Level 4 milestones are designed as the graduation target but do not represent a graduation

requirement. Making decisions about readiness for graduation is the purview of the residency

program director. (See the Milestones FAQs for further discussion of this issue: “Can a

resident/fellow graduate if he or she does not reach every milestone?”).

NOTE: Program directors are urged to read the following article regarding appropriate use of the

Milestones (located under the Other Resources heading):

• Use of Individual Milestones Data by External Entities for High Stakes Decisions - A

Function for Which they Are not Designed or Intended

Milestones resources

The ACGME provides many resources for residents, faculty members, and

program administration and leadership, and new resources are developed regularly.

Visit the Milestones/Resources section of the ACGME website to review available resources

and tools.

ACGME Case Log System

When applicable, Case Logs must also be used by the program director to determine if

residents are able to engage in independent practice upon completion of their educational

program. The program director should monitor residents’ Case Logs throughout their training to

ensure they are able to meet Case Log minima for their specialty, if applicable, and to achieve

competence in key procedures.

179

COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.A. R

esident Evaluation

V.A.2. Final Evaluation

V.A.2.a) T

he program director must provide a final evaluation for each

resident upon completion of the program.

(Core)

V.A.2

.a).(2) The final evaluation must:

V.A

.2.a).(2).(a) become part of the resident’s permanent record

maintained by the institution, and must be

accessible for review by the resident in

accordance with institutional policy;

(Core)

V.A.2

.a).(2).(b) verify that the resident has demonstrated the

knowledge, skills, and behaviors necessary to

enter autonomous practice; and,

(Core)

V.A

.2.a).(2).(c) be shared with the resident upon completion of

the program.

(Core)

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GUIDANCE

It is important to note that the final evaluation requirement specified in Common Program

Requirement V.A.2.a).(2) is different from the verification of training and education specified in

Common Program Requirement II.A.4.a).(10). Program directors may use one form to meet

both the requirement for final evaluation and verification of training and education, but they must

ensure that the final evaluation includes the specific elements identified below as well as in

Common Program Requirement V.A.2.a).(1). Some of the most common elements that are

missed by programs and are cited by Review Committees when programs use the same form

for verification of training and final evaluation relate to:

• the specific language around readiness for autonomous practice; and,

• review of milestones and, as applicable, Case Log System data.

The Verification of Graduate Medical Education Training (VGMET) Form, which programs

can use or adapt to their needs, was jointly developed by several organizations: the American

Hospital Association (AHA), the National Association Medical Staff Services (NAMSS), the

Organization of Program Director Associations (OPDA), and the ACGME. It is designed to

satisfy national credentialing standards, and to be completed once (and only once) by the

program director, and then copied and re-used in perpetuity.

V.A.2.a).(2).(a) [The final evaluation must:] become part of the resident’s

permanent record maintained by the institution, and must be accessible for

review by the resident in accordance with institutional policy.

This requirement is self-explanatory.

V.A.2.a).(2).(b) [The final evaluation must:] verify that the resident has

demonstrated the knowledge, skills, and behaviors necessary to enter

autonomous practice.

It is important for the program director to affirmatively state in the final evaluation, “Dr. [resident

name] has demonstrated the knowledge, skills, and behaviors necessary to enter autonomous

practice.” It is also desirable to add the specialty or subspecialty, i.e., “…to enter autonomous

practice of [specialty].” This is a frequently missed and cited requirement and therefore, program

directors are strongly encouraged to ensure that this language is included in the final evaluation.

Whil

e Milestones assessments and Case Logs must be used in the determination of an

individual resident’s ability to practice autonomously, the achievement of specific milestones by

an individual resident or the number of procedures performed do not need to be documented in

the final evaluation. See Common Program Requirement V.A.2.a).(1) for additional information.

V.A.2.a).(2).(c) [The final evaluation must:] be shared with the resident upon

completion of the program.

This requirement is self-explanatory.

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COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.A. Resident Evaluation

V.A.3. A Clinical Competency Committee must be appointed by the program

director.

(Core)

V.A.3.a) At a minimum, the Clinical Competency Committee must

include three members of the program faculty, at least one of

whom is a core faculty member.

(Core)

V.A.3.a).(1) Additional members must be faculty members from

the same program or other programs, or other health

professionals who have extensive contact and

experience with the program’s residents.

(Core)

Background and Intent: The requirements regarding the Clinical Competency

Committee do not preclude or limit a program director’s participation on the Clinical

Competency Committee. The intent is to have flexibility for each program to decide the

best structure for its own circumstances, but a program should consider: Its program

director’s other roles as resident advocate, advisor, and confidante; the impact of the

program director’s presence on the other Clinical Competency Committee members’

discussions and decisions; the size of the program faculty; and other program-relevant

factors. Inclusivity is an important consideration in the appointment of Clinical

Competency Committee members, allowing for diverse participation to ensure fair

evaluation. The program director has final responsibility for resident evaluation and

promotion decisions.

Program faculty may include more than the physician faculty members, such as other

physicians and non-physicians who teach and evaluate the program’s residents.

There may be additional members of the Clinical Competency Committee. Chief

residents who have completed core residency programs in their specialty may be

members of the Clinical Competency Committee.

V.A.3.b) The Clinical Competency Committee must:

V.A.3.b).(1) review all resident evaluations at least semi-annually;

(Core)

V.A.3.b).(2) determine each resident’s progress on achievement of

the specialty-specific Milestones; and,

(Core)

V.A.3.b).(3) meet prior to the residents’ semi-annual evaluations

and advise the program director regarding each

resident’s progress.

(Core)

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GUIDANCE

The membership of the Clinical Competency Committee (CCC) and the roles of the program

director, physician and non-physician faculty members, and chief residents are outlined in the

Background and Intent section preceding these requirements. The requirements are

purposefully stated in general terms to allow programs flexibility to include individuals who are

most appropriate locally, and to structure their meetings according to their specific needs. Note

that the role of the chief resident on the CCC is clarified. Chief residents who have completed

specialty or core residency programs can be members of the CCC. For example, someone who

has completed an internal medicine or pediatrics residency program and is then appointed as

chief resident would qualify for membership. However, chief residents in surgery are in their fifth

year of the educational program and are residents, and therefore cannot serve on the CCC.

Program coordinators are essential in the CCC process through their involvement with many, if

not all, aspects of the program, and their knowledge of the residents. Program coordinators may

attend CCC meetings in an administrative role at the discretion of the program director.

However, the program coordinator cannot be a CCC member, or make judgments in or after the

meeting regarding resident performance. Program coordinators should provide assessment and

feedback through the program’s assessment system, such as by participating in multisource

assessment instruments.

Accreditation Data System (ADS) screenshot: Clinical Comptency Committee

membership

All programs are expected to provide the membership of the CCC as part of a new application

or during the ADS Annual Update. This question is located on the Program Tab > Overall

Evaluation Methods – CCC Membership.

V.A.3.b).(1): If there is a disagreement in assessment between the program director and the

CCC, note V.A.2. and V.A.2.a) The program director must provide a final evaluation for

each resident upon completion of the program.

(Core)

Common Program Requirements V.A.3.b).(1) - (3) articulate three critical responsibilities of the

CCC. The CCC must review all resident evaluations at least semi-annually. Based on the size

and structure of the program, this expectation may be insufficient to assess all residents and

some programs may have CCCs that meet quarterly or monthly. The CCC is also responsible

for reviewing each resident’s progress on the specialty-specific Milestones. Finally, the CCC

must meet prior to the residents’ semi-annual evaluations and advise the program director about

each resident’s progress.

Resources

Online resources related to CCCs and the Milestones can be found at

https://www.acgme.org/milestones/resources/.

183

COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.B. Faculty

Evaluation

V.B.1. The program must have a process to evaluate each faculty

member’s performance as it relates to the educational program at

least annually.

(Core)

Background and Intent: The program director is responsible for the educational program and

all educators While the term “faculty” may be applied to physicians within a given institution

for other reasons, it is applied to residency program faculty members only through approval

by a program director. The development of the faculty improves the education, clinical, and

research aspects of a program. Faculty members have a strong commitment to the resident

and desire to provide optimal education and work opportunities. Faculty members must be

provided feedback on their contribution to the mission of the program. All faculty members

who interact with residents desire feedback on their education, clinical care, and research. If

a faculty member does not interact with residents, feedback is not required. With regard to

the diverse operating environments and configurations, the residency program director may

need to work with others to determine the effectiveness of the program’s faculty

performance with regard to their role in the educational program. All teaching faculty

members should have their educational efforts evaluated by the residents in a confidential

and anonymous manner. Other aspects for the feedback may include research or clinical

productivity, review of patient outcomes, or peer review of scholarly activity. The process

should reflect the local environment and identify the necessary information. The feedback

from the various sources should be should be summarized and provided to the faculty on an

annual basis by a member of the leadership team of the program.

V.B.1

.a) This evaluation must include a review of the faculty member’s

clinical teaching abilities, engagement with the educational

program, participation in faculty development related to their

skills as an educator, clinical performance, professionalism,

and scholarly activities.

(Core)

V.B.1

.b) This evaluation must include written, anonymous, and

confidential evaluations by the residents.

(Core)

V.B.2

. Faculty members must receive feedback on their evaluations at least

annually.

(Core)

V.B.3

. Results of the faculty educational evaluations should be

incorporated into program-wide faculty development plans.

(Core)

Background and Intent: The quality of the faculty’s teaching and clinical care is a

determinant of the quality of the program and the quality of the residents’ future clinical care.

Therefore, the program has the responsibility to evaluate and improve the program faculty

members’ teaching, scholarship, professionalism, and quality care. This section mandates

annual review of the program’s faculty members for this purpose, and can be used as input

into the Annual Program Evaluation.

184

GUIDANCE

The section of the Common Program Requirements addressing faculty evaluation has several

components:

1. who to evaluate;

2. what to evaluate − clinical teaching abilities, engagement with the educational program,

participation in faculty development related to their skills as an educator, clinical

performance, professionalism and scholarly activities;

3. when to evaluate − faculty members’ feedback on their evaluations at least annually; and

4. how to use evaluations − results of faculty educational evaluations incorporated into

faculty development plans

Who to evaluate

As stated in the Background and Intent, all teaching faculty members who have significant

interactions with the residents must receive feedback.

What to evaluate

Faculty members should be evaluated based on their role in resident education, including

clinical care, teaching, and research, in aspects such as clinical productivity, review of patient

outcomes, or peer review of scholarly activity. Sometimes, the program director may need to

work with others to determine the effectiveness of faculty members’ performance regarding their

role in the educational program. The process should reflect the local environment and identify

the necessary information.

As not

ed in the Background and Intent, assessment of faculty members is an important part of

improving the teaching program. Feedback is important to help individual faculty members

measure and increase their contribution to the mission of the program and improve their

individual effectiveness as teachers. It is suggested that assessment include research and

scholarly activity, clinical work, and educational activities. The specific requirement for written

and confidential evaluations of faculty members is intended to collect the most honest feedback

from the residents, which requires minimizing any possibility for fear of retaliation or intimidation

of the residents resulting from comments made.

V.B.1.b) This evaluation must include written, anonymous, and confidential

evaluations by the residents.

Programs with a small number of residents often struggle to maintain the confidentiality of a

resident’s evaluation. For a confidential evaluation, the reviewer is not known by the individual

being evaluated, but the identity of the evaluator might be known by someone such as the

program director or departmental chair. For an anonymous evaluation, the evaluator is not

known by anyone, offering a higher level of security. Frequently, feedback from multiple

anonymous evaluations is aggregated so that it is impossible to guess the individual source.

The advantage

of a confidential evaluation is that someone can respond if needed to an

egregious situation if it is reported or that a residency program director or departmental chair

can place the information in better context. Confidential evaluations only work if the residents

trust their identity will be kept secret, which requires they must have a high degree of trust in the

individual who knows their identity. The trusted individual may be the program coordinator who

is collecting the evaluations or the program director or department chair who oversees the

faculty member. However, these individuals may be intimidating to a resident because of their

supervisory relationship. In this instance, the trusted individual must be someone else,

185

particularly when the resident is evaluating the program director and the department chair.

Another scenario has the trusted individual being someone outside of the program, such as the

designated institutional official (DIO) or an individual who reports to a different department.

The advantage

of an anonymous evaluation is that it is the most reassuring to the resident.

Anonymous evaluations may be accomplished by collecting them via a system that does not

identify an individual resident. Because it might be possible for faculty members to guess the

identity by timing when the evaluation appears, the individual comments might be collected

throughout the year and batched feedback might be best given at the end of the year or even

over two years for very small programs. Another option is to batch resident feedback across

multiple programs with which the faculty member is associated.

Confi

dentiality is at risk when the written evaluation contains details that might identify a specific

patient, case, or resident interaction that the faculty member can recall and attribute to the

specific individual resident.

Confi

dential faculty evaluations are a critical piece of information to help improve the program,

but they are a special challenge in small programs. Some of the strategies above may help to

collect that information while preserving confidentiality.

The ACG

ME monitors compliance with Common Program Requirements V.B.1.- 3. in various

ways, including:

• questions answered by program leadership as part of an application or during the ADS

Annual Update;

• documents submitted by programs as part of an application or site visit (e.g., sample

evaluation forms);

• questions answered by residents and faculty members as part of the annual

Resident/Fellow and Faculty Surveys; and

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

The Resident

/Fellow and Faculty Surveys include several questions that address the

requirements in section V.B.1.-3. The ACGME has prepared two documents, a “Resident/Fellow

Survey−Common Program Requirements Crosswalk” and a “Faculty Survey−Common Program

Requirements Crosswalk,” to provide additional information for programs on the key areas

addressed by the survey questions and how they map to the ACGME Common Program

Requirements. These documents can be found at

https://www.acgme.org/data-systems-

technical-support/resident-fellow-and-faculty-surveys.

Many i

nstitutions have “home-grown” versions of faculty evaluation forms. In addition,

departments may have annual evaluation forms that address clinical performance, role in

education, and scholarship. Some examples of these efforts are included below:

1. Kassis,

Karyn, Rebecca Wallihan, Larry Hurtubise, Sara Goode, Margaret Chase, and

John Mahan. 2017. “Milestone-Based Tool for Learner Evaluation of Faculty Clinical

Teaching.” MedEdPORTAL Publications 13.

https://doi.org/10.15766/mep_2374-

8265.10626.

Created a 10-question evaluation tool to assess clinical teaching skills with descriptive

Milestones behavior anchors using a combination of the Stanford Faculty Development

Clinical Teaching Model and annual ACGME Resident/Fellow Survey questions.

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Conclusion: The tool provided faculty members with more meaningful teaching evaluations

and feedback.

Domains:

• Milestone 1: Establishes positive learning domain

• Milestone 2: Maintains control of educational session

• Milestone 3: Establishes learning goals

• Milestone 4: Promotes understanding and retention of knowledge and skills

• Milestone 5: Provides formative feedback

• Milestone 6: Promotes clinical reasoning

• Milestone 7: Promotes evidence-based medicine

• Milestone 8: Promotes self-directed learning in learners

• Milestone 9: Balances supervision and autonomy

• Milestone 10: Displays professionalism

2. Mintz, Marcy, Danielle A. Southern, William A. Ghali, and Irene W. Y. Ma. 2015.

“Validation of the 25-Item Stanford Faculty Development Program Tool on Clinical

Teaching Effectiveness.” Teaching and Learning in Medicine 27(2): 174–81.

https://doi.org/10.1080/10401334.2015.1011645

Domains:

• Learning climate

• Control of session

• Communication of goals

• Promotes understanding and retention

• Evaluation

• Feedback

Promotes self-directed learning

3. Williams, Brent C., Debra K. Litzelman, Stewart F. Babbott, Robert M. Lubitz, and Tim

P. Hofer. 2002. “Validation of a Global Measure of Facultyʼs Clinical Teaching

Performance.” Academic Medicine 77(2): 177–80.

https://doi.org/10.1097/00001888-

200202000-00020.

Created a Global Rating Scale (GRS) – a single-item, five-point global measure of faculty

members’ clinical teaching performance previously known to be reliable.

Evaluation completed by 98 senior medical residents from four academic institutions; also

completed the 26-item Stanford Faculty Development questionnaire for 10 faculty members

with whom they had teaching contact during residency.

The GRS correlated highly with measures of seven specific aspects of teaching

effectiveness. The scale is reportedly simple to use, readily administered as part of an

incentive or reward program, or for review in promotion decisions.

V.B.2.-V.B.3 Faculty members must receive feedback on their evaluations at least

annually; results of faculty educational evaluations should be incorporated into

program-wide faculty development plans.

The feedback should include strengths and opportunities for improvement, and be considered in

planning for faculty development sessions and tracked as part of the Annual Program

Evaluation. For example, if residents’ evaluations of faculty members consistently show that

faculty members’ evaluations are not constructive and do not provide information to help the

residents improve, there might be a need to provide faculty development on resident evaluation.

187

COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.C. P

rogram Evaluation and Improvement

V.C.1. The program director must appoint the Program Evaluation

Committee to conduct and document the Annual Program

Evaluation as part of the program’s continuous improvement

process.

V.C.1

.a) The Program Evaluation Committee must be composed of at

least two program faculty members, at least one of whom is a

core faculty member, and at least one resident.

(Core)

V.C.1

.b) Program Evaluation Committee responsibilities must include:

V.C.1.b).(1) review of the program’s self-determined goals and

progress toward meeting them;

(Core)

V.C.1

.b).(2) guiding ongoing program improvement, including

development of new goals, based upon outcomes;

and,

(Core)

V.C.1

.b).(3) review of the current operating environment to identify

strengths, challenges, opportunities, and threats as

related to the program’s mission and aims.

(Core)

Background and Intent: To achieve its mission and educate and train quality

physicians, a program must evaluate its performance and plan for improvement in the

Annual Program Evaluation. Performance of residents and faculty members is a

reflection of program quality, and can use metrics that reflect the goals that a program

has set for itself. The Program Evaluation Committee utilizes outcome parameters and

other data to assess the program’s progress toward achievement of its goals and aims.

The Program Evaluation Committee advises the program director through program

oversight.

V.C.1

.c) The Program Evaluation Committee should consider the

outcomes from prior Annual Program Evaluation(s),

aggregate resident and faculty written evaluations of the

program, and other relevant data in its assessment of the

program.

(Core)

Background and Intent: Other data to be considered for assessment include:

• Curriculum

• ACGME letters of notification, including citations, Areas for Improvement, and

comments

• Quality and safety of patient care

• Aggregate resident and faculty well-being; recruitment and retention; workforce

diversity, including graduate medical education staff and other relevant

188

academic community members; engagement in quality improvement and patient

safety; and scholarly activity

• ACGME Resident and Faculty Survey results

• Aggregate resident Milestones evaluations, and achievement on in-training

examinations (where applicable), board pass and certification rates, and

graduate performance.

1. Aggregate faculty evaluation and professional development

V.C.1

.d) The Program Evaluation Committee must evaluate the

program’s mission and aims, strengths, areas for

improvement, and threats.

(Core)

V.C.1

.e) The Annual Program Evaluation, including the action plan,

must be distributed to and discussed with the residents and

the members of the teaching faculty, and be submitted to the

DIO.

(Core)

189

GUIDANCE

As the Background and Intent outlines, programs must evaluate their performance and plan for

improvement in the Annual Program Evaluation. Common Program Requirement V.C.1.

requires that each program must have a Program Evaluation Committee (PEC) appointed by

the program director to advise the program director through program oversight and conduct and

document the Annual Program Evaluation.

V.C.1.a) Composition of the PEC

The PEC must include at least two program faculty members, at least one of whom is a core

faculty member, and at least one resident. Members of the PEC should know the program well

and be invested in program improvement and success. Resident members are important

because they “live and work” within the context of the program.

Accreditation Data System (ADS) screenshot: composition of the PEC

Programs must provide the membership of the PEC in ADS when submitting a new application

or as part of the ADS Annual Update.

V.C.1.b) PEC responsibilities

The PEC has three key responsibilities as outlined in Common Program Requirements

V.C.1.b).(1)-(3):

1. review of the program’s goals and progress toward meeting them;

2. guiding ongoing program improvement, including development of new goals, based

upon outcomes; and

3. review of the current operating environment to identify strengths, challenges,

opportunities, and threats as related to the program’s mission and aims.

V.C.1.c) Data to be considered for the Annual Program Evaluation

This requirement outlines three key elements the PEC must consider for the Annual Program

evaluation:

1. outcomes from prior Annual Program Evaluation(s);

2. aggregate resident and faculty written evaluations of the program; and

3. other relevant data.

The Back

ground and Intent provides further specification as to other relevant data the PEC can

consider:

• curriculum

• ACGME letters of notification, including citations, Areas for Improvement, and

Comments;

• quality and safety of patient care;

• aggregate resident and faculty well-being; recruitment and retention; and

• workforce diversity, including graduate medical education staff and other relevant

academic community members;

• engagement in quality improvement and patient safety;

190

• scholarly activity;

• ACGME Resident and Faculty Survey results;

• aggregate resident Milestones evaluations, and achievement on in-training examinations

(where applicable), board pass and certification rates, and graduate performance; and

• aggregate faculty evaluation and professional development.

This r

equirement permits flexibility to identify data and indicators that are feasible to measure

and relevant to an individual program’s aims.

Some Sponsoring Institutions have standardized

elements of Annual Program Evaluations and programs should consult with their designated

institutional official (DIO).

V.C.1.e) Dissemination of the Annual Program Evaluation and submission to the

DIO

While it is important that programs conduct and document an Annual Program Evaluation, this

requirement emphasizes the need to review and discuss the Annual Program Evaluation with

faculty members and residents and also share it with the (DIO. The Sponsoring Institution’s DIO

and Graduate Medical Education Committee (GMEC) are responsible for overseeing Annual

Program Evaluations. The DIO and GMEC may expect programs to submit Annual Program

Evaluation information in a specific format. The DIO should be contacted with any questions

about how to submit an annual review and action plan.

191

Suggested template for internal program use in the Annual Program Evaluation. Note

that this is a sample template and the ACGME does not require its use.

SAM

PLE Template – Annual Program Evaluation

(For Internal PROGRAM Use Only)

Program:

Date:

Academic Year:

Progr

am Evaluation Committee Membership:

Faculty Members:

1. _____________________________

2. _____________________________

3. _____________________________

Resi

dents:

1. _____________________________

2. _____________________________

Resident Complement

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Year 7

Positions

Approved

Current

Complement

Accred

itation Status of the Program

□ Continued Accreditation

□ Initial Accreditation

□ Continued Accreditation with Warning

□ Initial Accreditation with Warning

□ Probationary Accreditation

□ Continued Accreditation without Outcomes

Curr

ent Program Citations

Insert Text from ACGME

Letter of Notification (LON)

Current Program Response to Citation

Curr

ent Areas for Improvement (AFIs)

Insert Text from ACGME LON

Program Actions to Address

Areas for Improvement (AFIs)

192

Program Aims

Aim(s)

Met (M)/Unmet (U)

Plans f

or Unmet Goals

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

Str

engths of the Program

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

Challenges/Threats to the Program

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

Opportunities for the Program

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

Progr

am Curriculum

Curricular Element

Action: Modify (M),

Add (A) or Delete (D)

Steps Taken

Timeline for

Completion

Quali

ty Improvement (QI) and Patient Safety (PS)

QI/PS Activity

Active Role

Faculty (F) or

Resident

Has QI/PS

Improved in the

Past Year?

(Yes/No)

Describe

Improvement,

Including Efforts to

Include Faculty

Member(s) and

Residents

Describe QI/PS

Activities that

Can be Added or

Improved

193

Well-Being and Diversity

Activity

Successes

Needs Improvement

Well-being

Diversity

Recruitment

Retention

Scholar

ship

Resident/Faculty Scholarly

Activities

(append lists here)

If applicable, list efforts to increase scholarship

ACG

ME Annual Resident Survey

Areas with Improvement Areas with Deterioration

Plans to Address Areas of

Deterioration if Applicable

ACG

ME Annual Faculty Survey

Areas with Improvement Areas with Deterioration

Plans to Address Areas of

Deterioration if applicable

Wri

tten Evaluations of the Program

Who provides written evaluations of the program?

 Residents in this program

 Other hospital/clinic/facility personnel

 Residents/fellows in other programs

 Faculty members in other programs

 Faculty members in this program

Areas Identified for Program Improvement

Plans for Program Improvement/Target Date

194

Aggregate Resident Achievement of Milestones

Exceeded National Means Below National Means

Plans to Improve

Milestones Achievement

Aggrega

te Resident Performance on In-Training Examinations (if Applicable)

Performance of Cohort this

Year Compared to Prior Year

Subject Areas where Cohort

Fell Short of Program

Expectations

Plans to Improve

Performance on the

In-Training Examination

Aggrega

te Performance of Residents and Graduates on Board Certification Examinations

in the Specialty/Subspecialty Program

Number Eligible to Take

Number Eligible Who Took

the Written Examination

How Many of Those Who

Took the Exam Passed?

If appli

cable, how does the program plan to improve resident/graduate performance on

the examinations in the board certification process over the next year?

_________________________________________________________________

Perf

ormance of Program Graduates

In what ways does the program monitor the performance of program graduates?

 Surveys of the graduates

 Surveys of the partners of the graduates

 Surveys of the employers of the graduates

 Surveys of the practice sites (hospitals, clinics, etc.) of the graduates

 Monitoring of the continuing board certification of the graduates

 Monitoring of state licensing board actions against graduates

 Monitoring of medicolegal actions against graduates

 Program does not monitor program graduates’ performance

Areas for Improvement for Performance of

Graduates

Plans to Address Areas Identified

as Needing Improvement

195

Faculty Evaluation

By whom are the faculty members in this program evaluated (for their contributions to the

educational program)?

 Medical students

 Residents in this program

 Residents in other programs

 Peer faculty members in this program

 Peer faculty members in other programs

Areas for Improvement Identified for Faculty

Member Contributions to the Program

Plans to Address Areas Identified

as Needing Improvement

Faculty

Development Activities

List Faculty Development

Activities Available in the

Past Year

Percent Faculty Participation

If Applicable, How Does the

Program Plan to Increase

Participation in Faculty

Development Activities?

196

COMMON PROGRAM REQUIREMENTS

V.C.2. The program must complete a Self-Study and submit it to the DIO.

(Core)

Background and Intent: Outcomes of the documented Annual Program Evaluation can

be integrated into the Accreditation Self-Study process. The Self-Study is an objective,

comprehensive evaluation of the residency program, with the aim of improving it.

Underlying the Accreditation Self-Study is this longitudinal evaluation of the program

and its learning environment, facilitated through sequential Annual Program

Evaluations that focus on the required components, with an emphasis on program

strengths and self-identified areas for improvement. Details regarding the timing and

expectations for the Accreditation Self-Study are provided in the ACGME Manual of

Policies and Procedures. Additionally, a description of the

Self-Study process is

available on the ACGME website.

197

GUIDANCE

NOTE: The ACGME Program Self-Study was unlinked from the former 10-Year Accreditation

Site Visit. Click here for more information regarding the Program Self-Study.

Sponsor

ing Institution Self-Studies and 10-year Accreditation Site Visits are proceeding

according to the Institutional Review Committee’s announced plan.

Self-Study Description

The ACGME Program Self-Study was established as a key component of the ACGME’s current

accreditation model. With the goal of conducting an objective and comprehensive review of the

program, the Self-Study is a tool for program self-reflection and strategic planning that uses the

Annual Program Evaluation as a foundation on which to build the in-depth, multi-year program

evaluation.

Two conc

epts are fundamental in the development of the Self-Study:

1. determination of the program’s aims and mission; and

2. critical assessment of the institutional, local, regional, and even national environment

(context) in which the program operates.

These c

oncepts lead to a thoughtful analysis of program strengths, weaknesses, opportunities,

and threats that will allow a program to distinguish itself from other programs in the specialty

(e.g., highlighting differences between community and urban programs). Ultimately, the goal of

the Self-Study is to provide a platform for a forward-thinking and systematic approach to making

program improvements.

Progr

ams are encouraged to include a broad array of participants in the Self-Study process,

including program leaders, residents, faculty members, and other stakeholders, such as

program graduates, institutional and quality improvement personnel, leaders from related

programs, or nursing and other health care personnel who interact closely with the residents in

the program.

198

COMMON PROGRAM REQUIREMENTS

V. Evaluation

V.C.

Program Evaluation and Improvement

V.C.3. One goal of ACGME-accredited education is to educate physicians who

seek and achieve board certification. One measure of the effectiveness of

the educational program is the ultimate pass rate.

The progra

m director should encourage all eligible program graduates to

take the certifying examination offered by the applicable American Board of

Medical Specialties (ABMS) member board or American Osteopathic

Association (AOA) certifying board. [If certification in the specialty is not

offered by the ABMS and/or the AOA, V.C.3.a)-V.C.3.f) will be omitted.]

V.C.3

.a) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) an annual written exam, in the preceding

three years, the program’s aggregate pass rate of those taking the

examination for the first time must be higher than the bottom fifth

percentile of programs in that specialty.

(Outcome)

V.C.3

.b) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) a biennial written exam, in the preceding six

years, the program’s aggregate pass rate of those taking the

examination for the first time must be higher than the bottom fifth

percentile of programs in that specialty.

(Outcome)

V.C.3

.c) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) an annual oral exam, in the preceding three

years, the program’s aggregate pass rate of those taking the

examination for the first time must be higher than the bottom fifth

percentile of programs in that specialty.

(Outcome)

V.C.3

.d) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) a biennial oral exam, in the preceding six

years, the program’s aggregate pass rate of those taking the

examination for the first time must be higher than the bottom fifth

percentile of programs in that specialty.

(Outcome)

V.C.3

.e) For each of the exams referenced in V.C.3.a)-d), any program whose

graduates over the time period specified in the requirement have

achieved an 80 percent pass rate will have met this requirement, no

matter the percentile rank of the program for pass rate in that

specialty.

(Outcome)

Background and Intent: Setting a single standard for pass rate that works across

specialties is not supportable based on the heterogeneity of the psychometrics of

different examinations. By using a percentile rank, the performance of the lower five

199

percent (fifth percentile) of programs can be identified and set on a path to curricular

and test preparation reform.

There are specialties where there is a very high board pass rate that could leave

successful programs in the bottom five percent (fifth percentile) despite admirable

performance. These high-performing programs should not be cited, and V.C.3.e) is

designed to address this.

V.C.3

.f) Programs must report, in ADS, board certification status annually

for the cohort of board-eligible residents that graduated seven years

earlier.

(Core)

Background and Intent: It is essential that residency programs demonstrate knowledge

and skill transfer to their residents. One measure of that is the qualifying or initial

certification exam pass rate. Another important parameter of the success of the

program is the ultimate board certification rate of its graduates. Graduates are eligible

for up to seven years from residency graduation for initial certification. The ACGME

will calculate a rolling three-year average of the ultimate board certification rate at

seven years post-graduation, and the Review Committees will monitor it.

The R

eview Committees will track the rolling seven-year certification rate as an

indicator of program quality. Programs are encouraged to monitor their graduates’

performance on board certification examinations.

In the future, the ACGME may establish parameters related to ultimate board

certification rates.

200

GUIDANCE

V.C.3. Program Aggregate Board Pass Rate

Board pass rate is one outcome that can demonstrate how well a program prepares its

graduates for independent practice. Review Committees consider variability from year to year in

a program’s board pass rate during program review (especially in small programs). While one

resident failing the board exam(s) in a small program may have a relatively larger negative

impact on the pass rate, the opposite is also true; one resident passing the board exam(s) will

also have a greater positive impact and may provide the opportunity for program improvement

to occur more easily.

V.C.3.a) Annual written board examination pass rate

In specialties that offer an annual written board examination, the three-year rolling

average for first-time takers passing the written board examination will be calculated for

each program and ranked against other programs in the specialty. Those programs

above the fifth percentile in that ranking will not be cited by the Review Committee for

failure to meet the required standard for this program outcome measure.

V.C.3.b) Biennial written board examination pass rate

In specialties that offer a written board examination only on a biennial basis, the six-year

rolling average for first-time takers passing the written board examination will be

calculated for each program and ranked against other programs in the specialty. Those

programs above the fifth percentile in that ranking will not be cited by the Review

Committee for failure to meet the required standard for this program outcome measure.

V.C.3.c) Annual Oral Board Examination Pass Rate

In specialties that offer an annual oral board examination, the three-year rolling average

for first-time takers passing the oral board examination will be calculated for each

program and ranked against other programs in the specialty. Those programs above the

fifth percentile in that ranking will not be cited by the Review Committee for failure to

meet the required standard for this program outcome measure.

V.C.3.d) Biennial oral board examination pass rate

In specialties that offer an oral board examination only on a biennial basis, the six-year

rolling average for first-time takers passing the oral board examination will be calculated

for each program and ranked against other programs in the specialty. Those programs

above the fifth percentile in that ranking will not be cited by the Review Committee for

failure to meet the required standard for this program outcome measure.

V.C.3.e) 80 percent pass rate

Only programs meeting both of the following conditions will receive a citation for this

requirement:

1. the p

rogram must be in the lowest five percent of all programs in the specialty for board

pass rate; and,

2. the program must have a board pass rate below 80 percent.

201

In other words, if there are 100 programs in a specialty, approximately five programs could

receive that citation, but only if their individual board pass rate for graduates is below 80

percent.

The board pas

s rate for first-time takers will count those who pass in the numerator and those

who are taking the exam for the first time in the denominator. Residency graduates who do not

take the exam, or those who are taking it for the second time or more, do not count in the

denominator. A resident who delays taking the examination will be counted in the year that the

resident takes the exam.

The board pas

s rate for each program is reported to the ACGME directly from the ABMS

member board and the AOA board in the specialty. No names or other individual identifiers are

reported to the ACGME.

If board pass rates are an area of concern for a program, programs are strongly encouraged to

provide the Review Committee with an update on their efforts to improve this metric in the Major

Changes section of the Accreditation Data System (ADS) during the ADS Annual update. The

following list identifies strategies which programs may use to investigate and address concerns

related to board pass rates:

1. The program may evaluate its didactic curriculum to identify weaknesses and make

efforts to improve.

2. The annual in-training examination results can be helpful in identifying content area(s)

where residents did not perform well. In addition, the in-training examination helps

identify those residents who are underperforming in comparison to their peers.

3. A structured certifying board examination review can be implemented, addressing

content specifications of the specialty board.

4. Some residents may benefit from a more structured plan outlined in an individualized

learning plan (see Common Program Requirement V.A.1.d).(2)).

5. The Program Evaluation Committee should include board certification data and in-

training examination performance as part of the Annual Program Review. This review

could determine whether program changes such as changes in the didactic curriculum

and the establishment of conferences to address curricular weaknesses might be

needed.

V.C.3.f) Ultimate Board Pass Rate

The ultimate board pass rate of a program’s graduates is an important program outcome in

addition to the rolling average first-time pass rate noted in Common Program Requirements

V.C.3.a)-e). Neither should be considered in isolation. Note that most member boards of the

ABMS and AOA certifying Boards allow up to seven years for a candidate to achieve board

certification.

Whil

e the most recent three-year rolling average board pass rate may best reflect the

preparation of the most recent graduates, the ultimate certification rates likely reflect the

ultimate goal of the program: to produce graduates who can practice independently and achieve

board certification. This requirement is intended to allow the ACGME to gather data on this

outcome and determine its best use. The Program Evaluation Committee may also find this

information valuable in assessing the program aims and goals. A screenshot of the summary

data the ACGME provides to programs on ultimate resident board certification status can be

found below.

202

The requir

ement does not specify a minimum for the ultimate certification rate, and programs

will not currently be cited based on the requirement unless they fail to confirm the data provided

by the ABMS and AOA and populated in ADS for their residents on a yearly basis. Programs

203

cannot edit the graduate list, but they can edit the certification if incorrect, add a certification if it

is not displayed, or confirm that the program was not accredited or there were no graduates for

the specific reporting year. Data for the current reporting year can be edited as part of the

Annual ADS Update or through the end of the academic year. Once the rollover to a new

academic year occurs, the graduate data will be “View Only” and no edits can be made.

Accreditation Data System (ADS) screenshot: The screenshot below shows the

resident board certification data imported from the ABMS and AOA and which

programs must verify during the ADS Annual Update.

204

COMMON PROGRAM REQUIREMENTS

VI. The Learning and Working Environment

Residenc

y education must occur in the context of a learning and working

environment that emphasizes the following principles:

• Excell

ence in the safety and quality of care rendered to patients by fellows

today

• Excell

ence in the safety and quality of care rendered to patients by today’s

fellows in their future practice

• Excellence in professionalism

• Appreci

ation for the privilege of providing care for patients

• Comm

itment to the well-being of the students, residents, fellows, faculty

members, and all members of the health care team

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability

VI.A

.1. Patient Safety and Quality Improvement

VI.A.1.a) Patient Safety

VI.A

.1.a).(1) Culture of Safety

A cult

ure of safety requires continuous identification

of vulnerabilities and a willingness to transparently

deal with them. An effective organization has formal

mechanisms to assess the knowledge, skills, and

attitudes of its personnel toward safety in order to

identify areas for improvement.

VI.A

.1.a).(1).(a) The program, its faculty, residents, and fellows

must actively participate in patient safety

systems and contribute to a culture of safety.

(Core)

VI.A

.1.a).(2) Patient Safety Events

Report

ing, investigation, and follow-up of safety

events, near misses, and unsafe conditions are pivotal

mechanisms for improving patient safety, and are

essential for the success of any patient safety

program. Feedback and experiential learning are

essential to developing true competence in the ability

to identify causes and institute sustainable systems-

205

based changes to ameliorate patient safety

vulnerabilities.

VI.A

.1.a).(2).(a) Residents, fellows, faculty members, and other

clinical staff members must:

VI.A

.1.a).(2).(a).(i) know their responsibilities in reporting

patient safety events and unsafe

conditions at the clinical site, including

how to report such events; and,

(Core)

VI.A.1.a).(2).(a).(ii) be provided with summary information

of their institution’s patient safety

reports

. (Core)

*VI.

A.1.a).(2).(b) Residents must participate as team members in

real and/or simulated interprofessional clinical

patient safety and quality improvement

activities, such as root cause analyses or other

activities that include analysis, as well as

formulation and implementation of actions.

(Core)

VI.A.1.a).(3) Quality Metrics

Access to da

ta is essential to prioritizing activities for

care improvement and evaluating success of

improvement efforts.

VI.A

.1.a).(3).(a) Residents and faculty members must receive

data on quality metrics and benchmarks related

to their patient populations.

(Core)

[The Review Committee may further specify]

206

GUIDANCE

A number of studies prove why it so important to teach residents and fellows safe patient care

and quality improvement. The examples provided below demonstrate what residents and

fellows learn during their education and training stays with them and affects their practice for

many years to come: the 32-year-old fellow today has the potential to be practicing beyond

2054.

1. Asch,

David A. 2009. “Evaluating Obstetrical Residency Programs Using Patient

Outcomes.” JAMA 302(12): 1277. https://doi.org/10.1001/jama.2009.1356

Asch et al. studied 4,906,169 deliveries by 4,124 physicians from 107 US obstetrics and

gynecology residency programs. The programs were ranked based on FLEX, NBME Parts I,

II, III, and USMLE Steps 1, 2, 3 scores. The study found that women treated by obstetricians

in the bottom quintile of programs had one-third higher complication rates than those from

the top quintile, and that the effect was durable through 15-17 years after residency.

2. Chen, C

andice, Stephen Petterson, Robert Phillips, Andrew Bazemore, and Fitzhugh

Mullan. 2014. “Spending Patterns in Region of Residency Training and Subsequent

Expenditures for Care Provided by Practicing Physicians for Medicare Beneficiaries.”

JAMA 312(22): 2385. https://doi.org/10.1001/jama.2014.15973

Chen et al evaluated spending patterns in regions of residency education and training and

graduates’ subsequent expenditures in practice based on multilevel, multivariable analysis

of 2011 Medicare claims data from family medicine and internal medicine residents

completing residency between 1992 and 2010. The Hospital Referral Regions (HRR) were

classified based on expenditures as low-, average-, and high-spending. The table below

documents that spending levels during residency were associated with the same pattern of

expenditures for subsequent care provided by graduates.

3. Sirovich, Brenda E., Rebecca S. Lipner, Mary Johnston, and Eric S. Holmboe.

2014. “The Association between Residency Training and Internists’ Ability to

Practice Conservatively.” JAMA Internal Medicine 174(10): 1640.

https://doi.org/10.1001/jamainternmed.2014.3337.

207

Sirovich et al. evaluated the association between residency education and training and

internists’ ability to practice conservatively following graduation, assessing the responses of

6,639 first-time takers of the American Board of Internal Medicine certifying exam (357

programs). They divided the management options according to Appropriately Conservative

Management (ACM) and Appropriately Aggressive Management (AAM) subscales. They

defined the correct response as the least or most aggressive management strategy, and

found that regardless of overall medical knowledge, internists trained in HRRs (Hospital

Referral Regions) with lower-intensity medical practice were more likely to recognize when

conservative management was appropriate and, more importantly, were capable of

choosing an aggressive approach when indicated.

Additional references

• Chan, David K., Thomas H. Gallagher, Richard Reznick, and Wendy Levinson. 2005.

“How Surgeons Disclose Medical Errors to Patients: A Study Using Standardized

Patients.” Surgery 138(5): 851–58. https://doi.org/10.1016/j.surg.2005.04.015

• Gallagher, Thomas H. 2003. “Patients’ and Physicians’ Attitudes Regarding the

Disclosure of Medical Errors.” JAMA 289(8): 1001.

https://doi.org/10.1001/jama.289.8.1001.

• Gallagher, Thomas H., Jane M. Garbutt, Amy D. Waterman, David R. Flum, Eric B.

Larson, Brian M. Waterman, W. Claiborne Dunagan, Victoria J. Fraser, and Wendy

Levinson. 2006. “Choosing Your Words Carefully.” Archives of Internal Medicine

166(15): 1585. https://doi.org/10.1001/archinte.166.15.1585

• Kessler, David A. 1993. “Introducing MEDWatch. A New Approach to Reporting

Medication and Device Adverse Effects and Product Problems.” JAMA 269(21): 2765–

68. https://doi.org/10.1001/jama.1993.03500210065033

• Leape, Lucian L. 2002. “Reporting of Adverse Events.” New England Journal of

Medicine 347(20): 1633–38. https://doi.org/10.1056/nejmnejmhpr011493.

• Nebeker, Jonathan R., Paul Barach, and Matthew H. Samore. 2004. “Clarifying Adverse

Drug Events: A Clinician’s Guide to Terminology, Documentation, and Reporting.”

Annals of Internal Medicine 140(10): 795.

https://doi.org/10.7326/0003-4819-140

-10-

200405180-00009.

• White, Andrew A., Thomas H. Gallagher, Melissa J. Krauss, Jane Garbutt, et al. 2008.

“The Attitudes and Experiences of Trainees Regarding Disclosing Medical Errors to

Patients.” Academic Medicine 83(3): 250–56.

https://doi.org/10.1097/acm.0b013e3181636e96

Clinical Learning Environment Review (CLER) findings for graduate medical

education in patient safety

The ACGME established the CLER Program to provide formative assessment and feedback to

participating sites of ACGME-accredited Sponsoring Institutions. CLER findings and other

information contained in CLER National Reports are not linked to ACGME Program

Requirements but may provide useful insights for programs. Actions taken in response to CLER

findings should not be interpreted as fulfilling Program Requirements.

Findings o

f CLER site visits for creating an environment for safe patient care and quality

improvement are summarized in CLER Issue Brief No. 2 (2016) and CLER Issue Brief No. 3

(2016), which can be found on the Resources and Documents

page of the CLER section of the

ACGME website.

208

COMMON PROGRAM REQUIREMENTS

VI. The Learning and Working Environment

VI.A

.2. Supervision and Accountability

VI.A.2.a) Although the attending physician is ultimately responsible for

the care of the patient, every physician shares in the

responsibility and accountability for their efforts in the

provision of care. Effective programs, in partnership with

their Sponsoring Institutions, define, widely communicate,

and monitor a structured chain of responsibility and

accountability as it relates to the supervision of all patient

care.

Supervi

sion in the setting of graduate medical education

provides safe and effective care to patients; ensures each

resident’s development of the skills, knowledge, and attitudes

required to enter the unsupervised practice of medicine; and

establishes a foundation for continued professional growth.

VI.A

.2.a).(1) Residents and faculty members must inform each

patient of their respective roles in that patient’s care

when providing direct patient care.

(Core)

VI.A.2.a).(1).(a) This information must be available to residents,

faculty members, other members of the health

care team, and patients.

(Core)

Background and Intent: Each patient will have an identifiable and appropriately

credentialed and privileged attending physician (or licensed independent practitioner

as specified by the applicable Review Committee) who is responsible and accountable

for the patient’s care.

VI.A

.2.a).(2) The program must demonstrate that the appropriate

level of supervision in place for all residents is based

on each resident’s level of training and ability, as well

as patient complexity and acuity. Supervision may be

exercised through a variety of methods, as appropriate

to the situation.

(Core)

[The Review Committee may specify which activities

require different levels of supervision.]

Background and Intent: Appropriate supervision is essential for patient safety and high-

quality teaching. Supervision is also contextual. There is tremendous diversity of resident-

patient interactions, education and training locations, and resident skills and abilities, even at

the same level of the educational program. The degree of supervision for a resident is

expected to evolve progressively as the resident gains more experience, even with the same

patient condition or procedure. The level of supervision for each resident is commensurate

with that resident’s level of independence in practice; this level of supervision may be

209

enhanced based on factors such as patient safety, complexity, acuity, urgency, risk of serious

safety events, or other pertinent variables.

VI.A.2.b) Levels of Supervision

To pr

omote appropriate resident supervision while providing

for graded authority and responsibility, the program must use

the following classification of supervision:

(Core)

VI.A

.2.b).(1) Direct Supervision:

VI.A

.2.b).(1).(a) the supervising physician is physically present

with the resident during the key portions of

the patient interaction; or,

(Core)

[The Review Committee may further specify]

VI.A

.2.b).(1).(a).(i) PGY-1 residents must initially be

supervised directly, only as described in

VI.A.2.c).(1).(a).

(Core)

[The

Review Committee may describe

the condition under which PGY-1

residents progress to be supervised

indirectly]

VI.A

.2.b).(1).(b) the supervising physician and/or patient is not

physically present with the resident and the

supervising physician is concurrently

monitoring the patient care through appropriate

telecommunication technology.

(Core)

[The Review Committee may choose not to

permit this requirement. The Review Committee

may further specify]

VI.A

.2.b).(2) Indirect Supervision: the supervising physician is not

providing physical or concurrent visual or audio

supervision but is immediately available to the

resident for guidance and is available to provide

appropriate direct supervision.

(Core)

VI.A

.2.b).(3) Oversight - the supervising physician is available to

provide review of procedures/encounters with

feedback provided after care is delivered.

(Core)

VI.A

.2.c) The program must define when physical presence of a

supervising physician is required.

(Core)

VI.A

.2.d) The privilege of progressive authority and responsibility,

conditional independence, and a supervisory role in patient

care delegated to each resident must be assigned by the

program director and faculty members.

(Core)

210

VI.A.2.d).(1) The program director must evaluate each resident’s

abilities based on specific criteria, guided by the

Milestones

. (Core)

VI.A

.2.d).(2) Faculty members functioning as supervising

physicians must delegate portions of care to residents

based on the needs of the patient and the skills of

each resident.

(Core)

VI.A

.2.d).(3) Senior residents or fellows should serve in a

supervisory role to junior residents in recognition of

their progress toward independence, based on the

needs of each patient and the skills of the individual

resident or fellow.

(Detail)

VI.A

.2.e) Programs must set guidelines for circumstances and events

in which residents must communicate with the supervising

faculty member(s).

(Core)

VI.A

.2.e).(1) Each resident must know the limits of their scope of

authority, and the circumstances under which the

resident is permitted to act with conditional

independence.

(Outcome)

Background and Intent: The ACGME Glossary of Terms defines conditional

independence as: Graded, progressive responsibility for patient care with defined

oversight.

VI.A.2.f) Faculty supervision assignments must be of sufficient

duration to assess the knowledge and skills of each resident

and to delegate to the resident the appropriate level of patient

care authority and responsibility.

(Core)

211

GUIDANCE

The Common Program Requirements in VI.A.2. are closely linked with Common Program

Requirement IV.A.3., which addresses resident responsibilities and graded supervision.

The respons

ibilities and supervision of the residents must be clearly delineated. As stated in

VI.A.2.a).(1).(a)-(b), each resident must have an identifiable and appropriately credentialed and

privileged attending physician who is responsible and accountable for a patient’s care. These

responsible attending physicians along with their contact must be made available to residents,

faculty members, and other members of the health care team.

As s

tated in Common Program Requirement VI.A.2.a).(2), the program must demonstrate that

the level of supervision in place for each resident is based on the individual resident’s level of

education and ability, as well as patient complexity and acuity. Progressive authority and

conditional independence are a privilege and must be assigned by the program director and

faculty members. The Clinical Competency Committee (CCC) is key in helping the program

director assign progressive authority based on criteria established by the program and through

Milestones assessments. In addition, during each rotation, supervising faculty members can

help assess the skills of each resident.

Superv

ision may be exercised through a variety of methods. For many aspects of patient care,

the supervising physician may be a more advanced resident or fellow. Other portions of care

provided by the resident can be adequately supervised by the immediate availability of the

supervising faculty member, fellow, or senior resident physician, either on site or by means of

telephonic and/or electronic modalities. Some activities require the physical presence of the

supervising faculty member. In some circumstances, supervision may include post-hoc review

of resident-delivered care with feedback.

Telemedi

cine provides an additional method of supervision. Various models of telemedicine

such as tele-stroke, tele-psychiatry, tele-dermatology, and tele-ophthalmology have increased in

recent years. The use of telemedicine is increasingly adopted by institutions because of added

patient satisfaction, ability to provide care and follow-up in remote areas, significant cost

reduction, and in response to pandemic conditions, as was seen during the COVID-19

pandemic. Recognizing this trend and in this context, Review Committees have the option to

allow use of telesupervision and may also choose to further specify aspects of such use.

Distinct levels of supervision detailed in Common Program Requirement VI.A.2.b) include

Direct, Indirect, and Oversight. While supervision is critical to a resident’s professional

development, there is also such a thing as “over-supervision,” which occurs when more

advanced residents, though deemed capable, are not allowed to make independent decisions

and provide autonomous care. This is detrimental to the development of the skills, knowledge,

and attitudes required to enter the unsupervised practice of medicine.

An additional dimension to supervision is continuity in faculty assignments. Because of multiple

constraints, faculty members are increasingly adopting shorter assignments. One-week faculty

rotations are common, with some even taking assignments that last only two or three days.

Such brief supervision assignments provide insufficient time for faculty members to get to know

residents to determine their knowledge and skills, and therefore should be avoided, if possible.

Bernabeo, et al. (2011) have demonstrated that short faculty supervision assignments are,

indeed, detrimental to patient care.

212

present, the ACGME monitors compliance with the requirements in section VI.A.2. in various

ways, including:

• questions answered by program leadership as part of an application or during the

Accreditation Data System (ADS) Annual Update;

• questions answered by residents and faculty members as part of the annual

Resident/Fellow and Faculty Surveys; and

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

Reference

Bernabeo, Elizabeth C., Matthew C. Holtman, Shiphra Ginsburg, Julie R. Rosenbaum, and

Eric S. Holmboe. 2011. “Lost in Transition: The Experience and Impact of Frequent

Changes in the Inpatient Learning Environment.” Academic Medicine 86(5): 591–98.

https://doi.org/10.1097/acm.0b013e318212c2c9.

ADS Screenshots: ADS questions regarding back-up systems for applications

and programs at all accreditation statuses

The Resident

/Fellow and Faculty Surveys include several questions that address the

requirements in section VI.A.2. The ACGME has prepared two documents, a “Resident/Fellow

Survey-Common Program Requirements Crosswalk” and a “Faculty Survey-Common Program

Requirements Crosswalk” to provide additional information for program on the key areas

addressed by the survey questions and how they map to the ACGME Common Program

Requirements. These documents can be found at

https://www.acgme.org/data-systems-

technical-support/resident-fellow-and-faculty-surveys/.

213

Clinical Learning Environment Review (CLER) Program findings for graduate

medical education in supervision

The ACG

ME established the CLER Program to provide formative assessment and feedback to

participating sites of ACGME-accredited Sponsoring Institutions. CLER Program findings and

other information contained in CLER National Reports are not linked to ACGME Program

Requirements but may provide useful insights for programs. Actions taken in response to CLER

Program findings should not be interpreted as fulfilling requirements.

Findings of the ACGME’s Clinical Learning Environment Review (CLER) Program regarding

supervision are reported in CLER Issue Brief No. 6 (2016), which can be found on the

Resources and Documents

page of the CLER Program section of the ACGME website.

214

COMMON PROGRAM REQUIREMENTS

VI. The Learning and Working Environment

VI.B. P

rofessionalism

VI.B.1.

Programs, in partnership with their Sponsoring Institutions, must

educate

residents and faculty members concerning the professional

and ethical responsibilities of physicians, including but not limited

to their obligation to be appropriately rested and fit to provide the

care required by their patients.

(Core)

Background and Intent: This requirement emphasizes the professional responsibility

of residents and faculty members to arrive for work adequately rested and ready to

care for patients. It is also the responsibility of residents, faculty members, and other

members of the care team to be observant, to intervene, and/or to escalate their

concern about resident and faculty member fitness for work, depending on the

situation, and in accordance with institutional policies. This includes recognition of

impairment, including from illness, fatigue, and substance use, in themselves, their

peers, and other members of the health care team, and the recognition that under

certain circumstances, the best interests of the patient may be served by transitioning

that patient’s care to another qualified and rested practitioner.

VI.B.2

. The learning objectives of the program must:

VI.B.2

.a) be accomplished without excessive reliance on residents to

fulfill non-physician obligations;

(Core)

Background and Intent: Routine reliance on residents to fulfill non-physician

obligations increases work compression for residents and does not provide an optimal

educational experience. Non-physician obligations are those duties which in most

institutions are performed by nursing and allied health professionals, transport

services, or clerical staff. Examples of such obligations include transport of patients

from the wards or units for procedures elsewhere in the hospital; routine blood

drawing for laboratory tests; routine monitoring of patients when off the ward; and

clerical duties, such as scheduling. While it is understood that residents may be

expected to do any of these things on occasion when the need arises, these activities

should not be performed by residents routinely and must be kept to a minimum to

optimize resident education.

VI.B.2

.b) ensure manageable patient care responsibilities; and,

(Core)

[The Review Committee may further specify]

Background and Intent: The Common Program Requirements do not define

“manageable patient care responsibilities” as this is variable by specialty and PGY

level. Review Committees will provide further detail regarding patient care

responsibilities in the applicable specialty-specific Program Requirements and

accompanying FAQs. However, all programs, regardless of specialty, should carefully

215

assess how the assignment of patient care responsibilities can affect work

compression, especially at the PGY-1 level.

VI.B.2

.c) include efforts to enhance the meaning that each resident

finds in the experience of being a physician, including

protecting time with patients, providing administrative

support, promoting progressive independence and flexibility,

and enhancing professional relationships.

(Core)

VI.B.3

. The program director, in partnership with the Sponsoring Institution,

must provide a culture of professionalism that supports patient

safety and personal responsibility.

(Core)

Background and Intent: The accurate reporting of clinical and educational work hours,

patient outcomes, and clinical experience data are the responsibility of the program

leadership, residents, and faculty.

VI.B.4

. Residents and faculty members must demonstrate an understanding

of their personal role in the safety and welfare of patients entrusted

to their care, including the ability to report unsafe conditions and

safety events.

(Core)

VI.B.

5. Programs, in partnership with their Sponsoring Institutions, must

provide a professional, equitable, respectful, and civil environment

that psychologically safe and that

is free from discrimination, sexual

and other forms of harassment, mistreatment, abuse, or coercion of

students, residents, faculty, and staff.

(Core)

Background and Intent: Psychological safety is defined as an environment of trust and

respect that allows individuals to feel able to ask for help, admit mistakes, raise

concerns, suggest ideas, and challenge ways of working and the ideas of others on the

team, including the ideas of those in authority, without fear of humiliation, and the

knowledge

that mistakes will be handled justly and fairly.

The A

CGME is unable to adjudicate disputes between individuals, including residents,

faculty members, and staff members. However, information that suggests a pattern of

behavior that violates the requirement above will trigger a careful review and, if

deemed appropriate, action by the Review Committee and/or ACGME, in accordance

with ACGME Policies and Procedures.

VI.B.

6. Programs, in partnership with their Sponsoring Institutions, should

have a process for education of residents and faculty regarding

unprofessional behavior and a confidential process for reporting,

investigating, and addressing such concerns.

(Core)

216

GUIDANCE

The Common Program Requirements in VI.B. are central to the mission of every residency

program, to instill in residents an understanding of and ability to meet the professional and

ethical responsibilities inherent in being a physician. In addition to elements described in

Section II of the Common Program Requirements regarding the responsibility of the program

director as a model of professionalism and Section IV regarding the educational program and

the Core Competencies, professionalism as detailed in Section VI addresses other components

of the program’s obligation with regard to how expectations for demonstrating professionalism

must be addressed.

VI.B.1. Programs, in partnership with their Sponsoring Institutions, must educate

residents and faculty members concerning the professional responsibilities of

physicians, including their obligation to be appropriately rested and fit to provide

the care required by their patients.

The Background and Intent associated with this requirement provides additional context for this

requirement. “This requirement emphasizes the professional responsibility of residents and

faculty members to arrive for work adequately rested and ready to care for patients. It is also the

responsibility of residents, faculty members, and other members of the care team to be

observant, to intervene, and/or to escalate their concern about resident and faculty member

fitness for work, depending on the situation, and in accordance with institutional policies. This

includes recognition of impairment, including from illness, fatigue, and substance use, in

themselves, their peers, and other members of the health care team, and the recognition that

under certain circumstances, the best interests of the patient may be served by transitioning that

patient’s care to another qualified and rested practitioner.”

VI.B.2.a) [The learning objectives of the program must:] be accomplished without

excessive reliance on fellows to fulfill non-physician obligations.

The Background and Intent associated with this requirement provides further context and

examples of “non-physician obligations. “Routine reliance on residents to fulfill non-physician

obligations increases work compression for fellows and does not provide an optimal educational

experience. Non-physician obligations are those duties which in most institutions are performed

by nursing and allied health professionals, transport services, or clerical staff. Examples of such

obligations include transport of patients from the wards or units for procedures elsewhere in the

hospital; routine blood drawing for laboratory tests; routine monitoring of patients when off the

ward; and clerical duties, such as scheduling. While it is understood that residents may be

expected to do any of these things on occasion when the need arises, these activities should

not be performed by residents routinely and must be kept to a minimum to optimize resident

education.”

VI.B.2.b) [The learning objectives of the program must:] ensure manageable

patient care responsibilities.

The Background and Intent associated with this requirement acknowledges that “The Common

Program Requirements do not define ’manageable patient care responsibilities‘ as this is

variable by specialty/subspecialty and PGY level. Review Committees will provide further detail

regarding patient care responsibilities in the applicable specialty- and subspecialty-specific

Program Requirements and accompanying FAQs. However, all programs, regardless of

specialty/subspecialty, should carefully assess how the assignment of patient care

responsibilities can affect work compression.”

217

For spec

ific requirements pertaining to patient number caps and other patient care

responsibilities, refer to the specialty-specific Program Requirements, which can be accessed

from the applicable specialty section of the ACGME website: https://www.acgme.org/specialties

VI.B.2.c) [The learning objectives of the program must:] include efforts to

enhance the meaning that each resident finds in the experience of being a

physician, including protecting time with patients, providing administrative

support, promoting progressive independence and flexibility, and enhancing

professional relationships.

VI.B.3. The program director, in partnership with the Sponsoring Institution, must

provide a culture of professionalism that supports patient safety and personal

responsibility.

This r

equirement is closely linked to the professionalism competencies in Common Program

Requirements IV.B.1.(a).(1).(a)-(g).

Prof

essionalism includes an understanding of one’s personal role in the management of

patients as relates to the safety and welfare of patients entrusted to the physician’s care. This

encompasses the ability to report unsafe conditions and adverse events. Physicians must also

take responsibility to ensure they are fit for work. This requirement emphasizes the professional

responsibility of faculty members and residents to arrive for work adequately rested and ready

to care for patients. It is also the responsibility of faculty members, residents, and other

members of the care team to be observant, to intervene, and/or to escalate their concern about

other residents’ or faculty members’ fitness for work, depending on the situation, and in

accordance with institutional policies. These responsibilities include:

• management of time before, during, and after clinical assignments;

• Recognition of impairment (illness, fatigue, substance use) in themselves, their peers,

and other members of the health care team;

• Commitment to lifelong learning;

• monitoring patient care performance; and

• accurate reporting of clinical and educational work hours, patient outcomes, and clinical

experience data

218

Accreditation Data System (ADS) screenshots: ADS Common Program

Requirements questions

NOTE: Some of the questions only apply to applications while others apply to

programs at all accreditation statuses

219

VI.B.4. Residents and faculty members must demonstrate an understanding of

their personal role in the safety and welfare of patients entrusted to their care,

including the ability to report unsafe conditions and safety events.

Education alone on the role of residents and faculty in providing safe patient care is not

sufficient. This requirement emphasizes that residents must also demonstrate an understanding

of their role in the safety and welfare of patients and reporting unsafe conditions and safety

events.

VI.B.5. Programs, in partnership with their Sponsoring Institutions, must provide

a professional, equitable, respectful, and civil environment that psychologically

safe and that is free from discrimination, sexual and other forms of harassment,

mistreatment, abuse, or coercion of students, residents, faculty, and staff.

VI.B.6. Programs, in partnership with their Sponsoring Institutions, must provide

a professional, equitable, respectful, and civil environment that is free from

discrimination, sexual and other forms of harassment, mistreatment, abuse, or

coercion of students, residents, faculty members, and staff members

A prof

essional, equitable, respectful, and civil environment that is psychologically safe and free

from discrimination, sexual and other forms of harassment, mistreatment, abuse, or coercion of

students, residents, faculty members, and staff members is a comprehensive way of expressing

the idea that inclusiveness and belonging are essential to fostering an effective learning

environment for all. Professionalism refers to the way in which individuals are handled in a

professional manner within and outside the learning environment. This implies that the

standards, practices, and motivations of the profession are used to fulfill the social contract

between medicine and society. It further implies that elements of evaluation are evidence-based

and fairly administered and includes the ability to recognize and not penalize differences as lack

of professionalism while taking into consideration that professionalism should not be centered

on identities of privilege and power. Professionalism demands that honesty, integrity, and

accountability of the individuals and the organization are foundational to the process. An

equitable environment refers to ensuring that resources are provided according to need in the

learning environment and that all individuals are treated in a fair manner. Respectful means that

individuals in the learning environment are all encouraged to treat one another with dignity and

humility such that the supposition of dominant cultural norms is exchanged for sensitivity,

listening, acceptance, welcoming, and fostering a sense of belonging. Civility refers to a wide

220

range of behaviors, from emotional to physical, and should employ courtesy and politeness

between individuals who share the learning environment.

The ACG

ME recently clarified that the naming of offenses including mistreatment, abuse,

harassment including sexual harassment, and coercion is based on the principle that even a

single resident who is the victim of these behaviors has standing to complain about violations of

this requirement and can lead to an investigation.

ADS screenshot: ADS Common Program Requirement question for applications

and the ADS Annual Update for programs at initial accreditation

Clinical Learning Environment Review (CLER) Program for graduate medical

education in professionalism

The ACGME established the CLER Program to provide formative assessment and feedback to

participating sites of ACGME-accredited Sponsoring Institutions. CLER findings and other

information contained in CLER National Reports are not linked to ACGME Program

Requirements but may provide useful insights for programs. Actions taken in response to CLER

findings should not be interpreted as fulfilling requirements.

Findings of CLER site visits on professionalism are reported in Issue Brief No. 8 (2016), which

can be found on the Resources and Documents page of the CLER section of the ACG

website.

The Milestones

Online resources related to the Milestones and assessment of professionalism can be found at

https://www.acgme.org/milestones/resources/.

221

COMMON PROGRAM REQUIREMENTS

VI. The Learning and Working Environment

VI.C. W

ell-Being

Psychological, emotional, and physical well-being are critical in the

development of the competent, caring, and resilient physician and require

proactive attention to life inside and outside of medicine. Well-being

requires that physicians retain the joy in medicine while managing their

own real-life stresses. Self-care and responsibility to support other

members of the health care team are important components of

professionalism; they are also skills that must be modeled, learned, and

nurtured in the context of other aspects of residency training.

Resident

s and faculty members are at risk for burnout and depression.

Programs, in partnership with their Sponsoring Institutions, have the same

responsibility to address well-being as other aspects of resident

competence. Physicians and all members of the health care team share

responsibility for the well-being of each other. A positive culture in a

clinical learning environment models constructive behaviors, and prepares

residents with the skills and attitudes needed to thrive throughout their

careers.

VI.C.1.

The responsibility of the program, in partnership with the

Sponsor

ing Institution, must include:

VI.C.1.a) attention to scheduling, work intensity, and work

compression that impacts resident well-being;

(Core)

VI.C.1

.b) evaluating workplace safety data and addressing the safety of

residents and faculty members;

(Core)

Background and Intent: This requirement emphasizes the responsibility shared by the

Sponsoring Institution and its programs to gather information and utilize systems that

monitor and enhance resident and faculty member safety, including physical safety.

Issues to be addressed include, but are not limited to, monitoring of workplace

injuries, physical or emotional violence, vehicle collisions, and emotional well-being

after safety events.

VI.C.1

.c) policies and programs that encourage optimal resident and

faculty member well-being; and,

(Core)

Background and Intent: Well-being includes having time away from work to engage

with family and friends, as well as to attend to personal needs and to one’s own health,

including adequate rest, healthy diet, and regular exercise. The intent of this

requirement is to ensure that residents have the opportunity to access medical and

dental care, including mental health care, at times that are appropriate to their

individual circumstances. Residents must be provided with time away from the

222

program as needed to access care, including appointments scheduled during their

working hours.

VI.C.1.c).(1) Residents must be given the opportunity to attend

medical, mental health, and dental care appointments,

including those scheduled during their working hours.

(Core)

VI.C.1.d) education of residents and faculty members in:

VI.C.1.d).(1) identification of the symptoms of burnout, depression, and

substance use disorders, suicidal ideation, or potential for

violence, including means to assist those who experience

these conditions;

(Core)

VI.C.1.d).(2) recognition of these symptoms in themselves and how to

seek appropriate care; and,

(Core)

VI.C.1.d).(3) access to appropriate tools for self-screening.

(Core)

Background and Intent: Programs and Sponsoring Institutions are encouraged to

review materials in order to create systems for identification of burnout, depression,

and substance use disorders. Materials and more information are available in Learn at

ACGME (https://dl.acgme.org/pages/well-being-tools-resources).

Individuals experiencing burnout, depression, a substance use disorder, and/or

suicidal ideation are often reluctant to reach out for help due to the stigma associated

with these conditions and may be concerned that seeking help may have a negative

impact on their career. Recognizing that physicians are at increased risk in these

areas, it is essential that residents and faculty members are able to report their

concerns when another resident or faculty member displays signs of any of these

conditions, so that the program director or other designated personnel, such as the

department chair, may assess the situation and intervene as necessary to facilitate

access to appropriate care. Residents and faculty members must know which

personnel, in addition to the program director, have been designated with this

responsibility; those personnel and the program director should be familiar with the

institution’s impaired physician policy and any employee health, employee assistance,

and/or wellness/well-being programs within the institution. In cases of physician

impairment, the program director or designated personnel should follow the policies of

their institution for reporting.

VI.C.1.e)

providing access to confidential, affordable mental health

assessment, counseling, and treatment, including access to

urgent and emergent care 24 hours a day, seven days a week.

(Core)

Background and Intent: The intent of this requirement is to ensure that residents have

immediate access at all times to a mental health professional (psychiatrist,

psychologist, Licensed Clinical Social Worker, Primary Mental Health Nurse

Practitioner, or Licensed Professional Counselor) for urgent or emergent mental health

223

issues. In-person, telemedicine, or telephonic means may be utilized to satisfy this

requirement. Care in the Emergency Department may be necessary in some cases, but

not as the primary or sole means to meet the requirement.

The reference to affordable counseling is intended to require that financial cost not be

a barrier to obtaining care.

VI.C.2

. There are circumstances in which residents may be unable to attend

wor

k, including but not limited to fatigue, illness, family

emergencies, and medical, parental, or caregiver leave. Each

program must allow an appropriate length of absence for residents

unable to perform their patient care responsibilities.

(Core)

VI.C.2

.a) The program must have policies and procedures in place to

ensure coverage

of patient care and ensure continuity of

patient care.

(Core)

VI.C.2

.b) These policies must be implemented without fear of negative

consequences for the resident who is or was unable to

provide the clinical work.

(Core)

Background and Intent: Residents may need to extend their length of training

depending on length of absence and specialty board eligibility requirements.

Teammates should assist colleagues in need and equitably reintegrate them upon

return.

224

GUIDANCE

Tools and resources for institutions and programs to support physician well-being are located at:

https://www.acgme.org/meetings-and-educational-activities/physician-well-being/.

The ACG

ME monitors compliance with the Common Program Requirements in section VI.C. in

various ways, including:

• questions answered by program leadership as part of an application or during the

Accreditation Data System (ADS) Annual Update;

• questions answered by fellows and faculty members as part of the annual

Resident/Fellow and Faculty Surveys;

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation; and,

• documentation provided as part of an application or during Initial Accreditation.

ADS Screenshots: ADS Annual Update Common Program Requirements

questions

The Resident

/Fellow and Faculty Surveys include several questions that address the

requirements in section VI.C. The ACGME has prepared two documents, a “Resident/Fellow

Requirements Crosswalk” and a “Faculty Survey-Common Program Requirements Crosswalk,”

to provide additional information for programs on the key areas addressed by the survey

questions and how they map to the ACGME Common Program Requirements. These

documents can be found at

https://www.acgme.org/data-syst

ems-technical-support/resident-

fellow-and-faculty-surveys.

225

COMMON PROGRAM REQUIREMENTS

VI. The Learning and Working Environment

VI.D. Fat

igue Mitigation

VI.D.1.

Programs must educat

e all residents and faculty members in

recognition of the signs of fatigue and sleep deprivation, alertness

management, and fatigue mitigation processes.

(Detail)

Background and Intent: Providing medical care to patients is physically and mentally

demanding. Night shifts, even for those who have had enough rest, cause fatigue.

Experiencing fatigue in a supervised environment during training prepares fellows for

managing fatigue in practice. It is expected that programs adopt fatigue mitigation

processes and ensure that there are no negative consequences and/or stigma for using

fatigue mitigation strategies.

Str

ategies that may be used include, but are not limited to, strategic napping; the judicious

use of caffeine; availability of other caregivers; time management to maximize sleep off-

duty; learning to recognize the signs of fatigue, and self-monitoring performance and/or

asking others to monitor performance; remaining active to promote alertness; maintaining a

healthy diet; using relaxation techniques to fall asleep; maintaining a consistent sleep

routine; exercising regularly; increasing sleep time before and after call; and ensuring

sufficient sleep recovery periods.

VI.D.3

. The program, in partnership with its Sponsoring Institution, must

ensure adequate sleep facilities and safe transportation options for

fellows who may be too fatigued to safely return home.

(Core)

226

GUIDANCE

The ACGME monitors compliance with the requirements in section VI.D. in various ways,

including:

• questions answered by program leadership as part of an application or during the

Accreditation Data System (ADS) Annual Update;

• questions answered by fellows and faculty members answer as part of the annual

Resident/Fellow and Faculty Surveys; and,

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

ADS Screenshots: ADS questions related to fatigue mitigation

The Resident

/Fellow and Faculty Surveys include several questions that address the

requirements in section VI.D. The ACGME has prepared two documents, a “Resident/Fellow

Survey-Common Program Requirements Crosswalk” and a “Faculty Survey-Common Program

Requirements Crosswalk” to provide additional information for programs on the key areas

addressed by the survey questions and how they map to the ACGME Common Program

Requirements. These documents can be found at

https://www.acgme.org/data-systems-

technical-support/resident-fellow-and-faculty-surveys/.

Clinical Learning Environment Review (CLER) Program findings for graduate

medical education (GME) in fatigue management, mitigation and duty hours

227

The ACGME established the CLER Program to provide formative assessment and feedback to

participating sites of ACGME-accredited Sponsoring Institutions. CLER findings and other

information contained in CLER National Reports are not linked to ACGME Program

Requirements but may provide useful insights for programs. Actions taken in response to CLER

findings should not be interpreted as fulfilling requirements.

Findings of

CLER site visits relating to fatigue management, mitigation, and clinical work and

education hours are summarized in CLER Issue Brief No. 7 (2017), which can be found on the

Resources and Documents

page of the CLER section of the ACGME website.

Additional Resources

1. Fatigue mitigation: https://sites.duke.edu/thelifecurriculum/2014/05/08/the-life-curriculum/

2. Well-being:

https://gmewellness.upmc.com/?_ga=2.214765521.794333632.1657210383-

1973063117.1654787161

228

COMMON PROGRAM REQUIREMENTS

VI. The Learning and Working Environment

VI.E. C

linical Responsibilities, Teamwork, and Transitions of Care

VI.E.1

. Clinical Responsibilities

The cl

inical responsibilities for each resident must be based on PGY

level, patient safety, resident ability, severity and complexity of

patient illness/condition, and available support services.

(Core)

[Optimal clinical workload may be further specified by each Review

Committee]

Background and Intent: The changing clinical care environment of medicine has meant

that work compression due to high complexity has increased stress on residents.

Faculty members and program directors need to make sure residents function in an

environment that has safe patient care and a sense of resident well-being. It is an

essential responsibility of the program director to monitor resident workload.

Workload should be distributed among the resident team and interdisciplinary teams

to minimize work compression.

VI.E.2

. Teamwork

Resident

s must care for patients in an environment that maximizes

communication and promotes safe, interprofessional, team-based

care in the specialty and larger health system.

(Core)

[The Review Committee may further specify]

Background and Intent: Effective programs will have a structure that promotes safe,

interprofessional, team-based care. Optimal patient safety occurs in the setting of a

coordinated interprofessional learning and working environment.

VI.E.3

. Transitions of Care

VI.E.3

.a) Programs must design clinical assignments to optimize transitions

in patient care, including their safety, frequency, and structure.

(Core)

VI.E.3

.b) Programs, in partnership with their Sponsoring Institutions, must

ensure and monitor effective, structured hand-over processes to

facilitate both continuity of care and patient safety.

(Core)

VI.E.3

.c) Programs must ensure that residents are competent in

communicating with team members in the hand-over process.

(Outcome)

229

GUIDANCE

Common Program Requirements, VI.E., Clinical Responsibilities, Teamwork, and Transitions of

Care, focus on team-based care and transitions of care.

present, he ACGME monitors compliance with the requirements in section VI.E. in various

ways, including:

• questions answered by program leadership as part of an application or during the

Accreditation Data System (ADS) Annual Update;

• questions answered by fellows and faculty members as part of the annual

Resident/Fellow and Faculty Surveys; and,

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

ADS Screenshot: ADS Annual Update question regarding hand-off for

applications and programs with Initial Accreditation

The Resident/Fellow and Faculty Surveys include several questions that address the

requirements in section VI.E. The ACGME has prepared two documents, a “Resident/Fellow

Survey-Common Program Requirements Crosswalk” and a “Faculty Survey-Common Program

Requirements Crosswalk,” to provide additional information for programs on the key areas

addressed by the survey questions and how they map to the ACGME Common Program

Requirements. These documents can be found at

https://acgme.org/data-syst

ems-technical-

support/resident-fellow-and-faculty-surveys/.

Clinical Learning Environment Review (CLER) Program findings for graduate

medical education in care transitions

The ACGME established the CLER Program to provide formative assessment and feedback to

participating sites of ACGME-accredited Sponsoring Institutions. CLER findings and other

information contained in CLER National Reports are not linked to ACGME Program

Requirements but may provide useful insights for programs. Actions taken in response to CLER

findings should not be interpreted as fulfilling requirements.

CLER

Issue Brief No. 5 (2016) addresses care transitions, and can be found on the

Resources

and Documents page of the CLER section of the ACGME website.

230

As w

ith all of the CLER Issue Briefs, this section is preceded by a narrative. In this instance, a

chief resident expresses frustration over a nursing home transfer of a critically ill patient with an

acute abdomen about whose very complicated prior medical and surgical history she had

absolutely no information. This lack of knowledge by the receiving physician posed significant

risks to the care of the patient. This narrative highlights the risks of communication failure when

patients are transferred from one service to another, or from one institution to another.

The following is a list of elements that should be common to all hand-offs, as noted in CLER

Issue Brief No. 5:

1. creation of “to-do” lists;

2. use of “if-then” statements;

3. ability and expectation for the receiver of information to ask questions;

4. “read-back” at the end of a patient hand-off; and

5. setting of expectations for when it is essential to move the hand-off to the patient’s

bedside.

References

1. Abraham, Joanna, Thomas G. Kannampallil, and Vimla L. Patel. 2008. “Bridging Gaps in

Handoffs: A Continuity of Care Based Approach.” Journal of Surgical Education 65(6):

476-485. https://pubmed.ncbi.nlm.nih.gov/22094355/.

2. Cohen, Michael D., Brian Hilligoss, and André Kajdacsy-Balla Amaral. 2011. “A Handoff

Is Not a Telegram: an Understanding of the Patient Is Co-Constructed.” Critical

Care 16(1): 303. https://doi.org/10.1186/cc10536.

3. Solet, Darrell J., J. Michael Norvell, Gale H. Rutan, and Richard M. Frankel. 2005. “Lost

in Translation: Challenges and Opportunities in Physician-to-Physician Communication

During Patient Handoffs.” Academic Medicine 80(12): 1094–99.

https://doi.org/10.1097/00001888-200512000-00005.

4. Wohlauer, Max V., Vineet M. Arora, Leora I. Horwitz, Ellen J. Bass, Sean E. Mahar, and

Ingrid Philibert. 2012. “The Patient Handoff.” Academic Medicine 87(4): 411–18.

https://doi.org/10.1097/acm.0b013e318248e766.

Resources

Inadequate hand-offs can result in a real potential for patient harm, from minor to severe. There

are numerous efforts across specialties, institutions, and regulatory organizations to improve

hand-offs. The following links provide examples and information related to hand-offs:

5. Agency for Healthcare Research and Quality:

https://psnet.ahrq.gov/primers/primer/9/Handoffs-and-

Signouts

6. The American College of Obstetricians and Gynecologists provided a committee opinion

on communication strategies for patient hand-offs:

https://www.acog.org/clinical/clinical-guidance/

committee-

opinion/articles/2012/02/communication-strategies-for-patient-handoffs

7. Standardization of Inpatient Handoff Communication – from the American Academy of

Pediatrics Committee on Hospital Care

https://pediatrics.aappublications.org/content/138/5/e20162681

231

COMMON PROGRAM REQUIREMENTS

VI. The Learning and Working Environment

VI.F. C

linical Experience and Education

Programs, in partnership with their Sponsoring Institutions, must design

an effective program structure that is configured to provide residents with

educational and clinical experience opportunities, as well as reasonable

opportunities for rest and personal activities.

Background and Intent: The terms “clinical experience and education,” “clinical and

educational work,” and “clinical and educational work hours” replace the terms “duty

hours,” “duty periods,” and “duty.” These terms are used in response to concerns that

the previous use of the term “duty” in reference to number of hours worked may have

led some to conclude that residents’ duty to “clock out” on time superseded their duty

to their patients.

VI.F.1

. Maximum Hours of Clinical and Educational Work per Week

Cli

nical and educational work hours must be limited to no more than

80 hours per week, averaged over a four-week period, inclusive of all

in-house clinical and educational activities, clinical work done from

home, and all moonlighting.

(Core)

Background and Intent: Programs and residents have a shared responsibility to ensure

that the 80-hour maximum weekly limit is not exceeded. While the requirement has

been written with the intent of allowing residents to remain beyond their scheduled

work periods to care for a patient or participate in an educational activity, these

additional hours must be accounted for in the allocated 80 hours when averaged over

four weeks.

Work f

rom Home

While the requirement specifies that clinical work done from home must be counted

toward the 80-hour maximum weekly limit, the expectation remains that scheduling be

structured so that residents are able to complete most work on site during scheduled

clinical work hours without requiring them to take work home. The new requirements

acknowledge the changing landscape of medicine, including electronic health records,

and the resulting increase in the amount of work residents choose to do from home.

The requirement provides flexibility for residents to do this while ensuring that the time

spent by residents completing clinical work from home is accomplished within the 80-

hour weekly maximum. Types of work from home that must be counted include using

an electronic health record and taking calls from home. Reading done in preparation

for the following day’s cases, studying, and research done from home do not count

toward the 80 hours. Resident decisions to leave the hospital before their clinical work

has been completed and to finish that work later from home should be made in

consultation with the resident’s supervisor. In such circumstances, residents should

be mindful of their professional responsibility to complete work in a timely manner and

to maintain patient confidentiality.

232

Residents are to track the time they spend on clinical work from home and to report

that time to the program. Decisions regarding whether to report infrequent phone calls

of very short duration will be left to the individual resident. Programs will need to

factor in time residents are spending on clinical work at home when schedules are

developed to ensure that residents are not working in excess of 80 hours per week,

averaged over four weeks. There is no requirement that programs assume

responsibility for documenting this time. Rather, the program’s responsibility is

ensuring that residents report their time from home and that schedules are structured

to ensure that residents are not working in excess of 80 hours per week, averaged over

four weeks.

VI.F.2

. Mandatory Time Free of Clinical Work and Education

VI.F.2.a) Residents should have eight hours off between scheduled

clinical work and education periods.

(Detail)

Background and Intent: There may be circumstances when residents choose to stay to

care for their patients or return to the hospital with fewer than eight hours free of

clinical experience and education. This occurs within the context of the 80-hour and

the one-day-off-in-seven requirements While it is expected that resident schedules will

be structured to ensure that residents are provided with a minimum of eight hours off

between scheduled work periods, it is recognized that residents may choose to remain

beyond their scheduled time, or return to the clinical site during this time-off period, to

care for a patient. The requirement preserves the flexibility for residents to make those

choices. It is also noted that the 80-hour weekly limit (averaged over four weeks) is a

deterrent for scheduling fewer than eight hours off between clinical and education

work periods, as it would be difficult for a program to design a schedule that provides

fewer than eight hours off without violating the 80-hour rule.

VI.F.2

.b) Residents must have at least 14 hours free of clinical work

and education after 24 hours of in-house call.

(Core)

Background and Intent: Residents have a responsibility to return to work rested, and

thus are expected to use this time away from work to get adequate rest. In support of

this goal, residents are encouraged to prioritize sleep over other discretionary

activities.

VI.F.2

.c) Residents must be scheduled for a minimum of one day in

seven free of clinical work and required education (when

averaged over four weeks). At-home call cannot be assigned

on these free days.

(Core)

Background and Intent: The requirement provides flexibility for programs to distribute

days off in a manner that meets program and resident needs. It is strongly

recommended that residents’ preference regarding how their days off are distributed

be considered as schedules are developed. It is desirable that days off be distributed

throughout the month, but some residents may prefer to group their days off to have a

“golden weekend,” meaning a consecutive Saturday and Sunday free from work. The

requirement for one free day in seven should not be interpreted as precluding a golden

233

weekend. Where feasible, schedules may be designed to provide residents with a

weekend, or two consecutive days, free of work. The applicable Review Committee will

evaluate the number of consecutive days of work and determine whether they meet

educational objectives. Programs are encouraged to distribute days off in a fashion

that optimizes resident well-being, and educational and personal goals. It is noted that

a day off is defined in the ACGME Glossary of Terms as “one (1) continuous 24-hour

period free from all administrative, clinical, and educational activities.”

VI.F.3

. Maximum Clinical Work and Education Period Length

VI.F.3

.a) Clinical and educational work periods for residents must not

exceed 24 hours of continuous scheduled clinical

assignments.

(Core)

VI.F.3

.a).(1) Up to four hours of additional time may be used for

activ

ities related to patient safety, such as providing

effective transitions of care, and/or resident education.

Additional patient care responsibilities must not be

assigned to a resident during this time

(Core)

Background and Intent: The additional time referenced in VI.F.3.a).(1) should not be

used for the care of new patients. It is essential that the resident continue to function

as a member of the team in an environment where other members of the team can

assess resident fatigue, and that supervision for post-call residents is provided. This

24 hours and up to an additional four hours must occur within the context of 80-hour

weekly limit, averaged over four weeks.

VI.F.4

. Clinical and Educational Work Hour Exceptions

VI.F.4.a)

In rare circumstances, after handing off all other

responsibi

lities, a resident, on their own initiative, may elect

to remain or return to the clinical site in the following

circumstances: to continue to provide care to a single

severely ill or unstable patient; to give humanistic attention to

the needs of a patient or patient’s family; or to attend unique

educational events.

(Detail)

VI.F.4

.b) These additional hours of care or education must be counted

toward the 80-hour weekly limit.

(Detail)

Background and Intent: This requirement is intended to provide residents with some

control over their schedules by providing the flexibility to voluntarily remain beyond

the scheduled responsibilities under the circumstances described above. It is

important to note that a resident may remain to attend a conference, or return for a

conference later in the day, only if the decision is made voluntarily. Residents must not

be required to stay. Programs allowing residents to remain or return beyond the

scheduled work and clinical education period must ensure that the decision to remain

is initiated by the resident and that residents are not coerced. This additional time

must be counted toward the 80-hour maximum weekly limit.

234

VI.F.4.c) A Review Committee may grant rotation-specific exceptions

for up to 10 percent or a maximum of 88 clinical and

educational work hours to individual programs based on a

sound educational rationale.

VI.F.4

.c).(1)

In preparing a request for an exception, the program

direct

or must follow the clinical and educational work

hour exception policy from the ACGME Manual of

Policies and Procedures.

(Detail)

Background and Intent: Exceptions may be granted for specific rotations if the

program can justify the increase based on criteria specified by the Review Committee.

Review Committees may opt not to permit exceptions. The underlying philosophy for

this requirement is that while it is expected that all residents should be able to train

within an 80-hour work week, it is recognized that some programs may include

rotations with alternate structures based on the nature of the specialty. DIO/GMEC

approval is required before the request will be considered by the Review Committee.

VI.F.5

. Moonlighting

VI.F.5

.a) Moonlighting must not interfere with the ability of the resident

to achieve the goals and objectives of the educational

program, and must not interfere with the resident’s fitness for

work nor compromise patient safety.

(Core)

VI.F.5

.b) Time spent by residents in internal and external moonlighting

(as defined in the ACGME Glossary of Terms) must be

counted toward the 80-hour maximum weekly limit.

(Core)

VI.F.5

.c) PGY-1 residents are not permitted to moonlight.

(Core)

Background and Intent: For additional clarification of the expectations related to

moonlighting, please refer to the Common Program Requirement FAQs (available at

http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements).

VI.F.6

. In-House Night Float

Night

float must occur within the context of the 80-hour and one-

day-off-in-seven requirements.

(Core)

[The maximum number of consecutive weeks of night float, and

maximum number of months of night float per year may be further

specified by the Review Committee.]

VI.F.7

. Maximum In-House On-Call Frequency

Residents must be scheduled for in-house call no more frequently than

every third night (when averaged over a four-week period).

(Core)

VI.F.8

. At-Home Call

235

VI.F.8.a) Time spent on patient care activities by residents on at-home

call must count toward the 80-hour maximum weekly limit.

The frequency of at-home call is not subject to the every-

third-night limitation, but must satisfy the requirement for one

day in seven free of clinical work and education, when

averaged over four weeks.

(Core)

VI.F.8

.a).(1) At-home call must not be so frequent or taxing as to

preclude rest or reasonable personal time for each

resident.

(Core)

[The

Review Committee may further specify under any requirement in VI.F. –

VI.F.8.a).(1)]

Background and Intent: As noted in VI.F.1., clinical work done from home when a

resident is taking at-home call must count toward the 80-hour maximum weekly limit.

This change acknowledges the often significant amount of time residents devote to

clinical activities when taking at-home call, and ensures that taking at-home call does

not result in residents routinely working more than 80 hours per week. At-home call

activities that must be counted include responding to phone calls and other forms of

communication, as well as documentation, such as entering notes in an electronic

health record. Activities such as reading about the next day’s case, studying, or

research activities do not count toward the 80-hour weekly limit.

In their evaluation of residency/fellowship programs, Review Committees will look at

the overall impact of at-home call on resident/fellow rest and personal time.

236

GUIDANCE

Section VI.F. of the Common Program Requirements addresses clinical experience and

education. As the Background and Intent box clarifies, the terms “clinical experience and

education,” “clinical and educational work,” and “clinical and educational work hours” replace the

terms “duty hours,” “duty periods,” and “duty.” These changes were made in response to

concerns that use of the term “duty” in reference to number of hours worked may have led some

to conclude that residents’ duty to “clock out” on time superseded their duty to their patients.

The goal of the earliest standards regarding clinical and educational work hours to the most

recent refinements of these standards has remained the same. Through these standards,

ACGME has continually sought to ensure that “conditions conducive to resident learning,

socialization to the medical profession, and safe and effective patient care consistently occur.

(Nasca and Philibert, 2008).

present, the ACGME monitors compliance with the requirements in section VI.F. in various

ways including:

• questions answered by program leadership as part of an application or during the

Accreditation Data System (ADS) Annual Update;

• questions answered by fellows and faculty members answer as part of the annual

Resident/Fellow and Faculty Surveys; and

• questions asked by Accreditation Field Staff during site visits of the program at various

stages of accreditation.

The Resi

dent/Fellow and Faculty Surveys include several questions that address the

requirements in section VI.F. The ACGME has prepared two documents, a “Resident/Fellow

Survey-Common Program Requirements Crosswalk” and a “Faculty Survey-Common Program

Requirements Crosswalk,” to provide additional information for programs on the key areas

addressed by the survey questions and how they map to the ACGME Common Program

Requirements. These documents, along with the Common Program Requirements FAQs

address multiple questions from the graduate medical education community and can be found

at https://www.acgme.org/data-syst

ems-technical-support/resident-fellow-and-faculty-surveys/.

VI.

F.1. Maximum Hours of Clinical and Educational Work per Week

The language in the requirements bears repeating: Clinical and educational work hours must be

limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-

house clinical and educational activities, clinical work done from home, and all moonlighting.

ADS Screenshot: As part of a program application or for the ADS Annual Update

for a program on Initial Accreditation, the program director must attest that

resident rotation schedules meet the 80-hour work week requirement.

Programs that regularly schedule residents to work 80 hours per week and still permit them to

remain beyond their scheduled work period will undoubtedly exceed the 80-hour maximum,

which would mean they are not in substantial compliance with the requirement.

237

The ACGME Review Committees strictly monitor and enforce compliance with the 80-hour

requirement. Where violations of the 80-hour requirement are identified, programs are subject to

citation and are at risk for an adverse accreditation action.

References

• Desai, Sanjay V., David A. Asch, Lisa M. Bellini, Krisda H. Chaiyachati, Manqing Liu,

Alice L. Sternberg, James Tonascia, et al. 2018. “Education Outcomes in a Duty-Hour

Flexibility Trial in Internal Medicine.” New England Journal of Medicine 378(16): 1494–

1508. https://doi.org/10.1056/nejmoa1800965

• Nasca, Thomas J, Philibert, Ingrid. 2008. “Resident Duty-Hour Limits.” Health

Affairs. 27(5):1484.

• Ouyang, David, Jonathan H. Chen, Gomathi Krishnan, Jason Hom, Ronald Witteles, and

Jeffrey Chi. 2016. “Patient Outcomes When Housestaff Exceed 80 Hours per

Week.” The American Journal of Medicine 129(9).

https://doi.org/10.1016/j.amjmed.2016.

03.023.

VI.F.2. Mandatory time free of clinical work and education

While the expectation is that schedules will be structured to ensure resdients are provided with

a minimum of eight hours off between scheduled work periods, the requirement recognizes that

residents may choose to remain beyond their scheduled time or return to the clinical site during

this time-off period to care for a patient preserves the flexibility for residents to make those

choices. The 80-hour weekly limit (averaged over four weeks) is also a deterrent for scheduling

fewer than eight hours off between clinical and educational work periods; it would be difficult for

a program to design a schedule that provides fewer than eight hours off without violating the 80-

hour rule.

The follo

wing requirements in this category are self-explanatory:

• VI.F.2.a) Residents should have eight hours off between scheduled clinical work

and education periods.

• VI.F.2.b) Res

idents must have at least 14 hours free of clinical work and

education after 24 hours of in-house call.

• VI.F.2.c) Residents must be scheduled for a minimum of one day in seven free of

clinical work and required education (when averaged over four weeks). At-home

call cannot be assigned on these free days.

ADS Screenshot: As part of a program application or for the ADS Annual Update

for a program on Initial Accreditation, the program director must attest that

residents will have one full day out of seven free from educational and clinical

responsibilities.

VI.F. 3. Maximum clinical work and education period length

VI.F.3.a) Clinical and educational work periods for residents must not exceed 24 hours of

continuous scheduled clinical assignments.

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VI.F.4. Clinical and educational work hour exceptions

The exceptions delineated in this requirement are intended to provide residents with some

control over their schedules by providing the flexibility to voluntarily remain beyond the

scheduled responsibilities under the circumstances described in VI.F.4.a). It is important to note

that a resident may remain to attend a conference, or return for a conference later in the day,

only if the decision is made voluntarily. Residents must not be required to stay. Programs

allowing residents to remain or return beyond the scheduled work and clinical education period

must ensure that the decision to remain is initiated by the resident and that residents are not

coerced. This additional time must be counted toward the 80-hour maximum weekly limit.

• VI.F.4.a) In rare circumstances, after handing off all other responsibilities, a

fellow, on their own initiative, may elect to remain or return to the clinical site in

the following circumstances: to continue to provide care to a single severely ill or

unstable patient; to give humanistic attention to the needs of a patient or patient’s family;

or to attend unique educational events.

• VI.F.4.b) These additional hours of care or education must be counted toward the 80-

hour weekly limit.

• VI.F.4.c) A Review Committee may grant rotation-spec

ific exceptions for up to 10

percent or a maximum of 88 clinical and educational work hours to individual programs

based on a sound educational rationale.

• VI.F.4.c).(1) In preparing a request for an exception, the program director must follow the

clinical and educational work hour exception policy from the ACGME Manual of Policies

and Procedures.

The provision for exceptions for up to 88 hours per week specifies that exceptions may be

granted for particular rotations if the program can justify the increase based on criteria specified

by the Review Committee. Currently, the only Review Committee that allows exceptions to the

80-hour weekly limit is the Review Committee for Neurological Surgery. The underlying

philosophy for this requirement is that while it is expected that all residents should be able to

learn and train within an 80-hour work week, it is recognized that some programs may include

rotations with alternate structures based on the nature of the specialty.

VI.F.7. In-House call

Residents must be scheduled for in-house call no more frequently than every third night (when

averaged over a four-week period).

ADS screenshot: As part of a program application or for the ADS Annual Update

for a program on Initial Accreditation, the program director must provide

information about the frequency of residents’ in-house call assignments.

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VI.F.8. At-Home call

There are a number of requirements related to at-home call:

• Time spent on patient care activities by residents on at-home call must count toward the

80-hour maximum.

• It is not subject to the every-third-night limitation, but must meet the requirement for one

day in seven off.

• It must not be so frequent that it precludes rest or reasonable personal time.

Act

ivities such as reading about the next day’s case, studying, or research activities do not

count toward the 80-hour weekly limit.

One of the most common misconceptions regarding Common Program Requirement VI.F.8. is

that residents are required to record every single minute they spend on at-home call answering

phone calls and providing documentation. This is not the expectation. However, program

directors must ensure that at-home call time is reasonable.

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