Program Director’s Guide to
Common Program
Requirements
Cuc Mai MD
GME Director of Faculty Development
November 2011
Goals & Objectives
 Improve in-depth understanding of ACGME common
program requirements
 Correlate ACGME common program requirements to the
program information form (PIF)
 Correlate ACGME common program requirements to the
resident survey
Why is this important?
 Compliance with requirements = Accreditation
Common Program Requirements
Speciality Specific
Requirement
Program
Information
Form (PIF)
Site Visitor’s
Report
Resident Survey
Results
Monitoring
Committee of
ACGME board
Board Scores
Resources
 www.acgme.org
Step 1
Step 2
Step 3
More fun
reading !!!
When you need clarification…
 If unclear directive, see FAQs or speciality specific RRC
guidelines
 3 types of requirements
 “Must”: no exceptions
 “Should”: almost a must; need to have a strong
educational rationale for not doing
 “Suggested”: is not required and not citable
ACGME Common Program Requirements Outline
I. Institutions
II. Program Personnel and Resources
III. Resident Appointments
IV. Education Programs
V. Evaluation
VI. Resident Duty Hours
VII. Innovative Projects
I. Institutions
 I.A. Sponsoring Institution
 I.B. Participating Sites
I. A. Sponsoring Institution
 Must assume responsibility for the program and must
ensure that the PD has sufficient protected time and
financial support
 Internal Review: formal mid-cycle review conducted by
the GMEC. Reviewer group must include at least one
faculty member and one resident from sponsoring
institution not from program being reviewed.
I.B. Participating Sites
 A program letter of agreement (PLA) must exist between the
program and each participating site providing a required
assignment.
 Document needs to be renewed at least every 5 years.
 Additions or deletions need to be update from the ACGME
Accreditation Data Systems (ADS)
 See handout.
I.B. Participating Sites
 PLA
 Identify faculty who assumes education and supervisory
responsibility for residents
 Specify faculty responsibilities for teaching, supervision,
and formal evaluation of residents
 Specify the duration and content of the education
experience
 State the policies and procedures that will govern resident
education during that assignment
II. Program Personnel & Resources
 II. A. Program Director
 II. B. Faculty
 II. C. Other Program Personnel
 II. D. Resources
 II. E. Medical Information Access
II. A. Program Director
 Qualifications expertise acceptable to Review committee,
Board Certification, and Current Medical licensure and Staff
appointment
 Provide each resident with documented semiannual
evaluation of performance with feedback
 Evaluate program faculty and approve the continued
participation of program faculty based on evaluation
II. A. Program Director
 Comply with sponsoring institution’s written policies and
procedures
 Review with DIO before submitting ACGME information or
requests for the following
 Changes in resident complement
 Major changes in program structure or length of training
 Progress reports requested by the Review committee
 Responses to proposed adverse actions
 Requests for increases or change to resident duty hours
 Voluntary withdrawal of ACGME accredited programs
 Requests for appeal of an adverse action
 Proposals to ACGME for approval of innovative educational
approaches
 Correspondence about program citations
II. B. Faculty
 Must be a sufficient number of faculty with documented
qualifications to instruct and supervise all residents at that
location.
 Establish and maintain an environment of inquiry and scholarship
with an active research component
 Must regularly participate in organized clinical discussions,
rounds, journal clubs, and conferences.
 Demonstrate scholarship
 Encourage and support residents in scholarly activities
Accreditation Data System (ADS)
III. Resident Appointments
 III. A. Eligibility Criteria
 III. B. Number of Residents
 III. C. Resident Transfers
 III. D. Appointment of Fellows and Other Learners
III. B. Number of Residents
 Increasing number of residents require PRIOR residency
review committee and DIO approval
 Request for change should be documented in ADS
IV. Educational Programs
 IV. A. 5. ACGME Core Competencies
 IV. B. Residents’ Scholarly Activities
IV. Educational Program
 Goals for the program must be distributed to residents and
faculty annually
 Competency based goals and objectives for each assignment at
each educational level must be distributed to residents and
faculty annually. These should be reviewed by residents at the
start of each rotation
 Regularly scheduled didactic sessions
 Delineation of resident responsibilities for patient care,
progressive responsibility for patient management, and
supervision of residents over the continuum of the program
IV. Educational Program
 Resident Survey Questions:
 Has your program provided you with goals and
objectives for each rotation and major
assignment in either a hard copy or electronic
form?
 Has your program provided you with its
general goals and objectives in either a hard
copy or electronic form?
IV. Educational Program
 Resident Survey:
 How sufficient is the supervision you receive from
faculty and staff in your program?
 How often do your faculty and staff provide an
appropriate level of supervision for residents?
 How often has your clinical education been
compromised by excessive service obligations?
IV. A. 5. ACGME competencies
 Patient Care
 Medical Knowledge
 Practice-based Learning and Improvement
 Interpersonal and Communication Skills
 Professionalism
 Systems-based practice
IV. A. 5. ACGME competencies
 ACGME Outcomes Project
 Minimal Threshold model
Competency Based model
IV. A. 5. ACGME competencies
 Patient Care
 Provision of learning experiences can be
documented through rotation schedules, written
goals and objectives, and resident files.
 Completed procedure/case logs
IV. A. 5. ACGME competencies
 Medical Knowledge
 Documentation by written didactic curriculum,
lecture schedule, reading assignments
IV. A. 5. ACGME competencies
 Practice Based Learning and Improvement
 Residents must demonstrate the ability to investigate and evaluate
their care of patients, to appraise and assimilate scientific evidence, to
improve patient care based on constant self evaluation and life-long
learning
 Identify strengths, deficiencies, and limits in one’s knowledge and
expertise
 Set Learning and improvement goals
 Identify and perform appropriate learning activities
 Analyze practice using quality improvement methods and
implement changes with the goal of practice improvement
 Locate, appraise, and assimilate evidence
 Use information technology to optimize learning
 Participate in the education of patients, families, students, residents,
and other health professionals
IV. A. Practice based learning
improvement
 PIF question
 Describe one learning activity in which residents
engage to identify strengths, deficiencies, and
limits in their knowledge and expertise; set
learning and improvement goals; identify and
perform appropriate learning activities to
achieve self identified goals.
IV. A. Practice based learning
improvement
 PIF question
 Describe one example of a learning activity in
which residents engage to develop the skills
needed to use information technology to locate,
appraise, and assimilate evidence from scientific
studies and apply it to their patients’ health
problems. The description should include a)
locating information b) using information
technology c) appraising information d)
assimilating evidence information 3) applying
information to patient care
IV. A. Practice based learning
improvement
 PIF question
 Give one example and the outcome of a planned
quality improvement activity or project in which
at least one resident participated in the past
year that required the resident to demonstrate
an ability to analyze, improve, and change
practice or patient care. Describe planning,
implementation, evaluation, and provisions of
faculty support and supervision that guided this
process.
IV. A. Practice based learning
improvement
 PIF question
 Describe how residents: A) develop teaching
skills necessary to educate patients, families,
students, and other residents B) Teach patients,
families, and others C) Receive and incorporate
formative evaluation feedback into daily
practice.
IV. A. Interpersonal and
Communication Skills
 Residents must demonstrate interpersonal and
communication skills that result in the effective
exchange of information and collaboration with
patients, their families, and health professionals.
IV. A. Interpersonal and
Communication Skills
 PIF question
 Describe one learning activity in which residents
develop competence in communicating
effectively with patients and families across a
broad range of socioeconomic and cultural
backgrounds, and with physicians, other health
professionals, and health related agencies.
IV. A. Interpersonal and
Communication Skills
 PIF question
 Describe one learning activity in which residents
develop their skills and habits to work
effectively as a member or leader of a health
care team or other professional group. In the
example, identify the members of the team,
responsibilities of the team members, and how
team members communicate to accomplish
responsibilities.
IV. A. Interpersonal and
Communication Skills
 PIF question
 Explain (a) how the completion of
comprehensive, timely, and legible medical
records is monitored and evaluated, and (b) the
mechanism for providing residents feedback on
their ability to competently maintain medical
records.
IV. A. Professionalism
 Residents must demonstrate a commitment to
carrying out professional responsibilities and an
adherence to ethical principles.
IV. A. Professionalism
 PIF question
 Describe at least one learning activity, other
than lecture, by which residents develop a
commitment to carrying out professional
responsibilities and an adherence to ethical
principles.
 How does the program promote professional
behavior by the residents and faculty?
 How are lapses in these behaviors addressed?
IV. A. Professionalism
 Resident Survey:
 To what extent does your program provide an
environment where residents/fellows can raise
problems or concerns without fear of
intimidation or fear of retaliation?
IV. A. Systems-based Practice
 Residents must demonstrate an awareness of and
responsiveness to the larger context and system of
health care, as well as the ability to call
effectively on other resources in the system to
provide optimal health care.
IV. A. Systems based Practice
 PIF question:
 Describe the learning activity through which
residents achieve competence in the elements of
systems-based practice; work effectively in
various health care delivery settings and
systems, coordinate patient care within the
health care system; incorporate considerations
of cost-containment and risk-benefit analysis in
patient care; advocate for quality patient care
and optimal patient care systems; and work in
interprofessional teams to enhance patient
safety and care quality.
IV. A. Systems based Practice
 PIF question:
 Describe an activity that fulfills the requirement
for experiential learning in identifying system
errors. Important elements include faculty
guidance and active engagement by residents
with written goals and objectives; resident
assessment; and aggregated resident outcomes.
IV. B. Residents’ Scholarly
Activities
 Curriculum MUST advance residents’ knowledge of the
basic principles of research, including how research is
conducted, evaluated, explained to patients, and
applied to patient care.
 Should participate in scholarly activity
 Sponsoring institution and program should allocate
adequate educational resources to facilitate resident
involvement in scholarly activities.
IV. B. Residents’ Scholarly
Activities
 Resident Survey:
 Does your program offer you the opportunity to
participate in research or scholarly activities?
V. Evaluation
 V. A. Resident
 V. B. Faculty
 V. C. Program
V. A. Resident Evaluation
 Faculty must evaluate resident performance in a timely
manner and document evaluation at completion of the
assignment. Evaluations must be accessible for review
 Program
 Provide objective assessments of all ACGME competencies
 Use multiple evaluators
 Document progressive resident performance improvement
appropriate to educational level
 Provide each resident with documented semiannual
evaluation of performance with feedback
V. A. Resident Evaluation
 Resident Survey:
 Overall, how satisfied are you with the written
or electronic feedback you receive after you
complete a rotation or major assignment?
 If you want to review feedback on your
performance, are you able to access your
evaluations?
V. B. Faculty Evaluation
 Must provide faculty with evaluation ANNUALLY
 MUST include annual written confidential
resident evaluations
 SHOULD include a review of faculty’s clinical
teaching abilities, commitment to the
educational program, clinical knowledge,
professionalism, and scholarly activities.
V.B. Faculty Evaluations
 PIF question:
 Describe the system used by the residents to provide
annual confidential written evaluations of the teaching
faculty
 Describe the program’s system for evaluating and
providing feedback to the teaching faculty
V.B. Faculty Evaluations
 Resident Survey:
 Do you have the opportunity to evaluate faculty
members at lease once a year?
 How satisfied are you that your program treats
your evaluations of faculty members
confidentially?
V. C. Program Evaluation
 MUST document formal, systematic evaluation of
curriculum ANNUALLY
 MUST monitor and track
 Resident performance
 Faculty Development
 Graduate Performance
 Program Quality: assessed by residents in writing
annually and this must be used to improve
program. SHOULD document action plan if
deficiencies found.
V. C. Program Evaluation
 PIF question:
 Describe the approach used for program evaluation.
 Describe one example of how the program used the
aggregated results of residents’ performance and/or
other program evaluation results to improve the
program
V. C. Program Evaluation
 PIF question:
 Describe the improvement efforts currently
undertaken in the program based on feedback
from the ACGME resident survey. What
improvements, if any, has the program
undertaken to address potential issues
identified by the most recent ACGME resident
survey summary report? Review your survey
summary.
 Board Pass Rates for past three years
V. C. Program Evaluation
 Resident Survey:
 Do you have the opportunity to evaluate your
overall program at least once a year?
 How satisfied are you that your program treats
your evaluations of the program confidentially?
 How satisfied are you with the way your
program uses the evaluations that
residents/fellows provide to improve the
program?
VI. Resident Duty Hours in the Learning
and Work Environment
 VI. A. Professionalism, Personal Responsibility, and Patient
Safety
 VI. B. Transitions of Care
 VI. C. Alertness Management & Fatigue Mitigation
 VI. D. Supervision of Residents
 VI. E. Clinical Responsibilities
 VI. F. Teamwork
 VI. G. Resident Duty Hours
VI. Resident Duty Hours in the
Learning and Work Environment
From: www.acgme.org
VI. Resident Duty Hours in the Learning &
Working Environment
 Must educate residents & faculty concerning the
professional responsibilities of the physician to
appear for duty rested and fit
 Must be committed to and responsible for patient
safety and resident well being in a supportive
educational environment
VI. Resident Duty Hours in the
Learning & Working Environment
 Must ensure a culture of professionalism that supports patient
safety and personal responsibility.
 Must demonstrate an understanding and acceptance of their
personal role in the following:
 Assurance of their fitness for duty
 Recognition of impairment, including illness and fatigue, in
themselves and in their peers
 Attention to lifelong learning
 Monitoring of their patient care performance improvement
indicators
 Honest and accurate reporting of duty hours, patient outcomes,
and clinical experience data
VI. B. Transitions of Care
 Must design clinical assignments to minimize the
number of transitions of patient care.
 Must ensure and monitor effective, structured handover processes to facilitate both continuity of care and
patient safety.
 Must ensure that residents are competent in
communicating with team members in the hand-over
process
 Must ensure the availability of schedules that inform all
members physicians responsible for patient’s care
VI. C. Alertness Management/Fatigue
Mitigation
 Must educate faculty members and residents to
recognize the signs of fatigue and sleep deprivation
 Educate all faculty members and residents in alertness
management and fatigue mitigation processes
 Adopt fatigue mitigation processes
 Must have a process to ensure continuity in the event
resident is unable to perform
 Must have adequate sleep facilities and/or safe
transportation options for residents who may be too
fatigued
VI. D. Supervision of Residents
 Each patient must have an identifiable attending who is
ultimately responsible for patient care.
 Must demonstrate appropriate level (graded) of
supervision in place for residents and must use
appropriate classification of supervision.
 Direct: supervisor is physically present with patient and
resident
 Indirect: a) direct supervision immediately available b)
with direct supervision available
 Oversight: supervisor is available to provide review of
encounter after care is delivered
VI. G. Resident Duty Hours
 Maximum Hours per week is 80, averaged over a 4 week
period, inclusive of all in-house call and moonlighting.
 Moonlighting must not interfere with educational
program and PGY-1 not permitted to moonlight.
 Must have minimum of one day free of duty every week,
when averaged over 4 weeks. No at home call on these
days.
VI. Resident Duty Hours
 PGY-2 residents and above
 Must be scheduled for in-house call no more frequently
than every third night, averaged over a 4 week period.
 May be schedule to a maximum of 24 hours of continuous
duty.
 Strategic napping especially after 16 hours of continuous
duty and between the hours of 10 pm and 8 am is strongly
suggested.
 Time for transitions of care must be no longer than an
additional four hours.
 Must not have additional clinical responsibilities after 24
hours of continuous in-house duty
VI. Resident Duty Hours
 PGY 1 residents must not exceed 16 hours per duty
period length.
 Should have 10 hours
 Must have 8 hours free of between duty periods
VI. Resident Duty Hours
 Resident Survey:
 How often did you break the rule that duty hours must
be limited to 80 hours per week, averaged over a fourweek period, inclusive of all in-house call activities?
 How often did you break the rule that residents/fellows
must be scheduled for a minimum of 1 day in 7 free
from all residency related duties, averaged over a 4week period?
 How often did you break the rule that there should be a
10-hour time period provided between all daily duty
periods and after in house call?
VI. Resident Duty Hours
 Residents, on their own initiative, may remain
beyond their duty to continue to provide care for
single patient if severely ill, academic importance,
humanistic attention. Resident must document
reasons for maintaining care and submit
documentation to program director.
 Program director must review each submission and
track both individual and program wide episodes of
additional duty
Conclusions
 It is important that GME faculty have an in-depth
understanding of common program requirements.
 PIFs and Resident survey questions correspond directly
to these requirements.
 It is important that GME faculty are aware of additional
resources to review.