Accreditation Council for Graduate Medical Education (ACGME)
Institutional Review Committee (IRC)
515 North State Street, Suite 2000, Chicago, IL 60654
INITIAL INSTITUTIONAL APPLICATION
(Corresponding to Institutional Requirements, effective July 1, 2014 for Sponsoring Institutions)
ACGME Policies and Procedures require that an organization must achieve Initial Institutional Accreditation
prior to submission of application(s) for ACGME-accredited programs. Institutions applying for accreditation
under the single accreditation system for allopathic and osteopathic graduate medical education that have
achieved Pre-accreditation Status may initiate applications for accredited core programs.
INSTRUCTIONS
Getting Started
The institutional application process begins with completion of the “Intent to Apply for Institutional Accreditation” form
found on the Institutional Review page of the ACGME website.
The Initial Institutional Application consists of three parts: 1) data entered into the ACGME Accreditation Data System
(ADS); 2) an MS Word© document; and, 3) attachments submitted by the institution.

Data entered into ADS includes verification of designated institutional official (DIO) information, the
addition of other institutional personnel, basic information about the institution, and a listing of proposed
and/or existing participating sites.

The Initial Institutional Application is an MS Word© document (see the pages following these instructions).
It includes questions which correspond to the Institutional Requirements (effective July 1, 2014). Each item
is associated with a requirement; however, not all requirements have a corresponding item (i.e., question,
attachment, or other required documentation). Responses to questions should be written directly in the
spaces provided within the document. No sections of the Initial Institutional Application may be retyped in
another word processing program for any reason. Page numbers will automatically be inserted into the
final application document. The document has been developed in table format; all lines may show on the
screen. These lines, however, will not show up in a print copy. Blank rows in the table may be added or
deleted for better document flow from page to page.

Descriptions of the required attachments and directions for uploading are included in ADS.
Only specifically requested information should be included in the Initial Institutional Application. Do not
attach brochures, reprints, manuals, bylaws, or any other documentation to substitute for any specified information
requested in the Initial Institutional Application.
Submission
Upon completion, the Initial Institutional Application, including all its required attachments, must be uploaded into ADS.
No changes may be made to the Initial Institutional Application after submission to the ACGME following the
instructions provided in ADS.
Failure to provide complete information and/or requested attachments or to comply with all instructions in the
Initial Institutional Application will result in a citation for non-compliance with administrative responsibilities
of the DIO and the Graduate Medical Education Committee, and may result in a decision to withhold the
application by the IRC.
Contact the ACGME Administrator, Institutional Accreditation, with questions regarding this process. Contact
information can be found on the Institutional Review page of the ACGME website.
Initial Institutional Application - 2014
I.
STRUCTURE FOR INSTITUTIONAL OVERSIGHT
I.A.
Sponsoring Institution
I.A.1.-4.
Q1 Describe how the Sponsoring Institution will have ultimate authority for and oversight of
the ACGME-accredited residency/fellowship program(s). Include a discussion of the
Sponsoring Institution and any major participating sites, the proposed program(s) and
proposed complement of residents/fellows for each program, and the proposed
timeline for achieving ACGME accreditation for each program. (Limit response to 800
words)
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I.B.
GMEC
I.B.2.a)-b)
Q2 Describe the operating structure by which the GMEC will perform its required
responsibilities (e.g., Will the GMEC will use subcommittees, an executive committee,
or other means to fulfill its responsibilities? Will residents be included as members of
these subcommittees?).
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I.B.5.b)
Q3 Describe the procedures that the GMEC will use to monitor the action plans resulting
from the AIR.
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II.
INSTITUTIONAL RESOURCES
II.A.
Institutional GME Infrastructure and Operations
II.A.1.
Q4 Discuss how the Sponsoring Institution will provide adequate support for the DIO to
effectively carry out his or her educational, administrative, and leadership
responsibilities.
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II.A.3.
Q5 Describe how the Sponsoring Institution will provide salary support and resources for
effective administration of the GME Office.
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II.B.1II.B.5.
Q6 Describe the resources that the Sponsoring Institution will provide in support of its
ACGME-accredited programs. Include reference to financial support, time, and other
resources for the program director(s), programs, and program coordinators.
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II.C.
Resident/Fellow Forum
Initial Institutional Application – December 2014
II.C.
Q7 If more than one ACGME-accredited program will be supported by the Sponsoring
Institution, describe the plans to ensure that residents/fellows from all ACGMEaccredited programs will have an organization, council, town hall, electronic, or other
platform that will allow them to communicate and exchange information with each other
relevant to their ACGME-accredited programs and their learning and working
environment. Describe how concerns discussed at the resident forum will be brought to
the attention of the DIO and GMEC.
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II.F.
Support Services and Systems
II.F.1.a);
II.F.1.b)
Q8 By checking below, the DIO attests that the Sponsoring Institution provides the following
patient support services to a level that minimizes work that is extraneous to
residents/fellows achieving their Milestones and assures that residents’/fellows’
educational experience is not compromised by excessive reliance on them to fulfill
service obligations.
☐ Peripheral intravenous access placement
☐ Phlebotomy
☐ Laboratory
☐ Pathology
☐ Radiology
☐ Patient transportation
☐ Medical records
III.
RESIDENT/FELLOW LEARNING AND WORKING ENVIRONMENT
III.A.
Q9 Describe the systems and processes that the Sponsoring Institution will utilize to
ensure that residents/fellows will have learning and working environments in which
they can raise concerns and provide feedback without intimidation or retaliation and in
a confidential manner.
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III.B.1.a)-b)
Q10 Describe the Sponsoring Institution’s system(s) for reporting errors, adverse events,
unsafe conditions, and near misses in a protected manner that is free from reprisal.
Comment on how residents/fellows will be educated about and have access to these
systems. Include a description of residents’/fellows’ opportunities to contribute to root
cause analysis or other similar risk reduction processes.
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Initial Institutional Application – December 2014
III.B.2.a)
Q11 Describe how the Sponsoring Institution will ensure that residents/fellows have access
to data to improve systems of care, reduce health care disparities, and improve patient
outcomes.
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III.B.2.b)
Q12 Describe how residents/fellows will participate in patient safety and quality
improvement initiatives.
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III.B.3.a)
Q13 Describe how the Sponsoring Institution will facilitate the professional development of
core faculty members* and residents/fellows regarding effective transitions of care.
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III.B.3.b)
Q14 Describe how the Sponsoring Institution will ensure that all its participating sites
engage residents/fellows in standardized transitions of care consistent with the setting
and type of patient care.
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III.B.4.a)
Q15 Describe how the Sponsoring Institution will oversee supervision of residents/fellows
consistent with institutional and program-specific policies.
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III.B.4.b)
Q16 Describe the mechanisms by which residents/fellows will be able to report inadequate
supervision in a protected manner that will be free from reprisal.
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III.B.5.a)
Q17 Describe how the Sponsoring Institution will monitor compliance with resident/fellow
duty hour standards. Comment on the frequency of monitoring, how monitoring will
occur, and the role of the GMEC in monitoring compliance with duty hour standards.
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III.B.5.b)
Q18 Describe the fatigue management and mitigation program that will be utilized by the
Sponsoring Institution and its programs. Comment on how education will be provided
for residents/fellows and faculty members.
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III.B.6.a)
Q19 Describe how the Sponsoring Institution will facilitate and oversee the education of
residents/fellows and core faculty members in their fulfillment of educational and
professional responsibilities and scholarly pursuits.
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Initial Institutional Application – December 2014
III.B.6.b)
Q20 Describe how the Sponsoring Institution will monitor accurate completion of required
documentation by residents/fellows.
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III.B.6.c)
Q21 Describe how the Sponsoring Institution will identify and monitor resident/fellow
mistreatment in the learning and working environment and how it will address such
treatment when it is identified.
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IV.
INSTITUTIONAL GME POLICIES AND PROCEDURES
Q22 By checking below, the DIO attests that the following policies and procedures have
been reviewed and approved by the GMEC and are/will be available to
residents/fellows. The GMEC minutes should document their review and approval.
IV.A.1.
☐ Resident/fellow recruitment and selection
IV.A.2.
☐ Qualifications of applicants
IV.A.3.
☐ Electronic or written information provided to applicants
IV.B.
☐ Provision of an agreement of appointment/contract to each resident/fellow and
required elements of the agreement/contract
IV.C.
☐ Renewal and promotion
IV.D.
☐ Grievances
IV.E.
☐ Professional liability insurance
IV.F.
☐ Health and disability insurance
IV.G.
☐ Vacation and leaves of absence
IV.H.
☐ Resident services, including access to confidential counseling and behavioral health
services; policies concerning physician impairment, harassment, and
accommodation for disabilities
IV.I.
☐ Supervision
IV.J.
☐ Duty hours
IV.K.
☐ Vendor interactions between representatives/corporations and residents/fellows
IV.L.
☐ Non-competition
Initial Institutional Application – December 2014
IV.M.
☐ Disasters, including information about continuation of salary, benefits, and
assignments
IV.N.
☐ Closures and reductions, including information about communication with the
ACGME
*Core Faculty: All physician faculty who have a significant role in the education of resident/fellows
and who have documented qualifications to instruct and supervise. Core faculty devote at least 15
hours per week to resident education and administration. All core faculty should evaluate the
competency domains; work closely with and support the program director; assist in developing and
implementing evaluation systems; and teach and advise residents. (Source: ACGME Glossary of
Terms)
Initial Institutional Application – December 2014