Graduate Medical Education

Graduate Medical Education Policies and Procedures

Responsibilities of the Residency Program Director

There must be a single program director with authority and accountability for the operation of the program. The sponsoring institution’s GMEC must approve a change in program director. After approval, the program director must submit this change to the ACGME via the ADS.

The program director should continue in his or her position for a length of time adequate to maintain continuity of leadership and program stability.

Qualifications of the program director must include:

  1. requisite specialty expertise and documented educational and administrative experience acceptable to the Review Committee;
  2. current certification in the specialty by the American Board of Internal Medicine, or specialty qualifications that are judged to be acceptable by the Review Committee; and,
  3. current medical licensure and appropriate medical staff appointment.

The program director must administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas. The program director must:

  1. oversee and ensure the quality of didactic and clinical education in all institutions that participate in the program;
  2. approve a local director at each participating institution who is accountable for resident education;
  3. approve the selection of program faculty as appropriate;
  4. evaluate program faculty and approve the continued participation of program faculty based on evaluation;
  5. monitor resident supervision at all participating institutions;
  6. prepare and submit all information required and requested by the ACGME, including but not limited to the program information forms and annual program resident updates to the ADS, and ensure that the information submitted is accurate and complete;
  7. provide each resident with documented semiannual evaluation of performance with feedback;
  8. ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and implemented by the sponsoring institution;
  9. provide verification of residency education for all residents, including those who leave the program prior to completion;
  10. implement policies and procedures consistent with the institutional and program requirements for resident duty hours and the working environment, including moonlighting, and, to that end, must:
    1. distribute these policies and procedures to the residents and faculty;
    2. monitor resident duty hours, according to sponsoring institutional policies, with a frequency sufficient to ensure compliance with ACGME requirements
    3. adjust schedules as necessary to mitigate excessive service demands and/or fatigue; and,
    4. if applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
  11. monitor the need for and ensure the provision of back up support systems when patient care responsibilities are unusually difficult or prolonged;
  12. comply with the sponsoring institution’s written policies and procedures, including those specified in the Institutional Requirements, for selection, evaluation and promotion of residents, disciplinary action, and supervision of residents.
  13. be familiar with and comply with ACGME and Review Committee policies and procedures as outlined in the ACGME Manual of Policies and Procedures;
  14. obtain review and approval of the sponsoring institution’s GMEC/DIO before submitting to the ACGME information or requests for the following:

    1. all applications for ACGME accreditation of new programs;
    2. changes in resident complement;
    3. major changes in program structure or length of training;
    4. progress reports requested by the Review Committee;
    5. responses to all proposed adverse actions;
    6. requests for increases or any change to resident duty hours;
    7. voluntary withdrawals of ACGME-accredited programs;
    8. requests for appeal of an adverse action;
    9. appeal presentations to a Board of Appeal or the ACGME; and,
    10. proposals to ACGME for approval of innovative educational approaches.

  15. obtain DIO review and co-signature on all program information forms, as well as any correspondence or document submitted to the ACGME that addresses:
    1. program citations; and,
    2. request for changes in the program that would have significant impact, including financial, on the program or institution.


Approved by GMEC: 3/27/2015