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Sponsoring Institution
By: Cheryl Haynes, BA Cheryl@PartnersInMedEd.com
Words Matter
The best advice we can give to those working in Graduate Medical Education is “words matter.” When it involves ACGME accreditation compliance, words are crucial. Remember that Field Representatives conducting site visits for the ACGME are not necessarily physicians, nor are they familiar with the specifics of every specialty. Instead, they are guided by the written words in the Institutional, Common, and Specialty-Specific Requirements. Their job is to verify that institutions and programs meet specific requirements and report their findings to the appropriate Review Committee. To do so, they are looking for words: specific words.
In a recent ACGME Letter of Notification, the Institutional Review Committee placed an institution on continued accreditation with warning and assigned several citations. Most of the citations were due to the misuse of words.
As an example, I.A.7 – I.A.7.b) of the Institutional Requirements address the Statement of Commitment. Specifically, the requirements (words) are:
“A written statement, reviewed, dated, and signed at least once every five years by the DIO, a representative of the Sponsoring Institution’s senior administration, and a representative of the governing body, must document the Sponsoring Institution’s: GME mission; and commitment to GME by ensuring the provision of the necessary administrative, educational, financial, human, and clinical resources.”
Per this Institution’s Statement of Commitment:
“…the institution pledges to dedicate the financial, personnel, equipment, facilities, and other resources to support an appropriate learning environment.
- Fund the Office of Graduate Medical Education to support programs, GMEC and the Designated Institutional Official.
- Provide sufficient educational, financial, and human resources to ensure the effective implementation and support of all programs in compliance with all accreditation requirements.
- Provide professional, informational and support services to meet the educational goals of each program as well as resident well-being.
…affirms its commitment to Graduate Medical Education and its intent to Institutional, Common, and Program Requirements established by the ACGME.”
Do you think they met the requirement? The institution received the following citation:
“The information provided to the IRC does not demonstrate substantial compliance with the requirements. The Sponsoring Institution’s written statement does not ensure the provision of the administrative and clinical resources needed for GME.”
The statement addressed educational, financial, and human resources, but it failed to include administrative and clinical resources, thus it was cited for non-compliance. The Institution’s intent was there, but the words were not, and words matter.
The same institution was cited for non-compliance related to their Harassment Policy. Their policy states that the institution has a zero-tolerance policy for any, and all, forms of harassment. The citation stated that the policy did not specifically reference sexual harassment. Words matter.
I worked with an institution that has unique, “creative” names for their committees, so there are no labeled “Graduate Medical Education Committee” meetings or minutes. They have not had a site visit yet, but I predict they will read about their creativity in the form of a citation…words matter!
The ACGME Field Representatives must rely on, and verify, specific words; it is up to the institution, and us, to ensure exact words are used.
Program
By: Heather Peters, M.Ed, Ph.D. Heather@PartnersInMedEd.com
Are You Ready for a Random Site Visit in the Next 2-3 Years?
All programs that have not been site-visited in the past 9 years or more are eligible for a random site visit – even if the program’s accreditation status is “continued accreditation.”
Partners® has created a Readiness Assessment process to assess critical site visit components in an efficient manner that requires minimal time commitment from your program administrative staff. Use this document at your next PEC, as a training tool for new administrators, APDs or core faculty, or as a refresher for those of you who are experienced in GME. The site visit process, as well as many documents, have dramatically changed over the past decade and may require significant updating or development.
Be sure your programs are ready! Not sure where to start? Contact us today to discuss how we can help your institution determine the readiness of your programs for a random site visit.
GME Office / Administration
By: Victoria Hanlon Tori@PartnersInMedEd.com
Recruitment Wrap-up
As the 2025 recruitment season comes to an end, it’s important to discuss and analyze what went well, what didn’t, and what you can improve upon for the following year. This often gets lost as daily operations take priority. However, recruitment debriefing and analysis are so important in supporting your program’s mission and process for continuous program improvement. GME administrators at both the institutional and program levels can help support post-recruitment efforts. Let’s look at a few ways how:
Data collection
Data is a must in order for you to analyze your recruitment practices based on your goals. If you’re using an electronic application service and/or matching program, there are numerous filters and reports you can access that have meaningful data. Demographic data, such as gender, ethnicity/self-identification, and type of medical school (osteopathic, allopathic, foreign medical school) can help you understand the diversity of applicants applying to your program. It is recommended to collect this information once recruitment season has ended.
Additionally, match data can be instrumental in understanding the success or not of your match and ranking methodology. I recommend the following: # of positions in the match, # of applicants interviewed, # of applicants ranked, rank order list positions of matched applicants, # of matched applicants via SOAP, list of ranked applicants and where they matched. This data can help you analyze the types of applicants you are matching, and maybe even more importantly, the ones you are not.
Administrator Action – Develop data collection tools/templates to collect data that may be important to your program. Add to your next PEC agenda for discussion.
Post-interview surveys
Some programs have been successful with post-interview or post-match surveys to understand applicants’ perceptions and satisfaction with the interview process. This information can be valuable in determining what changes you may need to make to your interview day or format to better attract applicants.
Administrator Action – If you currently don’t use a post-interview survey, consider taking the initiative to develop one and present it to your Program Director. Now would be the time to do this so it can be rolled out after rank order lists are due.
Annual Program Evaluation
One measure of program quality is recruitment and should be incorporated into your APE. The data and surveys identified above are a good place to start and can be brought to your PEC for discussion. You can also simply look at your match rate, if applicable, and identify what the program has done in the past year to enhance the recruitment of trainees.
Administrator Action – Identify whether recruitment is currently part of your APE. If not, add it to your list of metrics for review and discussion at your PEC.
Post-recruitment can be a bit of a downtime for administrators, so take advantage of this, especially while recruitment is fresh in your mind. This is the best time to think about next year, even if it’s casually writing yourself notes about things to do, or improve, that can be revisited once you begin working on recruitment for the next year.
Finance / Public Policy
By: Alfred Peters, MBA, M.Div, PhD Alfred@PartnersInMedEd.com
Patient Safey and Public Policy in ACGME Programs
Patient safety and quality improvement (PSQI) have become central to medical education under the Accreditation Council for Graduate Medical Education (ACGME). With evolving healthcare systems and mounting financial pressures, embedding PSQI into residency and fellowship training improves clinical outcomes and aligns with public policy goals of reducing healthcare costs and disparities.
Driving Change in Medical Education
Integrating PSQI into ACGME programs addresses dual objectives: enhancing clinical care and optimizing systemic processes. This shift began with the landmark reports To Err is Human (1) and Crossing the Quality Chasm (2), which exposed alarming rates of preventable errors and inefficiencies in care delivery. In response, the ACGME gradually increased its focus on PSQI, resulting in increased scrutiny for compliance in 2024.
Key ACGME Reforms
- Patient Safety and Quality Improvement (2024)
Introduced in 2012, ACGME began requiring residency programs to deliver structured training in error identification, safety reporting, and quality improvement. Today, residents must engage in safety reporting systems and use data to drive care improvements which ACGME monitors through ADS updates, site visits, and resident and faculty surveys. By preventing errors, these measures can reduce malpractice costs and improve resource allocation, directly supporting policy goals of cost containment in healthcare. (3) - Clinician Well-Being and Productivity (2023–2024)
Recognizing the link between burnout and medical errors, ACGME emphasized and required wellness programs for residents and faculty. Mental health and work-life balance investments improve resident performance and reduce costly turnover. These reforms reflect the economic reality that healthier clinicians contribute to safer, more efficient care systems. (3) - Interprofessional Collaboration (2024)
Clinical Learning Environment Review (CLER) was updated in 2024 and further emphasized collaborative teams of patient safety officers, GME leaders, and residents to oversee and participate in PSQI initiatives. This interdisciplinary model reduces silos, promotes accountability, and aligns training with healthcare finance trends emphasizing team-based, value-driven care. (4)
Challenges and Opportunities
Integrating PSQI into training programs presents challenges, including the need for significant resource investment in technology and personnel. However, the long-term financial benefits are clear: streamlined care processes, reduced errors, and compliance with public policies targeting healthcare efficiency. Additionally, involving residents in data-driven quality improvement initiatives prepares them for leadership roles in an increasingly metrics-focused healthcare landscape. (5)
Future Directions
Looking forward, ACGME reforms are poised to integrate equity into PSQI efforts, ensuring healthcare systems address disparities in access and outcomes. Policy advancements may also push for metrics-based assessments of PSQI training efficacy and embrace artificial intelligence to reduce costs and improve patient outcomes.
References:
- Institute of Medicine. To Err Is Human: Building a Safer Health System. [ed.] Linda T Kohn, Janet M Corrigan and Molla S Donaldson. Washington, DC: National Academy Press, 2000.
- —. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, 2001.
- Accreditation Council for Graduate Medical Education. Common Program Requirements (Residency). Chicago: IL: Accreditation Council for Graduate Medical Education, 2024.
- CLER Evaluation Committee. CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 3.0. Chicago, IL: Accreditation Council for Graduate Medical Education, 2024.
- Smith, Timothy M. An easier way to meet ACGME requirements on quality, safety. www.AMA-ASSN.org. [Online] July 31, 2024. [Cited: October 21, 2024.] https://www.ama-assn.org/education/improve-gme/easier-way-meet-acgme-requirements-quality-safety.
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