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Sponsoring Institution
By: Christine Redovan, MBA, MLIS Christine@PartnersInMedEd.com
Proposed ACGME Institutional Requirements
Proposed ACGME institutional requirements, effective July 1, 2025, have been posted for review and comment by the ACGME. As you read them, you may notice there are quite a few that have come directly from the CLER initiative. It is unclear which proposed requirements, and in what form, will make the final version; however, it is never too early to begin thinking about how your sponsoring institution (SI) will need to adapt. This article will focus on eight of the proposed requirements that will require additional resources and the development of new processes and workflows.
Note that each section is summarized. Full language is available at ACGME.
I.V.C. Requires SIs to ensure structured learning activities for residents, fellows, and faculty members incorporating interprofessional, team-based care. This requirement will require planning, hosting, and documenting learning activities that improve interprofessional relationships, communications, and workforce well-being. Ideally, the SI will work with each program, and their participating sites, to create learning activities that include broad-based and specialty-specific applications.
V.A.2. Residents must participate in a non-simulated interprofessional process addressing a real patient safety event. All first-year residents will be required to participate. This requirement will require heavy coordination between GME, programs, and other departments and include planning, documentation, and time for all involved. The rationale behind this requirement is to provide residents with real-life training in patient safety analysis, evaluation, and awareness.
V.A.3. There must be a program for responding to harm events that includes residents, fellows, and faculty members. This requirement provides direction for a distinct program that includes personnel with the skill set to support the impact of patient safety events experienced by physicians, including communication, and seeking resolution with patients and families, as well as support to the physician. The SI should include patient safety and risk management in program development.
V.B.2. & V.B.3. SIs must provide longitudinal training in clinical leadership and in health disparity/equity. As health systems become more complex, it is expected that physicians can navigate the issues that affect their organizations. Faculty time and resources will be critical to success. Might this be an opportunity for local or regional collaboration?
V.D., V.E., & V.F. All three of these requirements surround the creation of a GME + Primary Clinical Learning Environment interprofessional workgroup. These workgroups are to address supervision, well-being, and professionalism. These workgroups (committees) exist at the GME level in many SIs. The proposed requirements take it one step further by including institutional leaders of multiple professions within the clinical learning environment.
Notice a theme? We are moving to a much more integrated approach to GME as we prepare our trainees for the future of medicine and health care. Welcome to 2035!
Program
By: Cheryl Haynes, BA Cheryl@PartnersInMedEd.com
Navigating Change in GME Programs
Embracing change is a fundamental aspect of Graduate Medical Education. As administrators and educators, our role is to acknowledge these changes and understand and implement them effectively.
At the program level, we must adapt and use resources available to us to continue to run high quality, effective GME programs. For example, when accreditation changes occur, the tracked changes version of the accreditation requirements is a resource at your disposal to help navigate requirement changes. Pay close attention to the Background & Intent sections. The ACGME requirements tell us what changes, but they don’t tell us how to change. The Background & Intent section often gives us the “why,” which can guide us to the “how.” Tip: Be sure to save the tracked changes version of the requirements, as the ACGME eventually removes them from their website.
Two other great resources to assist with navigating accreditation changes are the FAQ’s and Guide to the Common Program Requirements. Make certain you are utilizing those documents and using them to guide your program through necessary changes.
Accreditation requirements aren’t the only change agents in our programs; continuous program improvement is a core principle of the ACGME, as evidenced by the mandatory Program Evaluation Committee (PEC) and the resulting Annual Program Evaluation (APE). Sometimes we get caught up in the mechanics of meeting and documenting the acts of the PEC and overlook the value of the process. The requirements guide us in examining our programs’ outcomes, such as ITE scores, evaluations, ACGME survey results, and action plan results. But what does this evidence reveal? Does it demonstrate that your program is meeting its mission and aims? Are more changes necessary? What should your program do differently as a result of the data the PEC reviewed? The APE itself is the process programs should use to organize their change efforts.
Documenting change is important also. The Major Changes section of the ACGME Accreditation Data System (ADS) requires programs to document changes that occurred in the previous year. Changes in leadership, program structure, and resources are required, but don’t forget that it is also an opportunity to tell your program’s story of improvement and how your program is evolving. For example, what is the program doing to address lower scoring areas on the ACGME Resident and Faculty Surveys? How about your APE action plans, as well as what the program is doing to address any areas for improvement identified on your most recent ACGME letter of notification? Summarizing the program’s plans, actions, and results in this section of ADS is a great way to show your commitment to program improvement and how you adapt to change.
The one constant in Graduate Medical Education is change. Expect it, plan for it, and use it to provide your residents and fellows with the best possible training and educational experiences.
GME Office / Administration
By: Carmela Meyer, MBA, EdD Carmela@PartnersInMedEd.com
In medicine, we know if it’s not documented in the medical record it didn’t happen. The same philosophy applies to the documentation for the Graduate Medical Education Committee (GMEC). As consultants, we see a significant number of Sponsoring Institutions (SIs) cited for administrative processes regarding the GMEC. The two most common citations include 1) sufficient number of meetings, and 2) appropriate documentation of the meeting (minutes).
Sufficient number of meetings: the specific language within the 2021 Institutional Requirements (IR) states:
I.B.3. Meetings and Attendance: The GMEC must meet a minimum of once every quarter during each academic year. (Core).
Meeting at least once per quarter did not change with the proposed changes of the IR. GMECs that receive citations typically read the meaning of this requirement as 4 times per year, not necessarily once every quarter. The GMEC is expected to meet once every quarter, which is further described in the 2023 IR Frequently Asked Questions (FAQs), “The academic year is from July 1 to June 30, and comprises four quarters which begin July 1, October 1, January 1, and April 1. During each quarter, the GMEC must meet at least once.” Furthermore, the minutes must document the date of each GMEC meeting.
Meeting Minutes: Several SIs struggle with the format and content requirements for the GMEC minutes. There is not a specific form required by the ACGME and the requirements do not state specifically the content expectations for minutes. The new IRs add language specifying that meeting minutes must document the oversight, review and approval of the functions of the GMEC.
I.B.3.b) The GMEC must maintain meeting minutes that document execution of all required GMEC functions and responsibilities. (Core)
The proposed IR language adds “for oversight, review, and approval. (Core)” It is required that any discussion or vote related to sections I.B.4 and I.B.4.b) be documented within the minutes. It is also recommended to document other areas of the IR such as work hours and program concerns.
The new requirements go farther to state the approval of responsibilities are required to be documented. In other words, GMECs must document the vote of items during the meetings. This has always been an expectation but is now more clearly stated.
One item not specifically identified within the current IRs nor the proposed, is the identification of next steps. Site visitors regularly comment on a lack of GMEC response to discussion. Even if the next step is additional investigation annotating who will investigate by when, this is a great way to show response. The key here is to be sure the action is then addressed in future minutes. For example, if the next step to a discussion is that the PDs distribute information to the residents/fellows prior to the next meeting. The next GMEC meeting should document following up: did the PDs distribute the requisite information.
The ACGME does not require a specific format for minutes, but it should be standardized for all GMEC minutes. It is helpful to have agenda items in the same order for each meeting. This makes it easier for the site visitor to follow. Voting and the next steps should be easy to locate. I recommend using a template that can easily be filled in after the meeting. Some SIs utilize an outline format. Personally, I prefer a matrix format.
Tracking: SIs are highly recommended to submit a tracking document of required GMEC functions and responsibilities. This sheet can be the cover sheet for submitting the GMEC minutes for the SI site visit. The document should clearly identify each of the required functions and what meeting date each item was discussed. If an item was discussed at every meeting, then each date should be identified. Site visitors can then compare this document to the actual minutes, making it easier for them to ensure that the GMEC fulfilled all required responsibilities throughout the year.
It is also expected that attendance be tracked. The site visitors will verify the required attendance at each meeting i.e., a resident voted on every decision. This is also a good way for the DIO to ensure the engagement of each member. Expectations for attendance should be clearly identified and tracking attendance will provide accountability.
Finance / Public Policy
By: Amy Durante, MHA Amy@PartnersInMedEd.com
We All Play a Part in GME Finance
While we all share the same mission of providing quality medical education to our residents and fellows, Sponsoring Institutions and programs have different processes when it comes to carrying out this mission as well as other GME related activities and tasks. GME finance and resident reimbursement is no different. Many shy away from the financial aspect of GME, thinking it’s “above their pay grade,” but everyone from the GMEC to the residents can contribute positively to maximize CMS resident reimbursement.
The following provides detail on how each role within GME can contribute:
The accuracy of the information is key, and everyone can play a part in ensuring that the information submitted for the IRIS and cost report are as accurate as possible.
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