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Sponsoring Institution
By: Cheryl Haynes, BA Cheryl@PartnersinMedEd.com
The Three A’s of GME Governance: Awareness, Accountability & Authority
Awareness. Accountability. Authority. These three elements are fundamental to effective GME governance. When they are aligned, institutions are better positioned to identify concerns early, assign responsibility, and take meaningful action before problems become systemic.
Work-hour concerns, faculty and resident/fellow turnover, reports of inadequate supervision or patient safety issues, accreditation citations, and unfavorable trends in survey or program data may suggest structural problems within a Sponsoring Institution (SI). GME leaders must monitor these indicators closely, identify recurring patterns and downward trends, and intervene before isolated concerns escalate into broader problems.
But awareness is only the first step. Once an issue is identified, who is accountable for fixing it?
ACGME Institutional and Common Program Requirements clearly define many of the responsibilities of the DIO, GMEC, and Program Directors. In practice, however, identifying accountability does not necessarily identify who can actually fix the problem.
Many GME challenges cross organizational boundaries. Their resolution may require the involvement of department chairs, clinical and operational leaders, patient safety and quality teams, finance, human resources, hospital executives, or other institutional stakeholders. The individual accountable for an outcome may therefore depend on multiple departments and layers of leadership that fall outside their direct purview.
This raises the third—and critical—question: Does the person held accountable for resolving the problem have the authority to dedicate the time, resources, and institutional support necessary to fix it?
A Program Director may be accountable for the quality of a residency or fellowship program but lack authority over clinical staffing, faculty effort, or departmental resources. A DIO may recognize a systemic threat to the learning environment but not control the operational or financial resources required to correct it. A GMEC may identify and escalate a concern but depend upon leaders outside of GME to implement the solution.
When accountability exceeds authority, even well-recognized problems can remain unresolved. The issue may be repeatedly discussed, monitored, and escalated without addressing the underlying cause—not because the accountable leader has failed to act, but because the governance structure has not given that leader the authority needed to resolve it.
If the person held accountable lacks the authority to achieve the expected outcome, the structure itself is part of the problem—and it should be addressed sooner rather than later.
Institutions that align awareness, accountability, and authority create the foundation for strong, responsive, and effective GME governance.
Continue the conversation: Join us October 29 for Institutional Policies Unlocked: What Everyone Needs to Know.
Program
By: Heather Peters, M.Ed., Ph.D. Heather@PartnersInMedEd.com
Continuity Clinic Conundrums in GME: Finding Consistency Without Requiring Sameness
Continuity clinic can be one of those deceptively simple phrases in GME. Internal medicine has continuity clinic. Pediatrics has continuity clinic. Family medicine has continuity clinic. From an institutional perspective, it can be tempting to assume that because the terminology is similar, the expectations—and therefore the systems needed to support them—are largely the same.
They aren’t.
Each specialty brings its own requirements, clinical environment, educational priorities, and operational realities. Program directors are right to point out that their programs are different. The challenge for the sponsoring institution is determining which differences matter and where consistency is still needed.
Consistency Does Not Require Sameness
Institutional consistency is sometimes interpreted as standardization: one process, one template, one way of doing things across every program. But consistency does not have to live at the level of implementation.
A more useful approach is to establish consistency at the level of principle and expectation, while allowing flexibility at the level of application.
Continuity clinic provides a useful example. Different specialties may structure continuity experiences differently because their accreditation requirements, patient populations, clinical settings, and educational goals differ. Requiring identical structures would make little sense.
But the sponsoring institution can still establish shared expectations: specialty-specific requirements are understood, appropriate resources are available, potential barriers are identified, and concerns that require institutional action have a reliable pathway for escalation.
The DIO Doesn’t Have to Be the Specialty Expert
One of the challenges of institutional oversight is the sheer breadth of specialty-specific requirements across an institution’s programs. A DIO cannot—and should not be expected to—know every specialty’s requirements as well as the program director does.
The program brings expertise in its specialty, learners, faculty, and clinical environment. The DIO and GME office bring expertise in GME systems, accreditation, institutional oversight, and the structures that support programs.
The question is not whether the institutional leader can become an expert in every specialty. It is whether the institution has a reliable way to identify the specialty-specific requirements that have institutional implications.
One practical approach is to identify those requirements explicitly and revisit them regularly with program leadership. A simple annual conversation can surface a great deal:
How are you meeting this requirement?
What does the institution need to do to support you in meeting it?
Those questions allow the program director to bring specialty expertise into the conversation while giving the DIO visibility into issues that may require institutional attention.
Look for the Common Architecture
Programs often appear more different when we focus on exactly how they perform the work. When we step back and examine what the underlying system is trying to accomplish, commonalities begin to emerge.
Programs may use different approaches while still needing clear expectations, defined responsibility, appropriate resources, communication pathways, monitoring, and follow-through.
That is where institutional consistency can live.
The goal is not to eliminate variation. Variation itself isn’t necessarily the problem. Unexamined variation is.
When programs do something differently, the useful question is not, Why aren’t they doing it the same way? It is, Why is this different?
Sometimes the answer will be a specialty requirement, a legitimate educational need, or a clinical reality. Sometimes it will reveal that a process simply developed differently over time without anyone intentionally deciding that it should.
Understanding the reason allows the institution to distinguish meaningful variation from the absence of a shared framework.
Different—and More Alike—Than We Think
Every GME program operates within its own specialty context. Those differences matter and should be respected. At the same time, programs share more underlying organizational needs than may be apparent when we focus only on specialty-specific details.
Healthy institutional oversight makes room for both realities.
The institution does not need to erase meaningful differences to create coherence. It needs systems that help leaders understand where program-specific needs intersect with institutional responsibility—and enough flexibility to support the differences that matter.
GME Office / Administration
By: Alfred Perez, PhD, MBA, MDiv Alfred@PartnersInMedEd.com
Is the Process Working—or Are People Working Around It? What day-to-day GME operations can tell us about the health of our systems
A deadline is met because the coordinator keeps a separate spreadsheet.
A faculty evaluation gets completed because someone sends three personal reminders.
A rotation starts on time because an experienced administrator knows whom to call when the formal process stalls.
The annual ADS update gets finished because someone has developed their own checklist over years of experience.
From the outside, each of these processes appears to be working.
But is the process working—or are capable people working around it?
That distinction matters.
The View from the GME Office
Program coordinators, program managers, and GME administrative staff occupy a unique position within graduate medical education. They work where accreditation requirements, institutional policies, hospital systems, educational processes, faculty responsibilities, and resident needs intersect.
That makes administrative staff some of the first people to recognize when a system is becoming cumbersome, duplicative, unclear, or overly dependent on individual effort.
The workload is substantial. A national survey of GME program and institutional coordinators found that 38.4% screened positive for burnout, 20.4% reported dissatisfaction with their work, and 27.9% indicated they were likely or very likely to leave their position within the next year. Leading sources of dissatisfaction included tracking down residents, fellows, and faculty to complete required tasks, overall workload, the level of detail that must be managed, and time pressure.¹
These findings are easy to interpret primarily as workload or well-being concerns.
But…. they may also be telling us something about workflow design.
Workarounds Are Data
There is an important distinction between work as designed and work as actually performed.
Every organization develops informal adaptations. People create spreadsheets, personal checklists, reminder systems, email folders, templates, side conversations, and shortcuts that help them get the job done.
Some adaptation is healthy. GME is too complex to operate without professional judgment and flexibility.
The concern is when the workaround becomes necessary for the process to function.
Consider some familiar examples:
- The official procedure says one thing, but everyone knows the process actually works another way.
- The same information is maintained in multiple locations because no one completely trusts any one source.
- A coordinator must repeatedly remind faculty or residents to complete routine responsibilities.
- A process works smoothly when one experienced person manages it but becomes difficult when that person is away.
- Staff maintain personal tracking systems because institutional systems do not provide the information they need.
- Routine requests require multiple emails because responsibility or authority is unclear.
- A predictable annual deadline still produces a last-minute scramble.
Individually, none of these necessarily signals a serious problem.
Collectively, they can be signs of structural friction.
And structural friction consumes organizational capacity.
The High-Performer Paradox
Counterintuitively, one of the challenges in GME is that strong administrative professionals can make weak systems harder to see.
Experienced coordinators learn where the gaps are. They anticipate problems, remember deadlines, maintain relationships across departments, know which person can solve a problem, and develop tools that compensate for limitations in formal processes.
The result can be a paradox:
The better the coordinator, the healthier the system appears.
This is especially important for program directors, GME leaders, and DIOs.
When work gets done consistently, leaders may reasonably conclude that the underlying process is effective. But sometimes performance is being sustained by individual expertise, institutional memory, and discretionary effort rather than by good system design.
A useful test is simple:
What happens when that person takes two weeks off?
If important processes suddenly become difficult to locate, understand, or execute, the organization may have developed dependence on a person rather than strength in a system.
This is particularly relevant in GME because much of the administrative cycle occurs only once each year. Experienced coordinators have described how knowledge can easily be lost when people do not encounter a process again until the following academic year.²
Listen to the Friction
GME administrative staff routinely encounter small operational problems that may never reach the GMEC, DIO, or executive leadership.
That does not make those problems unimportant.
In fact, repeated small problems can serve as useful leading indicators.
When coordinators say:
“I have my own spreadsheet for that.”
“I just do it myself because it is easier.”
“You have to know who to call.”
“The instructions say that, but this is how we actually do it.”
“I have to remind everyone several times.”
“Only Maria knows how that works.”
Those comments deserve attention.
They are not necessarily complaints. They may be informal process-mapping data.
The people closest to the workflow can often see inefficiencies long before those inefficiencies become visible in performance metrics, accreditation findings, missed deadlines, or turnover.
Recent work focused on GME coordinators reinforces this point. In one institutional initiative, 56.2% of coordinators reported that they did not have enough resources to be successful in their roles.³ Another recent GME leadership initiative began specifically by listening to coordinators about communication barriers, gaps in resources, and what they needed to do their work effectively.²
Listening to administrative staff, therefore, is not simply an employee-engagement exercise. It can be a form of organizational diagnosis.
From Heroic Effort to Sustainable Systems
The goal is not to eliminate every workaround or standardize every aspect of GME.
Programs are different. Situations require judgment. Good administrators should have latitude to solve problems.
The goal is to distinguish useful flexibility from compensatory work.
One practical way to begin is to choose one recurring GME process—onboarding, evaluations, CCC preparation, ADS updates, PLAs, reimbursement, recruitment, work-hour monitoring, or GMEC reporting—and ask the people who actually perform the work:
Where do you have to work around the process to make it work?
Then look for four things:
- Duplication. Where are we entering, maintaining, checking, or communicating the same information more than once?
- Ambiguity. Where is ownership unclear enough that someone has to track down the responsible person?
- Dependency. What only works because a particular person remembers how to do it?
- Friction. Which routine steps consistently require more emails, reminders, approvals, or effort than they reasonably should?
Not every problem needs new technology, another policy, or a major process redesign.
Sometimes the answer is much simpler: clarify ownership, eliminate a redundant step, create one shared checklist, establish a reliable calendar, or agree on a single source of information.
Small improvements in workflow can return meaningful capacity to a GME team.
A Question Worth Asking
The broader GME community is increasingly recognizing both the importance of administrative professionals and the burden created by complex administrative systems. The ACGME has explicitly identified reducing administrative burden associated with accreditation as an organizational priority and has already begun simplifying selected reporting requirements.⁴
At the same time, coordinators are increasingly being recognized not merely as administrative support, but as operational leaders who play a central role in keeping residency and fellowship programs functioning effectively.²
That creates an opportunity for GME leaders.
Instead of asking only:
“Did the work get done?”
Ask:
“What did it take to get the work done?”
For coordinators and GME staff, the workaround you created may be telling you something important about the system.
For program directors and DIOs, the people managing those workarounds may be one of your best sources of operational intelligence.
Strong GME systems should certainly benefit from talented people.
They just should not require heroic effort from them to make routine processes work.
Put it into practice: Use Is the Process Working? A GME Workflow Check to examine one recurring GME process for duplication, ambiguity, dependency, and friction.
Finance / Public Policy
By: Tori Hanlon, MS Tori@PartnersInMedEd.com
When GME Expectations Outpace Resources
Imagine a familiar scenario.
A sponsoring institution launches a new initiative intended to improve resident support, strengthen oversight, or enhance educational quality. The goal is worthwhile, and the GME community largely agrees with its value. Yet six months later, program coordinators are juggling additional responsibilities, faculty are being asked to contribute more time, and institutional leaders are struggling to find the bandwidth needed to support the effort consistently.
No one is opposed to the initiative itself. The strain comes from a different source: the system was asked to do more without a corresponding increase in capacity.
This situation is increasingly common across Graduate Medical Education. As expectations continue to grow, institutions are balancing accreditation requirements, learner support initiatives, workforce demands, data collection responsibilities, technology investments, and regulatory obligations. Each serves an important purpose. The challenge arises when new expectations are added without a clear understanding of what resources and infrastructure are necessary to sustain them.
From a finance and public policy perspective, conversations about resources often focus on dollars. Funding matters, but financial resources are only one component of system capacity. Time, personnel, expertise, technology, administrative infrastructure, and institutional support all contribute to a GME system’s ability to function effectively.
When these resources are aligned with expectations, organizations can adapt and grow. When they are not, the first signs of strain rarely appear in a budget report.
Instead, they show up in day-to-day operations.
A coordinator role remains vacant longer than expected. Faculty participation becomes more difficult to secure. Data requests take longer to complete. Committees spend more time responding to immediate issues and less time planning strategically. New responsibilities are absorbed by individuals who are already operating at capacity.
Viewed independently, these may seem like routine operational challenges. Viewed collectively, they may indicate that the system is carrying more than its current structure can support.
This distinction is important because organizational stress is often attributed to individual performance rather than system design. The question is not whether people are working hard enough. In most GME environments, they already are. The more useful question is whether the resources, processes, and infrastructure supporting the work have evolved alongside growing expectations.
Public policy presents a similar challenge. Efforts to address workforce shortages, improve accountability, expand training opportunities, or enhance educational outcomes often introduce new requirements. These goals may be both necessary and beneficial. Yet every new expectation consumes organizational capacity. Over time, institutions can find themselves managing an expanding list of priorities without a corresponding expansion of support structures.
A healthy GME system requires more than adequate funding. It requires alignment.
Are expectations clearly understood? Do available resources match intended outcomes? Is administrative infrastructure sufficient to support growing responsibilities? Can the organization absorb additional requirements without compromising existing commitments?
These questions do not necessarily require immediate solutions. However, they can help institutions recognize emerging pressure points before they become larger operational challenges.
As the GME community continues to face increasing demands, sustainability may be less about finding ways to do more, and more about understanding what systems need in order to do important work well.
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