Residency Accreditation Toolkit: Institutional Requirements
Sponsoring institutions have a set of requirements they must follow related to oversight of all their GME programs and maintenance of an appropriate working environment for residents.
Primary to the institutional requirements is the appointment of the Designated Institutional Official (DIO) who is responsible for the oversight of all sponsored graduate medical education (GME) programs and compliance with all institutional, common program, and specialty program requirements. In a single-residency-program institution, it may be practical to have the program director serve as the DIO, but with multiple programs, the DIO is a separate position to whom program directors report.Institutions must also have a Graduate Medical Education Committee (GMEC) that includes the DIO, a representative sample of program directors (commonly all), resident representatives, and a quality or safety official. The duties of the GMEC are detailed in the ACGME Institutional Requirements.The ACGME conducts an institutional site visit when initially certifying a sponsoring institution. A repeat institutional site visit is conducted every two years after initial certification. Continued accreditation may be earned in ten year increments with self-studies to be completed prior to each additional site visit.
ACGME Institutional Requirements Highlights
Sponsoring Institution
- Complies with Institutional Requirements and ensures program compliance with program requirements
- Identifies a DIO and a Governing Body with final authority for the institution and GME programs
- Provides adequate financial support and resources for DIO/GMEC/programs
Designated Institutional Official (DIO)
- Submits Annual Institutional Review (AIR) to Governing Body
Graduate Medical Education Committee (GMEC)
- Membership: DIO, at least 2 program directors, 2 residents/fellows, QI/patient safety officer (If single-program-institution must include MD or DO from another specialty involved in GME)
- GMEC Meetings: at least quarterly, must always have one resident in attendance
GMEC Responsibilities
- All GME program activities (19 items), identify performance markers for the AIR, conducts special reviews of under-performing programs
Resident/Fellow Forum
- Must occur for multi-program institutions
Learning and Working Environment
- Patient Safety, Quality Improvement, Transitions of Care programs available for residents
- Clinical Supervision, Work hours, Fatigue mitigation oversight must occur
- Professionalism education and culture must be present
Well-Being
- Prevention/recognition of burnout, counseling/mental health access 24/7
- Ensure food, safety and security for residents is available
Resident/Fellow Recruitment and Appointment
- Resident eligibility requirements defined
- Resident contract must include, and the institution must have policies for: grievance/due process, health insurance benefits, disability insurance, vacation/sick/parental leave, work hours, and moonlighting
- Institutions may not require residents to sign non-competition agreements
Clinical Learning Environment Review (CLER) Visits
CLER visits are intended to assess the learning environment of sponsoring institutions and their participating sites, primarily for the quality and safety of the environment for learning and patient care. These visits are not used for accreditation decisions, but in the future they may be. CLER visits assess six areas:
- Patient Safety—Opportunities for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care
- Quality Improvement—How institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes
- Transitions in Care—How institutions demonstrate effective standardization and oversight of transitions of care
- Supervision—How institutions maintain policies of supervision concordant with ACGME requirements in an environment that assures the absence of retribution
- Duty Hours and Fatigue Mitigation—How institutions: (i) demonstrate effective oversight of duty hours; (ii) design systems that facilitate fatigue mitigation; and (iii) provide effective education of faculty members and residents in fatigue mitigation
- Professionalism— how institutions teach professionalism, monitor behavior of residents and faculty, and respond to issues concerning: (i) accurate reporting of information; (ii) integrity in fulfilling responsibilities; and (iii) veracity in scholarly pursuits.
