GME Policies

Residents and clinical fellows may only access patient information for the purposes of providing care. Program directors are responsible for ensuring OGME is notified immediately when a trainee is dismissed or put on investigatory leave to ensure all access to confidential information is suspended or terminated as appropriate. Upon notification, OGME will suspend or terminate the trainee’s access to clinical care systems at UCSF Health. OGME will communicate with other clinical affiliates as appropriate to similarly suspend or terminate access to their systems.

Approved, GMEC: January 24, 2011

Approved, GMEC: May 15, 2023

It is the policy of the UCSF School of Medicine that all new, incoming residents (including interns), clinical fellows, and Non-MD trainees in any UCSF sponsored GME programs undergo a background check prior to beginning training. UCSF reserves the right to rescind an offer of appointment to any training program to any individual whose background investigation reveals a history of criminal conduct:

• That UCSF reasonably determines increases the risk of harm to patients or individuals on UCSF premises; or
• That was not accurately disclosed on the Attestation form completed at the time of contract signing or any other application in connection with the training program; or
• That is inconsistent with the high standard of ethical conduct required of all members of the academic community or is otherwise unbefitting a member of the academic community.

Procedure: All offers of admission and appointment to UCSF sponsored GME programs are specifically conditioned upon a criminal background investigation. Background checks will be carried out by an agency on behalf of UCSF OGME. By signing a UCSF GME contract letter, prospective trainees are consenting to a background investigation. Background checks consist of a verification of the name, date of birth, and social security number of the individual, confirmation of addresses in the United States within seven (7) years, and disclosure of any felony/misdemeanor convictions within seven (7) years. Seven checks are conducted as part of each trainee’s criminal background check, which include SSN, NCF (National Criminal File), OFAC-SDC (Office of Foreign Assets Control Specially Designated Nationals List), Criminal History, Federal Criminal Record, Sex Offender Record, and CA Medical License Suspended and Ineligible Provider List.

If the report reveals a discrepancy in name, date of birth, social security or addresses, or discloses a conviction for a felony and/or misdemeanor, OGME will make a copy of the report available to the individual. The individual will be permitted to provide any additional information to OGME that she/he wishes to be considered concerning the information disclosed. The program director and Associate Dean for GME (DIO), after consultation with appropriate university officers, will make the final decision as to whether the offer is to be withdrawn. If the trainee is in a matched position and the offer is withdrawn, it is the program’s responsibility to apply for a match waiver through the NRMP. For non-ACGME clinical fellows, if the information makes the individual unable to be credentialed and privileged, the offer of appointment to the program will be withdrawn. For non-ACGME 50 fellows appointed with attending privileges, should their non-ACGME GME appointment be terminated, their Clinical Instructor appointment will be terminated as well.

Approved, GMEC: January 24, 2011

Approved, GMEC: May 15, 2023

Programs must design schedules such that work hours are limited to no more than 80 hours per week during any given week, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting. Schedules must account for and anticipate unexpected circumstances which could lead to violations. This means that programs should design weekly schedules so that trainees are not scheduled for more than 72 hours/week.

The program must design an effective program structure that is configured to provide residents and fellows with educational opportunities as well as reasonable opportunities for rest, personal well-being, and for medical appointments.

Residents and fellows should have eight hours off between scheduled clinical work and education periods. There may be circumstances when residents and fellows choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80-hour and the one-dayoff-per-calendar-week requirements.

Residents and fellows must have at least 14 hours free of clinical work and education after 24 hours of inhouse call.

Residents and fellows must have one day in every calendar week free of clinical work (including moonlighting) and required education. This means all residents and fellows must have at least one day free from clinical and education work during each Sunday-to-Saturday period. At-home call cannot be assigned on these free days. Programs without work hour citations, areas for improvement, or substantial monitoring violations may apply to the GMEC, via the Work Hours Consultation Group, for adjusted free day schedules to promote resident and fellow wellbeing.

Clinical and educational work periods for residents and fellows must not exceed 24 hours of continuous scheduled clinical assignments. Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or trainee education.

In rare circumstances, after handing off all other responsibilities, a resident or fellow, on their own initiative, may elect to remain or return to the clinical site in the following circumstances: to continue to provide care to a single severely ill or unstable patient; humanistic attention to the needs of a patient or family; or to attend unique educational events. These additional hours of care or education will be counted toward the 80-hour weekly limit.

Night float must occur within the context of the 80-hour and one-day-off-per-calendar-week requirements. The maximum number of consecutive weeks of night float, and maximum number of months of night float per year may be further specified by each ACGME Review Committee.

Residents and fellows must be scheduled for in-house call in a manner that prevents work hour violations.

Time spent on patient care activities by residents and fellows on at-home call must count toward the 80hour maximum weekly limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one day per calendar week free of clinical work and education. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident. Residents and fellows are permitted to return to the hospital while on at-home call to provide direct care for new or established patients. These hours of inpatient patient care must be included in the 80-hour maximum weekly limit.

Each training program must have a program-specific policy addressing clinical and educational work hours and a work hour tracking system that are in compliance with both ACGME requirements and UCSF GME policies. It is the responsibility of each resident and fellow to ensure they are in compliance with their program’s policy, and it is also the responsibility of the program leaders and individual supervisors to ensure compliance. Programs must actively monitor resident and fellows work hours and should use MedHub or an equivalent method to accurately monitor resident and fellow work hours.

All programs will be required to have their trainees log 100% of their work hours in real time. In order to aid this task, programs are encouraged to use the MedHub auto-populate work hours feature for appropriate rotations. Programs must be notified of potential work hour violations in MedHub by listing a program administrator and/or program director/associate program director. Programs that have current ACGME work hour citations, areas for improvement, or non-compliance with work hours by ACGME survey will be required to notify the program director or associate program director with MedHub potential work hour violations in order to make needed adjustments to prevent violations.

GMEC and the Office of GME (OGME) will monitor work hour compliance for all programs in real time.

Approved, GMEC: July 18, 2011

Approved Major Revision, GMEC: October 16, 2017

Approved by GMEC: December 16, 2019

Approved Major Revision, GMEC: October 19, 2020

Approved Minor Revision, GMEC: August 19, 2024

Clinical Responsibilities: The The clinical responsibilities of each resident and fellow must be based on PGY level, patient safety, resident or fellow ability, severity and complexity of patient illness/condition, and available support services. Optimal clinical workload may be further specified by each ACGME Review Committee.

Teamwork: Residents and fellows must care for patients in an environment that maximizes communication and promotes safe, interprofessional, team-based care in the specialty and larger health system. Each ACGME Review Committee will define the elements that must be present in each specialty.

Transitions of Care: Each training program must have a program-specific policy addressing transitions of care that is consistent with ACGME and UCSF GME policy. With heightened awareness of the effects of handoffs on patient safety and education, the ACGME common program requirements include specific mandates to design systems, ensure competency for residents and clinical fellows, and monitor efficacy of handoffs.

Each training program must design clinical assignments to optimize transitions in patient care, including their safety, frequency, and structure. Programs and their faculty must be aware of the hazards of discontinuity and new regulations and best practices to ensure patient safety and to role model effective handoffs. Examples of strategies which have successfully minimized transitions include day/night teams, staggering of intern/resident/attending switch times and/or days to maintain continuity, outpatient clinic “pods” or teams, etc. As there is currently no single gold standard for clinical scheduling assignments, all training programs must design call and shift schedules to minimize transitions in patient care. Schedules should overlap with sufficient time to allow for face-to-face handoffs to ensure availability of information and an opportunity to clarify issues.

The institution and each program must ensure and monitor effective, structured handoff processes that facilitate both continuity of care and patient safety. Handoffs vary considerably across programs and clinical settings. They may include temporary transitions of direct patient care (e.g., day and night teams on inpatient services, scrubbing out of a procedure), complete transitions of direct patient care (e.g., emergency department shifts, end-of-rotation, end-of-training in outpatient and inpatient services), or transitions of indirect patient care (e.g., laboratory and radiology settings).

Each training programs must develop handoff procedures that are structured, and that reflect best practices (in-person whenever possible, occur at a time and place with minimal interruptions, etc.) 54 Handoffs should include at least:

• Patient summary (exam findings, laboratory data, any clinical changes);
• Assessment of illness severity; • Active issues (including pending studies);
• Contingency plans (“If/then” statements);
• Synthesis of information (e.g. “read-back” by receiver to verify);
• Family/caregiver contacts; • Any changes in responsible attending physician; and
• An opportunity to ask questions and review historical information.

Faculty oversight of the handoff process may occur directly or indirectly, depending on trainee level and experience. All programs should use the appropriate tools (written or computerized, including EHRbased tools) to assist them in this structured process. Each program must ensure that residents and fellows are competent in communicating with team members in the handoff process.

Each training program must assess Interpersonal and Communication Skills competency. Handoff skills are a specific skill within this competency. Programs must deliver focused and relevant training to build these skills, use clear assessment strategies, and document this competency.

Educational resources include:

• I-PASS Handoff Toolkits available on MedEd Portal (searchable on PubMed)
  • An evidence-based curriculum covering handoffs and communication tools
  • Includes tools for direct observation by faculty or peers
  • Online module available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375701/ (Videos and curricular materials are in appendices)
• Handoffs and Signout Primer: Agency for Healthcare Research and Quality (AHRQ)
  • A literature overview with links to additional resources
  • Available at: https://psnet.ahrq.gov/primer/handoffs-and-signouts
• UpToDate Articles
  • Patient Handoffs (https://www.uptodate.com/contents/patienthandoffs) focused on general handoff principles
  • Handoff of Surgical Patients (https://www.uptodate.com/contents/handoffsofsurgical-patients) focuses on OR and PACU setting

Assessment strategies include:

• Direct Observation
• Global Assessments of Interpersonal and Communication Skills may include specific items reflecting assessment of competence in the handoff process.
• Peer evaluation tools may be used to evaluate trainees in both giving and receiving handoffs.

Approved, GMEC: July 18, 2011

Approved, GMEC: September 26, 2011

Editorial Revision (update references): April 21, 2014

Approved, GMEC: October 16, 2017

Revision Approved, GMEC: June 12, 2023

I. Statement of Policy UCSF institutions and affiliates have each developed plans to guide institutional responses to local extreme emergent situations and disasters. In the event of a widespread emergency affecting operations, the extent to which a particular situation constitutes a local extreme emergent situation or disaster will be determined with reference to those institutional policies and plans. This GME Disaster Planning Policy is intended to augment existing institutional plans, focusing specifically on residents and fellows (trainees) in graduate medical education programs sponsored by the UCSF School of Medicine. The Policy is guided by the following principles:

a. UCSF is committed to ensuring a safe, organized and effective environment for training of its residents and fellows;

b. UCSF recognizes the importance of physicians at all levels of training in the provision of emergency care in the case of a local extreme emergent situation of any kind or a disaster;

c. Decisions regarding initial and continuing deployment of residents and fellows in the provision of medical care during a local extreme emergent situation or disaster will be made taking into consideration the importance of providing emergency medical care; the continuing educational needs of the trainees; and the health and safety of the trainees and their families.

d. As long as employed by UCSF, trainees will continue to receive their salary, benefit and professional liability coverage.

II. Timeline

• a. Upon the occurrence of the local extreme emergent situation or disaster and immediately following up to one week:
  • i. Residents and fellows able to report to work will report to the institution of their current rotation assignment following their most current call/shift schedules unless otherwise directed.
  • ii. Program Directors should partner with Site Directors and Medical Directors to ensure that plans are in place for appropriate staffing.
         1. Program Directors have the final decision-making authority on assignment of residents and fellows to clinical               areas.
         2. Staffing increases should not rely exclusively on residents and fellows. Faculty and APPs should be considered           in any staffing plans.
         3. Ongoing decision-making regarding deployment of trainees to provide needed clinical care will be based on the           safety of trainees (including work hours), the clinical needs of the institution, the ability to adequately supervise           trainees, and the educational needs of the trainees (training requirements).
  • iii. Those involved in making decisions in this period are:
         1. Leaders of Hospital Incident Commands
         2. Chief Medical Officers
         3. Dean School of Medicine and Vice Dean for Education
         4. Associate Dean for Graduate Medical Education, Designated Institutional Official (DIO)
  • iv. To the extent possible within the constraints of the emergency situation, decision-makers shall inform and consult with the UCSF Office of Legal Affairs, Residency and Fellowship Program Directors, Chairs of Clinical Departments, Chief Residents, and the the GME Committee.
• b. By the end of the first week following the occurrence of the local extreme emergent situation or disaster, if the emergency is ongoing:
  • i. An assessment will be made of:         
         1. the continued need for provision of clinical care by trainees; and
         2. the adequacy of trainee supervision;
         3. the likelihood that training can continue on site.
  • ii. The assessment will be made by:
         1. Associate Dean for Graduate Medical Education, DIO
         2. Dean School of Medicine and Vice Dean for Education
         3. Chief Medical Officers
         4. Leaders of Hospital Incident Commands
         5. UCSF Office of Legal Affairs
         6. Graduate Medical Education Committee, Executive Committee
• c. By the end of the second week following the occurrence of the local extreme emergent situation or disaster, if the emergency is ongoing:
  • i. The DIO will request an assessment by individual program directors and department chairs regarding their ability to continue to provide training;
  • ​​ii. The DIO will request suggestions for alternative training sites from program directors who feel they will be unable to continue to offer training at UCSF;
  • iii. The DIO will contact the ACGME to provide a status report;
  • iv. Those involved in decision making in this period are:
         1. Associate Dean for Graduate Medical Education, DIO
         2. Dean School of Medicine and Vice Dean for Education
         3. Individual Program Directors
         4. Individual Department Chairs
         5. Graduate Medical Education Committee, Executive Committee
  • v. Trainees who wish to take advantage of the UCSF Leave of Absence Policy or to be released from their contract will be accommodated.
• d. During the third and fourth weeks following the occurrence of the local extreme emergent situation or disaster, if the emergency is ongoing:
  • i. Program directors at alternative training sites will be contacted to determine feasibility of transfers as appropriate;
  • ii. Transfers will be coordinated with ACGME;
  • iii. UCSF Program Directors will have the lead responsibility for contacting other program directors and notifying the DIO and of the transfers; and
  • iv. The DIO will be responsible for coordinating the transfers with the ACGME.
• e. When the local extreme emergent situation or disaster is ended:
  • i. Plans will be made with the participating institutions to which residents and fellows have been transferred for them to resume training at UCSF;
  • ii. Appropriate credit for training will be coordinated with the ACGME and the applicable Residency Review Committees; and
  • iii. Decisions as to other matters related to the impact of the local extreme emergent situation or disaster on training will be made by the DIO and the GME Committee (GMEC).

Approved, GMEC: August 17, 2009

Approved, GMEC: November 16, 2009

Approved, GMEC: May 15, 2023

Recruitment, selection, and appointment of residents and clinical fellows are performed by the Program Directors with oversight of the Graduate Medical Education Committee (GMEC) and the Office of Graduate Medical Education (OGME) in accordance with the Accreditation Council for Graduate Medical Education (ACGME) and California Medical Board requirements. Each UCSF graduate medical education (GME) program has a formal, written process to ensure fair and consistent consideration and decision-making about applications for residency and clinical fellowship positions.

Eligibility

An applicant for graduate medical education at UCSF must have:

• A medical degree prior to residency/fellowship program start date from one of the following:
  • Medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME); or
  • Colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA); or
  • Medical schools outside of the United States or Canada recognized by the California Medical Board (http://www.medbd.ca.gov/applicant/schools_recognized.html)
• A passing score on USMLE Step I.
• A passing score on USMLE Step II Clinical Knowledge (CK).
• Completed all prerequisite training in an ACGME, RCPSC, or CFPC program. See below for exceptions.
• COMLEX exams will be accepted in lieu of USMLE exams for graduates of colleges of osteopathic medicine.

A passing score on USMLE Step II (CK) is required for all trainees beginning a UCSF GME program. To meet this requirement, applicants should have passed USMLE Step II (CK) prior to placement on UCSF rank order lists. In selected cases, with the approval of the Program Director and the Office of GME, applicants may be placed on UCSF rank order lists without the USMLE Step II (CK) score. Selected cases may include applicants applying to UCSF residency programs with an early residency match.

In addition, applicable Medical Board of California licensing requirements must be met:

• Graduates of US or Canadian medical schools:
  • 0 – 12 months of ACGME- or RCPSC-accredited training: As required by the Medical Board of California, within 180 days of starting ACGMEaccredited training in the state of California, the resident or fellow must obtain a postgraduate training license (PTL) from the Medical Board of California.
     
  • 12 months or more of ACGME- or RCPSC-accredited training: The California Medical Board requires all physicians complete at least 12 months of either ACGME- or RCPSC-accredited program training in order to be eligible for a full medical license. If the trainee just completed the 12 months of training in an ACGME- or RCPSC- accredited program outside the state of California, and is immediately continuing their training in an ACGMEaccredited program in California, the trainee has 90-days to obtain the full license. As a requirement of the initial license renewal, the resident or fellow must provide verification of receiving credit for 36 months of ACGME- or RCPSC-accredited training, of which 24 continuous months must be completed within the same program.

Applicants for non-ACGME accredited clinical fellowship positions are required to obtain a full and unrestricted California medical license prior to beginning a UCSF postgraduate medical education program.

• Graduates of medical schools outside of the United States or Canada: International medical graduates are only eligible for postgraduate training in California if they attended a medical school recognized on the World Directory of Medical Schools and the Foundation for Advancement of International Medical Education and Research (FAIMER) - https://www.faimer.org/resources/world-directory.html In addition, they must have a valid Education Commission for Foreign Medical Graduates (ECFMG) certificate at the time of application.
  • o 0 – 24 months of ACGME- or RCPSC-accredited training: As required by the Medical Board of California, within 180 days of starting ACGMEaccredited training in the state of California, the resident or fellow must obtain a postgraduate training license (PTL) from the Medical Board of California.
     
  • o 24 months or more of ACGME- or RCPSC-accredited training: The California Medical Board requires all physicians who graduated from a medical school outside of the United States or Canada to complete at least 24 months of either ACGME- or RCPSC-accredited program training in order to be eligible for a full medical license. If the trainee just completed the 24 months of training in an ACGME- or RCPSC- accredited program outside the state of California, and is immediately continuing their training in an ACGME-accredited program in California, the trainee has 90-days to obtain the full license. As a requirement of the initial license renewal, the resident or fellow must provide verification of receiving credit for 36 months of ACGME- or RCPSC-accredited training, of which 24 continuous months must be completed within the same program.

Applicants for non-ACGME accredited clinical fellowship positions are required to obtain either a full and unrestricted California medical license prior to beginning a UCSF postgraduate medical education program, or a 2111 licensure exception. 2111 licensure exemptions must be requested by the training program and submitted to the California Medical Board by the Office of Graduate Medical Education.

Licensure requirements of the California Medical Board can be found at www.mbc.ca.gov/Licensing/. Any applicant, resident, or fellow with concerns about eligibility for licensure should contact the Medical Board or seek personal legal counsel.

Non-U.S. citizens must possess a Permanent Resident Card, an appropriate educational visa, of DACA status prior to starting a postgraduate medical education program. UCSF sponsors J1 and H1B (including OPT) visas. H1B and OPT visas must pre-approved by the UCSF Office of Graduate Medical Education.

All prerequisite post-graduate clinical education required for initial entry or transfer into ACGME-accredited residency and fellowship programs must be completed in ACGMEaccredited residency or fellowship programs, or in Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited programs located in Canada. Programs must receive verification of each applicant’s level of competency in the required clinical field using ACGME or CanMEDS milestones assessments from the prior training program.

• Residency Programs: A physician who has completed a residency program that was not accredited by the ACGME, RCPSC, or CFPC may enter an ACGME-accredited residency program in the same specialty at the PGY1 level and, at the discretion of the program director at the ACGME-accredited program may be advanced to the PGY2 level based on ACGME milestones assessments at the ACGME-accredited program. This provision applies only to entry into residency in those specialties for which an initial clinical year is not required for entry. An ACGME Review Committee may grant an exception to this requirement for residency programs that require completion of a prerequisite residency program prior to admission.
   
• Fellowship Programs: A fellowship program may request an exception of its ACGME Review Committee (if the Review Committee allows exceptions) to the fellowship eligibility requirements if the applicant is exceptionally qualified and all of the following conditions are met:
   
  • An exceptionally qualified applicant has (1) completed a non-ACGMEaccredited residency program in the core specialty, and (2) demonstrated clinical excellence, in comparison to peers, throughout training. Additional evidence of exceptional qualifications is required, which may include one of the following: (a) participation in additional clinical or research training in the specialty or subspecialty; (b) demonstrated scholarship in the specialty or subspecialty; (c) demonstrated leadership during or after residency training; (d) completion of an ACGME-international-accredited residency program;
     
  • The program director and fellowship selection committee assessed the applicant’s suitability to enter the program, based on prior training and review if the summative evaluations of training in the core specialty;
     
  • Review and approval of the applicant’s exceptional qualifications by the GMEC or a subcommittee of the GMEC;
     
  • The applicant has satisfactorily completed the USMLE Steps 1, 2, and, if the applicant is eligible, 3; and
     
  • For an internal graduate, he or she must be verified by the Educational Commission for Foreign Medical Graduates (ECFMG) certification.

Applicants accepted by this exception must complete fellowship milestones evaluation (for the purposes of establishment of baseline performance by the Clinical Competency Committee), conducted by the receiving fellowship program within six weeks of matriculation. This evaluation may be waived for an applicant who has completed an ACGME Internationalaccredited residency based on the applicant’s milestones evaluation conducted at the conclusion of the residency program. If the trainee does not meet the expected level of milestones competency following entry into the program, the trainee must undergo a period of remediation, overseen by the Clinical Competency Committee and monitored by the GMEC or a subcommittee of the GMEC. This period of remediation must not count toward time in fellowship training.

Recruitment and Selection

UCSF graduate medical education programs participate in organized matching programs, where available, such as the National Residency Matching Program (NRMP). Other matching programs are utilized in specialties in which they are available.

Responsibility for selecting appropriate and qualified residents and clinical fellows lies with each program’s Program Director and faculty. Programs select from eligible applicants on the basis of preparedness and ability to benefit from the program in which they are appointed. Aptitude, academic credentials, personal characteristics such as motivation and integrity, and ability to communicate are considered in the selection.

It is the policy of UCSF and its affiliated hospitals that programs do not discriminate against qualified applicants based upon gender, ethnicity, race, age, religion, national origin, sexual orientation, physical or mental disability, marital status, or veteran status.

The offer of a residency or fellowship position is not final until the UCSF attestation statement has been completed by the applicant and reviewed by the program. The attestation form asks for information about matters that are relevant to liability, credentialing, and licensure requirements such as malpractice claims, drug and alcohol abuse, disciplinary action, and criminal convictions or pending charges. All “yes” responses require a detailed explanation. After review, an offer of a contract may be revoked or the conditions of the offer revised. Discovery of untruthful or misleading answers on the attestation form may subject an applicant to withdrawal of an offer or a resident or fellow to disciplinary action.

Approved, GMEC: August 25, 2008

Editorial Revision: May 18, 2009

Editorial Revision: May 17, 2010

Approved Major Revisions, GMEC: January 22, 2018

Approved Major Revision, GMEC: November 16, 2020

Administrative Revision (license law): September 2022

Each program will adopt procedures in writing which provide for regular, timely, and confidential evaluation of residents, clinical fellows, teaching faculty, rotations, and programs. Programs must also convene Clinical Competency and Program Evaluation Committees as directed by the ACGME Common Program Requirements.

Evaluation of Teaching Faculty

Residents and fellows must complete evaluations of their supervising teaching faculty as required by their programs. The number of evaluations that each trainee is required to complete will vary depending upon their service assignment and/or number of attending staff.

The confidentiality of teaching evaluation data is strictly ensured. All data, whether collected in MedHub or another system may only be provided in aggregated form in which a minimum of three evaluations must be completed about a teaching faculty before a report may be accessed. Each trainee evaluation of faculty must have a field for confidential comments that is provided only to the program director.

If the program director is also a teaching faculty in the program, the program director must not see the unaggregated evaluations completed about them by the trainees. The department chair or their designee must review these evaluations of the program director in a timely manner and ensure the program director only sees their evaluations in aggregate to protect trainee confidentiality.

At least annually, the program must evaluate faculty performance including clinical teaching evaluations and abilities, engagement with the educational program, participation in faculty development related to their skills as an educator, clinical knowledge, professionalism, and scholarly activities. Program directors in coordination with their department and division leadership must provide faculty feedback on their evaluations at least annually.

Evaluation of Training Program and Improvement

Trainees and teaching faculty must have the opportunity to evaluate the program confidentially and in writing at least annually. The program must use the results of trainee evaluations to improve the program. If deficiencies are found, the program must prepare a written plan of action to document initiatives to improve performance of the program. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.

Each program must monitor and track trainee performance, faculty performance, graduate performance, including performance of program graduates on the certification examination, and program quality.

Evaluation of Residents and Clinical Fellows

The teaching faculty must evaluate resident and clinical fellow performance in a timely manner during each rotation or similar educational assignment and document this evaluation at completion of the assignment. The program director or their designee with input from the CCC will review all evaluations of trainees on a regular basis. The program director or their designee will meet with each resident or fellow semi-annually to review their performance.

Supervisory faculty will submit written evaluations of each resident or fellow after each rotation. For rotations of greater than three months duration, evaluation must be documented at least every three months. Longitudinal experiences must be evaluated at least every three months and at completion of the experience. Evaluations must be always accessible to trainees. Faculty should be named in their evaluations of trainees.

The program must provide assessments of competence in patient care and procedural skills, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice on the specialty-specific milestones. Multiple evaluators (i.e. faculty, peers, patients, self, and other professional staff) must evaluate residents and clinical fellows. Individual programs should determine the appropriate rotations for possible peer evaluations and 360 degree evaluations that may include patients and non-physician providers. The program must document progressive resident and fellow performance appropriate to their educational level.

Summative Evaluation of Residents and Clinical Fellows

The specialty-specific milestones must be used as one of the tools to ensure residents and fellows are able to practice core professional activities without supervision upon completion of the program. At least annually, a summative evaluation must be completed for each trainee that includes their readiness to progress. The program director must also provide a summative evaluation for each trainee upon completion of the program. This evaluation must become part of the trainee's permanent record maintained by the program and must be accessible for review by the resident or fellow. This evaluation must include a review of the trainee’s performance during the final period of education and verify that the trainee has demonstrated sufficient competence to enter practice without direct supervision.

Anonymity and Confidentiality

UCSF training programs are encouraged to use MedHub to distribute and analyze evaluation data. Each program is responsible for the set-up, monitoring, and maintenance of its evaluations. The Office of Graduate Medical Education (OGME) provides assistance to the programs that use MedHub to ensure compliance with this policy and maintain confidentiality of evaluations.

MedHub, in addition to automation of the evaluation process, data collection, and advanced reporting, provides anonymity tools to guarantee confidentiality. The anonymity settings for a program may only be adjusted by OGME. All changes to anonymity are carefully considered and documented.

The ability to view completed evaluations in MedHub is determined by the MedHub user account type. The program administrator is able to view all evaluations. The program director is able to view all evaluations except evaluations completed by trainees about the program director as teaching faculty. Only program administrators are able to see individual evaluations of the program director. Additional access to evaluation data must be approved by OGME. Using the program settings in MedHub, programs should strictly limit who has access to evaluation data.

To ensure trainee confidentiality and encourage honest feedback, all evaluations by trainees must be suppressed until a minimum of three (3) evaluations, regardless of which evaluation system is used, are completed and submitted about an individual faculty, rotation, program, etc. In MedHub, the minimum number of completed evaluations may be set to a higher number, but no less than three. For example, if a rotation only has one resident per month, those teaching faculty may not see their evaluations until the fourth resident has completed and submitted evaluations. Therefore, residents and clinical fellows must complete evaluations in a timely manner to ensure adequate feedback for program improvement.

Trainees and faculty have the opportunity to provide “on the fly” feedback in MedHub through selfinitiated evaluations. This is done by utilizing the “Initiate an Evaluation for a Trainee (resident or fellow)” or the “Initiate an Evaluation for a Faculty” button in the evaluation tab in MedHub.

Resources: ACGME Common Program Requirements: Evaluation Section (V: A, B, C)

Approved, GMEC: October 16, 2023

Approved, GMEC: June 20, 2011 Editorial Revision: August 12, 2011

Approved Major Revisions, GMEC: November 20, 2017

Each program must educate all faculty members, residents, and fellows to recognize the signs of fatigue and sleep deprivation. Each program must also educate all faculty members and residents in alertness management and fatigue mitigation processes.

Residents and fellows must be encouraged to use fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning. Each program must ensure continuity of patient care, consistent with the program’s policies and procedures, in the event that a resident or fellow may be unable to perform his/her patient care responsibilities due to excessive fatigue.

The program, in partnership with the UCSF School of Medicine and Office of GME, must ensure adequate sleep facilities and safe transportation options for residents who maybe too fatigued to safety return home.

All UCSF residents, clinical fellows, and core teaching faculty are required to take the UCSF educational module "Sleep, Alertness, and Fatigue Education (SAFER)," located on the UC Learning Management System.

Approved, GMEC: October 16, 2017

Approved, GMEC: May 15, 2023

UCSF is committed to protecting the medical, personal, and other sensitive information about its patients. In health care, the doctor-patient relationship is built on trust and confidentiality. This trust is essential to obtain accurate health information from patients and critical to effectively treat patients. While privacy and confidentiality have always been a priority for health care providers, it has heightened importance in this era of electronic information, with increased speed of information flow and the risks associated with protecting this information. An increasing number of technological solutions have been implemented at UCSF to protect health care information. However, the key to ensuring that this information remains private and confidential is the team work of UCSF faculty, staff, students, residents, clinical fellows, and volunteers. UCSF’s efforts to protect patient privacy and confidentiality is supported by federal and state laws.

The Health Insurance Portability and Accountability Act (HIPAA) was passed to protect the confidential medical and billing records of patients. A particularly important element of HIPAA regulation pertains to patients' rights related to access and control their medical information. All members of the UCSF entity must incorporate the HIPAA rules into their daily activities. UCSF patients have a right to privacy. UCSF is committed to complying with HIPAA, not only because it is the law, but also because UCSF patients and their privacy are valued.

Failure to comply with the electronic data, security, or privacy standards under both federal and state laws can result in civil monetary penalties to the individual as well as penalties to the institution.

Annually, residents and clinical fellows will sign the UCSF Confidentiality of Patient, Employee, and University Business Information Agreement as part of their appointment paperwork.

For more information and to access the Privacy and Confidentiality Handbook please go to https://ohcp.ucsf.edu

Approved, GMEC: May 15, 2023

Preamble

The following guidelines have been developed to provide guidance to the School of Medicine on relationships with the health care industry* and to ensure independence of clinical decision making, educational curriculum and research programs. The guidelines were first issued in 2007 as an interim step in the development of more broad-based policies for all UCSF faculty, students and staff. The Office of the President published the University of California Health Care Vendor Relations Policy in March, 2008. The American Association of Medical Colleges published the Industry Funding of Medical Education Report in 2008. This guidance is consistent with the UCSF Industry Relations Policy (Policy 150-30) that was issued by the Office of the Executive Vice Chancellor and Provost May 1, 2010.

General Principles

The UCSF School of Medicine guidelines have been developed to ensure that all interactions with industry be conducted in ways that avoid actual or perceived conflicts of interest. Because of the importance of the relationship between industry and the University community, when conflicts arise, they must be addressed appropriately and all attempts must be made to minimize conflicts that affect clinical care, education or research.

All faculty, trainees, students and staff have a responsibility to ensure, to the best of their abilities that all decisions about clinical care, research activities and educational content are independent and unbiased. Decisions should made in the best interests of patients, students and the University and should not be based on any actual or perceived personal benefit that might be derived to the individual.

The University has a long history of collaboration with industry, including pharmaceutical companies and medical technology companies. These collaborations have benefited patients, our educational programs and research activities. However, these interactions could have the potential for undue and deleterious influence by industry on the activities of the School of Medicine, its faculty, trainees, students and staff. The following guidelines have been adopted to minimize the potential for real or perceived bias in clinical care, education or research. The goal of these guidelines is to ensure, to the extent possible that clinical decision-making, educational program content and research activities are as free from bias and outside influence as possible and that all real or potential conflicts are disclosed and resolved. The guidelines cannot identify every potential conflict, but provide general principles upon which faculty, students and staff should act. It is incumbent upon each of us to comply with the guidelines and, when real or potential conflicts are identified to disclose and eliminate them to the extent possible. Ultimately, all faculty, trainees, students and staff must adhere to the UCSF campus Industry Relations Policy.

Guidelines Regarding School of Medicine Relationships with Industry A. Compensation or Gifts

1. Personal gifts from an industry representative may not be accepted by any faculty, trainee, student or staff at any School of Medicine site, or at any location when participating in any University-related activity or during any clinical or other educational rotation.
    
2. Individuals may not accept compensation, including reimbursement for expenses associated with attending a CME or other activity in which the attendee has no other role. Reasonable honoraria and payment of expenses may be provided for speakers at accredited educational meetings, consistent with guidelines developed by the Accreditation Council for Continuing Medical Education (ACCME) and University policy.
    
3. No gifts or compensation may be accepted in exchange for listening to a sales talk or similar presentation by a representative of a commercial interest that produces or distributes health care goods and services.
    
4. Faculty, trainees, students and staff are strongly discouraged from accepting gifts of any kind from industry as part of non-professional activities. Individuals should be aware of and comply with applicable policies, such as the:
   
   * AMA Statement on Gifts to Physicians from Industry (http://www.amaassn.org/ama/pub/category/8484.html );
   * Accreditation Council for Continuing Medical Education Standards for Commercial Support (http://www.accme.org)
5. Meals and other gifts or donations funded directly by industry may not be provided at any UCSF School of Medicine location, including any site where UCSF educational or social activities occur. Vendors and other industry representatives may provide unrestricted funds to departments or divisions for educational programs. The funds will be managed according to the Standards for Integrity and Independence in Accredited Continuing Education.
    
6. No gifts may be accepted in exchange for modifying patient care, such as prescribing a specific medication. Support for research and educational programs must be provided without influence on clinical decision making.
    
7. Free samples, supplies or equipment designated for an individual are considered a gift and are prohibited. Vendors may donate products for evaluation or educational purposes to a department or division, if the University invites the donation and there is a formal evaluation process. Sample donations are restricted to the amount necessary to complete the evaluation. Other policies related to the management of samples must comply with the specific policies and procedures of each Medical Center. Faculty must abide by the policies developed at the clinical sites in which they practice.

B. Industry Support for Educational Programs

1. Commercial support for educational programs must be free of actual or perceived conflict of interest.
    
2. All educational programs within the School of Medicine must abide by the Standards for Integrity and Independence in Accredited Continuing Education. This requirement applies to all undergraduate, graduate and continuing medical education programs regardless of whether continuing medical education credit is offered.
    
3. All funds provided by industry or an industry representative to support educational programs must be given the University as an unrestricted grant. The funds can be provided to the Department, Program or Division, but cannot be given to an individual faculty member, trainee, student or staff. This requirement applies to all funds for meals or refreshments, speaker honoraria, or any other expense related to an educational program and includes noon conferences, grand rounds, and lectures at all UCSF sites. Funds that are provided by educational groups or other entities that act as “intermediaries” for industry must also be provided as unrestricted grants.
    
4. No gifts may be accepted in exchange for listening to a lecture or presentation by a representative of a commercial entity that produces health care or medical goods and services.
    
5. Vendors may provide educational activities on a UCSF site only if they are requested to do so by the department chair or designee. Participants in an educational program may not be required to attend any educational session in which an industry representative disseminates information about their products or services except when such services are provided as part of a contract for in-service or other training as part of an executed purchase decision.
    
6. The content of all educational programs will be determined by the UCSF program planning group and, when appropriate the CME office. Industry sponsors of educational programs may not determine the content or selection of speakers for educational programs.
    
7. These requirements do not apply to meetings governed by ACCME Standards or meetings of professional societies and other professional organizations that may receive partial industry support. Individuals who actively participate in meetings or conferences that are supported in whole or in part by industry, including lecturing, organizing the meeting or moderating sessions should abide by the following requirements:
   1. Financial support should be fully disclosed by the meeting sponsor;
   2. The content of the meeting or session must be determined by the speaker, not the industry sponsor;
   3. The speaker must provide a fair and balanced discussion, and;
   4. The speaker must make clear that the comments and content reflects the individual views of the speaker and not the University of California, the UCSF School of Medicine, or the Department.
8. Faculty, trainees, students and staff should carefully evaluate whether it is appropriate to participate in off-campus meetings or conferences that are fully or partially sponsored by industry because of the high potential for real or perceived conflict of interest.

C. Provision of Scholarships or Other Educational Funds for Students and Trainees

• Industry support for students and trainees participation in education programs must be free of any real or perceived conflict of interest. All educational grants or support of educational programs must be specifically for the purposes of education and must comply with the following requirements:
  • The School of Medicine Department, Program or Division must select the student(s) or trainee(s) for participation.
  • The funds must be provided to the Department, Program or Division and not directly to the student or trainee.
  • The Department, Program or Division determines that the education conference or program has educational merit.
  • There is no implicit or explicit expectation that the participant must provide something in return for participation in the educational program.
• This provision does not apply to regional, national or international merit-based awards which will be considered on a case-by-case basis.

D. Disclosure of Relationships with Industry

• Faculty and staff must disclose all financial interests with outside entities in accordance with UCSF and University of California policy. The specific disclosure obligation and method is dependent on the activity.
  • For research activities the relationship must be disclosed to the UCSF Conflict of Interest Advisory Committee.
  • All publications should be in compliance with the guidelines of the International Committee of Medical Journal Editors (www.icmje.org ).
  • All continuing medical education activities must be disclosed and resolved as defined by the Office of Continuing Medical Education and the ACCME (http://www.accme.org).
     
• Faculty or staff who serve as consultants, members of a speakers’ bureau, have an equity interest in or another relationship with industry for which they receive personal compensation or other support must recuse themselves from deliberations or decision making regarding the selection of products or services to be provided to the Medical Center or School of Medicine (eg; selection of drugs to be added to the formulary) by the company. Faculty with such ties to industry shall not participate in decisions regarding the purchase of related items, drugs, procedures in their department unless specifically requested to do so by the purchasing unit and after full disclosure of the faculty member’s industry relationship. Under all circumstances, the financial relationship must be disclosed and any conflict resolved prior to participation in any decision making.
   
• Faculty and staff are prohibited from publishing articles that are substantially or completely “ghost” written by industry representatives. Faculty and staff who publish articles with industry representatives must participate in the preparation of the manuscript in a meaningful way to include interpretation of data and/or the writing of the manuscript and shall be listed as authors or otherwise appropriately cited for their contribution. The financial interests of all authors shall be listed in accordance with the standards of the journal.
  ​
• Faculty with financial relationships with industry must ensure that the responsibilities to the company do not affect or appear to affect the ability to properly supervise and educate students, residents and other trainees, nor influence employment decisions for faculty and staff. All such relationships must be disclosed and resolved as defined by ACCME.
  ​​​​​

E. Access by Sales and Marketing Representatives to Faculty, Trainees, Staff and Students

1. Faculty, trainees, and staff at each UCSF site must abide by the policies and procedures for each institution (UCSF and UCSF Health, ZSFG, and VA Medical Centers with regard to meeting with industry representatives. In general representatives are permitted in non-patient care areas by appointment only. Company representatives are not permitted in any patient care areas except to provide scheduled and approved in-service training on devices and other equipment for which there is an executed University contract for these services. Involvement of students and trainees in such meetings should occur only for educational purposes and only under the supervision of a faculty member.

Relationship to Other University Policies

The guidelines supplement University policies on Conflict of Interest and the requirements of the Departmental Compensation Plan. Faculty and staff should familiarize themselves with the policies and reporting obligations. Where the guidelines and University policies conflict, the more restrictive of the two shall apply. Questions about the policies should be discussed with the department chair and/or administrative staff.

* For purposes of these guidelines, industry refers to proprietary entities that produce health care and medical goods or services.

Approved, GMEC: September 22, 2008

Approved, GMEC: May 15, 2023

Each program, in partnership with the Sponsoring Institution and participating sites, must ensure healthy and safe learning and working environments that promote resident and fellow well-being and provide for clean and private facilities. This includes providing space for lactation that has refrigeration capabilities, with proximity appropriate for safe patient care as well as time to pump. If no such space exists in reasonable proximity to the work area, the Department will designate on appropriate temporary space, which is not open to the general public, for the purpose of expressing and storing breast milk. Restrooms, spaces lacking privacy, or spaces lacking a locking door are not considered appropriate spaces for lactation purposes. However, an anteroom or lounge area connected to a restroom may be sufficient if the space is private, free from intrusion, and can be locked and shielded from view.

Program directors must work collaboratively with site directors and supervising faculty to have a proactive plan in place to ensure residents and fellows who are lactating have protected time at regular intervals for pumping on all types of rotations, including in-patient, ambulatory, research, etc. Information regarding options for protected time should be provided to residents and fellows prior to taking parental leave, at the time the leave is discussed.

Approved, GMEC: December 14, 2020

Approved Revision, by GMEC: March 20, 2023

Definition of Moonlighting

Moonlighting is optional, paid work that includes clinical care, research, consulting, patient record reviews, teaching, administrative work, etc.

Types of Moonlighting

• Internal moonlighting is defined as extra work for extra pay performed at a UCSF site (ex: UCSF Health Parnassus, UCSF Health Mission Bay, BCH Oakland, UCSF Health Stanyan Hospital, UCSF Health Hyde Hospital, San Francisco Veterans Affairs Medical Center, or Zuckerberg San Francisco General Hospital and Trauma Center) to which the resident/fellow normally rotates (i.e. a site that participates in the resident or clinical fellow's required training program).
   
• External moonlighting at a UCSF site is defined as extra work for extra pay performed at a UCSF site that does not participate in the resident or clinical fellow's training program.
   
• External moonlighting at a non-UCSF site is defined as extra work for extra pay performed at a non-UCSF site (whether that non-UCSF site is a site in the trainee’s training program or not).

Requirements

Each training program must have a program-specific policy addressing moonlighting. It is the responsibility of each resident and fellow to ensure that they are in compliance with their program's policy. Each program's policy must state whether or not moonlighting is permissible (both internal and external). If moonlighting is allowed, the policy must contain a method for written pre-approval, monitoring (which must include the method for tracking hours), and periodic review. Residents/fellows must not be required to engage in moonlighting, and this must be clearly stated in the program policy. Each program allowing moonlighting must demonstrate ongoing compliance with clinical and educational work hour requirements as well as trainees’ entry of clinical work hours.

Moonlighting must not interfere with the ability of the resident or fellow to achieve the goals and objectives of the educational program and must not interfere with the resident or fellow’s fitness for work nor compromise patient safety.

Residents and fellows are responsible for ensuring that moonlighting and other outside activities do not result in fatigue that might affect patient care or learning. Residents/fellows must have written permission from their program director to moonlight, and it is the responsibility of the resident or fellow to obtain written permission to moonlight from the program director prior to beginning any internal or external moonlighting activity. Programs and the program director will monitor the effect of moonlighting activities on a resident’s/fellow’s performance in the program, including that adverse effects may lead to withdrawal of permission to moonlight. Moonlighting activities are also monitored to ensure that moonlighting activities are not adversely affecting patient care, trainee learning, or trainee fatigue. If the program director determines that trainee performance does not meet expectations, permission to moonlight will be withdrawn. Any residents or fellows moonlighting without written pre-approval will be subject to disciplinary action. The UCSF School of Medicine or individual programs may prohibit moonlighting by residents/fellows.

Moonlighting and Work Hours

Time spent by residents and fellows moonlighting, both internal and external, must be counted towards the 80-hour maximum weekly limit and be closely monitored by the program in a manner similar to other work duties. Moonlighting hours must comply with the written policies of the ACGME, UCSF GME, and the program regarding clinical and educational work hours. Trainees may not moonlight if this will cause them to violate UCSF GME, ACGME and/or program work hour requirements.

Moonlighting cannot be conducted while a resident or fellow is on sick, family, or other personal leave.

Moonlighting is permitted while a resident or fellow is on vacation, but it must be that individual’s personal choice to engage in the moonlighting activity and trainees should not be pressured to moonlight. Moonlighting hours while on vacation cannot be logged in MedHub, so it is the program’s responsibility to ensure the resident or fellow does not exceed 80 hours of work while moonlighting on vacation. All other moonlighting hours must be logged in MedHub and failure to log these hours can result in loss of permission to moonlight.

Other Moonlighting Requirements for Specific Trainees

The following trainees are NOT allowed to moonlight even if their program allows moonlighting:

• PGY1 residents may not moonlight.
• Trainees with other visas (ie OPT, H1B) may not moonlight.

Trainees who hold a Postgraduate Training License (PTL), if granted permission by their program director, may only moonlight internally (at a UCSF site that is part of their training program) and must practice within the scope and duties of their ACGME residency/fellowship training program.

Trainees with J1 visas may moonlight assuming the following requirements are met:

• Moonlighting is allowed by their program and they receive the appropriate written permission from their program director.
• Trainees with J1 visas may only moonlight internally—at a UCSF clinical site that is part of their training program.
• Moonlighting activities must be educationally appropriate and not extend their training period.
• Prior written approval from both the program director and Intealth’s Responsible officer is required; completion and submission of a new request form (available on the Forms and Memos page of the ECFMG website) constitutes Intealth’s Responsible Officer approval. Programs, not individual trainees with J1 visas, must initiate this request.
• All moonlighting activities must comply with institutional policies, ACGME work hour limits, and the physician’s core training responsibilities.
• Trainees with J1 visas cannot function as independent practitioners with attending privileges when moonlighting. The moonlighting activities must not exceed the level of clinical activity and responsibility of the resident or clinical fellow in their training program.
   

ACGME trainees may not function as independent practitioners with attending privileges when moonlighting at a UCSF site (i.e. serving as a billing attending), unless their ACGME program requirements allow them to serve in this capacity. In this case, as part of their annual GME appointment, they must be appropriately credentialed with a concurrent appointment through the Office of Medical Staff Affairs and Governance (OMAG) as independent practitioners.

Non-ACGME fellows may moonlight at a UCSF site (presuming they have program permission) and function independently if, as part of their annual GME appointment, they are appropriately credentialed at the UCSF location with a concurrent appointment through the Office of Medical Staff Affairs and Governance (OMAG) as independent providers.

Moonlighting Supervision

When conducting internal or external moonlighting at a UCSF site, ACGME residents and fellows who are not allowed and do not have a concurrent annual appointment or credentialing to function as an independent practitioner must be supervised by faculty. Any moonlighting is not to exceed the level of clinical activity and responsibility of the resident or clinical fellow in his/her training program. Residents and fellows who are conducting external moonlighting at a UCSF site must be appropriately onboarded and oriented to that site and have appropriate access granted to the electronic medical record.

Liability Coverage

Moonlighting at a UCSF site (whether internal UCSF moonlighting or external UCSF moonlighting) is not to exceed the level of clinical activity, clinical scope, and responsibility of the resident or clinical fellow in his/her training program to ensure any moonlighting is within the course and scope of the resident/fellow’s employment with the University. As noted above, residents/fellows need to be sufficiently supervised and are only allowed to serve as independent practitioners (i.e. bill as an attending) with satisfaction of the conditions noted above.

For external moonlighting at non-UCSF sites, the trainee is not covered under UC's professional liability insurance program as that activity is outside the course and scope of University employment. The trainee is responsible for ensuring sufficient liability coverage from another source, DEA licensure, Medicare (or other governmental) provider number and billing training, and licensure requirements by the California Medical Board as well as any other requirements for clinical privileging at the employment site.

References: Intealth Attestation of Supplemental Clinical Activity within the Training Institution: https://www.ecfmg.org/evsp/supplemental-clinical-activity-attestation.p… ECFMG

Forms and Memos Page: https://www.ecfmg.org/evsp/resources.html

Approved, GMEC: July 18, 2011

Approved Major Revision, GMEC: October 16, 2017

Approved Minor Revision, GMEC: March 21, 2022

Approved Minor Revision, GMEC: July 18, 2022

Approved Major Revision, GMEC: November 17, 2025

Neither UCSF School of Medicine nor any of its ACGME-accredited programs will require residents/fellows to sign a non-competition guarantee or restrictive covenant.

Approved, GMEC: February 22, 1999

Approved, GMEC: December 15, 2003

Approved, GMEC: November 3, 2004

Approved, GMEC: May 15, 2023

The University, in accordance with applicable federal and state laws and University policies, does not discriminate and prohibits discrimination, including harassment, on the basis of race, color, national origin, religion, sex, gender, gender expression, gender identity, gender transition status, pregnancy (includes pregnancy, childbirth, and medical conditions related to pregnancy or childbirth), physical or mental disability, medical condition (cancer-related or genetic characteristics), genetic information (including family medical history), ancestry, marital status, age, sexual orientation, citizenship, or service in the uniformed services including protected veterans. The University also prohibits sexual harassment and sexual violence. University policies prohibit discrimination in employment, education (including the learning and working environment), admission, access and treatment in University programs and activities consistent with all applicable federal and state laws and University policies.

University policies prohibit retaliation for bringing a complaint of discrimination or harassment against any person employed; seeking employment; providing services pursuant to a contract; or applying for or engaged in a paid or unpaid internship, volunteer capacity, or training program leading to employment with the University of California. University policies also prohibit retaliation against a person who assists someone with a complaint of discrimination or harassment, or participates in any manner in an investigation or resolution of a complaint of discrimination or harassment. Retaliation includes threats, intimidation, reprisals, and/or adverse actions related to employment.

Trainees, like all members of the UCSF community, must comply with the UCSF Campus Code of Conduct (https://chancellor.ucsf.edu/sites/chancellor.ucsf.edu/files/2023- 07/Code%20of%20Conduct.pdf) and the University of California Anti-Discrimination Policy (https://policy.ucop.edu/doc/1001004/Anti-Discrimination).

Residents/fellows at UCSF have access to processes to raise and resolve complaints of discrimination and/or harassment in a safe and non-punitive environment and in a timely manner consistent with applicable laws and University regulations/policies/procedures.

The following offices have been designated as resources. Trainees who believe they may have been subjected to discrimination, harassment, and/or retaliation on the basis of a protected category or activity in the workplace may file a report, seek guidance and/or counseling:

• Office for the Prevention of Harassment and Discrimination: has authority over the UC Policy on Sexual Violence and Sexual Harassment and the UC Anti-Discrimination Policy. Reporting of any harassment and/or discrimination based on protected characteristics: 415-502-3400, [email protected]
   
• Office of Opportunity and Outreach: serves the campus in creating and sustaining opportunity for every individual at UCSF, https://opportunity.ucsf.edu, 415-476-7700 88 § Faculty and Staff Assistance Program (FSAP): provides free, confidential employee counseling services. [email protected], 415-476-8279
   
• CARE Program: provides free, confidential support to residents/fellows, faculty and staff who have experienced interpersonal violence, sexual assault, intimate partner violence, sexual harassment or stalking. https://careadvocate.ucsf.edu

Trainees are entitled to follow the University’s confidential harassment complaint reporting process (https://aaeo.ucsf.edu). Trainees who are serving as supervisors of others are considered mandatory reporters for any discrimination, harassment and/or retaliation on the basis of a protected category in the workplace and should report this to the Office for the Prevention of Harassment and Discrimination.

Referenced Policies:

UCSF Campus Code of Conduct: https://chancellor.ucsf.edu/sites/chancellor.ucsf.edu/files/2023-07/Cod…

University of California Anti-Discrimination Policy: https://policy.ucop.edu/doc/1001004/AntiDiscrimination

UC Sexual Violence and Sexual Harassment Policy: https://policy.ucop.edu/doc/4000385/SVSH

Approved, GMEC: January 11, 1999

Approved, GMEC: December 15, 2003

Approved, GMEC: November 3, 2004

Approved, GMEC: May 15, 2023

Approved, minor revisions, GMEC: March 18, 2024

Approved, minor revisions, GMEC: September 15, 2025

Approved, major revisions, GMEC: October 20, 2025

Graduate medical education must occur in the context of a learning and working environment that emphasizes excellence in the safety and quality of care rendered to patients by trainees today as well as in their future practice.

Patient Safety: Each program, its faculty, residents, and fellows must actively participate in patient safety systems and contribute to a culture of safety.

Residents, fellows, faculty, and other clinical staff must know their responsibilities in reporting patient safety events and unsafe conditions at their clinical sites, including how to report such events; and be provided with summary information of their clinical site’s patient safety reports. Residents and fellows must participate as team members in real and/or simulated interprofessional clinical patient safety and quality improvement activities, such as root cause analyses or other activities that include analysis, as well as formulation and implementation of actions.

Residents, fellows, and faculty must receive data on quality metrics and benchmarks related to their patient populations.

Supervision and Accountability: Each training program must have a program-specific policy addressing supervision that is consistent with ACGME, UCSF GME, UCSF Health, San Francisco Veterans Affairs Medical Center, and Zuckerberg San Francisco General Hospital and Trauma Center policies.

In addition, each program must set guidelines for circumstances and events in which trainees must communicate with the supervising faculty member(s), such as the transfer of a patient to an intensive care unit or end-of-life decisions.

Every patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable ACGME Review Committee) who is responsible and accountable for that patient’s care. This information must be available to residents, fellows, faculty, other members of the health care team, and patients. Residents, fellows, and faculty must inform each patient of their respective roles in that patient’s care when providing direct patient care. This information must be available to residents, faculty members, other members of the health care team, and patients.

Each training program must demonstrate that the appropriate level of supervision is in place for all residents and fellows based on each trainee’s level of training and ability as well as patient complexity and acuity. Supervision may be exercised through a variety of methods as appropriate to the situation. 90 To promote appropriate trainee supervision while providing for graded authority and responsibility, each program must use the following classification of supervision:

• Direct Supervision: The supervising physician is physically present with the trainee during the key portions of the patient interaction; or, the supervising physician and/or patient is not physically present with the trainee and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.
  • PGY-1 residents must initially be supervised directly with the supervisor physically present.
  • Each program must follow ACGME Review Committee-defined conditions under which PGY1 residents may be supervised indirectly.
• Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision. 
• Oversight: The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Programs must define when physical presence of a supervising physician is required.

Trainees may engage in the practice of medicine only in connection with their duties as a resident in an ACGME-accredited postgraduate training program in California, including its affiliated sites, or under those conditions as are approved in writing by the director of their program. For trainees PGY-2 and above, this may include moonlighting as permissible by GME and Program-specific policies.

Trainees must meet Medical Board of California licensing requirements and be registered with the DEA as required by their programs. Trainees who obtain a DEA license must enroll and complete the requirements for both PECOS and CURES. Refer to the Housestaff Information Booklet for additional information.

The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident and fellow must be assigned by the program director and faculty members. The program director must evaluate each trainee’s abilities based on specific criteria, guided by the Milestones. Faculty members functioning as supervising physicians must delegate portions of care to residents and fellows based on the needs of the patient and the skills of the trainees. Senior residents or fellows should serve in a supervisory role of junior trainees in recognition of their progress toward independence, based on needs of each patient and the skills of the individual trainee.

Each resident and fellow must know the limits of his/her scope of authority and the circumstances under which he/she is permitted to act with conditional independence. Faculty supervision assignments must be of sufficient duration to assess the knowledge and skills of each trainee and delegate to him/her the appropriate level of patient care authority and responsibility.

Approved, GMEC: July 18, 2011

Approved Major Revision, GMEC: October 16, 2017

Approved, GMEC: August 15, 2020

Approved Major Revision, GMEC: July 17, 2023

Each program, in partnership with the UCSF School of Medicine, must educate residents, fellows, and faculty concerning the professional responsibilities of physicians, including their obligation to be appropriately rested and fit to provide the care required by their patients.

The learning objectives of the program must be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events. In addition, they must be accomplished without excessive reliance on residents and fellows to fulfill non-physician obligations and ensure manageable patient care responsibilities.

The program director, in partnership with the UCSF School of Medicine, must provide a culture of professionalism that supports patient safety and personal responsibility.

Residents, fellows, and faculty must demonstrate an understanding of their personal role in the following:

• Provision of patient- and family-centered care;
• Safety and welfare of patients entrusted to their care, including the ability to report unsafe conditions and adverse events;
• Assurance of their fitness for work, including
  • Management of their time before, during, and after clinical assignments; and,
  • Recognition of impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team.
• Commitment to lifelong learning;
• Monitoring of their patient care performance improvement indicators; and
• Accurate reporting of clinical and educational work hours, patient outcomes, and clinical experience data.

Residents, fellows, and faculty must demonstrate responsiveness to patient needs that supersedes self-interest. This includes the recognition that, under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider.

Additionally, administrative assignments are required as part of resident/fellow professionalism expectations. This includes accurate completion of required documentation, including licensing requirements. Additional professionalism expectations include but are not limited to: timely completion of training sessions/modules; timely completion of supervisor/learner evaluations; timely responses to email queries from institution or program leadership/administration; and participation in program-mandated activities.

Programs, in partnership with the UCSF School of Medicine, must provide a professional, equitable, respectful, and civil environment that is free from discrimination, harassment, mistreatment, abuse, or coercion of students, residents, fellows, faculty, and staff. Programs, in partnership with the UCSF School of Medicine, should have a process for education of residents, fellows, and faculty regarding unprofessional behavior and a confidential process for reporting, investigating, and addressing such concerns

Approved, GMEC: October 16, 2017

Revision Approved, GMEC: June 12, 2023

This UCSF School of Medicine GME policy addresses GMEC oversight of reductions in size or closure of each of its ACGME-accredited programs, or closure of the UCSF School of Medicine.

UCSF School of Medicine and ACGME require Program Directors submit proposals for a temporary or permanent increase or decrease in resident/fellow complement, including closures, to the GMEC and DIO for approval prior to submission to the ACGME/RRC. The GMEC will weigh the potential benefits of a change in program size (or closure) against potential liabilities and may request justification and information on the projected impact of the proposed change.

The UCSF School of Medicine must inform the GMEC, DIO, and affected residents/fellows as soon as possible when it intends to reduce the size of or close one or more ACGME-accredited programs, or when the UCSF School of Medicine intends to close.

In the event of such a reduction or closure, UCSF School of Medicine will allow residents/fellows already in an affected ACGME-accredited program(s) to complete their education at the UCSF School of Medicine, or assist them in enrolling in (an)other ACGME-accredited program(s) (in which they are deemed eligible by the receiving program) in which they can continue their education.

Approved, GMEC: February 22,1999

Approved, GMEC: December 15, 2003

Approved, GMEC: November 3, 2004

Approved, GMEC: May 15, 2023

Approved, GMEC: October 20, 2025

Residents and fellows play an important instructional role in the clinical education of medical students. In order to fulfill that responsibility, residents and fellows need to be familiar with the competencies and milestones expected of third- and fourth-year medical students and have orientation and faculty development resources available to enhance their teaching and assessment skills. To comply with LCME Standard: 9.1 Preparation of Resident and Non-Faculty Instructors, the following occurs:

• All incoming residents and fellows are required to attend GME New Resident and Fellow Orientation, which includes an orientation to their roles and responsibilities as trainees and teachers.
  • Attendance is collected and monitored centrally by the Office of GME.
  • The orientation is scheduled as a combination of synchronous and asynchronous modules.
  • The orientation covers the following topics:
    • UCSF School of Medicine (SOM) Learning Environment Policies that promote an inclusive learning environment (link: https://meded.ucsf.edu/about-us/guidelinespolicies/medical-student-poli…)
      • Anti-oppression
      • Diversity and Institutional Inclusion
      • Equity in Learning
      • Clinical Supervision of Medical Students
      • Duality of Interest Health Provider and Student Roles
      • Feedback
    • Information on Supporting a Fair Environment (SAFE) reporting
    • Information on reporting to the Office for the Prevention of Harassment and Discrimination
       
• Residents and fellows who will teach medical students participate in departmental clerkship orientations where they receive a copy of the clerkship objectives and the clerkship schedule.
   
• Residents and fellows who evaluate or assess medical students receive an annual online attestation form requiring them to review and acknowledge receipt of the medical school’s graduation milestones and competencies, clerkship objectives and core clinical experiences.
   
• The UCSF Center for Faculty Educators and the GME College offer teaching development workshops to help faculty, residents, fellows, and instructors improve teaching skills. Attendance is monitored centrally by the Center for Faculty Educators and the Office of GME.
   
• Clinical departments offer additional teaching development workshops to residents and fellows, including topics such as the creating a positive learning climate, setting expectations on the clerkship, giving effective feedback, precepting, team leadership, and small group facilitation. Model curricula on residents-as-teachers have been developed by the Center for Faculty Educators for dissemination into residency and fellowship programs.
   
• Residents or fellows who are teaching medical students in the clinical environment must have direct or indirect supervision in their teaching and assessment role by an individual who has a faculty appointment. Fellows who are appointed as non-ACGME fellows are allowed to teach and assess medical students independently, if they hold a concurrent faculty appointment (ex: clinical instructor appointment or volunteer clinical faculty).
   

Related Policies:

1. UCSF SOM Policies: https://meded.ucsf.edu/about-us/guidelines-policies/medical-studentpoli…

2. Orientation to Teaching Roles and Responsibilities: https://meded.ucsf.edu/aboutus/guidelines-policies/medical-student-poli…

3. Student Mistreatment Policy: http://meded.ucsf.edu/mse/medical-student-mistreatmentpolicy

4. Medical Student Duty Hour policy: http://meded.ucsf.edu/mse/medical-student-duty-hoursclinical-rotations

5. Duality of Interest Policy: Health Provider and Student Roles: https://meded.ucsf.edu/policies-procedures/duality-interest-health-prov…

GMEC approved: October 16, 2017

Minor Revisions, GMEC approved: July 17, 2023

GMEC approved: October 16, 2023

Minor Revisions for LCME, GMEC approved: August 18, 2025

The Graduate Medical Education Committee (GMEC), the governing body responsible for housestaff policies, reviews and approves the housestaff policies stated in this booklet. Policies may be subject to change during the year with approval by the GMEC. Revisions will be highlighted and dated as such and posted on the Graduate Medical Education (GME) website: https://meded.ucsf.edu/gme

Approved, GMEC: May 15, 2023

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) recognizes Sponsoring Institutions with Non-Standard Training (NST) programs to provide a framework for approving and overseeing training opportunities in the U.S. for physicians on J-1 visas sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG) through the Exchange Visitor Program of the U.S. Department of State. UCSF School of Medicine has received institutional recognition by the ACGME to conduct NST programs. As such, UCSF School of Medicine, working through the Designated Institutional Official (DIO) and the Graduate Medical Education Committee (GMEC), bears the responsibility for each NST program and NST trainee under its auspices. This responsibility includes the following:

1. Ultimate Authority: UCSF School of Medicine, an ACGME-accredited Sponsoring Institution has ultimate authority and oversight of its NST programs. (ACGME NST Req. 1.1)
2. Adequate Resources: Ensures availability of adequate personnel, clinical activities, and other resources for conducting NST programs without adverse impact on the education of residents/fellows. (ACGME NST Req. 1.1.a)
3. Compliance with Regulations: Ensures compliance with regulations that govern the participation of sponsors in the Exchange Visitor Program of the United States Department of State. (ACGME NST Req. 1.1.c)
4. Learning and Working Environment: Ensures that trainees in the learning and working environment have the opportunity to raise concerns and provide feedback without fear of intimidation or retaliation and in a confidential manner. (ACGME NST Req. 2.5)

The DIO, in collaboration with the GMEC, has authority and responsibility for the oversight and administration of each of the UCSF School of Medicine’s NST programs, as well as for ensuring compliance with the Recognition Requirements for Sponsoring Institutions with NST Programs. (ACGME NST Req. 1.2). The DIO, working in collaboration with the Office of GME, oversees the preparation and submission of all information about the NST programs required and requested by the ACGME. (ACGME NST Req. 1.2.a)

The purpose of NST programs is to advance trainee education and clinical training. NST fellowships are not intended to compensate for clinical needs. When establishing a new NST fellowship training program, the GMEC must consider whether the program has sufficient administrative/educational resources for sustaining the program and its trainees and meeting ACGME NST requirements.

DEFINITIONS

Non-Accredited Fellowship Program (non-ACGME Program): Time-limited clinical training experience with faculty supervision for medical school graduates that is not accredited by the Accreditation Council for Graduate Medical Education (ACGME).

Non-Standard Training (NST) Program: Clinical training for foreign national physicians in advanced subspecialty programs for which there is no Accreditation Council for Graduate Medical Education (ACGME) accreditation or American Board of Medical Specialties (ABMS) Member Board certification.

Non-Standard Training (NST) Program Focus Area: A defined clinical or research discipline in which an international medical graduate receives additional training in the U.S. outside of ACGME-accredited programs. Focus areas are typically defined by a narrow or highly specialized field in medicine that does not fall under the scope of existing ACGME-accredited specialties or subspecialties. NST focus areas are approved by the ACGME and are used to support J-1 visa sponsorship through the Educational Commission for Foreign Medical Graduates (ECFMG).

Non-Standard Training (NST) Trainee: A physician in an NST program who holds a J-1 visa sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG).

Institutional Recognition: An ACGME process for approval of ACGME-accredited Sponsoring Institutions to conduct NST programs. Institutional Recognition is distinct and separate from ACGME accreditation processes.

POLICY ON PROGRAM STRUCTURE

• Programs must have formal approval to become an NST program by the GMEC and the ACGME prior to extending any training offer to a NST Trainee. (ACGME NST Req. 1.1.b)
   
• UCSF School of Medicine must sponsor an ACGME-accredited residency/fellowship program in the most closely related specialty/subspecialty for each NST program. The most closely related ACGME-accredited residency/fellowship program must maintain a status of Continued Accreditation or Continued Accreditation with Warning. (ACGME NST Req 1.1.b.1)
   
• There must be a single NST program director, from among the core physician faculty members of the most closely related ACGME-accredited residency/fellowship program, who is responsible for the operation of each NST program. The NST program director must oversee NST trainee supervision, education and assessment at all participating sites (ACGME NST Req 1.3, 1.3.a). The NST program director must have a UCSF faculty appointment and cannot have volunteer or MSP appointments.
   
• NST trainees’ assignments/rotations must be limited to the participating sites of the most closely related ACGME-accredited program, as identified by the Sponsoring Institution and listed in ADS. (ACGME NST Req. 1.5)
   
• All NST programs must have a corresponding ACGME approved focus area. NST programs with focus areas that are not approved by the ACGME will not be allowed.
   
• NST programs must have a clear educational structure, including a formal didactic component. All non-standard fellowship programs must incorporate an academic component. (ACGME NST Req. 2.2)
   
• NST programs must comply with the UCSF School of Medicine/GME Clinical and Educational Work Hours Policy. This policy, which is more strict than the ACGME NST work hour requirements, requires programs design trainee schedules such that trainee work hours are limited to no more than 80 hours per week during any given week, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting; and trainees must have one day in every calendar week free of clinical work (including moonlighting) and required education. At-home clinical responsibilities cannot be assigned on a trainee’s free days of work. (ACGME NST Req. 2.6, 2.7)

POLICY ON PROGRAM SUSTAINABILITY

• Every NST fellowship program must identify clear and sustainable funding.
   
• Programs will not be approved for a single year (“one and done”) nor granted NST recognition solely to accommodate a single identified trainee.
   
• Programs without a trainee (regardless of visa status) for more than three consecutive years will be considered dormant and automatically closed. Formal re-application will be required prior to fellow recruitment.

NST PROGRAM REQUIREMENTS

• NST programs must adhere to all central School of Medicine, GME, UCSF campus, UC Office of the President and pertinent health affiliate policies.
   
• NST programs must provide a learning and working environment in which NST trainees have the opportunity to raise concerns and provide feedback without fear of intimidation or retaliation and in a confidential manner as appropriate. (ACGME NST Req. 2.5)
   
• Non-standard programs must design a program that adheres to the UCSF School of Medicine/GME Well-Being Policy and ACGME Well-Being Requirements.
   
• Each NST program must define the prerequisite education and/or training for entry into the NST program and ensure that NST trainees appointed to the NST program meet prerequisites for entry into the NST program. (ACGME NST Req. 2.1, 2.1.a.)
   
• The NST program must make available to NST trainees and faculty members a curriculum that includes: overall educational goals for the NST programs; delineation of NST trainee responsibilities for patient care, responsibility for patient management, and supervision during the NST program; and a description of the required educational experiences, didactic sessions, assessment methods and procedural experience requirements. (ACGME NST Req 2.a, 2.2.b, and 2.2.c). It is suggested that NST programs provide the NST program description to NST trainees and faculty members to meet this requirement.
   
• NST programs must have a supervision policy which complies with the School of Medicine/GME Patient Safety, Quality Improvement, Supervision and Accountability Policy as well as with ACGME-dictated levels of supervision. A supervising faculty member must be physically present to supervise the NST trainee with all patients until the NST program director has documented the NST trainee’s ACGME Milestones achievement as a sufficient basis for delegating progressive authority and responsibility and conditional independence, as assigned by the NST program director and faculty members. (ACGME NST Req. 2.3.a.)
   
• No later than three months from the NST trainee’s starting date in the NST program, each NST program director must complete an initial competence assessment of each NST trainee in the NST program, including an ACGME Milestones assessment from the most closely related ACGME-accredited specialty or subspecialty. (ACGME NST Req. 2.3)
   
• ​​The program must establish a feedback process that includes written formative, semiannual, and summative evaluations. Summative evaluations will be completed for each NST trainee upon the NST trainee’s completion of, or separation from, the program. This feedback process must also include semi-annual review meetings between the Program Director and trainee. Additional forms of evaluation are encouraged. (ACGME NST Req. 2.3.b and 2.4)
   
• The NST program must institute a plan for formal work hours logging through MedHub.
   
• ​​​​NST programs must use ADS, the accreditation data collection system for ACGME, and ensure all ADS details are kept current. NST programs are only required to maintain J-1 visa trainee information in their trainee roster in ADS but must operate as an NST program, following all NST program requirements at all times, regardless of the visa status of their trainees.
   
• When a program does not have a trainee on a J-1 visa, the program will be marked as inactive in ADS so the program will not be required to keep their trainee roster in ADS updated or incur ADS program fees. However, the NST program must continue to follow NST program requirements for all trainees, regardless of visa status.
   

NST TRAINEES

• All NST trainees will be appointed through the UCSF School of Medicine, Office of GME. NST programs will use the standard non-ACGME contract to ensure compliance with ACGME NST requirements. (ACGME NST Req. 2.1.b and 2.1.c) The agreement contains or give reference to NST trainee responsibilities, including any requirements for successful completion of the NST program); duration of training; financial arrangements related to the NST trainee; grievance and due process; professional liability coverage, including a summary of pertinent information regarding coverage; the availability of health insurance benefits for NST trainees and their eligible dependents; and vacation, and leave(s) of absence for NST trainee(s), including medical, parental, and caregiver leave(s) of absence, and compliant with applicable laws (ACGME NST Req. 2.1.b.1, 2.1.b.2, 2.1.b.3, 2.1.b.4, 2.1.b.5, 2.1.b.6, and 2.1.b.7). UCSF School of Medicine Office of GME will monitor implementation of the terms and conditions of the agreement through monitoring of appointment paperwork. (ACGME NST Req. 2.1.c)
   
• NST trainees will receive the appropriate institutional pay scale for residents/fellows based on PGY year.
   
• NST trainees will act strictly in the capacity of a physician in-training and will not be permitted to have attending privileges (i.e. bill independently for services rendered).
   
• Trainees who hold J-1 visas are not able to moonlight.

GMEC OVERSIGHT

In accordance with the standards set by ACGME, GMEC must:

• Review and approve the program description of each NST program, which must specify any qualifications for appointment of the NST program director; (ACGME NST Req. 1.4 and 1.4.a)
   
• Review and approve the appointment of each NST program director; (ACGME NST Req. 1.4.b)
   
• Complete and document an assessment of supervision and assessment of NST trainees at least annually; (ACGME NST Req. 1.4.c)
   
• Complete and document the impact of NST programs on the Sponsoring Institution’s ACGME-accredited programs at least annually; (ACGME NST Req. 1.4.d)
   
• Review and approve the following for NST programs prior to their occurrence:
  • Changes in complement
  • Changes in participating sites
  • Change in program director
  • Change in program duration
  • Program closure

NST PROGRAM APPLICATION PROCESS

• Any request to create a non-standard fellowship program requires the submission of a fully completed Non-ACGME/NST application. This application includes: the NST Program Description; the Supervision Policy; the Block Diagram; the Program Director CV; the ACGME Milestones from the most closely related ACGME-accredited specialty/subspecialty; and an Attestation and Certification Form.
   
  • The Program Description specifies any qualification for appointment of the NST program director (ACGME NST Req. 1.4.b); includes the overall educational goals for the NST program, the delineation of NST trainee responsibilities for patient care, responsibility for patient management, and supervision during the NST program; and includes a description of required educational experiences, didactic sessions, assessment methods, and procedural experience requirements.
     
  • The Attestation and Certification form must be signed by the NST program director, the program director for the most closely related ACGME-accredited specialty/subspecialty, and the Department Chair. Program Directors from the most closely related ACGME-accredited specialty/subspecialty programs must certify that the proposed non-standard program will not have an adverse impact on the education of residents/fellows in the ACGME-accredited program.
     
• NST program applications must be submitted to the Office of GME prior to September 1st for NST trainees to be appointed for work by the following July.
   
• Those requesting to establish a non-standard program may NOT recruit or offer training to anyone prior to formal NST program approval by GMEC and ACGME. Offers made in advance of such approval will not be considered valid by UCSF School of Medicine.

ADDITIONAL RESOURCES:

1) ACGME Requirements for NST Programs: https://www.acgme.org/globalassets/pfassets/programrequirements/2025-re…

2) Non-Standard Training Recognition Resources by ACGME including guidance document and approved focus areas: https://www.acgme.org/programs-andinstitutions/institutions/non-standar…

Approved by GMEC: August 18, 2025

Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care and responsibility to support other members of the health care team are important components of professionalism; they are also skills that must be modeled, learned and nurtured in the context of other aspects of residency and fellowship training.

Each program in partnership with the UCSF School of Medicine, has the same responsibility to address well-being as it does to evaluate other aspects of resident and fellow competence. Physicians and all members of the health care team share responsibility for the well-being of each other.

This responsibility of each program, in partnership with the UCSF School of Medicine must include:

• Efforts to enhance the meaning that each resident and fellow finds in the experience of being a physician, including protecting time with patients, minimizing non-physician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships;
   
• Attention to scheduling, work intensity, and work compression that impacts resident and fellow well-being;
   
• Evaluating workplace safety data and addressing the safety of residents, fellows, and faculty;
   
• Policies and programs that encourage optimal resident and faculty member well-being; and
   
  • Residents and fellows must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours
     
• Attention to resident and faculty member burnout, depression, and substance abuse. The program, in partnership with the UCSF School of Medicine and Office of GME, must educate faculty, residents, and fellows in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. Residents, fellows, and faculty must also be educated to recognize those symptoms in themselves and how to seek appropriate care.

The program, in partnership with the UCSF School of Medicine must:

• Encourage residents, fellows, and faculty to alert the program director other designated personnel or programs when they are concerned that another resident, fellow, or faculty 100 member may be displaying signs of burnout, depression, a substance use disorder, suicidal ideation, or potential for violence;
   
• Provide access to appropriate tools for self-screening; and,
   
• Provide access to confidential affordable mental health assessment, counseling, and treatment, including access to urgent and emergent care 24 hours a day, seven days a week.

There are circumstances in which residents and fellows may be unable to attend work, including but not limited to fatigue, illness, and family emergencies. Each program must have policies and procedures in place that ensure coverage of patient care in the even that a resident or fellow may be unable to perform his/her patient care responsibilities. These policies must be implemented without fear negative consequences for the resident or fellow who is unable to provide the clinical work.

Approved, GMEC: October 16, 2017

Revision, Approved, GMEC: June 12, 2023

UCSF School of Medicine provides services and systems to ensure a healthy and safe clinical and educational environment at all training sites.

• access to food during all clinical and educational assignments for trainees;
   
• sleep/rest facilities that are safe, quiet, clean, and private, that are available and accessible for residents/fellows, with proximity appropriate for safe patient care;  
   
• safe transportation options for residents/fellows who may be too fatigued to safely return home on their own;
   
• clean and private facilities for lactation with proximity appropriate for safe patient care, and clean and safe refrigeration resources for the storage of breast milk;
   
• accommodations for residents/fellows with disabilities, consistent with UCSF policy;
   
• institutional processes for ensuring the availability of resources to support residents’/fellows’ well-being and education by minimizing impact to clinical assignments resulting from leaves of absence;
   
• peripheral intravenous access placement, phlebotomy, laboratory, pathology and radiology services and patient transportation services provided in a manner appropriate to and consistent with educational objectives and to support high quality and safe patient care;
   
• medical records available at all participating sites to support high-quality and safe patient care, residents’/fellows’ education, quality improvement and scholarly activities;
   
• safety and security measures appropriate to the clinical learning environment site;

The UCSF Graduate Medical Education Committee is the authoritative body to review concerns related to work conditions as well as issues related to the program and/or faculty. Residents/fellows who have concerns about their work conditions, program or faculty should address their Program Director and/or Chair. If problems or concerns are not resolved at this level, these should be brought to the attention of the DIO/Chair of the GMEC or, in the DIO’s absence, a designee. The GMEC is then charged with the resolution of the concern or issue working with appropriate stakeholders in the School of Medicine and/or Health Systems.

Approved, GMEC: September 20, 2004

Approved, GMEC: November 3, 2004

Revision, Approved, GMEC: June 12, 2023