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Medical Education
Graduate Medical Education

Accreditation

About

GME Committee (GMEC)

Accreditation Systems

Surveys

Timeline

How

Change program director

Change program coordinator

Apply for a new program

Change resident complement

Procedures for Away Rotations

 

 

GME Committee (GMEC)

The Graduate Medical Education Committee (GMEC) is responsible for establishing and implementing policies and procedures, overseeing program compliance with ACGME program guidelines, and reviewing all program changes. The GMEC reports to the Dean of the School of Medicine, to the Faculty Council of the School of Medicine, and at least annually to the Executive Medical Board of each of the three major participating hospitals (Moffitt-Long/Mt. Zion Medical Centers, San Francisco General Hospital and the San Francisco Veterans Administration Medical Center).

Voting membership on the committee includes the designated institutional official (Associate Dean, Robert Baron, MD, MS), residents and fellows nominated by their peers, representative program directors, and administrators. It may also include other members of the faculty or other members.

The GMEC typically meets on the third Monday of each month at 4:00 to 5:30 p.m.. at the Parnassus Campus. 

Submissions for the GMEC meeting agenda should be sent to the GME Accreditation Manager, by the first of each month. Communications should be addressed to the Designated Institutional Official (DIO) and/or the Graduate Medical Education Committee (GMEC). 

 

Accreditation Systems

ACGME Accreditation Data System (ADS)

The ACGME Accreditation Data System (ADS) maintains pertinent program information including: past communications from review committees; resident/fellow and faculty survey reports; and other critical program data. The ACGME requires that programs use the system to report milestones and other data, and to request program changes. Each program is given one unique user identification and password which is shared by the program director and program coordinator.

GME Accreditation Database

The UCSF GME Accreditation Database is a web-based system built on the Salesforce platform and is used to track accreditation data and documents. Programs will commonly use the system when completing their annual program director's update and/or when adding training sites. Programs can access documents (policies, goals and objectives, etc.) from other programs within their specialty in the database “library”. The database login is intended to be shared between the program coordinator and program director.

 

Surveys

ACGME Resident/Fellow Survey

Trainees in all ACGME programs are surveyed by the ACGME every year between December and June. Aggregate reports are made available to programs with four or more trainees if a 70% response rate is reached. To access survey reports: log into the ACGME Accreditation Data System (ADS), select Reports, and then select Survey. Programs should review their survey reports with their trainees annually and address areas where issues are reported. FAQs and survey guides are available on the ACGME website.

ACGME Faculty Survey

Physician faculty members and program directors in all ACGME programs are surveyed by the ACGME every year between December and June. Aggregate reports are made available to programs with four or more faculty member if a 70% response rate is reached. Programs should review their survey reports annually and address areas where issues were reported.

ACGME Annual Update

The ACGME conducts an Annual Update which program directors are required to complete in the summer. The program is responsible for verifying and updating critical accreditation program information, entering and verifying the records for all trainees, and indicating which trainees have graduated. The Annual Update is located within the Overview tab in ADS. The Annual Update consists of updating several sections on the following tabs: Program, Faculty, Residents, and Sites.  The Overview tab highlights missing data that requires your attention. Programs may continue to update their ADS information at any time throughout the academic year, as needed. Programs can view a report of their ADS data by selecting the Summary tab.

UCSF GME Annual Program Directors' Update

The Office of GME conducts an Annual Program Directors’ Update which program directors are required to complete in the summer. In addition to maintaining accreditation requirements the data is used for reports to the medical staff of each of our affiliated sites; for budgetary and financial discussions; for campus efforts in diversity; to address issues related to UME and GME collaboration; for sharing best practices; and for many other important functions. The Annual Program Directors’ Update login is sent to program directors and can be shared with program coordinators.

 

Change program director

The Designated Institutional Official (DIO) and Graduate Medical Education Committee (GMEC) must review and approve a program’s request to change their program director before the request is submitted to the program’s review committee. Program’s expecting to change program directors should:

  1. Review the program director section of their review committee’s guidelines to ensure that the proposed candidate poses the required qualifications.
  2. Draft a letter to the DIO (Associate Dean Robert Baron, MD, MS) explaining the reason for the change; the new program director’s qualifications; and the expected date for the change. This letter must be signed by the department chair.
  3. Submit the letter and a current version of the proposed program director's CV to the GME Accreditation Manager.

The letter and CV will be presented to the GMEC for review. The proposed program director is invited to attend the meeting.

After the GMEC approves the change the GME Accreditation Manager will submit the request in the ACGME's Accreditation Data System (ADS). The proposed program director will then receive an email from the ACGME requesting that he/she log into ADS to accept the change. The change in program director will not go into effect until the proposed program director completes this step.

The DIO and Accreditation Manager will meet with the new program director to discuss his/her new role and orient him/her to the position.

 

Change program coordinator

Programs should notify the Office of Graduate Medical Education if a program coordinator changes. We will provide training to the new program coordinator and give them access to GME systems. We will also offer the new program coordinator training in GME systems and procedures.

 

Apply for a new program

If you are interested in applying for a new ACGME training program contact the DIO or the GME Accreditation Manager to arrange a time to discuss plans for a new program. The Office of Graduate Medical Education must initiate the program application process in the ACGME Accreditation Data System (ADS) and will assist you in preparing the application. After the application is finalized the GME Committee (GMEC) must approve the application. The final application will be submitted to the ACGME via ADS. The ACGME review committee will notify the training program of the final outcome.

The Office of Graduate Medical Education recommend that you read the ACGME program specific guidelines to learn about the structure and requirements for your proposed program.

 

Change in resident complement

Programs are approved by their ACGME review committee for a specific number of trainees based upon availability of resources. There are two types of changes in resident complement: temporary and permanent. Programs should begin preparing their request for a change in resident complement far in advance since it requires a substantial amount of time to collect data. In addition, the requests must be reviewed and approved by both the GME Committee (GMEC) and the program’s ACGME review committee.

Temporary change

  1. Programs interested in increasing their resident complement should log into the ACGME Accreditation Data System (ADS) and review their review committee’s requirements for complement changes. Log into ADS > select the program tab > under change requests, select complement change.
  2. Prepare a letter for the GMEC with a brief description of the educational reasons for the temporary resident complement change. Describe the specific circumstances for the temporary increase, and the provisions that will be taken to ensure adequacy of support (funding) and educational resources. The rationale must be exclusively educational and not based on specialty demands. The letter should also include the dates for the change.
  3. Email the letter to the GME Accreditation Manager. The request will be presented to the GME Committee at their monthly meeting.
  4. After the request is approved by the GME Committee (GMEC) you will be asked to enter it in ADS. The Office of GME will then approve the request and it will be send on to your review committee.
  5. Typically review committees approve temporary changes in resident complement within a few weeks of submission. Programs are notified of their approval by email.

Permanent change

  1. Programs interested in permanently increasing their resident complement should log into the ACGME Accreditation Data System (ADS) and review their review committee’s requirements for complement changes. Instructions: Log into ADS > select the program tab > under change requests, select complement change.

Typically review committee’s require the following information for a request:

  • Educational rationale for change
  • A brief update explaining any major changes to the training program since the last academic year
  • A current and proposed block diagram
  • Case log reports
  1. Prepare a letter for the GME Committee (GMEC) which includes a brief description of the educational reasons for the permanent resident complement change. This may include the exposure of residents or fellows to new technology, and the development of rotations that amplify or expand educational experiences. The narrative should justify the request in terms of institutional support, funding, emerging technology, clinical experiences, faculty support, and other institutional facilities that are available; also include the proposed implementation plan. The rationale must be exclusively educational and not based on specialty demands. The letter should include the dates for the change.
  2. Email the letter to the GME Accreditation Manager. The request will be presented to the GME Committee at their monthly meeting.
  3. After the request is approved by the GME Committee you will be asked to enter it in ADS. The Office of GME will then approve the request and it will be sent to your review committee.
  4. Depending on the review committee, and the specifics for the request, the change will either be approved by the executive director or be reviewed by the full review committee at the review committee’s meeting. (Review committee meetings schedules can be found on their individual ACGME homepage http://www.acgme.org/acgmeweb/tabid/83/ProgramandInstitutionalGuidelines.aspx). Therefore a program may receive approval within a few weeks or it may be many months before receiving approval.
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