Accreditation

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 (UCSF Health, Zuckerberg San Francisco General Hospital, and the San Francisco Veterans Administration Medical Center).

Voting membership on the committee includes the designated institutional official, residents and fellows nominated by their peers, representative program directors, representative program administrators, representatives from the major clinical sites, and a patient safety officer.

The GMEC typically meets virtually on the third Monday of each month from 4:10 to 5:30 p.m. See below for future meeting dates.

Submissions for the GMEC meeting agenda should be sent to the GME Accreditation Specialist, Emerald Wong (emerald.wong@ucsf.edu) and Accreditation Manager, Cindy Gaytan Morrison (cindy.gaytanmorrison@ucsf.edu) prior to agenda closing dates. Agenda requests will undergo an initial review by the accreditation team to ensure requests meet all ACGME requirements before they are confirmed on the agenda.

Submissions should be addressed to the Designated Institutional Officer (DIO) and/or the Graduate Medical Education Committee (GMEC). Submissions are not guaranteed on the agenda until a confirmation has been received from the accreditation team. 

The following items must be approved by the GMEC:

• Applications for ACGME accreditation of new programs 

  • Growth Expansion applications 

  • NST applications 

• Requests for changes in resident/fellow complement (temporary complement changes still need GMEC approval)

• Major changes in each of its ACGME-accredited programs’ structure or duration of education, including any change in the designation of a program’s primary clinical site 

• Additions and deletions of each of its ACGME-accredited programs’ participating sites 

• Appointment of new program directors 

• Exceptionally qualified candidates for resident/fellow appointments who do not satisfy the Sponsoring Institution’s resident/fellow eligibility policy and/or resident/fellow eligibility requirements in the Common Program Requirements. *IMPORTANT* this request MUST be submitted PRIOR to ranking applicant

A program director, who must be the faculty member of the program, has authority and accountability for the overall program, including compliance with all applicable program requirements. If the current program director plans to separate from UCSF, step down from the role, retire, or go on extended leave, a new interim or permanent program director must be appointed. 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.

New Program Director Request

If you are interested in applying for a new ACGME training program contact the GME Accreditation Manager to arrange a time to discuss plans for a new program. The Office of Graduate Medical Education recommends that you read the ACGME program-specific guidelines to learn about the structure and requirements for your proposed program. Please follow the link below for more information on how to submit a new program proposal to GMEC:

New ACGME Program Proposal

A complement is the maximum number of residents or fellows approved by a Review Committee per PGY level and/or per program based upon availability of resources. Programs are required to request approval of all complement changes, whether temporary or permanent, by the Graduate Medical Education Committee (GMEC).

Additionally, permanent increases require prior approval from the program’s Review Committee. Temporary complement increases fewer than 90 days may not need Review Committee approval but must still be submitted for GMEC review. Specialty-specific instructions for requesting a complement increase are found in the “Documents and Resources” page of the applicable specialty section of the ACGME website.

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. Please follow the link below for information on how to submit a complement change to GMEC:

Permanent and Temporary Complement Changes

An exceptionally qualified applicant is a resident or fellow who has not met qualifications to be eligible for appointment to an ACGME accredited program. Programs may accept an exceptionally qualified international graduate applicant who does not satisfy the eligibility requirements listed in your program requirements, but who does meet the additional qualifications and conditions listed in the Resident/Fellow Eligibility Exception section of your program requirements.

The program must request approval to accept an exceptionally qualified candidate and provide documentation of the candidate’s qualifications for the Designated Institutional Official (DIO) and Graduate Medical Education Committee (GMEC) to review and approve before they rank or offer a position to an applicant.

Exceptionally Qualified Applicant Request 

A major change refers to any significant modification to the structure or curriculum of an ACGME accredited residency or fellowship program. All major changes require formal review and approval by the Designated Institutional Official (DIO) and the Graduate Medical Education Committee (GMEC) before they take effect. These changes can include shifts in curriculum, resident/fellow assignments, or rotation lengths that impact resident/fellow education.

Examples of Major Changes:

• Changes to the Curriculum: This includes modifications to the educational curriculum, such as changes to the structure or duration of required clinical rotations, or the introduction of new program tracks or specializations.

• Changes in the Program’s Clinical Experience: Significant alterations to the clinical training experience, including changes to the types or scope of clinical rotations offered, or modifications to the participating sites for a rotation, particularly if the primary site for a rotation is changing.

• Resident/Fellow Assignments: Adjustments to how resident/fellow time is allocated between clinical and educational activities such as changes in protected time for didactic lectures.

• Exceptions to Work Hour Requirements: Requests for exceptions to the standard clinical and educational work hour requirements.

To submit a request to the GMEC for a program major change, please email ucsf-accreditation@ucsf.edu to discuss required documentation the GMEC will need to review as part of your request. 

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.

ACGME Resident/Fellow Survey

Trainees in all ACGME programs are surveyed by the ACGME every year between January and April. Results are typically available through the ADS website in May for most programs. 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 January and April. Results are typically available through the ADS website in May for most programs. 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. OGME requires each program to submit their annual update for review by the OGME accreditation team prior to submitting to the review committee. Due dates are assigned each year in July.

UCSF GME Annual Program Directors' Update

The Office of GME conducts an Annual Program Directors’ Update (APDU) 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 APDU  is sent via Qualtrics link to program directors and program administrators each year in July.

UCSF GME Annual Program Evaluation

The ACGME requires the Annual Program Evaluation (APE) to be completed annually and documented as part of the continuous program improvement. The APE’s are to be completed as part of the Program Evaluation Committee (PEC) and documented in meeting minutes. APE’s should be saved each year by the program and collected for future use in the ACGME 10-year Self-Study. The APE is also collected by OGME and reviewed on an annual basis in July.