Accreditation

The Office of Graduate Medical Education facilitates institutional accreditation; collaborates with the GMEC to oversee UCSF ACGME-accredited programs; and assists programs with accreditation-related matters

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 (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 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, Jennifer Vogt, MBA, one week prior to the meeting. Communications should be addressed to the Designated Institutional Official (DIO) and/or the Graduate Medical Education Committee (GMEC).

The following items must be approved by the GMEC

  • Change program director
  • Apply for a new program
  • Change resident complement
Change In 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 follow the guidelines in the link below:

New Program Director Request

Apply for a New Program

If you are interested in applying for a new ACGME training program contact the the GME Accreditation Manager to arrange a time to discuss plans for a new program. 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. Please follow the link below for more information on how to submit a new program proposal to GMEC:

New ACGME Program Proposal

Change in Resident/Fellow 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. Please follow the link below for information on how to submit a complement change to GMEC:

Permanent and Temporary Complement Changes

Accreditation: Data Collection and Management

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) 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.