ACGME Programs

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.

Voting membership on the committee includes the designated institutional official, residents and fellows nominated by their peers, representative program directors, representative program administrators, representative vice chairs of education, representative education leaders from the major clinical sites, Office of GME faculty leaders 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 ([email protected]) and Accreditation Manager, Cindy Gaytan Morrison ([email protected]) 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

Programs interested in initiating a new program request should log into the ACGME website, review the program requirements for the new ACGME program as well as review committee’s requirements and upcoming Review Committee meeting dates. Please note that some specialty review committees have a different closing date for new program applications. The review and approval process for a new ACGME program first involves submitting a growth application to the Office of GME, the Graduate Medical Education Committee (GMEC), UCSF ACGME Expansion Committee, then a final approval by the Dean. Once approved by the Dean, new program proposals may move forward with the formal ACGME application in ADS.  Once new program applications are completed, the application must then be reviewed and approved by GMEC before submission in ADS to the ACGME review committee.  Please note that the Office of GME will only accept and review applications yearly. 

New ACGME Program Request Guidelines

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

A complement is the maximum number of residents or fellows approved by a Review Committee 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).

Temporary complement increases fewer than 90 days (ex: trainee returning from leave) 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.

Temporary complement increases that are longer than 90-days may, in addition to GMEC approval, need to be approved by the ACGME Expansion Committee (ex: programs seeking temporary complement increase for one year due to grant/military funding of trainees). 

Accredited program expansion (i.e. permanent complement increase) require prior approval from GMEC, the ACGME program expansion committee, Dean’s approval and then approval from the ACGME Review Committee.

Temporary complement increases can be submitted to GMEC at any time (please review GMEC submission dates).  Programs seeking permanent accredited program expansion (permanent complement increase) should begin preparing their request far in advance since it requires a substantial amount of time for approval. Deadlines for permanent accredited program expansion are March 1^st and September 1^st.  Please follow the link below for information on how to submit a complement change to GMEC:

Permanent and Temporary Complement Change Request

A request must be submitted to the GMEC for the approval of a resident/fellow candidate who does not satisfy our 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/offering a position to an applicant.

Please submit the required documents below to [email protected] by one of our GMEC agenda closing deadlines found above.

• Formal letter from the program director addressed to the GME Committee requesting approval to recruit the exceptionally qualified candidate signed by the program director and chair of the department, and/or vice chair of education.
  • The letter must demonstrate evaluation by the program director and selection committee of the applicant’s suitability to enter the program, based on prior training and review of the summative evaluations of this training.
  • The letter should also note how this candidate has demonstrated clinical excellence in comparison to their peers throughout their training.
• Copy of candidate's CV
• Copy of candidate’s ECFGM Certificate,
• Letters of recommendation highlighting candidate’s clinical excellence.
• If your program is a fellowship, please also include proof that the applicant has successfully completed residency in the core specialty and has satisfactorily completed USMLE Steps 1, 2, and 3.
• Please provide an excerpt (PDF) from your ACGME Program Requirements pertaining to resident/fellow eligibility requirements – The Resident/Fellow Eligibility and Eligibility Exception sections only.

Applicants being considered for these positions must be informed that their training may not lead to certification by ABMS member boards or AOA certifying boards

The program director must submit any additions or deletions of participating sites in their program for sites routinely providing an educational experience, required for some or all residents, of one month or more through the ACGME’s Accreditation Data System (ADS). (Core. PR.1.6.) Any additions or deletions of participation site for a program must first be reviewed and approved by the Graduate Medical Education Committee (GMEC). To submit a request to add or delete a participating site to your program, please follow the link below.

ADS Participating Site Change 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 (including shift of resident FTE among clinical sites), 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.

• Shifts in resident/fellow FTE among the clinical sites: For shifts of resident/fellow FTE among the main clinical sites (SF VA, ZSFG or UCSF Health sites), approval by GMEC and a growth application may be required. Please review requirements here to see if a growth application is indicated.

To submit a request to the GMEC for a program major change, please email [email protected] 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.