Policy of the Graduate Medical Education Committee
Section: Educational Administration
Subject: Institutional and Program Agreements for Educational Activities
Number: 1.110
Date Developed: 12/99
Last Review/Revision: 2/05, 10/07, 7/10
Replaces:  policy of the same name, dated 5/03
ACGME Requirements Source: Institutional IC; Common IB

Purpose
To define the requirements for inter-institutional agreements and letters of agreement for the University of Arkansas for Medical Sciences College of Medicine (UAMS-COM) and its sponsored residency Programs. 

Definitions

Site: An organization providing educational experiences or educational assignments/rotations for residents/fellows (e.g., a hospital, a private medical practice, a nursing home, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office).

Major Participating Site: A Review Committee-approved site to which all residents in at least one program rotate for a required educational experience, and for which a master affiliation agreement must be in place. To be designated as a major participating site in a two-year program, all residents must spend at least four months in a single required rotation or a combination of required rotations across both years of the program. In programs of three years or longer, all residents must spend at least six months in a single required rotation or a combination of required rotations across all years of the program. The term “major participating site” does not apply to sites providing required rotations in one year programs.

Master Affiliation Agreement: Initiated by the Sponsoring Institution, a written document that addresses GME responsibilities between the sponsoring institution and a major participating site.

Program Letter of Agreement (PLA): A written document that addresses GME responsibilities between an individual accredited program and a site other than the sponsoring institution at which residents receive a required part of their education.

Policy

1.  Master Affiliation Agreements

The Sponsoring Institution retains responsibility for the quality of GME, including when resident education occurs in other sites.  The master affiliation agreement addresses the responsibilities and will be reviewed and updated as necessary by the Associate Dean for GME every five years.

 2.  Program Letters of Agreement

Each Program Director must prepare appropriate letters of agreement between the residency program sponsored by the UAMS-COM and each of the participating sites to which the residents rotate.  These letters of agreement should:

1. Identify the faculty who will assume administrative, educational and supervisory responsibility for the residents;

2. Specify the faculty responsibilities for teaching, supervision, and formal evaluation of resident performance;

3.  Specify the duration and content of the educational experience;

4. Establish the policies and procedures that govern resident education during the assignment.

Procedure

1. The Program Director obtains the template for the letter of agreement, which contains the requirements noted above, from the Associate Dean for GME.

2. The Program Director adds additional information to the template in order to comply with any special program requirements.

3. The Program Director signs the letter of agreement and returns it to the Associate Dean for GME who obtains the appropriate signatures from the institutional officials. 

4. All letters of agreement will include the following signatures: Program Director, Associate Dean for GME of the UAMS-COM, and the Medical Director or his/her designee of the participating institution.

5. Once all signatures are obtained, the Program Director keeps the original copy and supplies copies to each participating site and to the Associate Dean for GME.

6. Letters of agreement are reviewed and/or revised every five years or upon a change in leadership of the residency program (e.g. if a new program director is appointed).