a) oversee and ensure the quality of didactic and clinical
educational in all sites
that participate in the program;
b) approve
a local Director at each participating site who is
accountable for resident
education;
c) approve
the selection of program faculty as appropriate;
d)
evaluate program faculty and approve the continued
participation of program
faculty based on evaluation;
e) monitor
resident supervision at all participating sites;
f)
prepare and submit all information required and requested by the
ACGME, including but not
limited to the program information forms
and annual program resident
updates to the ADS, and ensure that
the information submitted is
accurate and complete;
g) provide
each resident with documented semiannual evaluation of
performance with feedback;
h) ensure
compliance with grievance and due process procedures as
set forth in the Institutional
Requirements and implemented by the
sponsoring institution;
i) provide
verification of residency education for all residents,
including those who leave
the program prior to completion;
j)
implement policies and procedures consistent with the institutional
and program requirements for
resident duty hours and the working
environment, including
moonlighting, and, to that end, must:
(1) distribute these policies & procedures to residents and faculty;
(2) monitor resident duty hours, according to sponsoring
institutional
policies, with a frequency sufficient to ensure compliance with
ACGME requirements;
(3)adjust schedules as necessary to mitigate excessive service
demands and/or fatigue; and,
(4)
if applicable, monitor the demands of at-home call and adjust
schedules as necessary to mitigate excessive service
demands and/or fatigue.
k)
monitor the need for and ensure the provision of back up support
systems when patient care
responsibilities are unusually difficult or
prolonged;
l)
comply with the Sponsoring Institution’s written policies and
procedures, including
those specified in the Institutional
Requirements, and enforce
specific program
policies/procedures
regulating training of residents within the
program. These
policies/procedures include, but are not limited to:
1) Selection of residents/fellows
2) Evaluation and promotion of residents/fellows
3) Dismissal of residents/fellows
4) Work environment and duty hours
5) Supervisory lines of responsibility for patient care
6) Raising and resolving concerns in a confidential and protected
manner
7) Moonlighting
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m) be
familiar with and comply with ACGME and RC policies and
procedures as outlined in
the ACGME Manual of Policies and
Procedures;
n) obtain
review and approval of the sponsoring institution’s
GMEC/DIO before submitting to
the ACGME information or requests
for the following:
(1)all applications for ACGME accreditation of new programs;
(2)changes in resident complement;
(3) major changes in program structure or length of training;
(4)
progress reports requested by the RC;
(5)
responses to all proposed adverse actions;
(6)
requests for increases or any change to resident duty hours;
(7) voluntary withdrawals of ACGME-accredited programs;
(8)
requests for appeal of an adverse action;
(9)
appeal presentations to a Board of Appeal and,
(10)
proposals to ACGME for approval of innovative educational
approaches.
o) obtain
DIO review and co-signature on all program information
forms, as well as any
correspondence or document submitted to
the ACGME that addresses:
(1)
program citations; and,
(2)
request for changes in the program that would have significant
impact, including financial, on the program or institution.
3. Ensure the COM Housestaff Office receives the appropriate eligibility
credentials each
June and the residents/fellows complete the
following forms annually:
ECFMG Certification
Annual GME Survey
Physician Health Questionnaire
TB Skin Test
Resident Agreement of Appointment
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