o        all applications for ACGME accreditation of new program and subspecialties

o        changes in resident complement

o       major changes in program structure or length of training

o        additions and deletions of participating institutions used in a program

o        appointment of new program director

o        progress report requested by any Residency Review Committee

o        responses to all proposed adverse actions

o        requests for increases or any change in resident duty hours

o         voluntary withdrawal of ACGME-accredited program

o        requests for an appeal of an adverse actions

o        appeal presentation to a Board of Appeal of the ACGME

• Institution-wide survey of residents’/fellows’ perception of their educational and work environments
• Completed between April 1 and May 15 each year
• Residents/fellows notified in early March about requirement to complete the survey and instructions for access
• Instructions also provided to Program Directors and Coordinators
• Residents/fellows who complete the survey by the deadline receive their step level increase in pay

• Accreditation requirements specify that all applicants (defined as those who are invited for interviews) must receive the terms and conditions for appointment (employment).
• This information is updated annually in July and readily available in the electronic Resident Handbook at http://www.uams.edu/gme/benefits.htm, listed as Terms & Conditions for Appointment in the Table of Contents:
• There are several ways to distribute this information to your applicants:
  • Incorporate the information into your program brochure
  • Attach the information to the brochure
  • Incorporate in or attach the information to the letter from you to the applicant
  • Print it from the website, distribute to applicants when they arrive to interviews
• Many Program Directors require applicants to sign an attestation confirming they received and reviewed the information.
• See GMEC policy 1.200 found at http://www.uams.edu/gme/1.200.html.

§        The courses supply basic knowledge that applies to all areas of clinical practice.  

§        Completion of the courses is required for graduation from UAMS.

§        Residents and fellows who entered accredited programs prior to July 2007 must complete three courses: Ethics, Medical Legal, and Foundations in Systems Based Practice and the ACGME Competencies.

§        Residents and fellows who entered an accredited program on or after July 1, 2007 must complete four courses, the three listed above and the SAFER course,

§        Courses should be completed within the first six months of entering training at UAMS.  If a resident completed the courses as a resident, then entered a UAMS fellowship the courses are not completed again as a fellow. 

§        A score of 80% or greater must be obtained on each quiz contained in each course. Residents/fellows are given an unlimited number of attempts to take the quizzes, and the highest score obtained will be recorded. 

§        On a regular basis, program directors are notified about who has completed the courses.

§        Course completion status is always available on New Innovations for the resident, program director, and program coordinator to access; and is updated monthly.

• Defined as all clinical and academic activities related to the  program: patient care, administrative duties relative to patient care, time spent in-house during call, scheduled educational activities such as conferences.
• Duty hours do not include reading and preparation time spent away from the duty site.
• *80 hours/week (includes in-house call & internal moonlighting = extra clinical duties at UH, VAH, ACH, etc)
• *1/7 day completely free of clinical duties (1 = 24 hours)

• *In-house call no more often than every third night

* = Averaged over four weeks

• 10 hrs for rest/personal time between daily duty periods and in-house call

• Continuous on-site duty must not exceed 24 consecutive hrs; additional 6 hrs for didactic activities, transfer of care, out patient clinic (RCs vary as to provision of new patient care during this time) and maintain continuity of medical and surgical care.
• Approved activities in the 6-hr transition period vary by specialty – specific requirements available at www.acgme.org.
• Program Director must pre-approve in writing all external/internal moonlighting.
• All Programs must monitor the duty hours of residents, especially on off-service rotations.
• All healthcare team members should be educated in the duty hour requirements and assist with compliance.
• GME Committee monitors all programs duty hours.
• See GMEC policy 3.200 at http://www.uams.edu/gme/3.200.html.

• Covers four key roles – Educator, Administrator, Scholar and Evaluator in a practical way to assist program directors in those roles. 
• Program director sessions are offered during monthly program director meetings and a corresponding program for coordinators is offered during the monthly program coordinator meeting. 

§        Evaluations of resident/fellow –

o       Formative – documented at completion of each assignment and semiannually

o       Summative – upon completion of program

§        Evaluation of faculty – at least annually

§        Program improvement and evaluation –at least annually, program must monitor and track several areas.

• Attend quarterly subcommittee meetings and internal reviews as assigned.  Continuously remind residents who are members to attend these meetings as well.

§        Each March the GME Committee sets the date when services change for the following January.  Program Directors and Coordinators will be notified of the date.

§        The GME Committee is the only entity that sets this date; it cannot be changed by individual programs. 

§        This ensures that all resident/fellows know when and where to report at the conclusion of the holiday season and so that all services can expect off-service residents on the same day.

§        The date varies each year depending on the day on which January 1 falls, its relation to the weekend, etc.

• JCAHO specifies residencies/fellowships have job descriptions delineating the residents'/fellows' responsibility for patient care. 
• Ms. Teresa Jeffus worked with Program Directors to prepare these for all programs whose residents/fellows rotate through University Hospital.
• Job descriptions are found on the UAMS Intranet at: http://intranet.uams.edu/rjd/
• Must be shared with all teaching faculty

§        Medicare reimburses at 1.0 FTE for only those residents who are in an initial residency program. 

§        Medicare defines the initial residency period as the time necessary to qualify for the initial board exam (e.g., 3 years for internal medicine, 5 years for general surgery). 

§        Residents beyond this initial training period, i.e. those in fellowships or those who start one program and transfer to another program, are tracked by the Medicare office at University Hospital. 

§        Program Directors must know how much prior training applicants have had.  Once the initial residency time has expired, the department must cover the difference between the amount of support that Medicare (i.e., University Hospital) provides and the total cost of the resident.  This amount will be billed to the department in June of each year.

• The ACGME policy on moonlighting (and the GME Committee policy) requires that:
  • Residents are not required to moonlight, and
  • Program Director must monitor the resident performance to assure the factors such as resident fatigue are not contributing to diminished learning or detracting from patient safety
  • Program Director acknowledge in writing that he/she is aware that the resident is moonlighting and this information should be part of the resident's folder
• Program Director may also choose to monitor the number of hours and the nature of workload of residents engaged in moonlighting experiences
• In-house moonlighting counts toward 80-hour workweek limit 
• Each program should specify rules about moonlighting for residents/fellows and abide by the GME Committee policy on moonlighting
• A template approval form can be obtained from Sally Marus at 296-1159.
• See GMEC policy 3.300 at http://www.uams.edu/gme/3.300.htm.

• Faculty who wish to develop new residency/fellowship programs that can be accredited by the ACGME must obtain approval from the Dean for the COM to sponsor the program.

• Instructions and application form can be found on GMEC policy 1.120 Sponsorship of New Programs at http://www.uams.edu/gme/1.120.html#1.120.99.
• Approval must be obtained prior to submitting the application to the ACGME, and the GME Committee must review the application prior to submission.

§        Accreditation requirements (and our GME Committee policy on Evaluation and Promotion) and specify that a Program Director must notify a resident/fellow in writing four months prior to the end of the "contract" period of a decision to non-promote or non-reappoint. 

§        This is usually by March 1^st each year 

§        Program Director considering this type of decision should notify the Associate Dean as early as possible to review appropriate documentation.

§        If this is likely, try to prepare the resident/fellow in the months prior to the end of February – some are surprised, become angry and then may grieve the decision.

§        See GMEC policy 1.300 at http://www.uams.edu/gme/1.300.html.

• Each residency/fellowship program must have the following program-specific policies. Templates are available for each of the policies - contact Sally Marus 296-1159:

o       Eligibility, selection and appointment

o       Academic actions of reappointment, evaluation, promotion and other disciplinary actions

o       Procedure for addressing resident/fellow concerns in a confidential manner

o       Resident fatigue

o       Effects of leave on completing the program

o       Supervision for care of patients (this info is also required to appear in the written curriculum)

o       Duty hours and work environment

o       Moonlighting - You may elect to use the GMEC policy, but must provide guidelines for moonlighting to your residents/fellows (e.g., Moonlighting is not allowed in the _____ Program, or the _______ Program adheres to the GMEC Policy on Moonlighting (see below)).

• Only residents who are currently enrolled in ACGME or AOA accredited residency/fellowship programs at other institutions, may take short-term rotations at UAMS. 
• Follow GMEC policy 1.130 at http://www.uams.edu/gme/1.130.htm

Suspected impairment, chemical dependency or abuse

• When impairment or chemical dependency is suspected the program director must contact another practitioner who is a member of the Medical Staff Health Committee (at ACH for pediatric-based trainees or UAMS MC for others) for assistance and advice.
• Follow GME policy 2.300 at http://www.uams.edu/gme/2.300.html

• Follow GMEC policy 1.210 at http://www.uams.edu/gme/1.210.htm
• Residents/fellows who are considering a transfer from one UAMS COM program to another UAMS COM program may discuss general information with the Program Director of the receiving program.
• After this initial general discussion, the resident may pursue the transfer after obtaining written notification from the current Program Director.
• Program Director of the receiving program should not discuss any specific details with the resident until he/she receives this written notification.
• When a resident wishes to seriously pursue a transfer to a program outside of UAMS COM, the resident must discuss the possibility of leaving the current program with his/her current Program Director and obtain written notification from the current Program Director to pursue the transfer.
• Failure to abide by these rules may result in the resident not being allowed to transfer or the filing of a complaint with the RRC or specialty boards. 

• ECFMG certificate must be valid in order for a resident/fellow to begin the program.
• It is very important/essential that the Program Coordinator completes an “indefinite form” for each residents/fellow - this will ensure that they remain valid throughout their program time and no delays or lapses occur.
• Questions about VISAs should be directed to Tiffany Edwards in OHR (686-7073)

• ACGME will notify of the annual scheduled update in the fall; continuously update through the year as changes are made in the program.

• Program Directors who develop websites for their residency/fellowship programs are asked to provide a link to the COM Resident Handbook at http://www.uams.edu/gme/resident/res_handbook.asp .
• Program Directors Handbook, available at http://www.uams.edu/gme/PD/pd_handbook.asp, contains all of the policies of the GME Committee and other helpful information.

 updated 4/23/08