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Institutional Policies – GMEC

Assessment of educational effectiveness of programs (annual program evaluation and program evaluation committee)

GMEC approved: March 2012
GMEC updated and approved: March 2013
GMEC updated and approved: July 2014

Policy

The WSU Graduate Medical Education Committee (GMEC) is responsible for oversight of all WSU-sponsored graduate medical education programs in accordance with the Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements. Annual Program Evaluations (APEs) and Action Plan for Improvement for all ACGMEaccredited programs are reviewed by GMEC or its Subcommittees which present summaries and recommendations to the GMEC each year as part of the Annual Institutional Review.

ACGME programs must have a Program Evaluation Committee (PEC) appointed by the program director. The PEC functions in compliance with both the common program and program-specific requirements. The goal of the PEC is to oversee curriculum development and program evaluations for its respective GME training program. Each ACGME-accredited residency program shall establish a program specific policy, describing the responsibilities, procedures and members of the program’s PEC.

Each PEC must be composed of at least two program faculty members and one residents from the program (unless the program does not have any enrolled residents/fellows). Faculty members may include physicians and non-physicians from the core program or required rotations in other specialties that teach and evaluate the program’s residents/fellows. The PEC will meet at least annually even if there are no residents/fellows enrolled in the program.

The PEC committee’s responsibilities are to:

  • Plan, develop, implement and evaluate educational activities of the program
  • Review and make recommendations for revision of competency-based curriculum goals and objectives
  • Address areas of non-compliance with ACGME standards
  • Review the program and document on behalf of the program the formal, systematic evaluation of the curriculum at least annually and render a written Annual Program Evaluation (APE) using the standard GME template. This Annual
  • Program Evaluation and written Action Plan for Improvement which delineates how initiatives will be measured and monitored must be submitted to the GMEC annually through the Subcommittee for Compliance and Improvement.
  • The PEC will be provided with confidential residents and faculty evaluation data by the program’s administrative staff to conduct their business. Data includes but it is not limited to:
    1. ACGME Program Requirements
    2. Program Goals and Objectives
    3. Program Policies
    4. Program Block Diagram
    5. The Prior year’s APE and Action Plan for improvement as well as data to be used to measure progress on individual initiatives, as specified in the prior year’s AP.
    6. Summary of Faculty Development completed
    7. Summary of faculty Scholarly Activity (will also be used to update ADS)
    8. Summary of resident Scholarly Activity (will also be used to update ADS)
    9. Resident Performance
    10. Graduate performance, including board pass rates
    11. Most recent ACGME Letters of Notification, including citations
    12. ACGME and Annual GME Resident Survey Faculty Development
    13. ACGME and Annual GME Faculty Survey
    14. Resident evaluation of the Program, Rotations, Faculty
    15. Faculty Evaluation of the Program
    16. Aggregate data from general competency assessments, including In-training examination performance
    17. Case or procedure logs
    18. Compliance with policies and requirements
    19. Resident remediation and attrition
    20. Clinical Learning Environment focus areas
    21. Other
  • Using the APE and Action Plan for Improvement the PEC will monitor and track each of the following:
    1. Resident performance
    2. Faculty development
    3. Graduate performance, including performance on certifying examination
    4. Program quality
    5. Progress in achieving goals set forth in previous year’s action plan
  • Review recommendations from the Clinical Competency Committee. The program director is ultimately responsible for the work of the PEC. The program director must ensure the annual Action Plan for Improvement is reviewed and approved by the program’s teaching faculty. The approval must be documented in meeting minutes. The program’s annual action plan and reporton the program’s progress on initiatives from the previous year’s action plan must be sent to the GME Office annually by the specified deadline.

    The Subcommittee for Compliance and Improvement will review the APE material and resulting Action Plan for Improvement and will make a decision to:

  • Accept the Action Plan for Improvement as written
  • Request clarification and additional information
  • Determine the need for a Special Program Review or Focused Program Review (see 2.2 GMEC Program Oversight through Program Review) This decision accompanied by the APE summary report will be presented to the GMEC.

Clinical Competency Committee Membership and Meetings

GMEC approved: July 2014

Policy

The goal of the CCC is to assess and evaluate the resident’s performance in each of the six ACGME core competencies. The committee’s purpose is to serve as an advisory board to the program director with regard to all resident issues, including, but not limited to, feedback, evaluation, curriculum organization, promotion, remediation, certification and disciplinary action.

Membership

Each program is required to operate a CCC, a group comprised of three or more members of the active teaching faculty and others as appropriate (see chart below).

May serve as member of CCC May attend CCC
meetings, but are not members of the CCC
Cannot serve or attend CCC meetings
  1. Program faculty members
  2. Program directors
  3. Other health professions (e.g. nursing, interprofessional faculty members)
  1. Chief residents who meet all of the following criteria: have completed core residency programs in their specialties, possess a faculty appointment in their program, are eligible for specialty board certification
  2. Program coordinators
  1. Residents and chief residents who are still in accredited years of their programs and have not completed initial residency education

Each ACGME-accredited residency program shall establish a program specific policy, describing the responsibilities, procedures and members of the program’s CCC.

Frequency of meetings: Meetings must be conducted at least twice annually. In many programs, meetings must be conducted more frequently.

Function: The CCC is advisory to the program director. It considers all written rotational and other evaluations, and discusses any non-congruence between written evaluations and their experiences with each resident. The provision of frank verbal feedback by the CCC to the program director is an important process for determining whether the resident’s performance is accurately revealed in rotational evaluations. The committee will also prepare and report milestone evaluations for each resident that will be reported to the ACGME semi-annually as required.

The CCC discussion and recommendations are communicated to the program director for feedback to the resident, and are considered equal in weight to written evaluations. The CCC must record CCC meeting minutes, which must list the names of all residents considered and all CCC members in attendance.

ACGME recommendations for the CCC can be found at this website.

Closure/Reduction of Residency Program or Sponsoring Institution (IR IV.N.)

GMEC approved: March 2007
GMEC revised: July 2011
GMEC updated & approved: November 2014

Purpose

The purpose of this policy is to provide for an orderly and equitable transition when downsizing/closure of a program because of a decrease in resident enrollment, department restructuring for economic or programmatic reasons, or other reasons which may require downsizing/closure of a program or closure of the institution.

Policy

In the event the Sponsoring Institution or one of its GME programs is reduced or closed, the Wayne State University School of Medicine is committed to ensuring that residents enrolled in the WSU GME-sponsored programs are provided the opportunity to complete their training through a WSU-sponsored residency program or assist them in enrolling in another accredited program in which they may continue their education.

Procedure

The GMEC has oversight of decisions that may result in the reduction or closing of the Sponsoring Institution or one of its GME programs.

Once a decision is made, the GMEC, DIO and all affected residents in the program will be notified as soon as possible. The DIO will notify the ACGME of the decision and the proposed date of the intended action.

The program director and the DIO will assist all residents in developing future training plans.

The program director will prepare a transfer letter for each resident detailing their progress in core competency education, milestones and an evaluation of their overall performance. This letter will be sent to the program director accepting the resident and a copy of the letter will be placed in the resident’s educational file.

The residency program will send resident files to the program accepting the resident in a timely manner.

Establishment of a new ACGME–accredited program

GMEC approved: March 2007
GMEC revised: July 2011
GMEC updated and approved: July 2014

Policy

The Wayne State University School of Medicine Graduate Medical Education Committee is responsible for oversight of all graduate medical education programs in accordance with the Accreditation Council for Graduate Medical Education Institutional Requirements. All training programs in GME must seek accreditation from the ACGME if such accreditation is available. If
accreditation is not available, an application for a non-accredited program must be completed (see “Applications for Non-accredited fellowships”). All requests for new training programs must be approved by the GMEC and the Residency Review Committee of the ACGME before implementation.

Procedure

Contact with the DIO for guidance is required 12 to 18 months before the anticipated start date for residency requests.

The program director of the proposed new training program shall petition the GMEC in an application also signed by the department chair.

The application to the GMEC must include:

  • Educational rationale for the training program, including duration of training, participating institutions/facilities, faculty, program director, clinical rotations, adequacy of patient care and procedural volume to support the program
  • Determine the impact of the new program on other training programs
  • Develop the residents’ rotational schedule
  • Develop the full-time equivalency budget by hospital on the rotational schedule
  • Suggest possible sources of funding, including the department, for GME follow-up
  • Inform the GMEC about how the program determined the number of residents per year and the total number of residents
  • Describe the didactic structure, including at least the core curriculum educational structure, goals and objectives, and assessment tools
  • Assure that the program director’s qualifications meet RRC guidelines
  • Assure that adequate administrative structure and support are available
  • Assure that key faculty members are available and that their absences from other programs do not create adverse effects
  • Estimate resident duty hours and describe the system of monitoring duty hours
  • Include letters of support from programs providing required rotations and from programs that could be affected

The GME Office will review the application and present its report to the GMEC. The GMEC will communicate its findings and recommendations to the program director and department chair. If the GMEC finds in favor of the new program, the DIO will initiate the application in ACGME ADS. The program director will be notified by the ACGME to complete the application. Once the application is complete, the DIO has final approval before the application is submitted to the ACGME allowing reasonable time for review – minimum two weeks

The opinion of the GMEC is final. The GME Office is responsible for the ACGME initial accreditation fee.

Monitoring

All applications for new programs will be reviewed and approved by the GMEC before official application may be made to the ACGME.

The DIO must review the final application before submission to the ACGME.

Extreme Emergent Situation and Disaster policy (IR I.V.M.)

GMEC approved: November 2007
GMEC revised: July 2011
GMEC updated and approved: September 2011
GMEC updated and approved: November 2014

Purpose

To define responsibilities during emergencies including “disasters” which impact an entire community or region for an extended period of time and “extreme emergent situations” localized to one institution, a participating institution or a clinical setting.

Policy

In the event of a disaster impacting the graduate medical education programs sponsored by WSU, the GMEC has established this policy to protect the well-being, safety, and educational experience of residents/fellows enrolled in our training programs.

Definitions

Extreme emergent situation is defined as a local event (such as a hospital-declared disaster for an epidemic) that impairs the ability of WSU to support resident education or the work environment but does not rise to the level of an ACGME-declared disaster as defined by ACGME Policies and Procedures.

Disaster is defined as an event or set of events causing significant alteration to the ability of WSU to support many residency programs as defined by the ACGME policies and procedures (e.g. Hurricane Katrina).

Declaration of Extreme Emergent Situation

A declaration of an extreme emergent situation may be initiated by the DIO in collaboration with the hospital chief executive officer, chief operating officer, chief medical officer, affected program directors and department chairs. The first point of contact for answers to questions regarding a local emergent situation shall be the GMEC/DIO. When possible, an emergency GMEC meeting will be convened to assess the situation.

Declaration of a Disaster

When warranted, the ACGME chief executive officer, with consultation of the ACGME Executive Committee and the chair of the Institutional Review Committee, will make a declaration of a disaster. A notice will be posted on the ACGME website with all information relating to ACGME’s response to the disaster.

Procedure for Extreme Emergent situation

Once a declaration of an extreme emergent situation is declared:

  • Administrative support for all GME programs and residents, as well as assistance for continuation of resident assignments, will be provided to all programs.
  • Program directors of each program will meet with the DIO and other university/hospital officials to determine the clinical duties, schedules and alternate coverage arrangements for each residency program.
  • The DIO and university/ hospital administration will keep in mind that all ACGME institutional, common and specialty-specific program requirements continue to apply in an emergent situation with regard to clinical assignments within a training program.
  • Program directors will remain in contact with the DIO regarding plans to address the situation and additional resources as needed. ACGME guidelines for development of those plans will be implemented.
  • Residents are, first and foremost, physicians, whether they are acting under normal circumstances or in an extreme emergent situation. Residents are expected to performaccording to their degree of competence, level of training, scope of license and context of the specific situation.
  • Residents will not be first-line responders without consideration of the need for appropriate supervision based on the clinical situation and their level of training and competence. Residents at an advanced level of training who are fully licensed in the state of Michigan may provide patient care independent of supervision based on the rules and policies of the institution.
  • The following will be taken into consideration regarding a resident’s involvement in an extreme emergent situation:
    • The nature of the health care and clinical work that a resident will be expected to deliver
    • The resident’s level of post-graduate education, specifically regarding specialty preparedness
    • Resident safety, consideration of their level of training, associated professional judgment and the nature of the situation
    • Board certification eligibility during or after a prolonged extreme emergent situation
    • Reasonable expectations for duration of engagement in the situation
    • Self-limitations according to the resident’s maturity to act under significant stress or duress for an extended period of time.
  • The DIO will contact the ACGME IRC executive director if (and only if) the situation causes serious, extended disruption that might impair the ability of WSU to support the institution/ program ability to remain in compliance with ACGME requirements. The ACGME IRC or DIO will alert the respective Residency Review Committee.
  • If the situation is complex, the DIO may need to submit in writing a description of the situation to the ACGME executive director.
  • The DIO will receive electronic confirmation of the extreme emergent situation from the ACGME Emergency Disaster-IRC, which will include copies to all Emergency Disasters of Residency Review Committees.
  • Upon receipt of this confirmation by the DIO, program directors may contact the executive directors of their respective RRCs if necessary to discuss any specialty specific concerns regarding interruptions to resident education or the effect on the educational environment. Program directors are expected to follow their institutional disaster policies regarding communication processes to update the DIO of any specialty specific issues. The DIO will have an active role in any emergent situation, ensuring the safety of patients and residents through the duration of the situation.
  • If notice is provided to the ACGME, the DIO will notify the ACGME IRC executive director when the extreme emergent situation has been resolved.

Procedure for When a Disaster is declared

  • Administrative support for all GME programs and residents, as well as assistance for continuation of resident assignments, will be provided to all programs.
  • To maximize the likelihood that residents will be able to complete program requirements within the standard time required for certification in that specialty, the DIO will meet with each program director and appropriate university or hospital officials to determine whether transfer to another program is necessary to provide adequate educational experiences to residents and fellows.
  • Once the decision is made that the sponsoring institution can no longer provide an adequate educational experience for residents, the sponsoring institution will, to the best of its ability, arrange for the temporary/permanent transfer of residents to programs at other sponsoring institutions until such time as the participating institution is able to resume providing the experience. (Notification of placement will be communicated to residents no less than 10 days after the declaration of the disaster.).Residents who transfer to other programs as a result of a disaster will be provided by their program directors an estimated period necessary for relocation within another program.
  • Should that initial time estimate need to be extended, the resident will be notified by his/her program director vie written or electronic communication identifying the estimated period of the extension.
  • It will be the intent of WSU to provide the appropriate administrative support, to the extent possible, to re-establish a permanent educational experience that meets the standards of the ACGME as quickly as possible. If this cannot be achieved within a reasonable amount of time following the disaster, WSU will take appropriate steps to arrange permanent transfers of residents to other accredited programs.
  • If more than one program/institution is available for temporary or permanent transfer of a particular resident, the preferences of each resident must be considered.
  • The program director and DIO are jointly responsible for maintaining ongoing communication with the GMEC throughout the placement process.
  • The DIO will provide initial and ongoing communication to hospital officials and all affected program directors.
  • Program directors and the DIO will determine/confirm the location of all residents, determine the means for ongoing communication and notify emergency contacts of any resident who is injured or cannot be located.
  • The DIO will contact the ACGME Institutional Review Committee executive director within 10 days after the declaration of the disaster to discuss the due date for submission of plans for program reconfigurations and resident transfers.
  • The ACGME website will provide phone numbers and email addresses for emergency and other communication with the ACGME from disaster-affected institutions and programs. The DIO will ensure that each program director and resident is provided with information annually about this emergency communication availability.
  • The DIO will access information on the ACGME website to provide program directors and residents with assistance in communicating and documenting resident transfers, program reconfigurations and changing participating sites.
  • The DIO and program director will call or email the IRC executive director with information and or requests for information. Residents will call or email the IRC executive director with information and/or requests for information if they are unable to reach their program director or DIO.
  • In the event of a disaster affecting other sponsoring institutions of graduate medical education programs, the program leadership at Wayne State University will work collaboratively with the DIO, who will coordinate on behalf of the school of medicine the ability to accept transfer residents from other institutions. This will include the process to request complement increases with the ACGME that may be required to accept additional residents for training. Programs under a proposed or actual adverse accreditation decision by the ACGME will not be eligible to accept transfer residents.

All program directors and residents must be familiar with this policy and communication plan.

Gifts, Gratuities and Conflict of Interest-Vendor Policy (IR I.V.K)

GMEC approved: March 2007
GMEC updated and approved: September 2011
GMEC updated and approved: January 2015

Purpose: The purpose of the policy is to ensure that GME activities at WSU and affiliated institutions are not compromised through vendor influence, either collectively or through interactions with individual residents and fellows.

Policy

This policy addresses WSU SOM GME programs and residents behavior in outside relationships with vendors in educational contexts, which may include clinical training sites. It is the policy of the WSU SOM GME that clinical decision-making, education, and research activities be free from influence created by improper financial relationships with, or gifts provided by, Industry. For purposes of this policy, “Industry ” is defined as all pharmaceutical manufacturers, and biotechnology, medical device, and hospital equipment supply industry entities and their representatives . In addition, clinicians, residents and their staff should not be the target of commercial blandishments or inducements – great or small -the costs of which are ultimately borne by our patients and the public at large. These general principles should guide all potential relationships or interactions between WSU SOM GME personnel and Industry representatives. The following specific limitations and guidelines are directed to certain specific types of interactions. For other circumstances, WSU SOM GME personnel should consult in advance with their department chairs, program directors or their senior departmental administrators to obtain further guidanceand clarification. Charitable gifts provided by industry in connection with fundraising done by or on behalf of WSU SOM GME shall be subject to other policies.

Activities Included but not limited to:

  • Gifts and Provision of Meals: WSU SOM GME personnel shall not accept or use personal gifts (including food) from representatives of Industry, regardless of the nature or dollar value of the gift. Gifts from Industry that incorporate a product or company logo on the gift (e.g., pens, notepads or office items such as clocks) introduce a commercial, marketing presence that is not appropriate to a non-profit educational and healthcare system. Meals or other hospitality funded directly by Industry may not be offered in any facility owned and operated by the WSU SOM.
    • WSU SOM GME personnel may not accept meals or other hospitality funded by Industry, whether on-campus or off-campus, or accept complimentary tickets to sporting or other events or other hospitality from Industry. Modest meals provided incidental to attendance at an off-campus event may be accepted.
    • Industry wishing to make charitable contributions to the WSU SOM GME may contact the WSU SOM Development Office or other charitable foundations legally organized to support other WSU SOM GME entities. Such contributions shall be subject to any applicable policies maintained by the WSU SOM and the receiving organizations.
  • Consulting Relationships: Faculty and trainees are permitted to engage in consulting relationships with Industry about research and scientific matters. They may provide valuable advice to Industry in the service of product innovation or refinement. Examples of such legitimate activities include:
    • Assistance in designing and overseeing clinical trials.
    • Technical assistance in creating or improving medical devices.
    • Advice on potential avenues for future scientific research.
    • WSU SOM GME recognizes the obligation to make the special knowledge and intellectual competence of its faculty and residents/fellows available to government, business, labor, and civic organizations, as well as the potential value to the residents, the University, and WSU SOM.
    • However, consulting arrangements that simply pay WSU SOM faculty and residents/fellows a guaranteed amount without any associated duties shall be considered gifts and are consequently prohibited.
    • In order to avoid gifts disguised as consulting contracts, when WSU SOM GME faculty and residents/fellows have been engaged by Industry to provide consulting services, the consulting contract must provide specific tasks and deliverables, with payment of fair market value commensurate with the tasks assigned.
    • The Department Chair, Program Director or Senior Departmental Administratorreserves the right to require faculty and residents/fellows to modify or terminate consulting arrangements that are not consistent with WSU SOM policies. Faculty and trainees are prohibited from engaging in consulting relationships that are solely or primarily for commercial marketing purposes.
  • Site Access: The University and WSU SOM always reserve the right to refuse access to their facilities or to limit activities by Industry representatives consistent with their non-profit mission. However, interaction with representatives of Industry is appropriate as it relates to exchange of scientifically valid information and other data, interactions designed to enhance continuity of care for specific patients or patient populations, as well as training intended to advance healthcare and scientific investigation. Such access is restricted to their roles in providing technical assistance and education on products or medical devices.
    • All industry representatives must have an appointment before visiting any WSU SOM office or clinic. Enforcement of this policy is the responsibility of the administrator for each site. Residents/Fellows may request a presentation by or other information from a particular company.
    • Representatives without an appointment as outlined above are not allowed to conduct business in patient care areas (inpatient or outpatient), in practitioners’ office areas, or other areas of WSU SOM clinical facilities. While in WSU SOM facilities, all Industry representatives must be identified by name and current company affiliation in a manner determined by such department, as applicable.
    • All Industry representatives with access to University and WSU SOM clinical facilities and personnel must comply with institutional requirements for training in ethical standards and organizational policies and procedures.
    • On-campus vendor fairs intended to showcase Industry products may be permitted if approved by the appropriate (WSU SOM or University) departments or Deans. Such events must comply with the “no gifts” provisions of Sections 1 and 3 of this policy. In such situations, vendors would not be permitted to distribute free samples, free meals, raffle tickets, or any other gifts to attendees.
  • Support of Continuing Education in the Health Sciences: Industry support of continuing education (“CE”) in the health sciences can provide benefit to patients by ensuring that the most current, evidence-based medical information is provided to healthcare practitioners. In order to ensure that potential for bias is minimized and that CE programs are not a guise for marketing, all CE events hosted or sponsored by the WSU SOM physicians must comply with the ACGME Standards for Commercial Support of Educational Programs (or other similarly rigorous, applicable standards required by other health professions) , whether or not CE credit is awarded for attendance at the event. All such agreements for Industry support must be negotiated through and executed by the WSU SOM Division of CME, and must comply with all policies for such agreements. Any such educational program must be open on equal terms to all interested practitioners, and may not be limited to attendees selected by the company sponsor(s). Industry funding for such programming should be usedto improve the quality of the education provided and should not be used to support hospitality, such as meals, social activities, etc. except at a modest level. Industry funding may not be accepted for social events that do not have an educational component. Industry funding may not be accepted to support the costs of internal department meetings or retreats (either on- or off-campus).
    • WSU SOM facilities (clinical or non-clinical) may not be rented by or used for Industry funded and/or directed programs, unless there is a CE agreement for Industry support that complies with the policies of the WSU SOM Division of CME. Dedicated marketing and training programs designed solely for sales or marketing personnel supported by Industry are prohibited.
  • Industry Sponsored Meetings or Industry Support for Off-Campus Meetings: WSU SOM GME residents/fellows may participate in or attend Industry-sponsored meetings, or other off-campus meetings where Industry support is provided, so long as: (a) the activity is designed to promote evidence-based clinical care and/or advance scientific research; (b) the financial support of Industry is prominently disclosed ; (c) attendees do not receive gifts or other compensation for attendance; (d) meals provided are modest (i.e., the value of which is comparable to the Standard Meal Allowance as specified by the United States Internal Revenue Service) and consistent with the educational or scientific purpose of the event. In addition, if a WSU SOM representative is participating as a speaker: (a) all lecture content reflects a balanced assessment of the current science and treatment options, and the speaker makes clear that the views expressed are the views of the speaker and not the WSU SOM (b) compensation is reasonable and limited to reimbursement of reasonable travel expenses and a modest honorarium. Travel sponsored by a membership based professional organization, with no commercial activity, is permitted.
  • Industry Support for Scholarships or Fellowships or Other Support of Students, Residents, or Trainees: The WSU SOM GME programs may accept Industry support for scholarships or discretionary funds to support trainee or resident travel or non-research funding support, provided that all of the following conditions are met:
    • Industry support for scholarships and fellowships must comply with all University or WSU SOM requirements for such funds, including the execution of an approved budget and written gift agreement through WSU SOM Development Office, and be maintained in an appropriate restricted account. Selection of recipients of scholarships or fellowships will be completely within the sole discretion of the Program Director for the residency or fellowship. Written documentation of the selection process will be maintained.
    • Industry support for other trainee activities, including travel expenses or attendance fees at conferences, must be accompanied by an appropriate written agreement and may be accepted only into a common pool of discretionary funds, which shall bemaintained under the direction of the department administrator for the residency program. Industry may not earmark contributions to fund specific recipients or to support specific expenses. Residency programs may apply to use monies from this pool to pay for reasonable travel and tuition expenses for residents/fellows to attend conferences or training that have legitimate educational merit. Attendees must be selected by the program based upon merit and/or financial need, with documentation of the selection process provided with the request. Approval of particular requests shall be at the discretion of the program director.
  • Authorship and Speaking: Authorship on papers by WSU SOM personnel should be consistent with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Ethical Considerations in the Conduct and Reporting of Research: Authorship and Contributorship developed by the International Committee of Medical Journal Editors ( www .icmje.org). Ghostwriting (honorary authorship) is explicitly forbidden.
    • The content of all presentations given or co-authored by WSU SOM personnel must be evidence based. All clinical recommendations must be in the best interest of patients based on evidence available at the time of the presentation. Participation on pharmaceutical industry funded speaker’s bureaus, i.e. promotional speaking concerning specific pharmaceutical products, is forbidden.
  • Other Industry Support for Research: WSU has established policies and contract forms to permit Industry support of basic and clinical research in a manner consistent with the nonprofit mission of the University and WSU SOM. Researchers may accept, for testing purposes, samples of unique research items or drugs, produced by only one manufacturer, where no other alternatives exist. Should multiple options exist, acceptance of samples is acceptable only if received from all companies manufacturing similar products, so that a decision to purchase may be made based exclusively on the performance of the product, without preference for any given manufacturer.
    • All products received as gifts for researchmust be disclosed and explicitly acknowledged in all pertinent documents, including publications. True philanthropic gifts from Industry may be accepted through the WSU SOM Development Office.

Procedure

WSU SOM personnel shall report their outside relationships with Industry using the Wayne State “Conflict of Interest Form” at least annually and more often as needed to disclose new relationships. All relevant outside relationships with industry will be made available to the public on the WSU SOM website. Suspected violations of this policy shall be referred to the individual’s program director, who shall determine what actions, if any, shall be taken. The DIO shall also be notified of suspected violationsby WSU SOM GME residents/fellows. Violations of this policy by a WSU SOM GME residents may result in the following actions (singly or in any combination), depending upon the seriousness of the violation, whether the violation is a first or repeat offense, and whether the violator knowingly violated the policy or attempted to hide the violation:

  • Counseling of the individual involved
  • Letter of Concern, probation or other corrective action;
  • Banning the violator from any further outside engagements for a period of time;
  • Requiring that the violator return any monies received from the improper outside relationship;
  • Requiring the violator to complete additional training on conflict of interest;

Any disciplinary action taken hereunder shall follow the established procedures of the WSU SOM GME.

References

WSU SOM Policy on Conflicts of Interest and Interactions between Representatives of Certain Industries and Faculty, Staff and Students of the WSU SOM – distributed November 2014 WSU Conflict of Interest Policy http://policies.wayne.edu/administrative/08-01-conflict-ofinterest.php WSU Policy on Financial Conflict of Interest and Commitment for Researchers http://irb.wayne.edu/policies-human-research.php WSU Policy on Consulting by University Faculty and Research Personnel http://policies.wayne.edu/research/03-4-consulting.php

GMEC Composition and Responsibilities (IR I.B.)

GMEC approved: September 2013
GMEC updated and approved: July 2014

The WSUSOM GMEC is responsible for oversight of all GME programs in accordance with ACGME institutional requirements. The GMEC establishes and implements policies regarding the quality of education and the work environment for residents/fellows in all WSUSOM GME programs, including non-accredited programs. Written minutes are maintained. Voting members or designees are required to attend 100 percent of the scheduled meetings annually (see GMEC Voting Member Attendance and Tracking)

Meetings (IR I.B.3) The GMEC meets at least quarterly but is scheduled for bi-monthly meetings pursuant to an annual meeting schedule set forth at the start of each academic year by the GME Office. Other committee meetings and meeting schedules are established by the heads of those committees.

Leadership and Membership (IR I.B.1.) The GMEC convenes under the leadership of a chair

Voting membership includes:

  • The DIO and GMEC chair (if different from the DIO)
  • Minimum of two residents nominated by their peers
  • Representative residency program directors
  • GME administrative director
  • GME director of Research and Education
  • Quality and Safety officer (or designee)
  • Administrative representative of the WSUSOM (vice dean of Education)

Voting Member Designees

A voting member unable to attend a GMEC meeting may appoint a designee to attend in his/her stead.

The GMEC has established criteria for voting member designees:

Voting Member Recommended Designees
Designated institutional official/GMEC chair GME administrative director
GME director of Research and Education
Program director Associate program director, department chair or core faculty member (a physician who spends 10 hours per week on average teaching/mentoring program trainees as identified on the PIF or equivalent). Program coordinators may not serve as designees for program directors.
Peer-elected residents Alternate peer-elected residents
Quality and Safety officer Representative from Quality and Safety Initiative

Non-voting members include:

  • Hospital partners administration
  • Department chairs
  • Accredited/unaccredited fellowship program directors
  • Other GME office administration
  • GMEC subcommittee, Task-Force and/or Council chairs
  • Residency program coordinators

Additional GMEC Members and subcommittees

To carry out portions of the GMEC’s responsibilities, additional GMEC membership may include other members as may be deemed appropriate by the GMEC. These may include subcommitteesthat address required GMEC responsibilities whose membership must include peer-selected residents/fellows and whose actions must be reviewed and approved by the GMEC.

GMEC Voting Member Attendance and Tracking (IR I.B.3)

GMEC required voting members or their designees must attend 100% of regular bi- monthly GMEC meetings. Individual PDs must attend at least 4 of the 6 scheduled meetings (remaining 2 may be designee).

Procedure for tracking attendance

GMEC voting member and designee attendance is taken at each GMEC meeting via sign-in sheet. The GME Office maintains a GMEC voting member attendance tracking sheet for each academic year (July to June). The GMEC voting member attendance tracking sheet tracks the year-to-date attendance and compliance rates for individual voting members. GMEC attendance is reported annually to the WSUSOM dean and the governing body of the institution as part of the Annual Institutional Review.

GMEC Responsibilities (IR I.B.4.)

Responsibilities of the GMEC include:

Oversight of:

  • The ACGME accreditation status of the sponsoring institution and its ACGME-accredited programs
  • The quality of the GME learning and working environment within the sponsoring institution, its ACGME-accredited programs and its participating sites
  • The quality of educational experiences in each ACGME-accredited program that lead to measurable achievement of educational outcomes as identified in the ACGME common and specialty/subspecialty-specific program requirements
  • The ACGME-accredited programs’ annual evaluation and improvement activities All processes related to reductions and closings of individual ACGME-accredited programs, major participating sites and the sponsoring institution
  • The GMEC must demonstrate effective oversight of underperforming programs through a special review process (see GMEC Program Oversight through program review)

Review and approval of:

  • Institutional GME policies and procedures
  • Annual recommendations to the sponsoring institution’s administration regarding residents stipends and benefits
  • Applications for ACGME accreditation of new programs
  • Requests for permanent changes in residents complement
  • Major changes in ACGME-accredited programs’ structure or duration of education
  • Additions and deletions of ACGME-accredited programs’ participating sites
  • Appointment of new program directors
  • Progress reports requested by a review committee
  • Responses to clinical learning environment review reports
  • Requests for exceptions to duty hour requirements
  • Voluntary withdrawal of ACGME program accreditation
  • Requests for appeal of an adverse action by a review committee
  • Appeal presentations to an ACGME appeals panel.

Annual Institutional Review (AIR)

The GMEC must demonstrate effective oversight of the sponsoring institution’s accreditation through an annual institutional review.

The GMEC must identify institutional performance indicators for the AIR that includes:

  • Results of the most recent institutional self-study visit
  • Results of ACGME surveys of residents/fellows and core faculty
  • Notification of ACGME-accredited programs’ accreditation status and self-study visits
  • Reports from the Subcommittee for Compliance and Improvement.

The AIR must include monitoring procedures for action plans resulting from the review.

The DIO must submit a written annual executive summary of the AIR to the governing body.

GMEC Program Oversight through Program Review

GMEC approved: July 2014

Policy

The GMEC is responsible for oversight of all graduate medical education programs in accordance with the ACGME. This oversight will consist of program reviews dependent on program performance.

Standard Program Reviews
Periodic Program Reviews

These reviews will be conducted at the mid-point of a program’s ACGME accreditation period
Pre-Self Study Review
These reviews will be conducted two years prior to a program’s projected self-study date.
Mock Self-Study
These reviews will be done at some point immediately prior to the scheduled self-study date.

Corrective Program Reviews
Special reviews (IR I.B.6)

The GMEC conducts special reviews of all underperforming accredited residency and fellowship programs.

Criteria for identifying underperformance
One or more of the following criteria that deviates from expected results may result in the scheduling of a Special Review:

  • Adverse ACGME Accreditation Status, e.g. accreditation with warning, probationary accreditation, withdrawal of accreditation, reduction in complement
  • Unfavorable annual communication from ACGME (LON), e.g. new citations, new concerning trends, extended citations
  • Resident or Faculty complaint to the ACGME
  • Resident or Faculty complaint to the GME office
  • Program attrition – Faculty and/or Resident
  • Program changes
  • Deficiencies in scholarly activity
  • Board pass rate not meeting the ACGME specialty RRC required rate
  • Clinical experience deficiencies (patient or procedural logs – quantity and/or quality)
  • Resident annual ACGME survey (negative trends/non-compliance)
  • Resident annual GME survey (negative trends/non-compliance)
  • Faculty annual ACGME survey (negative trends/non-compliance)
  • Faculty annual GME survey (negative trends/non-compliance)
  • Milestones and competencies – negative trends
  • Concerns from APE
  • Other indicators at the discretion of the DIO and GMEC

A program’s inability to demonstrate success in any of the following focus areas:

  • Integration of residents/fellows into institution’s patient safety programs,
  • program attrition
  • Integration of residents/fellows into institution’s quality improvement programs and efforts to reduce disparities in health care delivery
  • Establishment and implementation of supervision policies
  • Transitions in care
  • Duty hours policy and/or fatigue management and mitigation Education and monitoring of professionalism

The special review process results in a report that describes the quality improvement goals, the corrective actions, and the process for GMEC monitoring of outcomes.

Procedure

When a residency/fellowship program is deemed to have met the established criteria for designation as an underperforming program, the DIO/chair of the GMEC shall schedule a special review. Special reviews shall occur within 90 days of a program’s designation as “underperforming.”

Special Review Panel
Each special review shall be conducted by a panel including at least one member of the GMEC, who shall serve as chair of the panel; one additional GMEC member and one residents. Additionalreviewers may be included on the panel as determined by the DIO/GMEC. Panel members shall be from within the sponsoring institution but shall not be from the program being reviewed or, if applicable, from its affiliated subspecialty programs.

Preparation for the Special Review
The chair of the special review panel, in consultation with the DIO/GMEC and/or other persons as appropriate, shall identify the specific concerns to be reviewed as part of the special review process. Concerns may range from those that broadly encompass the entire operation of the program to single, specific areas of interest. Based on identified concerns, the program being reviewed may be asked to submit documentation before the special review that will help the panel gain clarity in its understanding of the identified concerns.

The Special Review
Materials and data to be used in the review process shall include:

  • The ACGME common, specialty/subspecialty-specific program and institutional requirements in effect at the time of the review
  • Accreditation letters of notification from the most recent ACGME reviews and progress reports sent to the respective RRC
  • Reports from previous internal reviews of the program (if applicable)
  • Previous annual program evaluations
  • Results from internal or external resident surveys, if available
  • Any other materials the special review panel considers necessary and appropriate.

The special review panel will conduct interviews with the program director, key faculty members, at least one resident from each level of training in the program and other individuals deemed appropriate by the committee.

Special Review Report
The special review panel shall submit a written report to the DIO and GMEC that includes, at a minimum, a description of the review process and the findings and recommendations of the panel. These shall include a description of the quality improvement goals, any corrective actions designed to address the identified concerns and the process for GMEC monitoring of outcomes. The GMEC may, at its discretion, choose to modify the special review report before accepting a final version.

Monitoring of Outcomes
The DIO and GMEC shall monitor outcomes of the special review process, including actions taken by the program and/or by the institution with special attention to areas of GMEC oversight.

Focused Reviews
Focused reviews may be done at the discretion of the GMEC and may involve one or more criteria of an underperforming program but may not trigger a Special Review.

GMEC Sub-committees and other organized groups reporting to the GMEC (IR I.B.2)

GMEC approved: July 2014
GMEC updated and approved: May 2015

Subcommittees

To carry out portions of the GMEC’s responsibilities, subcommittees whose membership is approved by the GMEC may be formed. Subcommittees that address required GMEC responsibilities must include a peer-selected residents. Subcommittee actions that address required GMEC responsibilities must be reviewed and approved by the GMEC.

Subcommittee for Compliance and Improvement

Under the direction of GMEC, the Subcommittee for Compliance and Improvement establishes and implements policies and procedures regarding the quality of education and the work environment for all residents/fellows in the ACGME- and non-ACGME-sponsored programs. The Compliance and Improvement Subcommittee creates formal written policies and procedures governing residents duty hours that correlate with the institutional and program requirements. The Compliance and Improvement Subcommittee also helps establish formal written policies for selection, evaluation, promotion and dismissal of residents/fellows in compliance with the institutional and program requirements. The Compliance and Improvement Subcommittee creates and revises these policies. The chair or designee presents the recommendations of the subcommittee to the GMEC for review and implementation. Selected program directors or their designees are members of this subcommittee. The resident representative is the president of the Resident Council – WSU or designee. Attendance at the Compliance and Improvement Subcommittee meetings follows the criteria set forth in the GMEC Composition and Responsibilities policy under GMEC Voting Member Attendance and Tracking (IR I.B.3)

The subcommittee is responsible for reviewing each residency program’s Annual Program Evaluation and resulting Action Plan to monitor program compliance to all institutional, common and program-specific ACGME requirements. The subcommittee will then make recommendations to the GMEC to approve the program’s action plan, ask for clarification and additional information or recommend a special review or other program reviews (see§ 2.2.7 GMEC Program Oversight through program reviews)

Other Groups

Councils, Task Force or other groups may be formed as needed to assist in the performance of the GMEC.

Program Coordinator Council

The Program Coordinator Council is a permanent group that establishes and implements processes that will be implemented in the administration of the residency programs. The subcommittee will be responsible for the development and training of program coordinators.

Resident Council –Wayne State University (IR II.C)

The Resident Council – WSU –Wayne State University is a forum for residents to communicate and exchange information with each other relevant to their ACGME-accredited programs and their learning and working environment. The RC-WSU –WSU meets bimonthly and is comprised ofpeer-elected residents from each program. All residents are welcome to attend these meetings and have the opportunity to raise a concern to the council.

The council serves as an integral line of communication between residents, faculty and staff. WSU GME is committed to advocating the highest quality of education and patient care experiences to all residents in an atmosphere of safety, mutual respect and teamwork. The RC-WSU is a venue in which residents can organize events and bring issues and concerns in a non-threatening and confidential manner to the GME Office and the GMEC. Representatives share ideas and educational experiences to further professional development and increase the quality of medical practice. The council president is a member of the GMEC and he or his designee presents information from RCWSU meetings to the GMEC. The president or designee is also a member of the GMEC Subcommittee for Compliance and Improvement (see “GMEC Sub-committees and other organized groups reporting to the GMEC (IR I.B.2)”).

Procedure for RC elections
At March GMEC, GME is to reiterate the institutional purpose of the RC-WSU and call for programs to conduct the election detailed below. Ideal representatives are residents who desire to improve resident education through active participation in the RC-WSU.

Departmental Elections
Each program with resident representation will hold its own election for one primary delegate, and at least one alternate delegate, who will be eligible to vote, hold office as a program representative within the WSU SOM GME Resident Council. These elections should be held prior to May 1. In absence of a majority vote, primary delegate may be appointed from the pool of nominees (PGY2 or greater, with the exception of TY) at the discretion of the program director.

Terms: RC-WSU membership is for one year and residents can seek additional terms. In order to be eligible for the executive committee, candidates must have served as a general member for at least one academic year.

Executive Committee Elections: President (carries out agenda items with VP), Vice President (assemble agenda), and Communications Officer (compiles and disseminates minutes):

  • Eligibility for Nomination: Any resident may run for any position on the Executive Committee provided they are a member in good standing. Nominations will be called for at the March Resident Council meeting and can be self or peer nomination. Each nominee will provide a statement of interest to the GME office liaison that addresses their qualifications and prospective RC-WSU goals for the coming academic year. Nominees may campaign between the March meeting and the May meeting. Candidates for any executive position must have at least 50% attendance at Resident Council – WSU meetings throughout the academic year in which the elections take place. The Board must approve exceptions. Nominees should be familiar with the resident council purpose.
  • Timing of elections: Elections will occur at the May Resident Council Meeting, permitting a change of leadership by the July meeting.
  • Election process: Elections of officers shall occur by balloting among members in good standing. The date and time of the election will be distributed to all residents two weeks prior to the election. A majority vote is required to attain office. Run-off elections will be held if no candidate receives a majority vote. In the event that there are no nominations for an elected position, a special meeting of the Executive Board shall be called and the position filled via appointment.

Non-accredited residencies/fellowships

GMEC approved: July 2014

Policy

Residency/Fellowship programs conducted by academic departments in advanced subspecialty disciplines for which there is no Accreditation Council for Graduate Medical Education accreditation or American Board of Medical Specialties member board certification or new fellowships that will be applying for ACGME accreditation at a future date are considered unaccredited residency/fellowships.

  • Non-accredited residencies/fellowships will be conducted directly by the responsible academic department, but subject to GMEC oversight.
  • Non-accredited GME programs shall be a minimum of 12 months in length.
  • The guiding principle for establishing a non-accredited GME residency/ fellowship programs must be that such a program shall provide an educational experience of comparable quality to other medical education programs while in no way interfering with, or detracting from, the training of residents and fellows in other sponsored GME programs.
  • Matters pertaining to the selection of trainees, and disciplinary and grievance processes, shall be the responsibility of the academic department, according to all applicable standards. Residents/Fellows in non-accredited programs will receive stipends and benefits corresponding to the schedule established by the GMEC for all residents/fellows.
  • Residents/Fellows in non-accredited programs will be processed and credentialed by the GME Office in accordance with the same policies and procedures that apply to fellows in accredited programs.
  • For existing non-accredited programs, the GMEC must review and approve all changes in training complement, major changes in program length or structure, and the appointment of new program directors.

The program director of the proposed new training program must petition the GME Committee in an application also signed by the chair of the department.

The application to the GME Committee must:

  • Establish the clinical need for the program at local, regional and national levels
  • Determine the impact of the new program on other training programs
  • Develop the residents’/fellows’ rotational schedule
  • Develop the FTE budget by hospital on the rotational schedule
  • Suggest possible sources of funding, including the department, for GME follow-up
  • Inform the GME Committee how the program determined the number of residents/fellows per year and the total number of residents/fellows
  • Describe the didactic structure, including the core curriculum educational structure, goals and objectives, and assessment tools
  • Assure that the program director’s qualifications meet the required guidelines
  • Assure that an adequate administrative structure and support are available
  • Assure that key faculty members are available and that their absences from other programs do not create adverse effects
  • Estimate residents duty hours and describe the system of monitoring duty hours include letters of support from programs providing required rotations and from programs that could be affected.

The GME Office will review the application and present its report to the GME Committee. The GMEC will communicate its findings and recommendations to the program director and the chair of the department. The opinion of the GMEC is final.

Oversight of Non-accredited Residencies/Fellowships

GMEC approved: July 2014

Policy

The Wayne State University School of Medicine Graduate Medical Education Committee is responsible for oversight of all graduate medical education programs in accordance with the Accreditation Council for Graduate Medical Education Institutional Requirements. Additionally, the GMEC has responsibility for oversight of non-accredited residency/fellowship programs.

The GMEC provides oversight of non-accredited graduate medical education programs by:

  • Reviewing and approving proposals for new programs
  • Approving appointments of new program directors
  • Approving requests for changes in fellow complement
  • Approving requests for major changes in program structure or length of training
  • Approving requests for increases or any change to fellow duty hours
  • Reviewing non-accredited program annual evaluations and action plans.

Non-accredited residency/fellowship programs must adhere to WSUSOM Graduate Medical Education Policies and ACGME Common Program Requirements.

Program Personnel and Resources

  • Program director: There must be a single program director with authority and accountability for the operation of the program. Qualifications of the program director must include:
    • Requisite specialty expertise acceptable to the GMEC and current certification in the specialty by the specialty board or specialty qualifications that are acceptable to the GMEC.
    • The program director must coordinate training with the core program director, if one exists. Programs which exist in departments with ACGME-accredited residencies need cooperation between program director to avoid training conflicts and to ensure compliance with medical education policies as defined by the GMEC. As such, the two program directors must work together to coordinate and optimize resident and fellow experiences.
    • The program director is responsible for all communications with the GMEC, including submitting requests for required approvals and an annual evaluation and action plan.
  • Faculty: There must be a sufficient number of faculty members with documented qualifications to instruct and supervise all fellows. The faculty must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities, and demonstrate a strong interest in the education of fellows.
  • Other Program Personnel: The program must jointly ensure the availability of all necessary professional, technical and clerical personnel for the effective administration of the program.
  • Resources: The program must ensure the availability of adequate resources for residents education. This includes administrative support for maintaining files for verification of training, evaluation and duty hour requirements. If applicable, all funding agreements must be approved and processed through the WSU SOM GME office.

Residents Eligibility and Appointments

The program director may not appoint more residents/fellows than approved by the GMEC. The program’s educational resources must be adequate to support the number of residents/fellows appointed to the program.

The prospective residents must meet the criteria for appointment as spelled out in the Recruitment, Selection, Non-Discrimination and Appointment Policy.

In addition to the criteria for appointment a prospective fellow must have successfully completed an ACGME-accredited core specialty program or meet other eligibility requirements as specified by the Review Committee or other accrediting body.

Letters of offer must be signed by the program director. The appointment of the residents will be made by contracts issued by the WSU SOM Graduate Medical Education office.

Educational Program

The curriculum and educational components must be documented. It is strongly suggested that the programs integrate the ACGME core competencies into the curriculum:

  • Patient Care: Residents/Fellows must be able to provide patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health.
  • Medical Knowledge: Residents/Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.
  • Practice-based Learning and Improvement: Residents/Fellows are expected to develop skills and habits to be able to (1) systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement; and (2) locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems.
  • Interpersonal and Communication Skills: Residents/Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families and health professionals.
  • Professionalism: Residents/Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
  • Systems-based Practice: Residents/Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.
  • Scholarly Activities: Residents/Fellows must demonstrate scholarly activity during their training period.

Evaluations

  • Residents/Fellow Formative Evaluation: The faculty must evaluate fellow performance in a timely manner, following the end of the rotation. For longitudinal rotations, evaluation must occur at a minimum twice a year. The fellowship program director must provide each fellow with documented evaluation and formative feedback at least twice a year. Evaluations must be available for review by the fellow. It is strongly suggested that fellowship program director provide objective assessments of competency in the six ACGME competencies.
  • Residents/Fellow Summative Evaluation: The fellowship program director must provide a summative letter of completion upon successful completion of the program. This evaluation must become part of the fellow’s permanent record maintained by the institution. This evaluation must document the fellow’s performance during the fellow’s education and verify successful completion of the program.
  • Faculty Evaluation: At least annually, the program must document evaluation of faculty performance as it relates to the educational program. If there are less than three residents/fellows per year, then it is advised to pool faculty evaluation results (e.g., every two to three years before presentation to faculty to preserve anonymity of the residents/fellows evaluating the faculty).
  • Program Evaluation and Improvement: The program must document evaluation of the program at least annually. These evaluations must include at a minimum an evaluation of the program by the residents/fellow. The Annual Program Evaluation template, as defined by the GME office, must be completed and returned to the GME office annually by a specified date.

Performance Requirements

Residents/fellows in non-accredited programs are subject to the same performance requirements as other WSU SOM residents/fellows. Continuation in the program, promotion to the next level of the program, and graduation from the program are contingent upon successful completion of program requirements and approval from the program faculty and program director.

Non-Compete Policy (IR I.V.L.)

GMEC approved: March 2015

Policy

Pursuant to ACGME institutional requirements, Wayne State University, the sponsoring institution or any of its ACGME accredited programs will not require residents or fellows to sign a noncompetition guarantee or restrictive covenant in return for fulfilling their educational obligations.

Outside Rotations

GMEC approved: March 2015

Purpose:

To define the conditions under which rotations outside of WSU SOM and its hospital partner sites are included in the WSU SOM GME ACGME accredited residency programs.

Policy

WSU SOM GME and all of its ACGME accredited residency programs aim to provide a full graduate medical education program for all residents. While WSU SOM GME is able to meet most educational requirements, it may be necessary for residents to complete a clinical rotation at a hospital or medical facility outside the system if a specific, accreditation-required clinical experience or a patient population is not available within the system (required rotation). There may also be circumstances when a resident may desire a specific clinical experience outside the system which is not required (elective rotation).

Procedure
Required Rotations

WSU SOM GME is responsible for ensuring that residents are provided the opportunity to meet all accreditation requirements. The Program Director is responsible for:

  1. Investigating and making arrangements for required outside rotations;
  2. If professional liability insurance is not provided by the institution where the outsiderotation is planned, the Program Director may request the rotation be added to the WSU SOM GME Professional Liability policy to cover the resident during the required outside rotation;
  3. Completing the Residency Program Rotation Request Form and Obtaining formal approval from the GMEC at least 90 days in advance of the start of the rotation;
  4. Developing the Program Letter of Agreement, which must specify which institution is providing professional liability coverage, obtaining all required signatures and submitting to the GME office at least 30 days in advance; and
  5. Providing program funding of costs associated with the required rotation.

Elective Rotations

Elective outside rotations must have the appropriate educational rationale. Department Chairs must agree to absorb resident salary and benefit costs in their department budget for the period away on the elective outside rotation.

Six months in advance of the elective rotation, the resident is responsible for completing the following:

  1. Investigating and making all arrangements for elective outside rotations;
  2. Completing the WSU Residency Program Outside Rotation Request Form – including the educational rationale, obtaining approval of the Program Director, Chair of the Department and the GMEC;
  3. Obtaining adequate professional liability insurance from the institution where the rotation is planned or from an independent source (inquire at the GME office); WSU SOM GME does not provide coverage for elective outside rotations; this is specified and must be acknowledged on the Outside Rotation Form
  4. Completing the visiting resident application supplied by the institution where the rotation is planned including all required documentation – i.e. licenses, graduation documentation, and immunization records
  5. Obtaining all required approvals/signatures on the Outside Rotation Form and submitting to both institutions;
  6. All costs associated with the elective rotation

International Elective Rotations
International elective rotations are discouraged however, with the appropriate educational rationale, they may be approved.

In addition to the above requirements for an outside elective rotation, residents requesting an international rotation must also provide:

  1. If appropriate, ACGME specialty RRC approval of completion of the international outside elective.
  2. Specialty Board approval of the completion of the international outside elective.
  3. Documentation of health insurance and professional liability coverage while out of the country.

Additional Requirements for Foreign Nationals:

Foreign nationals in some visa statuses who are seeking to participate in outside rotations may be subject to certain restrictions.

  1. Foreign nationals with an Employment Authorization Document (EAD) are eligible to participate in outside rotations without restriction, consistent with the guidelines above.
  2. Foreign nationals with J-1 status are eligible to participate in outside rotations, if coordinated with ECFMG. If a J-1 house officer’s outside rotation will be outside the Detroit metro area, the Program Director prepares and faxes a letter to ECFMG indicating the name of the physician, the name and address of the institution where the rotation will take place, and the planned duration of the outside rotation. ECFMG will document the outside rotation in the J-1 house officer’s SEVIS database record. If a J-1 house officer’s outside rotation is within the Detroit metro area, the Program Director notifies ECFMG if the outside rotation was not in the training plan.
  3. Foreign nationals with H-1B status may require additional/amended immigration filings with U.S. Citizenship and Immigration Services (USCIS) and/or the U.S. Department of Labor (DOL) if the requested rotation site was not specifically listed in the individual’s initial H-1B application.

Monitoring

All applications for rotations outside of WSU SOM and its hospital partner sites will be reviewed and approved by the GMEC to ensure compliance with this policy.

Program Director Appointment, Job Description and Responsibilities

GMEC Approved: July 2013
GMEC revised and approved: March 2015

Purpose

For each residency and fellowship program accredited by the Accreditation Council for Graduate Medical Education (ACGME), there must be a single program director with authority and accountability for the operation of the program as outlined in the ACGME Common Program Requirements (CPR) (CPR II.A.1.). Program directors are expected to continue in their positions for a length of time adequate to maintain continuity of leadership and program stability (CPR II.A.2.). It is the responsibility of Wayne State University School of Medicine (WSUSOM), as the sponsoring institution, to ensure that program directors of Wayne State University (WSU) programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) have sufficient protectedtime and financial support for their educational and administrative responsibilities to the program (CPR I.A.). It is also the responsibility of the Designated Institutional Official (DIO) and the GME Committee (GMEC) to ensure that any new program director meets the required qualifications for this role. To ensure successful transitions in program directors, a collaborative process is thus required between department chairs, the Designated Institutional Official (DIO) and the GMEC.

Policy

The purpose of Graduate Medical Education (GME) is to provide an organized educational program with guidance and supervision of the residents, facilitating the resident’s/fellow’s ethical, professional and personal development while ensuring safe and appropriate care for patients. The program director has the authority and accountability for the organization and implementation of these objectives for his/her program. The program director is responsible to the Chair of the Department, the Designated Institutional Official, and the GMEC for the overall conduct of the program in accordance with the program requirements of its ACGME Specialty Specific Residency Review Committee (RRC).

In order to assure the maintenance of the quality of each ACGME accredited residency program the WSU GMEC must approve the appointment of program directors. To appoint a new program director to an existing program, or to appoint a program director to a program applying for ACGME accreditation, the Department Chair proposes the change or appointment. This proposal is brought to the WSU GMEC for review and must be approved prior to submission of request to the ACGME. Support for the appointment by faculty and trainees should be obtained prior to submission to the WSU GMEC.

Qualifications of the Program Director

The minimum qualifications a program director must possess are:

  1. Requisite specialty expertise and documented educational and administrative experience acceptable to the Review Committee;
  2. Current certification by one’s American Board of Medical Specialty, or specialty qualifications that are acceptable to the Review Committee;
  3. Current medical licensure and appropriate medical staff appointment; d) A demonstration of active involvement in clinical practice, continuing medical education, and local, regional and national professional organizations and scientific societies; and commitment to self-assessment and improvement in areas of scholarship, administration, and education.
  4. An establishment and maintenance of environment of inquiry and scholarship for self, faculty and residents (including the scholarship of discovery, integration, application, and education); promoting education of residents as teachers and life-long learners.
  5. A commitment to developing a clinical learning environment with focus on quality improvement and safety, interdisciplinary teamwork, transitions of care and supervision, duty hours and fatigue management, and professionalism.

Duties and Responsibilities for Program Administration and Accreditation

The program director must administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas. The program director must:

  1. be familiar and comply with the ACGME’s institutional, common and program-specific requirements as outlined at: www.acgme.org;
  2. oversee and ensure the quality of didactic and clinical education in all sites that participate in the program;
  3. approve a local director at each participating site who is accountable for resident education;
  4. approve the selection of program faculty as appropriate;
  5. evaluate program faculty and identify faculty development needs;
  6. approve the continued participation of program faculty based on evaluation;
  7. monitor resident supervision at all participating sites; ensure the supervision of residents through explicit written guidelines of supervisory lines of responsibility for the care of patients;
  8. prepare and submit all information required and requested by the ACGME. This includes but is not limited to the program application forms and annual program updates to the ADS, and ensure that the information submitted is accurate and complete.
  9. ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and implemented by the sponsoring institution;
  10. provide verification of residency education for all residents, including those who leave the program prior to completion; provide a final evaluation for each resident who completes the program, including a review of the resident’s performance during the final period of education and verifying that the resident has demonstrated sufficient professional ability to practice competently and independently;
  11. 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 and procedures to the 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.
  12. monitor the need for and ensure the provision of back up support systems when patient care responsibilities are unusually difficult or prolonged;
  13. comply with the sponsoring institution’s written policies and procedures, including those specified in the Institutional Requirements, for selection, evaluation and promotion of residents, disciplinary action, and supervision of residents;
  14. be familiar with and comply with ACGME and Review Committee policies and procedures as outlined in the ACGME Manual of Policies and Procedures;
  15. obtain review and approval of the sponsoring institution’s GMEC/DIO before submitting information or requests to the ACGME, including:
    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 Review Committee;
    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 or the ACGME; and,
    10. proposals to ACGME for approval of innovative educational approaches.
  16. obtain DIO review and co-signature on all program application forms, as well as any correspondence or document submitted to the ACGME that addresses program citations, and/or, request for changes in the program that would have significant impact, including financial, on the program or institution;
  17. prepare and submit all information and documentation required and requested by the GME Office and or GMEC in an accurate, complete, and timely manner (e.g. Annual Program Evaluations, Responses to citations and ACGME surveys with action plans, Semi-Annual Resident Reviews, CCC minutes);
  18. ensure compliance with the ACGME annual surveys and the GME annual program survey by faculty and residents;
  19. maintain an accurate and current documentation of core faculty, residents, schedules, duty hours, evaluations, etc. on the residency management system (i.e. New Innovations);
  20. establish and maintain a standing Clinical Competency Committee with minutes of all meetings;
  21. provide each resident with documented semiannual competency-based evaluation, according to specialty-specific milestones, providing the evaluation in person, in the resident management system and in ACGME’s ADS, as required;
  22. ensure at least an annual review of the educational effectiveness of the program via a formal documented meeting with development of an action plan through the Annual Program Evaluation;
  23. maintain active relationships with other educational/professional/regulatory organizations, like the NRMP, Specialty’s National Program Directors Organization, Specialty’s National Professional Society, Specialty’s ABMS Board, AMA (including providing annual update to the AMA FREIDA on-line listing of programs), AAMC (including providing annual update to its National Graduate Medical Education Census), State Board of Medicine, and others.

Program Director Time Commitment

Per the ACGME Institutional Requirements, the Sponsoring Institution, in collaboration with each ACGME-accredited program, must ensure that: (II.B.1) program directors have sufficient financial support and protected time to effectively carry out their educational, administrative, and leadershipresponsibilities as described in the Institutional, Common, and specialty/subspecialty-specific Program Requirements. The program director must be provided the equivalent of at least one day a week protected time in order to fulfill the responsibilities inherent in meeting the educational goals of the program, or the amount of time required by the specialty’s respective RRC, whichever is greater. The time commitment shall be reported through the Faculty Activities Logging System (FALS).

Every program must have representation at 100% of the WSU GMEC meetings. Program directors represent their programs as voting members of the GMEC. The program director must personally attend at least 4 of the 6 annual GMEC meetings, he/she may delegate the remaining meetings to a voting designee (acceptable alternates are Associate Program Director or Chair), if needed. Program director needs to attend the majority of the GMEC Subcommittee for Compliance and Improvement meetings, and appoint program representation to the other GME task forces and subcommittees, as requested.

Procedure for Requesting a change in Program Director

To initiate a program director change or appointment request, the Chair submits to the GME Office the proposed program director’s CV with a letter of request verifying the following information:

  1. The program director will administer and maintain an educational environment conducive to educating trainees in each of the ACGME competency areas (CPR II.A.4.). Further, the program director has been delegated responsibility for and agrees to carry out the program director responsibilities as described in the Common Program Requirements II.A.4.a) – II.A.4.o).(2)
  2. The program director has been provided a written job description detailing the responsibilities of this position
  3. The program director meets the following qualification requirements:
    1. Requisite specialty expertise and documented educational and administrative experience acceptable to the relevant Review Committee, (II.A.3.a)
    2. Current certification in the specialty by a primary medical specialty board or specialty qualifications that are acceptable to the relevant Review Committee, (II.A.3.b)
    3. Current medical licensure and appropriate medical staff appointment, II.A.3.c) and d. Other documented qualifications as required by the relevant Review Committee, if applicable (e.g., based at the primary training site).
  4. The amount of protected time, defined by full time equivalent (FTE), that will be made available to the program director in order to support his/her educational and administrative responsibilities to the program. It is expected that this time will be partially utilized to participate in professional development activities including the New Program Director Orientation meeting with the DIO
  5. If approved by the GMEC, the GME Office will initiate a Program Director Change Request in the Accreditation Data System (ADS) no more than 60 days prior to appointment date. Oncethis change has been initiated, an email will be sent to the new program director identified on the change request form with instructions on how to complete the request. The email will include instructions to log into the ADS and will provide a username and password. The new program director will then be required to login and complete his/her professional information and an abbreviated CV, which will then be forwarded to the ACGME for approval. For some specialties, after this information is complete and submitted, the new program director will automatically be posted in ADS. For others, the request appears as “in progress”. Upon approval, the Review Committee will send a welcome letter to the program director. If the program director does not meet Review Committee requirements, the Review Committee will notify the program director and the DIO

Monitoring

  • Annual Program Evaluation
  • Special Review of the Program
  • ACGME Annual Resident Survey
  • ACGME Annual Faculty Survey
  • Annual GME resident evaluation of the program
  • Annual GME faculty evaluation of the program

Resident Complement – ACGME Approval

GMEC approved: November 2008
GMEC revised: July 2011
GMEC updated and approved: March 2015

Purpose

To ensure that all WSU SOM ACGME accredited residency programs adhere to the ACGME requirement that all ACGME accredited residency programs do not exceed their approved complement of residents and to provide programs with the requirements for applying for an approved increase in complement.

Policy

In order to comply with the ACGME requirement that the number of approved residents does not exceed the number of active residents, the Graduate Medical Education Committee (GMEC) will review the status of each program on an annual basis during review of the residency program’s submission in the ACGME’s Accreditation Data System and through review of the program’s Annual Program Evaluation. Programs with more approved residents than active residents must submit an explanation to DIO and the GMEC. In the unexpected event that the number of residents exceeds the number of approved residents, the program must apply for a complement increase through the ACGME.

Requirements for application for complement increase

ACGME Review Committees require prospective approval for increase in residents complement. The financial costs of residents positions are borne by participating sites, and an appropriate prospective review must direct the planning process. In addition, timing is important – the participating sites have individual financial years, and timing of the request should align with the appropriate interval for its consideration.

Programs must hold a status of Continued Accreditation to be considered for a complement increase. Programs with statuses of Continued Accreditation with Warning, Initial Accreditation, Initial Accreditation with Warning, or Probationary Accreditation are not eligible for an increase.

Per ACGME Policy the RRC will consider requests for a change in complement between full reviews through the Accreditation Data System (ADS) mechanism. Consideration for approval will be given to programs with:

  • An accreditation status that is not on warning/probation
  • No serious duty hour violations
  • Reasonable compliance on the most recent Resident Survey
  • Adequate faculty, facilities, patients
  • A sound educational rationale
  • A stable administrative structure and program leadership

An application for increasing the complement of a program must be completed and approved by the GMEC . This application must include an educational rationale for this change in the resident complement and must also include financial support for the increase.

The educational rationale for an increase in resident complement need not be an educational innovation or change in program structure. For programs in good standing that can demonstrate that they have adequate resources (patients, faculty, facilities, and funding), the Committee will consider “the desire and ability to educate an increased number of residents” as an adequate educational rationale. However, the Review Committee will carefully consider how the complement increase will affect the residency program.

Any request for an increase in complement that is received within a year of an anticipated full review with site visit will be approved on a temporary basis until the full review can be completed. A decision on a permanent increase will be made at the time of the full review.

Permanent and temporary increases in resident complement require prior approval of the designated institutional official (DIO), and must be submitted to the Review Committee through the Accreditation Data System (ADS) for prior approval.

Procedure

  1. Program identifies need to apply for complement increase – temporary or permanent.
  2. Program director completes WSU Complement Increase Application – including educational rationale and financial consideration
  3. Program director submits application to the GMEC for approval to proceed with application 4. Once the GMEC approves the application the program director will officially initiate an
    application for a change in the approved complement ACGME ADS by selecting “Complement Change” from the right panel under the “Program” tab.
  4. The application will be sent electronically to the DIO for approval – the application will not go forward without DIO approval
  5. After the DIO has approved the request, the materials submitted in ADS are forwarded to the Review Committee for a final decision.
  6. Once the complement increase is approved the program may proceed with recruiting to fill the new position

Monitoring

ACGME accredited program resident complement numbers will be reviewed by the GMEC during the Annual Program Evaluation and review of the residency programs ADS update to ensure compliance with this policy.

All applications for complement increase will be reviewed and approved by the GMEC before official application may be made to the ACGME.

Resident Transfer Policy

GMEC approved: March 2007
GMEC updated and approved: September 2011
GMEC updated and approved: March 2015

Purpose

Residents are considered ‘transfer’ residents under several conditions including:

  • Moving from a WSU SOM GME program to another program within WSU SOM GME.
  • Moving to/from a WSU SOM GME program from/to a program at a different sponsoring institution.
  • Entering a PGY-2 program requiring a preliminary year even if the resident was simultaneously accepted into the preliminary PGY-1 program and the PGY-2 program as part of the match (e.g., accepted to both programs right out of medical school). This applies to residents who complete their PGY-1 year in a WSU SOM GME program or an outside program.
  • Entering a subsequent residency program after successfully completing a residency program at WSU SOM or any other institution.

Policy

Transfers must be conducted in a manner that allows for the optimal transition for the resident and for the WSU SOM residency program.

NRMP guidelines regarding transfer before completion of one year post-Match will remain in effect for those residents who participated in the Match.

Transfer in:
Program Directors must ensure that the addition of a transfer resident will not adversely affect the ACGME resident complement for the program. Once an approved residency slot becomes available, the program director may recruit a resident candidate. Before accepting a transfer resident into a WSU SOM GME training program, the program director must obtain confirmation of the transfer resident’s satisfactory performance in the trainees’ current program. The program must also obtain verification of previous educational experiences and a summative competency-based performance evaluation including procedure list once available.

The accepting program director in conference with the program’s CCC will determine, based on the previous experience of the resident, the program year, ACGME specialty requirements and/or specialty board requirements the resident must meet to successfully complete the residency.

The accepting program director will notify the GME office of the transfer plan. The resident’s credentials must be reviewed by the GMEC to ensure they fulfill the criteria of the position.

Once approved by the GMEC the GME office will work with the residency program to fulfill all onboarding requirements including but not limited to: drafting the agreement of appointment, employment paperwork and other required documentation as needed.

Transfer Out
All requests for transfer out of a WSU SOM GME residency program must be made by March 1st of the current academic year. A resident must inform the program director of his/her desire to transfer to another program before any formal interview for such a transfer, and facilitate the communication of the two program directors relating to the transfer. Once this communication has been made the resident may contact the program director of the desired program to discuss the possibility of the transfer.

In this circumstance, trainees are expected to continue training in their current program until the end of their current appointment according to the terms of their Agreement of Appointment, unless an earlier resignation is mutually agreed upon by the trainee and program director. Notification of intent to transfer to another program must be done by March 1st of the current academic year.

Trainees who leave their program without the approval of their program director and prior to the end of the academic year are considered in violation of the terms of the Agreement of Appointment.

Transfers out of WSU SOM GME programs must be presented to the GMEC so the committee can monitor program attrition.

Procedures

Residents transferring INTO a WSU SOM GME program:

  • One to two months prior to anticipated transfer, obtain a statement regarding the resident’s current standing and indication of when the summative competencybased performance evaluation will be completed. An example of an acceptable verification statement is: “(Resident name) is currently a PGY (level) intern/resident in good standing in the (residency program) at (sponsoring institution). S/he has satisfactorily completed all rotations to date, and we anticipate s/he will satisfactorily complete her/his PGY( ) year on June 30, (year). A summary of her/his rotations and a summative competency-based performance evaluation will be sent to you by July 31, (year).”
  • Obtain written or electronic verification of previous educational experiences, including rotations completed and procedural/operative experience.
  • Obtain a written or electronic summative competency-based performance evaluation from the resident’s current program director.
  • Discuss the results of the summative evaluation with the current program director in person or via telephone, and keep written documentation of this discussion along with the training verification and summative evaluation in the resident’s permanent file.

Residents transferring FROM a WSU SOM GME program

  • For residents transferring out of a WSU SOM GME training program prior to completion of the program, the WSU SOM GME program director must provide timely verification of previous educational experiences and a summative performance evaluation to the program director of the program into which the resident is transferring.
  • For residents completing preliminary training in a WSU SOM GME training program and moving into another WSU SOM GME training program, the program director of the preliminary training program must provide timely verification of previous educational experiences and a summative performance evaluation to the WSU SOM GME program director of the program into which the resident is transferring.

Monitoring

  • Review of transfer applications by the GMEC
  • ACGME ADS updates
  • Onboarding checklist in New Innovations

Response to ACGME Correspondence Policy

GMEC approved: November 2008
GMEC revised: July 2011
GMEC updated and approved: March 2015

Policy

To ensure oversight of continued program accreditation the GMEC must be notified of any program receiving an ACGME Letter of Notification (LON) that includes citations, request for response or an adverse action accreditation decision including: probationary accreditation, withdrawal of accreditation or administrative withdrawal. The GMEC must review and approve any correspondence with the ACGME before it is submitted either by written progress report or entered in to ACGME ADS.

Procedure

If any programs receives an ACGME Letter of Notification (LON) that includes citations, request for response or an adverse action accreditation decision including: probationary accreditation, withdrawal of accreditation or administrative withdrawal, the program director must submit an immediate response to the DIO and prepare a written report addressing the LON to be presented at the GMEC. This GMEC meeting may occur ad hoc (if a response is required before the next GMEC meeting) or at the next regularly scheduled GMEC meeting. Time will be allocated for DIO review, program director revisions, GMEC review and final signatures according to the prescribed ACGME timeline for response.

The process for review is as follows:

  • Step 1: Program director drafts response to ACGME citations and or/adverse actions including action plan to address citations, and submits to GMEC within 30 days of receipt of letter.
  • Step 2: ACGME LON, program director’s response letter and program action plan are reviewed at the GMEC meeting. The GMEC either approves correspondence and plan, or requests revisions and resubmission.
  • Step 3(a): If Letter and Plan are approved by GMEC. The program director submits a followup report in six months.
  • Step 3(b): If GMEC request letter and/or plan revisions. The program director resubmits correspondence and action plan at the next GMEC meeting. Once approved by the GMEC, the program director submits a follow-up plan in six months.
  • Step 4: After GMEC approval and finalization, the program director updates “response to citations” on ACGME ADS.
  • Step 5: If a progress report is requested by the ACGME (separate from the ADS update), the letter must also be signed by the DIO before submission to the ACGME.

Monitoring

All ACGME letters of notifications and response from the residency program will be reviewed by the GMEC to ensure compliance with this policy.

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