New ACGME Requirements Provide a Proactive Risk Assessment for Teaching Hospitals

March 08, 2012

On July 1st, the Accreditation Council for Graduate Medical Education (ACGME) implemented new requirements that all academic medical centers and teaching hospitals must meet and adhere to going forward.  As most risk managers at hospitals are aware, medical malpractice and employment claims are prevalent in organizations associated with teaching programs and many of these claims carry over into aspects of patient care.  The newly released program requirements provide proactive measures and a structural guide to obtain and measure program excellence.  A summary of these requirements are below; however a complete version of the assessment can be found on the ACGME website. The requirements describe the role and importance of residency programs in graduate medical education.

  • Section One highlights the importance of a Program Letter of Agreement (PLA) and teaching, supervision and evaluation details from the perspective of sponsoring institutions and participating sites.
  • Section Two describes the qualifications and responsibilities of the residency program director and other program personnel and resources. A few of the highlighted responsibilities include the supervision of residents, assurance of due process for disciplinary actions, and fostering an environment that promotes scholarship, research and clinical competence.
  • Section Three describes the appointment and transfer process for residents, fellows and other learners.
  • Section Four describes the components of the residency educational program.  The section includes the delineation of resident responsibilities for patient care, progressive responsibility for patient management, and the supervision of residents throughout the program. In addition, the section outlines ACGME patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, and systems based practice standards and how the standards must be integrated into the residency program.
  • Section Five outlines the program infrastructure and necessary rigor for resident and faculty evaluation and maintenance.
  • Section Six provides the specific requirements related to resident work hours in the learning and working environment.  It also describes the ideal balance of professionalism, personal responsibility, patient safety and program competency.  Moonlighting and mandatory time free of duty are also outlined in this section.
  • Section Seven highlights experimentation, innovation and the necessary steps a residency program must take if they choose to deviate from any of the articulated ACGME requirements.

As mentioned, the comprehensive “Common Program Requirements” can be found on the ACGME website.  Risk managers and residency directors are encouraged to review the document and assure they are in compliance with all current requirements.  ACGME believes that accordance with the requirements will assure the establishment and maintenance of quality resident education and patient safety programs.

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