ACGME Compliance

The program director is the “buck stops here” individual for all aspects of ACGME compliance. The two major areas of compliance are as follows:

Compliance with Program Requirements

The program director is delegated the responsibility of ensuring that his/her program is in substantial compliance with both the Common Program Requirements and the specialty Program Requirements (PR’s). Both sets of PR’s can be viewed on and downloaded from the ACGME web page, www.acgme.org. It is wise to perform at least an annual assessment of the program’s status in light of program requirements, and to make ongoing changes in the curriculum to strengthen areas of important PR’s.

All PR’s go through revisions on a regular cycle, usually every five years. Each specialty’s PR’s have the date the current version took effect listed at the end of the PR document. Thus, the timing of new PR’s can be anticipated.

Compliance with Reporting Requirements

An area that is often problematic is communication. There are two important reporting requirements:

1. Notification: The program director must formally notify the RRC of significant changes in the program, including:

   · Notifying the RRC of a new Chair or new program director
   
   · The addition or deletion of a major participating institution
   
   · Change in resident/fellow complement
   
   · Major change in the educational program

Please note that all formal correspondence to the RRC, including the PIF’s submitted for an accreditation site visit, must be pre-reviewed by the GMEC and cosigned by Sharon Dooley as Chair of the GMEC. Please see the separate topic on this program director’s web regarding the GMEC.

2. Annual WebAds Update: Each program director receives electronic notification from ACGME when it is time to update the program information. If this does not occur in a timely fashion, the GMEC and the RRC are notified. If the program director continues to fail to respond, there is the potential of an adverse action against the program by the RRC. Thus, we encourage prompt response to notification from ACGME to engage WebAds for the annual update. Please see instructions in this section on WebAds.

In addition to the above, some specialties require reporting of annual data, and several now require ongoing submission of each trainee’s experience. The program director is responsible for ongoing monitoring to ensures trainees are entering data in a timely fashion.