New Program Director Orientation

Although you may have been provided a “job description” by your chair or departmental leadership, the Accreditation Council for Graduate Medical Education (ACGME) also prescribes responsibilities that you will be expected to fulfill. These are included under the Common Program Requirements (PR) on their site. See especially sections III. A. and B., IV. A, and V. A. The sine qua non of being a program director is being familiar with your program requirements (PRs) and ensuring that your program is in substantial compliance.

Program requirements go through a review cycle, typically undergoing revision about every five years. Proposed changes are posted on the ACGME website the year prior to taking effect (usually with a July 1 start) and you are encouraged to submit comments. Once the new PRs for your specialty take effect, you are responsible for your program's compliance. Thus, especially when you are anticipating an accreditation site visit, make sure that you are familiar with recent changes, if any, in your PRs. Please understand that you are also responsible for complying with the Common Program Requirements. You should always feel free to correspond with the individual at the ACGME who directs your specialty Residency Review Committee (RRC). They may be reached by phone or email. Find Residency Review Committee (RRC) contacts via the Specialties section of the ACGME site. The ACGME staff is always happy to answer simple questions. Formal correspondence, however, should be sent for the following:

• 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 must be pre-reviewed by the GMEC and cosigned by Joshua Goldstein, MD, as chair of the GMEC. Please see the separate topic on the GMEC page.

On an annual basis, you will receive an email from the ACGME requesting that you update your program on the ACGME WebADS system. See the separate topic of ACGME Compliance with instructions for engaging WebADS. If you fail to respond to this request, both the GME office and your RRC will be notified. Thus, please be timely in your response. You should have a copy of your most recent accreditation letter which provides three important pieces of information:

Your Accreditation Status

Hopefully your program has continued full accreditation. Other possibilities include provisional status (for new programs) or probationary status.

The Duration of Your Accreditation Cycle

The longest accreditation cycle is five years, which is reserved for the very best programs. An “average” cycle is three years. If you only have one or two years, especially if there is a warning sentence at the end of the letter, this indicates that your program may be headed for probation unless attention is given to citations.

Citations or Concerns

Regardless of whether comments are designated as noncompliance citations, concerns or “areas which will receive special attention at the next site visit,” these are all areas for which the RRC judged you to be deficient in some way and ones which you should correct as soon as possible. RRCs do not look kindly on changes that are made shortly before a subsequent accreditation site visit.

If you do not have a copy of your most recent accreditation letter, please contact Valerie Rodriguez at valerie.rodriguez@northwestern.edu. There are copies of all correspondence with the ACGME in the GME office.

You have numerous administrative obligations to your trainees. Although some of these obligations may be delegated to your program coordinator or administrator, the ultimate responsibility lies with you. These obligations include:

• Filing appointment/stipend forms with the McGaw GME office for new trainees.
• Responding to requests for information regarding program organization, including rotation schedules.
• Notifying the McGaw GME office for changes in rotation schedules, which have implications for which institution is billed for trainees stipends.
• Notifying the McGaw GME office for a change in status of a trainee, including sick leave, maternity leave, other leaves of absence and extension of training for any reason.
• Carrying out due process in disciplinary actions (see separate topic on this program director’s web).
• Filing reappointments (requires your original signature).
• Filling out credentialing forms for ex-residents and fellows, even when you do not know or remember these trainees.
• Ensuring that all interviewees for training positions are referred to the Stipend page so they may be familiar with anticipated stipend rates and benefits.
• Being familiar with all graduate medical education policies.

McGaw office staff will be happy to assist you or your coordinator/administrator with any of these tasks.

The Graduate Medical Education Committee (GMEC) is an important interface between you and the ACGME. The GMEC is delegated specific responsibilities for monitoring programs by the ACGME.

The Graduate Medical Education Committee asks for your cooperation in:

• Responding promptly to requests ranging from surveys to copies of program policies
• Participating in internal reviews as a member of a team
• Cooperating fully with the process of internal review of your own program, which occurs about mid-cycle between ACGME Residency Review Committee site visits
• Providing requested progress reports from internal review recommendations and RRC citations or concerns