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House Staff Policies and Procedures Manual section navigation

  • Section 1: House Staff General Responsibilities
  • Section 2: School of Medicine's General Responsibilities
  • Section 3: Summary of Benefits
  • Section 4: Leave Time
  • Section 5: Requirements For Appointment
  • Section 6: Clinical Experience and Educational Work Hours and Moonlighting Policies
  • Section 7: Disciplinary Actions
  • Section 8: Counseling and Support Services
  • Section 9: Behavioral Health Statement
  • Section 10: Graduate Medical Education Committee
  • Section 11: Personnel Files
  • Section 12: Other Services
  • Section 13: Workers' Compensation
  • Section 14: Infection Control
  • Section 15: EEO Employer-Disability/Veteran Statement
  • Section 16: Liability Insurance and Risk Management Programs
  • Section 17: Standards of Conduct
  • Section 18: The Health Insurance Portability and Accountability Act
  • Section 19: Release of Information to the Media
  • Section 20: Conflict of Interest
  • Section 21: No Solicitation
  • Section 22: Weapons
  • Section 23: Smoke-Free Workplace
  • Section 24: Drug-Free Workplace
  • Section 25: Dress Code
  • Section 26: Conflict of Interest/Industry Relations
  • Section 27: Care and Use of Property/Equipment
  • Section 28: Pastoral Services
  • Section 29: Security
  • Section 30: Teaching Responsibilities
  • Section 31: Department Orientation
  • Section 32: Policy on Consensual Teacher (Faculty or Resident)-Student (Resident or Student) Relationships
  • Section 33: Grievance
  • Section 34: Hearing and Appellate Review Procedures for Termination of a Residency Appointment
  • Appendix A: Policy and Procedure on Resident Recruitment & Appointment
  • Appendix B: Residency Appointment Agreement
  • Appendix C: EEO Employer-Disability/Veteran Statement and Department of Accessibility Services
  • Appendix D: Clinical Experience and Educational Work Hours and Moonlighting
  • Appendix E: Professional & General Liability Insurance
  • Appendix F: Institutional Policies

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  • Section 10: Graduate Medical Education Committee

Section 10: Graduate Medical Education Committee

10.01 Structure - GMEC/Subcommittees/Program Oversight Committees

The Graduate Medical Education Committee (GMEC) serves as the organizational vehicle for the house staff. The missions of the GMEC are:

  • To serve as a forum to discuss concerns and issues identified by the house staff;
  • To evaluate and monitor the activities and quality of the training programs ;
  • To advise the Office of Graduate Medical Education on matters involving the administration of the training program; and
  • To advise and make recommendations to the Dean on all aspects of Graduate Medical Education.

GMEC recommendations approved by the Dean which will materially change the program are presented by the Dean to the Council of Chairs for their final approval.

The Document Review Subcommittee (DRS) is a standing committee of the GMEC that meets at least quarterly to review Internal Reviews completed in the previous quarter, to review all letters sent to or received from ACGME during the quarter, and to compile and organize the various documents for efficient review by the GMEC. The Chair of this committee is the DIO or his designee. In addition to the Chair, the DRS will consist of at least three members of the GMEC including a resident representative.

The Clinical Experience and Education Work Hours Subcommittee (Formerly Duty Hours) is a standing committee of the GMEC. The Chair of this committee is a Program Director from the GMEC appointed by the DIO. In addition to the Chair, members of this committee include at least three members of the GMEC including a resident representative.

The Program Oversight Subcommittee is a standing committee of the GME that determines the parameters the institution should use to evaluate each program (annual program reports, annual survey results, and WebADS data) and annually reviews and updates the Institution's policy regarding special reviews.

Other sub-committees of the GMEC may be formed from time to time to address the needs of our residency training programs.  

10.02 Membership

The GMEC, which is chaired by the Associate Dean for GME/DIO or designate, administratively includes the Assistant Dean for GME, Program Directors, and representatives of each of our hospitals.  Residents from each core program and fellows from surgical, internal medicine and pediatric subspecialties are the mainstay of the membership.  They must be peer-elected, but they can be from any level of training.  The House Staff Organization elects two of its members to join the GMEC and, like the other elected resident representatives, take an active part in discussing and voting on the issues.  Any resident or fellow may attend the GMEC meeting to present ideas and concerns after notifying the GME Office to provide time on the agenda.  These additional residents and other occasional guests are not voting members; however, they are expected to fully discuss their areas of concern. 

10.03 Meeting Schedule/Agenda

The GMEC meets quarterly at noon on the third Wednesday. All members of the house staff, and Program Director or faculty member may recommend agenda items and may attend the meeting. Agenda items should be sent to the Committee Chair through the OGME (Suite 327 SOM) at least five days before the next regularly scheduled committee meeting.

10.04 Open Meeting

Committee meetings are open to all residents, Program Directors and faculty. Residents should contact their Program Director and the Committee Chair regarding their plans to attend.

10.05 Records and Minutes

All minutes of the GME Committee meetings, along with associated reports and records, are available for review by members of the house staff, Program Directors and faculty.

10.06 Residents' Suggestions

Residents are invited and encouraged to contact the Assistant or Associate Dean for GME to discuss issues related to the School's policies for graduate medical education or the overall quality of the GME programs.

10.07 GMEC Responsibilities

 The specific responsibilities of the GMEC are required by the ACGME in the Institutional Requirement I.B.4, and include the establishment and implementation of policies and procedures addressing the following:

  1. Stipends and position allocation:  Annual review and recommendations to the Sponsoring Institution regarding resident stipends, benefits, and funding for resident positions.
  2. Communication with Program Directors:
    The GMEC must:
    • Ensure that communication mechanisms exist between the GMEC and all Program Directors within the institution.
    • Ensure that Program Directors maintain effective communication mechanisms with the site directors at each participating institution for their respective programs to maintain proper oversight at all clinical sites
  3. Resident work hours:
    The GMEC must:
    • Develop and implement written policies and procedures regarding resident work hours to ensure compliance with the Institutional, Common, and specialty/subspecialty-specific Program Requirements.
    • Consider for approval requests from Program Directors before submission to an RRC for exceptions in the weekly limit on work hours up to 10 percent or up to a maximum of 88 hours in compliance with ACGME Policies and Procedures for duty hour exceptions.
  4. Resident supervision: Monitor programs' supervision of residents and ensure that supervision is consistent with:
    • Provision of safe and effective patient care;
    • Educational needs of residents;
    • Progressive responsibility appropriate to residents' level of education, competence, and experience
    • Other applicable Common and specialty/subspecialty-specific Program Requirements.
  5. Communication with Medical Staff: Communication between leadership of the medical staff regarding the safety and quality of patient care that includes:
    • The annual report to the OMS;
    • Description of resident participation in patient safety and quality of care education; and,
    • The accreditation status of programs and any citations regarding patient care issues
  6. Curriculum and evaluation: Assurance that each program provides a curriculum and an evaluation system that enables residents to demonstrate achievement of the ACGME general competencies as defined in the Common and specialty/subspecialty-specific Program Requirements.
  7. Resident status: Selection, evaluation, promotion, transfer, discipline, and/or dismissal of residents in compliance with the Institutional and Common Program Requirements.
  8. Oversight of program accreditation: Review of all ACGME program accreditation letters of notification and monitoring of action plans for correction of citations and areas of non-compliance.
  9. Management of institutional accreditation: Review of the Sponsoring Institution's ACGME letter of notification from the IRC and monitoring of action plans for correction of citations and areas of noncompliance.
  10. Oversight of program changes: Review of the following for approval, prior to submission to the ACGME by Program Directors:
    • All applications for ACGME accreditation of new programs;
    • Changes in resident complement;
    • Major changes in program structure or length of training;
    • Additions and deletions of participating institutions;
    • Appointments of new Program Directors;
    • Progress reports requested by any Review Committee;
    • Responses to all proposed adverse actions;
    • Requests for exceptions of resident duty hours;
    • Voluntary withdrawal of program accreditation;
    • Requests for an appeal of an adverse action; and,
    • Appeal presentations to a Board of Appeal or the ACGME.
  11. Experimentation and innovation: Oversight of all phases of educational experiments and innovations that may deviate from Institutional, Common, and specialty/subspecialty-specific program requirements, including:
    • Approval before submission to the ACGME and/or respective Review Committee;
    • Adherence to Procedures for "Approving Proposals for Experimentation or Innovative Projects" in ACGME Policies and Procedures; and,
    • monitoring the quality of education provided to residents for the duration of such a project.
  12. Oversight of reductions and closures: Oversight of all processes related to reductions and/or closures of:
    • Individual programs;
    • Major participating institutions
    • The Sponsoring Institution
  13. Vendor interactions: Provision of a statement or institutional policy (not necessarily GME specific) that addresses interactions between vendor representatives/corporations and residents/ GME programs.
House Staff Policies and Procedures Manual
  • Section 1: House Staff General Responsibilities
  • Section 2: School of Medicine's General Responsibilities
  • Section 3: Summary of Benefits
  • Section 4: Leave Time
  • Section 5: Requirements For Appointment
  • Section 6: Clinical Experience and Educational Work Hours and Moonlighting Policies
  • Section 7: Disciplinary Actions
  • Section 8: Counseling and Support Services
  • Section 9: Behavioral Health Statement
  • Section 10: Graduate Medical Education Committee
  • Section 11: Personnel Files
  • Section 12: Other Services
  • Section 13: Workers' Compensation
  • Section 14: Infection Control
  • Section 15: EEO Employer-Disability/Veteran Statement
  • Section 16: Liability Insurance and Risk Management Programs
  • Section 17: Standards of Conduct
  • Section 18: The Health Insurance Portability and Accountability Act
  • Section 19: Release of Information to the Media
  • Section 20: Conflict of Interest
  • Section 21: No Solicitation
  • Section 22: Weapons
  • Section 23: Smoke-Free Workplace
  • Section 24: Drug-Free Workplace
  • Section 25: Dress Code
  • Section 26: Conflict of Interest/Industry Relations
  • Section 27: Care and Use of Property/Equipment
  • Section 28: Pastoral Services
  • Section 29: Security
  • Section 30: Teaching Responsibilities
  • Section 31: Department Orientation
  • Section 32: Policy on Consensual Teacher (Faculty or Resident)-Student (Resident or Student) Relationships
  • Section 33: Grievance
  • Section 34: Hearing and Appellate Review Procedures for Termination of a Residency Appointment
  • Appendix A: Policy and Procedure on Resident Recruitment & Appointment
  • Appendix B: Residency Appointment Agreement
  • Appendix C: EEO Employer-Disability/Veteran Statement and Department of Accessibility Services
  • Appendix D: Clinical Experience and Educational Work Hours and Moonlighting
  • Appendix E: Professional & General Liability Insurance
  • Appendix F: Institutional Policies
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