Program director change
Although responsibility and authority for appointing new program directors rest with the Chair, the ACGME requires that the institution's Graduate Medical Education Committee approve the appointment of program directors.
- Where possible, plan transitions that allow time for a careful selection process and a smooth transfer of responsibility.
- Prepare a detailed job description and define the specific package to be offered. The job description must include requirements stipulated by the ACGME in both the “Common Program Requirements” and specialty program requirements. These may include Program Director credentials, time commitment, and specific responsibilities. The job description should also specify the frequency and manner of evaluation of the program director, in order to ensure that periodic constructive feedback is provided.
- Convene a Selection Committee to be advisory to the Chair. Consider including:
- one or more trainees from the program
- one or more program faculty
- the department's residency program director (if selecting a fellowship program director)
- a program director from another department
- a representative from Mass General Brigham GME.
- If no well-qualified internal candidate is available, the position should be advertised widely so that outstanding candidates can be identified through a national search (e.g., NEJM, specialty journals, letters to other department chairs soliciting suggestions, etc.). In some cases, it may be advisable to conduct a national search even where qualified internal candidates exist.
- Commitment to graduate medical education
- Excellent administrative skills, management ability and leadership qualities
- Outstanding interpersonal skills, including communication and collaboration
- Keen understanding of and enthusiasm for the program director role and responsibilities
- Excellence in teaching
- Suitable clinical, research, and/or administrative work to complement program director activities, if these are part-time
- Prior experience as a program director or academic medical center faculty member
- Fulfillment of specific program RRC requirements (e.g., minimum experience as a faculty member)
- Before a candidate's selection is finalized, the appointing Department Chair should send the completed “PD Transition Form” to the appropriate GME Director, which outlines the rationale, the selection process, the qualifications of the proposed candidate, and the resources (financial and administrative) being allocated for the role. (Negotiations may be ongoing, contingent upon committee approval.)
- If the process of identifying the chosen candidate did not involve a representative of the institution’s education committee or GME Office, the GME Director will arrange for the candidate to be interviewed on behalf of the Graduate Medical Education Committee before the Committee evaluates the proposed appointment
- The Graduate Medical Education Committee will review (i) the PD Change Form completed by the Department Chair; (ii) the candidate's CV; and (iii) the job description. The GME Director and/or interviewer will provide comments to the education committee, and the committee will vote.
- If/when the Department Chair confirms the appointment, the ACGME will be notified of the Graduate Medical Education Committee’s endorsement of the new Program Director appointment.
Approved 11/17/05, Mass General Brigham Education Committee; Revised 10/2012
Trainee complement change
Guidelines for ACGME-accredited and non-ACGME programs
Requesting an Increase in Trainee Complement
All requests for complement changes must describe the Educational Rationale, Resources, and an Implementation Plan, as detailed below. Requests should be submitted as a Word document to the GME Director assigned to the specialty and accreditation manager.
- ACGME Programs: The GME Committee must review and approve the proposal before submission to your ACGME Review Committee (RC) or ADS.
- Non-ACGME Programs: The GME Director, assigned to the specialty, will review the proposal.
- Requests for temporary increases of short duration often can address the necessary information in a short paragraph.
Requests for permanent complement increase must also include a statement of support from the program director(s) of related specialty or subspecialty program(s) that may be impacted by the increase and the approval by the Department Chair(s)/Division Chief(s).
Provide a detailed explanation of the educational rationale for your request.
For example, additional trainee/s would:
- Support new rotation/s* or other educational experiences to provide:
- training in new technology
- expanded opportunities for training in sub-specialty areas
- added elective time
* Be sure to include an explanation of why adding this new rotation/experience requires an expansion in the number of trainees.
- Allow program to meet (new) accreditation requirements (if applicable)
- Enhance recruitment
- For small programs, achieve a “critical mass” of trainees to enhance the learning environment (be specific)
- Provide increased time for didactics and/or research
- Improve the experience on defined rotation/s (be specific about what improvements would result)
If applicable, comment on physician workforce issues if there is a recognized need for more practitioners in this (sub)specialty Note: Programs often propose a complement increase with the reasoning that clinical service volume has increased. The education committees generally do not view this as a sufficient reason to approve an increase. There must be a clear rationale as to how the proposal improves education.
To justify an increased complement, you must show that you have the resources to support the education of an increased number of trainees without any negative impact on the current trainee/s in your program, or trainee/s in related (sub)specialty GME programs (please submit a statement of support from the program director(s) of a related (sub)specialty program(s) that may be impacted by the increase).
Please comment on such factors as:
- Clinical volume, especially where specific quotas are required by ACGME or ABMS
- Number of faculty (provide current and projected ratio of faculty and trainees)
- Space and facilities (i.e., educational space such as conference rooms, lab and/or clinic space; call rooms and other support space and resources, such as computers)
- Impact on affiliates (if applicable)
- How will the position(s) be funded? Please note that approval of an increase in trainee complement from the hospital’s education committee and/or from the ACGME does not imply that institutional funding is available. The program must ascertain the availability of appropriate funding before recruiting trainees to the additional position(s)**.
** For any additional FTEs to be supported by hospital or departmental funds, please submit documentation of approval by both the Department Vice President (VP) and the Department Chair. This can be in the form of a letter or email from the VP and the Chair confirming funding support. If the program is integrated across hospitals, approval from all institutional Department Chairs and Vice Presidents must be submitted.
Submit a proposed implementation plan for the total increase in trainee complement.
Please include the following:
- The current number of trainees and the requested total number (both by program year, for multi-year programs)
- A timetable of increased recruitment (e.g., a four-year program might add one trainee per year each of the next four years; a one-year program might add one position at the start of the next academic year)
- Attach block diagrams of the current and proposed trainee rotation schedules for the entire program
Trainee status change
Guidelines for contacting the GME Office regarding a trainee status change
Resident or fellow status change
The program director should contact the GME Office before putting a resident or clinical fellow on probation. Programs should also notify the New Innovations specialist and/or the Accreditation Manager in the GME Office when a resident or clinical fellow's status changes due to the circumstances described below.
- A trainee status changes when leaving the role defined by the appointment title and in payroll. For example, a resident can move from the role of resident to chief resident and back again, if the chief residency role is temporary.
- When a trainee takes time out of the program to enter a research year, there is a status change.
- Trainees who take a leave of absence will not only be required to have their status changed with the hospital, but the status will need to also change with the ACGME or another accrediting body. Programs must be aware that a trainee who takes time off may need to make up that time or extend his or her training. If this is an ACGME program, then a Trainee Complement may need to be approved.
The Vacation, Sick Time, and Leave Policy, which can be found on the Policies page, has details on each of the differing leaves.
The Leave of Absence Office can direct each program and trainee through the correct leave process and protocol.
The GME Director can provide the program with useful guidance and outline the process that needs to be followed prior to putting a resident on probation.
Programs should notify the GME Office in the event that a trainee's status changes from clinical training to a research year and when a trainee takes a leave of absence.
Participating site change
Guidelines for requesting additional participating sites or deleting an affiliate
Please provide the following information for GME Committee review prior to seeking RRC approval for the addition of participating site(s). The educational rationale for this request, the rotation schedule and description of the goals and objectives for the rotation, and discussion of financial support can be placed into one document. The approval by the Department Chair and the new Associate Director at the participating site can each be as brief as 1-2 sentences, and in the form of an email.
Please be sure to send your request electronically via email to the accreditation manager for your program for review by the education committee at least three weeks prior to the GMEC meeting at which you wish this request to be reviewed. The committee meeting dates are listed on the GME Calendar (login required).
- Explain the anticipated benefit of adding the participating site by describing what the rotation would add to the program/trainee experience overall (e.g., patient population, faculty expertise, help satisfy RRC citations, etc.).
- Explain why requiring this rotation will improve the education your trainee(s) will receive (i.e., how will the educational experience warrants travel away from the Sponsoring Institution).
- Describe the trainee supervision and oversight you will assign to the (Associate) Program Director to be appointed at the participating site.
- Describe any effect you anticipate adding this site will have on recruitment.
- Provide a description of the educational content (i.e., written goals and objectives) for this new rotation.
- Describe the duration of the rotation, whether it is required for all trainees in the program, and for multi-year programs, the total time to be spent at the affiliate.
- Describe the financial arrangements with this site (e.g., affiliate will reimburse trainee salary and expenses; trainee(s) from the affiliate's program will rotate to the Sponsoring Institution).
- Provide documentation of approval of this new affiliation from your Department Chair and the (Associate) Program Director at the affiliate.
Other requests
Additional instances when program leadership should contact the GME Office
All matters regarding GME programs should first be referred to one of the GME Directors. Any program changes requiring ACGME approval should be submitted to the GME accreditation manager for their program for GMEC review and approval.
Programs must also contact the GME Director assigned to their specialty before considering the following:
- Resident probation – The GME Director can provide the program with useful guidance and outline the process that needs to be followed prior to putting a resident on probation.
- Delay of a site visit – The ACGME conducts a large number of site visits annually and expects programs to accommodate the visit on the assigned date. On rare occasions it may be necessary to change the date. If you do need to reschedule, please contact the DIO and copy the accreditation manager before writing to the ACGME.
- New GME program recruitment – All new GME programs must be approved by the GME Director on behalf of the Mass General Brigham Graduate Medical Education Committee prior to recruiting potential trainees. This two-step application process can take up to four to six months. Programs should contact your accreditation manager for further information about this process.
- ECFMG recruitment for a non-ACGME unapproved program – Existing programs that have never been formally reviewed must contact the GME Office to undergo review and approval prior to accepting an ECFMG candidate. (see "Non-standard new training programs" below).
- Progress reports requested by, and to be submitted to, the RRC should be reviewed by the GME director prior to GMEC approval. Please see the Maintain Accreditation page for tips.
- Major changes in program structure or length of training
- Requests for exceptions of resident duty hours
- Responses to proposed adverse actions
- Requests to appeal an adverse action and appeal presentations to a Board of Appeal or the ACGME.
- Voluntary withdrawal of program accreditation.
The GME Directors, on behalf of the Mass General Brigham Graduate Medical Education Committee (MGB GMEC), oversee and must approve all applications for:
- Institutional sponsorship of any new GME programs, either residency or fellowship. The GME Director will work closely with the program to develop an optimum application for GME review. This process could take four to six months.
- New ACGME accreditation. The GME Director will work with the program on the ACGME application process and review program materials prior to their submission to the ACGME through the Accreditation Data System (ADS). The materials typically should be submitted to the GME Director for review at least a month prior to the ACGME application deadline.
- Fellowship programs applying for national accreditation other than ACGME. The GME Director will meet with the program and review the application prior to submission.
- "Non-standard” new training programs. Programs typically encounter the need for the approval of “non-standard” new training programs when recruiting an International Medical Graduate in need of an ECFMG-sponsored J1 clinical visa. Prior to offering a position, programs need to ensure that their program has been reviewed and approved and appears on the hospital’s ECFMG list. Program leadership should contact the GME Office if their training program has not been approved.
The Graduate Medical Education Committee (GMEC) oversees and must approve required documentation prior to the program’s submission of the request to the Residency Review Committee (RRC). Programs will be required to submit completed documentation to the GME Office and be included on the GMEC agendas. The GMEC meeting schedule is located on the GME Calendar.
