Accreditation and Compliance Flashcards

A PGY-2 internal medicine resident at an ACGME-accredited program has been regularly working additional clinical shifts at a private urgent care clinic on days off, accumulating approximately 12 extra hours per week. The program director is aware but has not included these hours in duty hour reporting, reasoning that they are 'voluntary and external.' Under ACGME Common Program Requirements, which statement BEST describes the compliance status of this arrangement?

Answer: The arrangement is non-compliant because all moonlighting hours — internal and external — must be counted toward the 80-hour weekly duty hour limit

ACGME Common Program Requirements are explicit: all moonlighting hours, whether internal (within the sponsoring institution or its affiliates) or external (at outside sites), must be counted toward the 80-hour maximum weekly duty hour limit. A program director has no authority to exclude external hours from reporting. Additionally, PGY-1 residents are categorically prohibited from any moonlighting — a separate, stricter rule — but upper-level residents' moonlighting still must be fully tracked and reported.

An ACGME Review Committee has had a residency program on Probationary Accreditation for two consecutive review cycles. The program has demonstrated only partial improvements and remains substantially out of compliance with several core requirements. Under ACGME accreditation policy, what is the most likely next accreditation action, and what immediate operational consequence does it carry?

Answer: The Review Committee will issue Withdrawal of Accreditation, and the program must cease accepting new residents while allowing current trainees to complete their training

When a program on Probationary Accreditation fails to achieve substantial compliance within the allowed timeframe, the ACGME Review Committee issues Withdrawal of Accreditation. There is no 'Extended Probationary' status — the accreditation ladder does not cycle back upward without demonstrated compliance. Upon withdrawal, the program must immediately cease enrolling new residents and fellows, though current trainees are typically permitted to complete their training or transfer. The ACGME does not reassign program director responsibilities as an accreditation action.

A residency program director plans to send a single PGY-3 resident to a community hospital affiliate for a two-week elective rotation. The program coordinator asks whether a Program Letter of Agreement (PLA) is required, given the brief duration and the fact that only one resident is involved. What is the correct answer under ACGME Institutional Requirements?

Answer: A PLA is required for any participating site where even a single resident rotates for any educational purpose, regardless of duration

ACGME Institutional Requirements define a 'participating site' as any site that provides a required or elective educational experience for at least one resident or fellow. A Program Letter of Agreement is required for every participating site — there is no minimum duration threshold, no minimum number of rotating trainees, and no exception for brief electives. The PLA must be signed by the program director and the appropriate representative at the affiliated site and must be reviewed and renewed at least every five years.

During a CLER (Clinical Learning Environment Review) site visit, the accreditation field representative evaluates the institution across all six CLER focus areas. A program administrator is preparing an orientation for new residents and must correctly identify those six areas. Which of the following lists is COMPLETE and ACCURATE?

Answer: Patient Safety, Health Care Quality, Care Transitions, Supervision, Fatigue Management and Mitigation, Professionalism

The ACGME CLER program evaluates sponsoring institutions across exactly six focus areas: (1) Patient Safety, (2) Health Care Quality, (3) Care Transitions, (4) Supervision, (5) Fatigue Management and Mitigation, and (6) Professionalism. Common distractors include 'Duty Hours' (which is an ACGME program requirement but not a distinct CLER focus area), 'Wellness' or 'Well-Being' (a related but separate initiative), and 'Diversity and Inclusion' (not among the original six). CLER visits occur approximately every 18 months and produce a Pathways to Excellence report, not a citation-based accreditation decision.

A sponsoring institution's GMEC is being restructured following a compliance review. The DIO must ensure the GMEC composition meets ACGME Institutional Requirements. Which statement MOST precisely describes what ACGME mandates regarding resident/fellow representation on the GMEC?

Answer: At least one resident/fellow representative must serve, selected by their peers, and must have a vote on GMEC decisions

ACGME Institutional Requirements mandate that the GMEC include at least one resident/fellow member who is selected by the residents/fellows (i.e., peer-selected, not appointed by the DIO or administration) and who holds a vote on GMEC matters. This peer-selection requirement and the voting right are both non-negotiable. The ACGME does not require one representative per specialty, does not allow a non-trainee proxy, and does not restrict residents to advisory-only roles. This ensures that trainees have authentic, uncoerced representation in GME governance.

After failing to fill a residency position through the NRMP Main Residency Match, a program director recruits and enrolls an unmatched applicant through a direct offer without following the ACGME-specified post-Match supplemental offer process. The program director justifies this by citing a genuine unfilled vacancy and the need to maintain program complement. Which accreditation consequence is MOST directly applicable?

Answer: The program is subject to a citation for non-compliance with ACGME Common Program Requirements governing resident recruitment, which could escalate to probationary status

ACGME Common Program Requirements mandate participation in ACGME-approved resident selection processes, which include the NRMP Match and its official post-Match processes (e.g., SOAP — Supplemental Offer and Acceptance Program). Recruiting and enrolling a resident through an unauthorized direct offer — even for a genuine unfilled position — constitutes non-compliance with accreditation requirements. This can result in an ACGME citation, and repeated or egregious violations can escalate toward probationary accreditation. There is no cure-by-retroactive-registration provision, and responsibility attaches to the program, not solely the DIO as an individual.