Program Administration Flashcards

A program director notifies you that a resident has exceeded the 80-hour weekly duty hour limit for the third consecutive week due to unexpected patient census surges. The program is not in an ACGME-approved exception. As the program administrator, what is the MOST appropriate immediate action?

Answer: Submit an immediate self-report to the ACGME through the Accreditation Data System and initiate a corrective action plan with the program director

Persistent, repeated duty hour violations require immediate self-reporting to the ACGME via the Accreditation Data System (ADS), not deferred reporting at the APE. The ACGME expects timely disclosure of non-compliance, and simultaneously developing a corrective action plan demonstrates the program's commitment to resident well-being and regulatory compliance. Retroactive schedule changes do not resolve the underlying systemic issue, and IGMEC waivers do not exist for retroactive or chronic violations.

During an ACGME site visit, the review committee asks for documentation of faculty scholarly activity over the past three years. The program has four core faculty members. How many distinct scholarly activities are minimally required to satisfy ACGME Common Program Requirements for most specialties?

Answer: A total of at least one per core faculty member over the three-year period, totaling 4

ACGME Common Program Requirements (Section IV.B.1) require that each core faculty member demonstrate scholarly activity. The minimum standard is at least one scholarly activity per core faculty member over the review period (typically three years), meaning the program needs at least 4 documented scholarly activities — one per faculty. Programs often exceed this, but this is the floor. It is not an annual per-faculty requirement nor a program-wide single requirement.

A fellowship program is undergoing its initial accreditation review. The sponsoring institution's DIO informs you that the fellowship program director has been in their role for only 8 months. Which of the following situations presents the GREATEST accreditation risk based on ACGME requirements?

Answer: The program director has not yet attended an ACGME-sponsored program director development workshop within the first year of appointment

ACGME requirements mandate that program directors new to their role attend an ACGME-sponsored program director development workshop (or equivalent) within a specified period of their appointment — failure to do so by the required deadline is a cited deficiency. While PIF updates and board certification timing are important, the workshop attendance requirement for new PDs carries explicit compliance timelines. Dual roles as core faculty in a related program are permissible with appropriate time allocation documentation and present less immediate accreditation risk than a missed mandatory development milestone.

Your program receives a Continued Accreditation with Warning from the ACGME Review Committee citing inadequate resident assessment data. The warning specifies a 12-month response deadline. Which combination of actions BEST fulfills the procedural requirements for responding to this citation?

Answer: Submit a Progress Report through ADS with supporting data, implement a revised assessment plan, and ensure the APE formally reviews the citation and response

A Continued Accreditation with Warning requires a formal Progress Report submitted through ADS within the specified deadline, accompanied by evidence of corrective action. Critically, the Annual Program Evaluation must formally document the committee's review of the citation and the corrective measures taken — this closes the institutional loop and demonstrates systematic quality improvement. Voluntary withdrawal is an extreme and strategically inadvisable step. Appeals are reserved for Withdrawal decisions, not Warning outcomes, and do not pause response timelines.

A resident in your program discloses a previously undisclosed disability to the GME Office midway through their PGY-2 year, requesting schedule accommodations under the ADA. The program director asks you how this affects a currently pending Clinical Competency Committee evaluation of the resident for marginal performance. What is the MOST legally and procedurally appropriate guidance?

Answer: Proceed with the CCC evaluation based solely on documented performance to date, while simultaneously engaging HR and legal to process the accommodation request on a parallel, separate track

ADA accommodation requests must be processed on a separate, confidential track from academic performance evaluations. The CCC's obligation is to evaluate documented competency-based performance objectively; it cannot pause solely due to a pending accommodation request, nor can it retroactively reinterpret past performance as disability-related without formal determination. Accommodations are prospective — they adjust future conditions, not historical assessments. Involving HR and legal concurrently ensures the accommodation process is properly handled while maintaining the integrity of the competency evaluation.

Your institution's Sponsoring Institution undergoes a merger with a health system that operates its own ACGME-accredited programs in overlapping specialties. Under ACGME Institutional Requirements, which action is REQUIRED before any residents can be transferred between the merging entities' programs?

Answer: The acquiring institution must seek ACGME approval of a Merger and Acquisition application, and no program-to-program resident transfers may occur until the ACGME has acknowledged the institutional change

ACGME Institutional Requirements mandate that sponsoring institutions notify and receive ACGME acknowledgment of mergers, acquisitions, and major organizational changes before they take effect with respect to accredited programs. Resident transfers across previously separate accredited programs prior to ACGME review and acknowledgment can jeopardize accreditation status for both entities. The ACGME has a formal Merger and Acquisition process that must be completed before programmatic consolidation. A joint GMEC resolution may be prudent governance but is not the ACGME-required prerequisite; the ACGME notification and approval process is.