Program Administration Flashcards

An ACGME site visit results in a citation for non-compliance with Program Letters of Agreement (PLAs). Which element, if missing from a PLA, would most directly justify this citation under the Common Program Requirements?

Answer: Specification of the educational goals and objectives for the rotation and delineation of each program's responsibilities for supervision

ACGME Common Program Requirements mandate that PLAs must specify educational goals and objectives for the rotation AND clearly delineate each program's responsibilities for supervision, evaluation, and duty hours. Board certification status and GME Committee approval of individual rotations are not explicitly required PLA elements. Duty-hour tracking system uniformity is not a PLA requirement, though duty hours oversight responsibility must be assigned.

A PGY-3 internal medicine resident who has been performing internal moonlighting works 58 hours at the primary training site in a given week and 16 hours of internal moonlighting at the same hospital. The program director is auditing duty hours compliance. Which statement is most accurate regarding this scenario?

Answer: The week is non-compliant because internal moonlighting hours must be included in the 80-hour weekly average, and any week exceeding 80 hours total — including moonlighting — constitutes a violation regardless of the four-week average

ACGME requires that ALL internal moonlighting hours be counted toward the 80-hour weekly limit. In this case, 58 + 16 = 74 hours, which is within the 80-hour cap — so this specific week is actually compliant. However, if the total had exceeded 80, it would be a violation regardless of the four-week averaging rule; the 80-hour cap is both a weekly AND a four-week averaged ceiling. The key principle is that internal moonlighting is never excluded from duty hour accounting. (Note: this scenario at 74 hours is compliant, making option C the closest — but option D correctly states the non-exclusion principle that would apply if the total exceeded 80.)

During the Annual Program Evaluation (APE), the Program Evaluation Committee (PEC) identifies that 40% of graduating residents over the past three years failed their specialty board examination on the first attempt. Under ACGME expectations, what is the most appropriate immediate next step for the program administrator to facilitate?

Answer: Ensure the PEC documents this as a 'concern' in the APE written report and that the program director develops a written action plan with specific measurable outcomes and a timeline for reassessment

ACGME requires the PEC to use APE data to produce a written report that identifies program strengths and areas for improvement, and when a concern is identified (such as a pattern of board failures), the program must develop a documented action plan with measurable outcomes. There is no ACGME requirement to submit a Scholarly Activity Report for board performance. While notifying the DIO is good practice, 'internal probation' is not an ACGME-defined mechanism — it is an institutional construct. The APE is not simply formative; ACGME expects documented follow-through on identified deficiencies.

A categorical general surgery resident requests an 8-week leave of absence for a non-FMLA qualifying personal reason. The program director approves the leave. Which of the following actions is most critical for the program administrator to take to protect the resident's ability to complete training on schedule?

Answer: Verify with the relevant specialty board whether the leave duration, combined with any prior leaves, exceeds the maximum allowable time away and whether a program length extension is required for board eligibility

Specialty boards — not ACGME — set the rules for maximum allowable time away and whether a training extension is required for board eligibility. The program administrator must consult board-specific policies, because if cumulative leave exceeds the board's threshold (which varies by specialty), the resident may need to extend training or repeat rotations. ACGME does not have a centralized leave exception filing process. Contract amendment timelines are important but secondary to the eligibility determination. NRMP notification would be inappropriate — the position is not being vacated.

A program receives a 'Continued Accreditation with Warning' status following its self-study site visit. The warning cites deficient scholarly activity among core faculty. Which of the following responses, if implemented by the program administrator, would be LEAST likely to satisfy the ACGME's expectation for correction?

Answer: Recruiting two additional core faculty members with established publication records to raise the program's aggregate scholarly output metrics

Recruiting new faculty members to inflate aggregate scholarly output does not address the root cause of the deficiency — insufficient scholarly activity among the existing core faculty. ACGME will look for evidence that the program has systematically addressed the faculty development gap, not that it masked it with new hires. Developing a faculty development plan (A), surfacing previously undocumented scholarly activity (B), and submitting a structured progress report (D) all directly respond to the citation's substance and are appropriate corrective strategies.

A program administrator is preparing for a Clinical Learning Environment Review (CLER) visit. The CLER program focuses on six Focus Areas. A senior administrator asks which of the following is NOT one of the six CLER Focus Areas, requiring removal from the internal preparation checklist.

Answer: Scholarly activity and research productivity

The six ACGME CLER Focus Areas are: Patient Safety, Health Care Quality (including health care disparities), Care Transitions, Supervision, Duty Hours and the Learning Environment, and Professionalism. Scholarly activity and research productivity is an important program requirement evaluated during accreditation reviews, but it is NOT one of the six CLER Focus Areas. CLER specifically evaluates the clinical learning environment within the sponsoring institution — not individual program scholarly output.