TAGME Accreditation and Compliance 5 — Questions and Answers
Question 1: Under ACGME Institutional Requirements, how often must the GMEC conduct a formal review of each ACGME-accredited program it oversees?
- At least annually (Correct answer)
- Every two years
- Every three years
- Only when a site visit is scheduled
Correct answer: At least annually
ACGME Institutional Requirements mandate that the GMEC conduct an annual review of each program to ensure ongoing compliance and educational quality.
Question 2: A fellowship program wants to add a new rotation at an off-site affiliated hospital. What must the sponsoring institution establish before trainees rotate there?
- A formal program letter of agreement (PLA) signed by both institutions (Correct answer)
- A verbal memorandum of understanding approved by the DIO
- A temporary waiver from ACGME allowing the unapproved site
- A site survey conducted by the GMEC within 30 days of the first rotation
Correct answer: A formal program letter of agreement (PLA) signed by both institutions
ACGME requires a written Program Letter of Agreement (PLA) between the sponsoring institution and each participating site before residents or fellows train there.
Question 3: Which body has the authority to withdraw ACGME accreditation from a residency program that fails to correct cited deficiencies?
- The relevant Review Committee (RC) (Correct answer)
- The GMEC of the sponsoring institution
- The DIO of the sponsoring institution
- The ACGME Board of Directors
Correct answer: The relevant Review Committee (RC)
Each specialty-specific Review Committee (RC) holds the accreditation decision-making authority for programs within its purview, including withdrawal.
Question 4: A program administrator notices the most recent ADS Annual Update was submitted with incorrect complement numbers. What is the proper corrective action?
- Contact the program director to submit a revision through ADS and document the correction (Correct answer)
- Notify ACGME by phone immediately as a compliance breach
- Wait until the next Annual Update cycle to correct the figures
- File an internal incident report with risk management
Correct answer: Contact the program director to submit a revision through ADS and document the correction
Errors in ADS submissions should be corrected promptly through the ADS portal with program director authorization, documented for compliance records.
Question 5: Which ACGME Common Program Requirement addresses the expectation that programs provide residents with access to mental health and wellness resources?
- Well-Being requirements within the Learning and Working Environment section (Correct answer)
- Supervision requirements within the Resident/Fellow Responsibilities section
- Clinical and Educational Work Hours requirements
- Faculty Development requirements
Correct answer: Well-Being requirements within the Learning and Working Environment section
The ACGME's Well-Being requirements, housed under Learning and Working Environment, mandate that programs support residents' mental, emotional, and physical health.
Question 6: When a sponsoring institution sponsors more programs than its resources can adequately support, ACGME may place the institution under which action?
- Institutional Review (Correct answer)
- CLER re-visit
- Focused Site Visit for all programs
- Immediate Withdrawal of Institutional Accreditation
Correct answer: Institutional Review
ACGME may initiate an Institutional Review when systemic concerns—such as resource insufficiency across programs—suggest the institution cannot fulfill its oversight responsibilities.
Question 7: A program director resigns unexpectedly. According to ACGME requirements, within what timeframe must the sponsoring institution notify ACGME of this change?
- Within 30 days (Correct answer)
- Within 60 days
- Within 90 days
- At the next Annual Update submission
Correct answer: Within 30 days
ACGME requires sponsoring institutions to report a change in program director within 30 days via ADS to ensure continuity of accredited oversight.
TAGME Accreditation and Compliance 5
Under ACGME Institutional Requirements, how often must the GMEC conduct a formal review of each ACGME-accredited program it oversees?