COTTAGE HEALTH SYSTEM POLICY

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SUBJECT:

GMEC Composition, Meetings, and Responsibilities

 

DEPT: MEDICAL EDUCATION
POLICY #: 8240.15

 

GOAL
To establish the role of the Graduate Medical Education Committee (GMEC).


POLICY
In accordance with the Institutional Requirements set forth by the Accreditation Council of Graduate Medical Education (ACGME) Santa Barbara Cottage Hospital is required to have a GME Committee. Voting membership on the committee must include the designated institutional official or his/her designee, program directors, trainees who have been selected by their peers, administrators and other members of the faculty. The GMEC meets on a monthly basis and the charge of this group is:
 

PROCEDURE 

Stipends and position allocation: 

  • Annual review and recommendations to Sponsoring Institution regarding trainee stipends, benefits and funding for trainee positions.

Communication with program directors:

  • Ensure communication mechanisms exist between the GMEC and all program directors within the institution.
  • Ensure that program directors maintain effective communication mechanisms with the site directors at each participating site for their respective programs to maintain proper oversight at all clinical sites.

Resident duty hours:

  • Develop and implement written policies and procedures regarding resident duty hours to ensure compliance with the Institutional, Common Program and specialty/subspecialty-specific Program Requirements.
  • Consider for approval requests from program directors prior to submission to an RRC for exceptions in the weekly limit on duty hours up to 10 percent or up to a maximum of 88 hours in compliance with ACGME policies and procedures for duty hour exceptions.

Resident supervision: Monitor programs' supervision of trainees and ensure that supervision is consistent with:

  • provision of safety and effective patient care;
  • educational needs of the residents;
  • progressive responsibility appropriate to trainees' level of education, competence and experience, and;
  • other applicable Common and specialty/subspecialty-specific Program Requirements.

Communication with medical staff: Communication between leadership of the medical staff regarding the safety and quality of patient care that includes:

  • the annual report to the OMS;
  • description of trainee participation in patient safety and
  • quality of care education and the accreditation status of programs and any citations regarding patient care issues.

Curriculum and evaluations: Assurance that each program provides a curriculum and an evaluation system that enables trainees to demonstrate achievement of the ACGME general competencies as defined in the Common and specialty/subspecialty-specific Program Requirements.

 

Resident status: Selection, evaluation, promotion, transfer, discipline, and/or dismissal of trainees in compliance with the Institutional and Common Program Requirements.

Oversight of program accreditation: Review of all ACGME program accreditation letters of notification and monitoring of action plans for correction of citations and areas of noncompliance.

 

Management of institutional accreditations: Review of the Sponsoring Institution's ACGME letter of notification from the IRC and monitoring of action plans for correction of citations and areas of noncompliance.

 

Oversight of program changes: Review of the following for approval, prior to submission to the ACGME by program directors:

  • all applications for ACGME accreditation of new programs;
  • changes in resident complement;
  • major changes in program structure or length of training;
  • additions and deletions of participating institutions;
  • appointment of new program directors;
  • progress reports requested by Review Committee;
  • responses to all proposed adverse actions;
  • requests for exceptions of resident duty hours;
  • voluntary withdrawal of program accreditation;
  • requests for an appeal of adverse action and;
  • appeal presentations to a Board of Appeal or the ACGME.

Internal Review: Must develop, implement and oversee internal review process (see further details in this manual).

 

Experimentation and innovation: Oversight of all phases of educational experimentations and innovations that may deviate from Institutional, Common and specialty/subspecialty-specific Program Requirements including: a) approval prior to submission to the ACGME and/or respective Review Committees; b) adherence to Procedures for "Approving Proposals for Experimentation or Innovative Projects" in ACGME Policies and Procedures; and, c) monitoring quality of education provided to trainees for the duration of such a project.

 

Oversight of reductions and closures: Oversight of all processes related to reductions and/or closures of: individual programs; major participating institutions and; the sponsoring institution.

 

Vendor interactions: Provision of a statement or institution policy (not necessarily GME-specific) that addresses interactions between vendor representatives/corporations and trainees/GME programs.

 

Role of the GMEC Resident Representatives: The GMEC Resident Representatives are selected each year by their peers to serve as the voice of all of the residents. Trainees who have concerns can contact one of the Resident Representatives at any time. The Resident Representatives will then bring the issue to the GMEC for resolution. Contact the Medical Education office for a current list of the GMEC Resident Representatives.

5/12

 


COTTAGE HEALTH SYSTEM POLICY

RECOMMENDED BY: J Robinson DATE: 2/08

ORIGINAL POLICY EFFECTIVE DATE: 2/08

APPROVED BY: R. Reid, MD DATE: 2/08

DATE REVISED:    DATE REVIEWED: 1/12