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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 (DIO), program directors, a minimum of two peer-selected trainees, a quality improvement/safety officer or his or her designee. In order to carry out portions of the GMEC’s responsibilities, additional GMEC membership may include others as determined by the GMEC. Subcommittees that address required GMEC responsibilities must include a peer-selected resident and subcommittee actions must be reviewed and approved by the GMEC. The GMEC meets on a monthly basis. Each meeting must include attendance by at least one resident member. The GMEC must maintain meeting minutes that document execution of all required GMEC functions and responsibilities.

PROCEDURE

GMEC Responsibilities must include:

Oversight of:

  • The ACGME accreditation status of the Sponsoring Institution and its ACGME-accredited programs;
  • The quality of the GME learning and working environment within the Sponsoring Institution, its ACGME-accredited programs, and its participating sites;
  • The quality of educational experiences in each ACGME-accredited program that lead to measurable achievement of educational outcomes as identified in the ACMGE Common and specialty/subspecialty-specific Program Requirements.
  • The ACGME-accredited programs’ annual evaluation and improvement activities; and,
  • All processes related to reductions and closures of individual ACMGE-accredited programs, major participating sites, and the Sponsoring Institution.

Review and approval of:

  • Institutional GME policies and procedures; including: 
    • Resident Eligibility & Selection 
    • Resident Agreement of Appointment/Contract 
    • Resident Promotion, Appointment Renewal and Dismissal 
    • Resident Grievance Procedure
    • Resident Liability Coverage
    • Resident Health and Disability Insurance
    • Resident Vacation and Leaves of Absence 
    • Resident Services: Behavioral health, Physician Impairment, Harassment and Accommodation for disabilities
    • Resident Supervision
    • Resident Duty Hours 
    • Resident Moonlighting
    • Vendors
    • Resident Non-Competition
    • Residency Program Closure or interruption secondary to Disaster 
    • Residency Closure/Reduction
    • Resident Fatigue Mitigation/Alertness Management
    • Resident House Staff Files
    • Resident Medical Records Delinquent
    • Resident Patient Safety
    • Resident Quality Improvement 
    • Resident Transitions of Care
    • Resident Professionalism
    • GME Curriculum Policy
    • GME Evaluation Policy 
    • GME Annual Institutional Review (AIR) Policy
    • GME Special Review Process
  • Annual recommendations to the Sponsoring Institution’s administration regarding resident/fellow stipends and benefits;
  • Applications for ACGME accreditation of new programs;
  • Requests for permanent changes in resident complement;
  • Major changes in ACGME-accredited programs’ structure or duration of education; 
  • Additions and deletions of ACGME-accredited programs’ participating sites; 
  • Appointment of new program directors;
  • Progress reports requested by a Review Committee; 
  • Responses to Clinical Learning Environment Review (CLER) reports;
  • Requests for exceptions to duty hour requirements;
  • Voluntary withdrawal of ACGME program accreditation;
  • Requests for appeal of an adverse action by a Review Committee; and,
  • Appeal presentations to an ACGME Appeals Panel.

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.

The GMEC must demonstrate effective oversight of the Sponsoring Institution’s accreditation through an Annual Institutional Review (AIR). See “GMEC Annual Institutional Review (AIR) Policy.”

The GMEC must demonstrate effective oversight of underperforming programs through a Special Review process. See “GMEC Special Review Process Policy.”

COTTAGE HEALTH SYSTEM POLICY
RECOMMENDED BY: E. Wroblewski, M.D. (CMO) DATE: 11/14
ORIGINAL POLICY EFFECTIVE DATE: 2/26/08
APPROVED BY: E. Wroblewski, M.D. (CMO) DATE: 11/14
DATE REVISED: 1/14
DATE REVIEWED: 1/12, 11/14