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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

1. 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, and 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.

GMEC Responsibilities must include

2. Oversight of:

a) The ACGME accreditation status of the Sponsoring Institution and its ACGME-accredited programs;

b) The quality of the GME learning and working environment within the Sponsoring Institution, its ACGME-accredited programs, and its participating sites;

c) The quality of educational experiences in each ACGME-accredited program that lead to measurable achievement of educational outcomes as identified in the ACGME Common and specialty/subspecialty-specific Program Requirements.

d) The ACGME-accredited programs’ annual program evaluations and self-studies; and,

e) All processes related to reductions and closures of individual ACGME-accredited programs, major participating sites, and the Sponsoring Institution.

f) The provision of summary information of patient safety reports by participating sites to residents, fellows, faculty members, and other residency-related clinical staff members. At a minimum, this oversight must include verification that such summary information is being provided by participating sites.

3. Review and approval of Institutional GME policies and procedures; including

a) Resident Eligibility and Selection

b) Resident Agreement of Appointment/Contract

c) Resident Promotion, Appointment Renewal and Dismissal

d) Resident Grievance Procedure

e) Resident Liability Coverage

f) Resident Health and Disability Insurance

g) Resident Vacation and Leaves of Absence

h) Resident Services: Behavioral Health, Physician Impairment, Harassment and Accommodation for disabilities

i) Resident Supervision

j) Resident Clinical and Educational Work Hours

k) Resident Moonlighting

l) Resident Non-Competition

m) Resident Program Closure or interruption secondary to Disaster

n) Residency Closure/Reduction

o) Resident Fatigue Mitigation

p) Resident House Staff Files

q) Resident Patient Safety

r) Resident Quality Improvement

s) Resident Transitions of Care

t) Resident Professionalism

u) Resident Well-being

v) GME Curriculum Policy

w) GME Evaluation Policy

x) GME Annual Institutional Review (AIR) Policy

y) GME Special Review Process

4. Review and approval of:

a) Annual recommendations to the Sponsoring Institution’s administration regarding resident/fellow stipends and benefits;

b) Applications for ACGME accreditation of new programs;

c) Requests for permanent changes in resident complement

d) Major changes in ACGME-accredited programs’ structure or duration of education;

e) Additions and deletions of ACGME-accredited programs’ participating sites;

f) Appointment of new program directors;

g) Progress reports requested by a Review Committee;

h) Responses to Clinical Learning Environment Review (CLER) reports;

i) Requests for exceptions to clinical and educational work hour requirements;

j) Voluntary withdrawal of ACGME program accreditation;

k) Requests for appeal of an adverse action by a Review Committee; and,

l) Appeal presentations to an ACGME Appeals Panel.

5. Role of 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.

6. 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.”

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

COTTAGE HEALTH 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: 11/17
DATE REVISED: 1/14
DATE REVIEWED: 1/12, 11/14