Description

In order to provide guidance, and in an effort to assist in understanding the range of responsibilities assigned to a Program Director, the University of Kentucky Graduate Medical Education Committee (GMEC) has developed this guidance document outlining GME Program Director expectations and responsibilities. 
UK Graduate Medical Education residency and fellowship programs are conducted within colleges, departments and/or divisions and exist within the environment and oversight of an accredited Sponsoring Institution. In accordance with UK Administrative Regulation 5:4, the Graduate Medical Education Committee (GMEC) and Senior Associate Dean for GME/ACGME Designated Institutional Official (DIO) are jointly responsible for the oversight of all UK GME programs. Each program director is responsible not only to the department/organizational unit housing the program for the organization and implementation of the program but also to the GMEC and the DIO. Specific tasks may be delegated, but the Program Director is responsible for the program as a whole, and for the timely and accurate completion of all required tasks. 
In addition to the ACGME or equivalent accrediting body, a number of other regulatory bodies impose requirements on the GME programs. These agencies include (but are not limited to) the University of Kentucky System, UK Healthcare Enterprise, Kentucky Medical (or equivalent) Licensure Board, The Joint Commission, National Resident Matching Program, the Veterans Health Care System, and other affiliated hospitals/health care entities. Compliance with these 
requirements is the responsibility of the Program Directors, working in concert with the GME Office, DIO, and GMEC.

Definitions: 
A. “House Staff” (plural “house officers,” collective “house staff”) - any intern, resident or fellow who is actively participating in a graduate medical education program that is 
supervised by the GMEC and is on the house staff roster. 
B. GME programs may be characterized as: 
1. ACGME accredited – for which there are specific ACGME program requirements 
2. Non-ACGME-accredited - for which there are no specific ACGME program requirements however other relevant accrediting body requirements (eg Commission on Dental Accreditation, American Board of Psychiatry and Neurology, American Society of Health-System Pharmacists, Commission on 
Accreditation of Medical Physics Education Programs, Accreditation Council on Optometric Education, Association of Clinical Pastoral Education). 
C. Program directors of non-ACGME programs are exempted from some responsibilities listed below under ‘ACGME Program Director Additional Responsibilities’ 

Responsibilities of all UK GME Program Directors include the following: 
A. Expectations for Participation in GMEC Governance  
1. Maintain current knowledge of, and compliance with, GME Policies. 
2. Maintain current knowledge of, and compliance with, ACGME Institutional and Program Requirements (www.acgme.org) or equivalent accreditation guidelines. 
3. Participate in the GMEC, including program representation at GMEC Meetings and its subcommittees, as requested. Program Directors designated as voting members of the GMEC must attend at least 70% of GMEC meetings occurring during each academic year. 
4. Respond promptly to requests from the GME Office/DIO and/or GMEC for information, documentation, and/or participation in GMEC or its subcommittees. Maintain accurate and complete residents/fellow and program files in compliance with institutional records retention policies, ACGME, and or other applicable accrediting bodies. 
5. Assist and collaborate with other program director(s) as needed to facilitate compliance with ACGME or equivalent accrediting requirements. 
6. Comply with all necessary aspects of participation, preparation, and execution of accreditation site visits, as directed by the site visitor and accrediting requirements. 
B. Educational Leadership Responsibilities 
1. Facilitate house staff participation in the educational and scholarly activities of the program, and ensure that they assume responsibility for teaching and supervising other house staff and students. 
2. Assist house staff in obtaining appointment to appropriate institutional and departmental committees and councils whose actions affect their education 
and/or patient care. 
3. Ensure house staff participation in training required by the institution. 
4. Ensure that the program’s policies regarding evaluation and performance feedback are followed for all house staff and faculty within the program. 
5. Develop overall educational goals for the program and ensure distribution to residents/fellows and faculty annually. 
6. Develop and oversee an educational curriculum including regularly scheduled didactics and clinical components with appropriate evaluation methods as defined in the ACGME Program Requirements for the specialty or, if a non-ACGME accredited program, evaluation as deemed sufficient by the applicable accrediting body. 
7. Periodically review/revise the curriculum for currency. 
8. Ensure that the program provides effective educational experiences for house staff  
that lead to measurable achievement of educational outcomes  
C. Administrative Oversight Responsibilities  
1. Administer and maintain an educational environment conducive to educating the house staff in all competency areas. 
2. Oversee and organize the activities and ensure the quality of the educational program in all sites that participate in the program. This includes ensuring a Program Letter of Agreement (PLA) is in place prior to a rotation commencing in addition to appointing a local site director, appropriate faculty and other program personnel, monitoring that there is appropriate house staff supervision, and that the rotation is providing the expected educational value. 
3. Approve a local site director at each participating site who is accountable for house staff education. 
4. Approve the selection of program faculty as appropriate. Participate in the evaluation of program faculty and approve the continued participation of program faculty based upon evaluation. 
5. Delineate house staff responsibilities for patient care, progressive responsibility for patient management, and supervision of house staff over the continuum of the program. Monitor supervision at all participating sites ensuring that it is appropriate and that it allows for progressively increasing responsibility, according to the house officer’s level of education, ability, and experience. 
6. Comply with the sponsoring institution’s written policies and procedures, for disciplinary action, grievance procedures, and due process. This includes proactive consultation with the Senior Associate Dean for GME/ACGME DIO prior to initiation of either informal (Notice of Concern) or formal academic actions.  
7. Create, implement, and review periodically program-specific policies to ensure consistency with institutional policies   
8. Monitor house staff work hours with a frequency sufficient to ensure compliance with ACGME and/or other applicable accreditation requirements. 
9. Adjust resident/fellow schedules as necessary to mitigate excessive service demands and/or fatigue. 
10. Monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue, if applicable. 
11. Monitor the need for and ensure the provision of back-up support systems when patient care responsibilities are unusually difficult or prolonged. 
12. Monitor residents/fellows for mental or emotional conditions inhibiting performance or learning and for the presence of substance abuse related impairment. Seek timely consultation with the DIO to escalate any concerns or need for further evaluation of a resident/fellow in accordance with GME policies. Be sensitive to the need for timely provision of confidential counseling and psychological support services. 
13. Comply with UK and your program’s written policies and procedures, for the recruitment, selection, evaluation and promotion of house officers, and supervision of house staff.  
14. Obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of all transferring 
house staff. 
15. Report the presence of other learners who are interfering or have the potential to interfere with resident/fellow education to the DIO/ GMEC. 
16. Manage clinical scheduling of house staff including, but not limited to: 
a. Creating rotation and on-call schedules 
b. Structuring on-call schedules to provide readily available supervision to trainees on duty, and ensuring that appropriate backup support is available 
when patient care responsibilities are especially difficult or prolonged. 
c. Structuring work hours and on-call time periods so as to focus on the needs of the patient, continuity of care, and the educational needs of the house officer, and to comply with requirements as set by the institution, ACGME, or equivalent accrediting body. 
17. Provide oversight and liaison with appropriate personnel of other institutions participating in the training of the program’s house staff. 
18. Participate in academic societies and in educational programs designed to enhance educational and administrative skills. 
D. ACGME Program Director Additional Responsibilities  
1. Maintain current knowledge of, and compliance with, the ACGME Program Requirements or equivalent accrediting guidelines pertaining to the program, as well as any other program policies and procedures, subspecialty program requirements, etc. 
2. Maintain current knowledge of, and compliance with, the ACGME Manual of Policies and Procedures.  
3. Comply with all necessary aspects of participation, preparation, and execution of ACGME accreditation site visits, as directed by the site visitor and accrediting requirements. 
4. Respond promptly to any communication from the ACGME or equivalent accrediting body requests for information, working with the GME Office to ensure compliance with all stated deadlines, as well as timely review by the DIO. 
5. Maintain accurate and complete program and resident/fellow records through the ACGME Accreditation Data System (ADS) 
6. Ensure that residents/fellows and program faculty complete annual ACGME surveys  
7. Obtain review and approval of the sponsoring institution’s GMEC/DIO before submitting correspondence to the ACGME or its Review Committees.  
8. Appoint and participate in ensuring the function and outcome of the Clinical Competency Committee (CCC) including completion of Semi-Annual Evaluations. 
9. Appoint and participate in the Program Evaluation Committee (PEC) and ensure on time submission of the Annual Program evaluation (APE) to the GME 
Office/DIO/GMEC. 
10. Provide competency-based goals and objectives for each assignment at each educational level as defined in the ACGME Common Program Requirements and distribute to residents/fellows and faculty annually.

Requirements

MD or DO with at least three (3) years of documented educational and/or administrative experience post-graduation

Board Certified by the American Board of Surgery in General Surgery