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Affiliation Agreement & Program Letters of Agreement Policy

I. Purpose of Policy

The purpose of this policy is the expectation that the Dartmouth-Hitchcock (D-H) Office of Graduate Medical Education (GME), with the support of the Graduate Medical Education Committee (GMEC), ensure that resident continue to receive stipends, benefits and Accreditation Council for Graduate Medical Education (ACGME)- compliant educational experiences when the residents participate in non- Dartmouth-Hitchcock (D-H) affiliated rotations.

II. Policy Scope

The policy applies to all residents that participate in domestic, non-D-H rotations in all residency and fellowship programs.

III. Definitions

Resident: Any physician in an accredited graduate medical education program, including interns, residents and fellows.


Master Affiliation Agreement (MAA): Maintained by the GME Office to establish inter-entity agreement across programs as defined by the ACGME.


Affiliation Agreement (AA): Required for rotations thirty days or more in length; rotations required for all residents in a specific program; and/or rotations to affiliate sites that are hospitals or similar corporate entities.


Program Letters of Agreement (PLA): Required for all other domestic, non-D-H rotations.


Addendum: Periodic updates to established AA’s or MAA’s.


Clinical Rotation: An educational activity that involves direct or in-direct patient care responsibilities.


Observership: An educational activity that involves direct or in-direct patient care responsibilities.


IV. Policy Statement

  • Written MAA’s, AA’s or PLA’s must be in place to document and define the relationship between Mary Hitchcock Memorial Hospital (MHMH) and the other institution or organization.

  • As required by the GME Office, a periodic addendum must be made to give notice of change or to update elements of the relationship. These written agreements must follow the current templates provided by the GME office and, per the Common Program Requirements, must:
    • Identify the faculty who will assume both educational and supervisory responsibilities for residents at the off-site location;
    • Specify off-site faculty responsibilities for teaching, supervision, and formal evaluation of residents;
    • Specify the duration and content of the educational experience including curricular goals and objectives;
    • State the policies and procedures that will govern resident education during the assignment;
    • Specify work environment and duty hour requirements;
    • Specify accreditation status of other facility if a hospital.

  • It is the responsibility of the Program Director to follow all established RRC-specific guidelines regarding additional expected content of these agreements.

  • In addition, AA’s and PLA’s must comply in writing with D-H institutional requirements up to and including:
    • Distinguish and define the rotation as either a clinical or an observership learning activity;
    • Specify professional insurance and liability
    • Research conducted by MHMH personnel at other site must be managed pursuant to relevant MHMH guidelines;
    • Each party must indemnify and hold harmless the other party from and against all losses, liabilities, and damages;
    • Compliance with Health Information Portability and Accountability Act (HIPAA) and its rules and regulations;
    • Access for Medicare audit purposes, until four (4) years after the termination of an AA or PLA;
    • Specify that an AA or PLA may be terminated without cause.

  • A PLA is not required for rotations to physician’s offices and ambulatory center(s) under the direct governance of D-H.

  • At no time will a resident or fellow be allowed to commence a non-D-H rotation without a completed, current AA or PLA on file in the GME Office.

  • When the outside facility has their own mandatory institutional form(s), it is possible that this could replace the D-H PLA, or AA, if the D-H legal department approves the form as an acceptable replacement.

  • Updates, Additions and Deletions
    • All MAA’s and AA’s must be renewed at least every five years.
    • Agreements must be updated with a standard Addendum whenever there are changes in Program Director or Participating Site Director, resident assignments, or revisions to the items specified in the Common Program Requirements.
    • The Program Director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all residents, of one month full time equivalent or more to the GMEC for review and approval.
    • Following GMEC approval, the Program Director must submit any additions or deletions of participating sites routinely providing educational experience, required for all residents, of one month full time equivalent or more through the ACGME Accreditation Data System (ADS).


D-H Policy ID: 11290

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