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Affiliation Agreement & Program Letters of Agreement Policy

Scope

The policy applies to domestic, non-DH rotations in all residency and fellowship programs.

Purpose

The Office of Graduate Medical Education and the GMEC endorse resident rotations to off-site locations to gain additional, specific educational experiences. It is the policy of the GMEC through the Office of Graduate Medical Education to ensure that residents continue to receive stipends, benefits and ACGME-compliant educational experiences when they participate in non-DH affiliated rotations.

Definitions
  • Master Affiliation Agreement - maintained by the GME Office to establish inter-entity agreement across programs as defined by the ACGME.
  • Affiliation Agreement - 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-DH rotations.
  • Addendum - periodic updates to established Affiliation Agreements or Master Affiliation Agreements.
Policy Guidelines
General
  • Written Master Affiliation Agreements, Affiliation Agreements or Program Letters of Agreement must be in place to document and define the relationship between MHMH and the other institution or organization. As required, 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, Affiliation Agreements and Program Letters of Agreement must comply in writing with D-H institutional requirements up to and including:
    • 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 HIPAA (Health Information Portability and Accountability Act) and its rules and regulations;
    • Access for Medicare audit purposes, until four (4) years after the termination of an Affiliation Agreement or Program Letter of Agreement;
    • Specify that an Affiliation Agreement or Program Letter of Agreement 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 DH.
  • At no time will a resident or fellow be allowed to commence a non-DH rotation without a completed, current Affiliation Agreement or Program Letter of Agreement on file in the GME Office.
Updates, Additions and Deletions
  • All Master Affiliation Agreements and Affiliation Agreements 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 an educational experience, required for all residents, of one month full time equivalent or more through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System (ADS).
  • The program director must submit any additions or deletions of participating sites routinely providing an educational experience required by an RRC that must be documented in the Program Information Form at the time of accreditation site visit and review through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System (ADS).
Related Policies and Reference Material
  1. DH Affiliation Agreement template
  2. DH Affiliation Agreement addendum template
  3. VAH Affiliation Agreement addendum template
  4. DH Program Letter of Agreement template
  5. GME Office Master Affiliation Agreements
    1. Veterans Affairs Medical Center, White River Junction
    2. Concord Hospital
    3. New Hampshire Hospital
    4. Southern New Hampshire Medical Center
  6. ACGME Institutional Requirements (I.C 1-3) at: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf
  7. ACGME Common Program Requirements (I.B.1-2) at:
    http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf