Dartmouth-Hitchcock

Review, Approval and Signature Policy

Scope

The policy applies to all ACGME-accredited residency and fellowship programs at DHMC.

Purpose

1. To define the requirements for the review, approval and co-signature of documents being submitted to the Accreditation Council for Graduate Medical Education (ACGME).
2. To ensure institutional oversight as required by the ACGME Institutional Requirements.

Policy Guidelines

Review of Documents

1. As set forth in the ACGME Institutional Program Requirements, documents and correspondence sent to the ACGME by Program Directors must be reviewed and approved by the DHMC Graduate Medical Education Advisory Committee (GMEC) and/or the Designated Institutional Official (DIO) as outlined in this document.
2. Documents requiring GMEC review and approval per the Institutional Program Requirements include:
   • All applications for ACGME accreditation of new programs;
   • Changes in resident/fellow complement;
   • Major changes in program structure or length of training;
   • Additions and deletions of participating sites;
   • Appointments of new program directors;
   • Progress reports requested by any Review Committee;
   • Responses to all proposed adverse actions;
   • Requests for exceptions of resident duty hours;
   • Voluntary withdrawal of program accreditation;
   • Requests for an appeal of an adverse action;
   • Appeal presentation to a Board of Appeal of the ACGME.
3. In addition to the above listed documents, the DIO is also required to review and sign-off on:
   • Program Information Forms (PIF's);
   • Any other documents or correspondence sent to the ACGME by the Program Director.

GMEC Approval and Co-Signature of Documents

1. GMEC approval and a co-signature by the DIO attest to the accuracy, completeness and support of the content of the document.  Therefore, it is essential that adequate time be allowed for review, including opportunity for recommending edits and/or corrections, prior to final approval or co-signature of a document.  To facilitate this process:
   • Documents that require GMEC approval must be received in the GME Office no later than one week (seven days) in advance of the GMEC meeting at which they will be reviewed and voted on.  Upon approval by the GMEC, the DIO will subsequently co-sign the document and return to the Program Director.
   • For PIF's and other documents that do not require GMEC review and approval, the DIO must receive the documents no later than four weeks (twenty-eight days) in advance of the "send deadline."  As noted above, advance receipt of these documents will provide adequate time to read and offer suggestions for edits and/or corrections.  Upon review of the final document, the DIO will cosign and return to the Program Director.
2. The DIO is required to co-sign all documents submitted to the ACGME by Program Directors.  In the DIO's absence:
   • The Associate Director of Graduate Medical Education is granted primary authority to co-sign documents submitted to the ACGME.
   • If the DIO and Associate Director of Gradate Medical Education are both absent, the Department Chair is granted authority to co-sign documents submitted to the ACGME.
   • All documents co-signed by the Associate Director or Department Chair will be reviewed by the DIO upon return to duty.

Responsibilities

1. The Program Director is responsible for:
   • Informing the DIO of upcoming pending documents that require GMEC approval and/or DIO signature.
   • Planning and implementing a timeline to ensure that documents requiring approval by the GMEC and/or co-signature by the DIO are forwarded by the deadlines noted above.
2. The GMEC is responsible for:
   • Reviewing documents from Program Directors for the ACGME, offering recommendations for edits and/or corrections, and approving documents prior to their final submission to the ACGME.
3. The DIO is responsible for:
   • Ensuring that documents forwarded by Program Directors for GMEC review and approval are added to the agenda of the next available GMEC meeting.
   • Reviewing, recommending edits/corrections, and co-signing PIF's and other documents submitted to the ACGME as outlined in this policy.
   • Establishing and implementing a plan for co-signing documents to be sent to the ACGME in the absence of the DIO.

Related Policies and Reference Material

1. ACGME Institutional Requirements at: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf
   Specific sections applicable to this policy include:
   • I.B.4.a (requirement to implement co-signature procedures)
   • III.B.10.a- k (requirement for GMEC review and approval)