Review, Approval and Signature Policy
I. Purpose of Policy
The purpose of this policy is to ensure that the Graduate Medical Education Committee (GMEC) and the Designated Institutional Official (DIO) have appropriate oversight for reviewing and approving all documents and correspondence sent to the Accreditation Council for Graduate Medical Education (ACGME) per the Institutional Requirements.
II. Policy Scope
The policy applies to all ACGME-accredited residency and fellowship programs at Dartmouth- Hitchcock (D-H).
Resident: Any physician in an accredited graduate medical education program, including interns, residents, and fellows.
Designated Institutional Official: the individual in a sponsoring institution who has the authority and responsibility for all of the ACGME-accredited Graduate Medical Education (GME) programs.
IV. Policy Statement
- Review of Documents
- Documents requiring GMEC review and approval per the Institutional Program Requirements
- All applications for ACGME accreditation of new programs;
- Requests for permanent 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 a Review Committee;
- Request for appeal of an adverse action by a Review Committee;
- Requests for exceptions to resident duty hour requirements;
- Voluntary withdrawal of program accreditation;
- Appeal presentation to an ACGME Appeals Panel.
- Documents requiring GMEC review and approval per the Institutional Program Requirements include:
- GMEC Approval and Co-Signature of Documents
- 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 cosignature
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 documents that do not require GMEC review and approval, the DIO must receive the
documents no later than one week (seven 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.
- The DIO is required to co-sign all documents submitted to the ACGME by Program Directors. In
the DIO's absence:
- The Director of Graduate Medical Education is granted primary authority to co-sign documents submitted to the ACGME.
- If the DIO and Director of Graduate 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 Director of GME or Department Chair will be reviewed by the DIO upon return to duty.
- 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 cosignature of a document. To facilitate this process:
D-H Policy ID: 11317
- Table of Contents
- About GME
- ACGME Competencies
- Eligibility & Selection
- Agreement of Appointment
- Programs & Benefits
- Position Overview
- Confidential Reporting
- GME Policies
- Academic Improvement Policy
- Affiliation Agreement & Program Letters of Agreement Policy
- Appeal of Disciplinary Action Policy
- Disaster Policy
- Disciplinary Action Policy
- Domestic and International Off-Site Rotation Policy
- Duty Hours Policy
- Evaluation Policy
- Extreme Emergent Situation Policy
- General Grievances Policy
- Governance of Shared Resources Policy
- Inbound Resident Rotators
- Leave of Absence Policy
- Medical Licensing (USMLE/COMLEX) Policy
- Moonlighting Policy
- Permanent Complement Increase Request
- Program Closure and Reduction Policy
- Resident Agreement of Appointment Policy
- Resident Learning Environment Policy
- Resident Promotion Policy
- Resident Responsibilities Policy
- Resident Stipend Policy
- Resident Supervision Policy
- Resident Transfer Policy
- Restrictive Covenant Policy
- Review, Approval and Signature Policy
- Special Program Review Policy and Protocol
- Time Lost from Residency
- Transitions of Care Policy
- Institutional Policies