Affiliation Agreement & Program Letters of Agreement Policy

I. Purpose of policy

This policy outlines the agreements that must be in place when a Resident in an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency or fellowship program rotates to a domestic teaching location not affiliated with Dartmouth-Hitchcock (D-H).

II. Policy scope

The policy applies to all Residents, Program Directors, Program Coordinators, and GME Office Staff of ACGME-accredited residency and fellowship programs at D-H.

III. Definitions

Accreditation Council for Graduate Medical Education (ACGME): The organization responsible for accrediting Sponsoring Institutions and residency and fellowship programs at D-H.

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

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

Affiliation Agreement (AA): An agreement that is 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): A contract between Mary Hitchcock Memorial Hospital (MHMH) and a domestic teaching location not affiliated with D-H.

Addendum: Periodic updates to established AAs or MAAs.

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

Observership: An educational activity with no direct or indirect patient care responsibilities.

IV. Policy statement

  • Whenever a Resident rotates to a domestic teaching facility not affiliated with D-H a written Master Affiliation Agreement (MAA), Affiliation Agreement (AA) or Program Letter of Agreement (PLA) must be in place to document and define the relationship between Mary Hitchcock Memorial Hospital (MHMH) and another institution or organization.
  • A periodic Addendum must be made to give notice of change or to update elements of the relationship to the GME Office.
  • Written agreements must follow the current templates provided by the GME Office
  • Per ACGME Common Program Requirements agreements 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 ACGME Review Committee (RC)-specific guidelines regarding additional expected content of the agreements.
  • In addition, AAs and PLAs 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 a non-D-H site must be managed pursuant to relevant MHMH policies and procedures;
    • 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 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 mandatory institutional form(s), it is possible that these 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 MAAs and AAs 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 Graduate Medical Education Committee (GMEC) for review and approval.
    • Following GMEC approval, the Program Director must submit the approved GMEC content through the ACGME Accreditation Data System (ADS).

V. References

Common Program Requirements. (2016). Retrieved from ACGME.org:

Specialty Specific Program Requirements. (2015-2016). Retrieved from ACGME.org:

D-H Policy ID: 11290