Review, Approval & Signature Policy

I. Purpose of policy

This policy defines the way in which documents and correspondence sent to the Accreditation Council for Graduate Medical Education (ACGME) regarding ACMGE-accredited programs at Dartmouth-Hitchcock (D-H) are overseen, reviewed, and approved by the Graduate Medical Education Committee (GMEC) and the Designated Institutional Official (DIO).

II. Policy scope

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

III. Definitions

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

Designated Institutional Official (DIO): 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 ACGME Institutional Program Requirements include:
      • 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
  • GMEC Approval and Co-Signature of Documents
    • GMEC approval and 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 it 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 advanced receipt of these documents provides adequate time to read and offer suggestions for edits and/or corrections. Upon review of the final document, the DIO will cosign and return it 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.

V. References

ACGME Institutional Requirements.(2015). Retrieved from

D-H Policy ID: 11317