Letter to the Community: ACGME Makes Changes in Response to GME Community’s Concerns

Dear Graduate Medical Education Colleagues,

As I wrote to you last week, the ACGME has launched a series of listening sessions with the graduate medical education (GME) community to gauge the impact of the current surge of COVID-19 cases experienced by your programs and Sponsoring institutions. We have heard about your staffing challenges, increased patient care volumes, and the physical and mental exhaustion suffered by your staff members. We have also been inspired by your continued dedication and service to your healing and educational mission. We have used the advice you have given us on how the ACGME can help ease the burden on your Sponsoring Institutions and programs to guide modifications to our accreditation processes during this crisis.

This letter will describe the changes being implemented to respond to the current environment, balanced with our accreditation responsibilities to you, the residents and fellows, the patients, and the public we all serve.

Site Visits

Background: Many participants in the listening sessions expressed concern about ACGME site visits during the COVID-19 surge. During this surge and its attendant staffing and volume challenges, all time must be spent caring for patients and supervising residents.

Response:  

1. 1. The ACGME will not schedule an accreditation or recognition site visit for a program at a Sponsoring Institution with Emergency categorization.
   2. A program at a Sponsoring Institution with Emergency categorization, with approval from its Sponsoring Institution, may request an exception be considered for a site visit for a program application.
   3. If a program has an accreditation or recognition site visit scheduled and then the Sponsoring Institution enters Emergency categorization, the program may request postponement of that site visit with approval from its Sponsoring Institution. The ACGME will review each request and communicate a decision to the Sponsoring Institution and program as soon as possible.
   4. A postponed program accreditation or recognition site visit will be rescheduled once the Sponsoring Institution returns to Non-Emergency categorization.
   5. A program may be scheduled for an accreditation site visit for an alleged potentially egregious event, including complaints, while its Sponsoring Institution is in Emergency categorization.
   6. A Sponsoring Institution may be scheduled for an accreditation site visit during Emergency categorization.
   7. Additionally, Sponsoring Institutions and programs that are not in Emergency categorization can request postponement of a scheduled accreditation or recognition site visit due to severe pandemic-related disruption to GME. The ACGME will review each request and communicate a decision to the Sponsoring Institution or program as soon as possible.

Please contact ACGME Field Activities (dfascheduling@acgme.org) to request postponement of a scheduled site visit.

CLER staff members will contact institutions with a CLER visit scheduled in January or February to ask if you would like to postpone the visit.

Mid-Year Milestones Reporting

Background: The Milestones reporting window was scheduled to end on January 14, 2022. During the listening sessions participants commented that programs and institutions in the early phase of the surge have not had time to enter their data. They asked if the window for reporting could be lengthened.

Response: As reported earlier this week, the mid-year window for Milestones reporting has been extended until February 11 to give programs an extra month to complete reviews and submit their reports. As of the time of this letter, approximately two-thirds of programs have already completed Milestones reporting.

Resident/Fellow and Faculty Surveys

Background: During the listening sessions, designated institutional officials (DIOs) and program directors expressed concern over the timing and need for the annual Resident/Fellow and Faculty Surveys, given disruptions from the Omicron surge.

The Resident/Fellow and Faculty Surveys are an important tool in the continuous improvement of GME programs. While many are concerned that the timing of its administration may affect results this year, our internal analysis of the Resident/Fellow Survey administered in the spring of 2020 failed to demonstrate significant differences in the “Third Window” responses (during the pandemic) versus the first two windows of administration (before the pandemic). The ACGME Review Committees, composed largely of practicing clinical faculty members, are aware of the extraordinary challenges faced by programs and their Sponsoring Institutions and should consider these conditions in their accreditation reviews. As can be seen from the ACGME Data Resource Book, adverse accreditation decisions are infrequent, and not more prevalent in the pandemic period when compared to pre-pandemic accreditation activity.

The ACGME had planned to change the process of accessing the Resident/Fellow and Faculty Surveys this year by directly communicating the availability of the survey to Residents/Fellows and faculty members. This change was designed to reduce the burden on program directors and coordinators in distributing the survey.

Response:

1. 1. We will maintain the existing system this year, giving program directors and coordinators the ability to initiate notice to their residents/fellows and faculty members that the survey is available to complete at a time they consider most appropriate during the reporting window.
   2. The reporting period for the ACGME’s annual surveys will now run from February 28, 2022 through April 17, 2022, so that responses can be collected after the projected peak of the current Omicron surge. This will provide a reporting period of seven weeks not significantly reduced from last year’s reporting period of eight-and-a-half weeks. As the survey results are valued by programs and institutions for their continuous quality improvement efforts, further delay would significantly delay release of the program and comparison data. With a window closing of April 17, we anticipate that programs will still receive their reports in early May. Further information on these changes will be communicated to you in early February.

Supplemental Payment to Residents and Fellows

Background: Many participants in the listening sessions indicated they are providing additional payments to residents and fellows working to support the institution during staffing shortages and the Omicron surge.

Response: While the ACGME requires that residents and fellows have contracts, we do not set salaries. However, there is nothing in the ACGME Requirements that prohibits additional payments to residents and fellows for the work they are performing. Note, however, that any additional work hours must be counted toward the clinical and educational work hour limits.

Emergency Categorization

Background: During the listening sessions there were several observations about COVID-19 Emergency categorization. One concern was the uneven disruption of programs in large Sponsoring Institutions and the inability for an individual program to request Emergency categorization. Additionally, there was concern that the criteria for extending or renewing Emergency categorization were not appropriate for the current surge, where disruptions are more commonly related to staffing shortages.

Response: The Emergency categorization application form is being updated to acknowledge that short-term staffing concerns may contribute to disruption to GME, and may support emergency categorization in the 61- to 90-day window. While Emergency categorization continues to apply to Sponsoring Institutions, DIOs—in partnership with program directors, the GMEC, and other GME leaders—have the discretion to use Emergency categorization to facilitate focused reassignment of residents and fellows.

As a reminder, this flexibility with requirements is provided consistent with the ACGME’s commitment to the safety of patients, as well as that of our residents, fellows, faculty members, and the entire health care community. The ACGME expects strict compliance in all settings with the following four requirements:

1. Work hours
2. Adequate resources and training for the roles residents/fellows assume
3. Adequate supervision in all aspects of resident/fellow activities
4. Fellows functioning in their core (primary) specialty during the surge in patient illness

We recently updated the COVID-19 section of our website. Updates include revised Frequently Asked Questions in the sections related to the Pandemic and Accreditation Decisions and the Pandemic and Program Requirements, as well as to the Guidance Statement on Competency-Based Medical Education during COVID-19 Residency and Fellowship Disruptions.

Due to the urgency of the current pandemic circumstances in some parts of the country, and the consistency of the suggestions received from DIOs and program directors, the ACGME has made these changes prior to completion of our listening sessions. The ACGME will continue to host these listening sessions with various members of the GME community over the next several weeks. Please check the COVID-19 section of our website frequently for updated information and resources that are developed in response to these sessions. The ACGME is extremely grateful to the community for your participation in these sessions and for your willingness to help the ACGME as an accreditor support you in continuing to provide patient care and education throughout the pandemic.

Once again, on behalf of the ACGME, I offer my sincere gratitude for the professionalism you have demonstrated and continue to demonstrate as we confront the pandemic with its resultant human suffering and tragic outcomes. All of us at the ACGME understand this comes at a personal and professional cost to you, your families, your colleagues on the faculty, your staff members, your residents and fellows, and the patients you serve. I urge you to continue to care for yourself and your colleagues, and to support each other’s physical and emotional needs during this most challenging time. It is only together that we will have the strength to meet the current challenge and continue to grow professionally.

Sincerely,

Thomas J. Nasca, MD, MACP
President and Chief Executive Officer
ACGME