GMEOC Response Policy/Process for ACGME Resident Survey

Upon receipt of a program's annual ACGME trainee survey results, the following occurs:


1.  GME Office compiles and distributes ACGME Survey Results to GME Leadership and Duty Hours Subcommittee

a.  Overall results reviewed by Dr. Getto and Dr. Goelzer at GME Leadership

b. Duty hour data analyzed by Duty Hour Subcommittee


2. Criteria below are used to identify Programs required to respond to areas of noncompliance or poor performance


a. Duty Hour Questions

1. Any program demonstrating non-compliance (i.e. gray box) on a duty hour question will be required to respond with an explanation/solution for the issue to be reviewed by the Duty Hours Subcommittee

2. If the response is inadequate, the Duty Hours subcommittee will request program logs.


b. On the remaining questions in the survey: 

1. Programs with 20 or more trainees must respond to "gray box" issues raised by 10 percent or more of respondents

2. Programs with fewer than 20 trainees must respond to "gray box" issues raised by more than one respondent

3. Programs with a history of negative responses to specific questions may be required to respond to survey results demonstrating less than the 10 percent threshold on the same question(s)

4. Programs with fewer than 4 trainees are not provided aggregate reports and thus will not be required to respond


3. GME Office distributes ACGME Survey Results to GMEOC


4. GMEOC members review Program Responses


5. GME Office communicates to Program Directors and Coordinators the areas of non-compliance/poor performance to which each program must respond.


6. GME Leadership may require follow up for programs not fitting these criteria based on specific program accreditation histories, recruitment, case mix, affiliate or other issues.


7. Internal Review Teams incorporate a Program's ACGME Survey Results and Responses into Internal Review Process for continued follow up