Policies & Procedures

GME Policies

Table Key

  • ACGME:  Scope includes Accreditation Council for Graduate Medical Education (ACGME)-accredited programs and trainees
  • CODA: Scope includes Commission on Dental Accreditation (CODA)-accredited programs and trainees
  • Non-ACGME: Scope may include all non-ACGME accredited programs and trainees, or only those identified as ACGME Non-Standard Training (NST) programs
  • Program Policy Required: Programs are required to develop and maintain a program-specific policy as outlined in the institutional policy.  These policies must be made available to program trainees and faculty, and shared with the GME Office in MedHub.  Recommended program policies are noted with an ‘R’.

PolicyRevisedACGMECODANon-ACGMEProgram Policy RequiredSummary
Annual Program Evaluation Policy2023-03XXOutlines requirements for Annual Program Evaluations (APEs) including appointment of a Program Evaluation Committee (PEC) and required PEC Charge, elements to be included in program assessment, completion of a SWOT, and documentation required by the GME Office to ensure compliance with the ACGME requirements for APE oversight.
Appointment and Performance Management Guidance for Fellow Non-ACGME 2021-07XThis guidance is intended to assist individuals who supervise and manage appointments of fellows in the Fellow Non-ACGME and Fellow Non-ACGME Stipend titles. Addresses processes for appointments, appointment renewals, managing individuals throughout their appointment term, and ending appointments.
Appointment Policy 2021-06XXOutlines requirements for appointment to a UW GME training program, including eligibility and completion of credentialing requirements, appointment duration and approved compensation reflected in the Compensation Schedule for RFPU-NW Members.
Case and Procedures Management Policy​2022-01XXSets forth expectations for resident case and procedure log management to ensure appropriate safeguards to manage PHI; maintenance of case and procedure logs to meet specialty board and ACGME requirements; and management of completed procedures and certification to meet Joint Commission requirements.
Chief Resident/Fellow Policy2021-03XProvides guidelines to programs for designating residents (or fellows) as Chief Residents during the academic year. Addresses requirements for job descriptions, additional compensation, and funding mechanisms for these positions.
Clinical Competency Committee Policy​ 2022-07XXREstablishes UW GME expectations and highlights relevant ACGME Common Program Requirements (CPRs) required for robust program Clinical Competency Committees (CCCs).
Compensation Schedule for RFPU-NW Members2022-07XXOutlines the annual compensation schedule for RFPU-NW members from July 1, 2022 - June 30, 2025.
Credentialing Policy 2021-11X
XXResidents must be fully credentialed by the GME Office prior to commencement of training in a UW GME program, and prior to reappointment to multi-year programs. Appointment to a UW GME training program is conditional and contingent upon successful completion of the credentialing process.
CVC Placement Training Policy 2024-11XXPolicy ensures standard practice of central line insertion at UW Medicine clinical sites to optimize patient safety and patient care outcomes.
Drug Enforcement Administration (DEA) Registration Policy 2024-01X
XXOutlines requirements for residents to obtain an individual DEA registration. These may be obtained on a fee-exempt basis while in the training program, and are restricted to activities within the scope of the program. Addresses when residents may use an institutional DEA and when a paid registration is required.
Educational Resources for Clinical Informatics Policy2018-03XTo ensure that the educational training experience for the UWSOM-sponsored Clinical Informatics training program complies with the institutional and program-specific Review Committee requirements, and that the allocation of clinical and other resources is appropriately monitored.
Educational Resources for Critical Care Programs Policy2016-10XTo ensure that the educational training experiences for all critical care training programs comply with the institutional and specialty-specific Review Committee requirements, and that the allocation of clinical and other resources is appropriately monitored.
Educational Resources for Pain Medicine Policy2016-10XTo ensure that the educational training experience for the UWSOM-sponsored Pain Medicine training program complies with the institutional and program-specific Review Committee requirements, and that the allocation of clinical and other resources is appropriately monitored.
Eligibility, Recruitment, and Selection Policy2023-03XXXAddresses required program policies, specialty-specific program requirements, eligibility exception requests, requirements for use of national matching/application services, required communications to applicants invited to interview.
Eligibility, Recruitment, and Selection Policy for Non-ACGME Programs2022-07XXThis policy is designed to ensure fair and consistent consideration and decision-making for all applicants to non-ACGME clinical fellowship programs in the UW School of Medicine.
Emergency Safe Ride Home Policy 2022-11XXOutlines program that reimburses trainees for rides home in specific situations. See online submission form.
Faculty Evaluation Policy2019-10XEstablishes UW GME expectations of faculty evaluations and highlights relevant ACGME Common Program Requirements (CPRs) for program directors to ensure faculty engagement in the education and supervision of residents and fellows.
GMEC Approved Non-ACGME Accredited Programs Policy 2024-06XAddresses UW GMEC oversight of non-ACGME clinical programs, required applications for new programs, areas of support for non-ACGME fellowships.
Graduation Certificate Policy2020-12X
XXGraduation certificates are issued through the UW GME Office. This is to ensure verification of successful completion of training program, authority of certificate signatories, accuracy of training dates, prevention of unauthorized use of the Dean’s signature, and centralization of the cost to generate certificates. See Graduation Certificate Reprint Form. 
Grant Funding Policy2023-06XEstablishes standard expectations for ACGME-accredited programs regarding grant funding for positions, and communication of restrictions related to training grants as it affects medical residents and fellows, with specific focus on salary and benefits.
Immunization and Health Screening Policy2022-03X
XXOutlines immunization requirements for all residents and fellows at initial onboarding, fit testing, and annual screening and respiratory protection requirements.
Industry Interactions Policy2024-10X
XXThe purpose of this policy is to ensure that educational activities at UW Medicine, affiliated training sites, and conference locations are not compromised by industry influence and that interactions with industry are conducted in ways that avoid actual or perceived conflicts of interest.
Institutional Clinical and Educational Work Hours Policy2022-06XXXThe purpose of this policy is to ensure effective oversight of institutional and program-level compliance with ACGME clinical and educational work hour requirements.
Institutional Supervision and Accountability Policy2022-03XXSets requirements to define, communicate and monitor resident supervision. Includes specialty-specific requirements for direct and indirect supervision via telecommunication technology, program requirements for supervision of invasive procedures and procedure management, and requirements for program-specific policies.
Leave Policy2022-11XXXThis policy addresses all relevant leave provisions and policies regarding resident leave, as required by the ACGME and RFPU-NW CBA and in accordance with state law, federal law, and University of Washington policy. See Leave Entry Guidelines
Licensure Examination Policy 2021-09X
XXTo meet educational and program eligibility requirements and national standards in preparation for licensure and certification by the ABMS and ABDS, residents must successfully pass specified steps of the applicable licensure examination. These must be completed according to the specified timeline by training year.
Meals Policy2022-11XXResidents must have access to appropriate food services 24 hours a day during clinical and educational assignments. See Meals Policy FAQs. 
MedHub User Access Controls Policy2021-01X
XXAccess to MedHub is controlled and documented to secure the confidentiality and integrity of the data contained therein. The GME Office grants access to MedHub only with appropriate authorization, for the duration needed, and at the minimum functional access level necessary to complete assigned duties and functions.
Medical Volunteer Activities Policy 2022-11X
XXAddresses guidelines for the approval of volunteer activities involving trainees. These activities are distinguished from moonlighting activities, in which the trainee is serving as as a licensed independent practitioner and from international rotations that fall within the scope of the training program. See Medical Volunteer Activity Request Forms. 
Moonlighting and Outside Work Policy 2024-10XXXOutside Work is defined as any voluntary, clinical or non-clinical work that is outside of a trainee’s regularly scheduled program duties. This includes Internal and External Moonlighting, Extra Pay for Extra Duty and Additional Non-Clinical Work. Outside work requires pre- approval by the resident’s Program Director and GME Office. See Moonlighting and Outside Request resources. 
New Program Director Appointment Policy2022-07XXXOutlines the responsibilities of all program directors and the process for approval of new program directors. The policy further sets expectations for departmental and institutional support required for program director appointment.
New Rotation Site Policy2015-02XTraining programs are required to obtain GME Office approval before assigning trainees to any new site, including those within and outside of UW Medicine and its close affiliates, for all required and elective rotations. In some cases, especially for global health training experiences, ACGME and/or ABMS approval must also be obtained.
Physician Impairment Policy 2024-06XCovers categories of physician impairment, requirements for monitoring and reporting of impaired residents, and institutional and state resources available to support residents.
Policy and Procedure Policy 2021-06X
XXAddresses process for addressing institution oversight of GME programs through development of GME policies and program-specific policies.
Program Reduction and Closure Policy 2021-06XXOutlines processes for the UWSOM/UWSOD to address reduction or closure of a GME program, or closure of the institution, working in collaboration with the affected training program(s). Includes steps to ensure current residents are able to complete their education within the program or within a program at another institution.
Remediation Policy and Grievance Procedure 2024-09XXThis policy and process is designed to ensure that actions that might adversely affect a resident’s status in a program due to resident performance are taken only after following an appropriate and fair process for remediation, while simultaneously ensuring patient safety, quality of care, and the orderly conduct of the training program.
Residency and Fellowship Position Appointment (RFPA) Agreement 2024-20252024-01XXOutlines the terms and conditions of resident and fellow appointments to a UW GME training program, including the established educational and clinical practices, policies, procedures, and resources that apply to residents and fellows, and the relevant parties subject to the terms of the agreement.
Resident and Fellow Evaluation Policy2023-12XXEstablishes UW GME expectations and highlights relevant ACGME Common Program Requirements (CPRs) required for robust program evaluation systems to oversee resident and fellow performance. Includes expectations for feedback, formative and summative evaluations, and final evaluations at completion of the program.
Resident and Fellow Files Policy2019-06XXOutlines relevant institutional and accreditation policies for management and maintenance of resident files.
Scheduling and Boarders Policy 2023-06XXA critical element of a high-quality educational experience is timely availability of schedules for training experiences. This policy outlines expectations for program management of resident schedules, and coordination of schedules and educational experiences of residents boarding in other UW programs.
Special Review Policy2021-07XPrograms identified by the GMEC as underperforming based on the quality of various program metrics will undergo a Special Review as required by the ACGME. These reviews are intended to reduce ACGME citations, improve program quality, identify areas for improvement, and advocate for learners in the program.
State Licensing Policy 2021-06X
XXResidents must hold an active provider license or permit in the state where they are training. Policy addresses license categories and compliance monitoring.
Substantial Disruptions in Patient Care and Education Policy 2021-06X
XXOutlines institutional responsibilities to addresses support of programs and trainees in the event of a disaster or other substantial disruption in patient care or education. Includes communications, trainee support, continuity of patient care, and ongoing management of administrative functions.
Supervision Policies​XXLinks to program-level supervision policies.
Telehealth Policy 2022-06XXOutlines requirements completion of telehealth training prior to engaging in patient care using telecommunication technologies; specialty-specific supervision requirements; and professional licensing laws and restrictions on providing care via telehealth to patients located outside of the state of their primary training site.
Transfer Policy2021-07XXTo define the transfer process for residents transferring into a UWSOM or UWSOD GME training program from another program within or outside the UWSOM or UWSOD
Transitions of Care Policy2018-12XXResidents are required to adhere to general institutional policies and to program-specific policies for transitions of care. All residents must be trained and systematically assessed for competency in the transition of care process, which includes hand-off skills and communication with team members during the hand-off process.
Visa Policy2023-03XXForeign nationals applying to a UW graduate medical education training program must have U.S. legal permanent residence or a valid Employment Authorization Document (EAD) that can be extended to cover the training period or be eligible to apply for a J-1 visa, F-1 OPT, or H-1B visa.
Visiting Resident and Fellow Policy 2024-05XOutlines requirements for GME programs to accept visiting trainees matriculated in ACGME-accredited residency and fellowship programs at outside institutions for rotations of limited duration in UW GME training programs.
Well-Being Policy 2019-12XXWell-being of residents, fellows, and faculty members is a key element of a positive learning and working environment. Policy addresses required infrastructure, resources and support systems to ensure trainee and faulty well-being.

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Phone: 206.543.6806
Email: uwgme@uw.edu
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Box 358047
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