Policies / New Program Director Appointment Policy

Date Established: 05/01/2012

Revision History: 11/04/2021, 07/14/22

Policy Reviewers: GME Office, Policy Subcommittee, UW Graduate Medical Education Committee (GMEC)

All University of Washington School of Medicine (UWSOM) graduate medical education (GME) training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and sponsored by UWSOM, and GME Committee (GMEC) Approved non-ACGME programs, which include non-ACGME fellowship programs that fall under ACGME recognition of Non-Standard Training (NST) for J-1 visa sponsorship.

This policy outlines 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.

3. Background

For each residency and fellowship program accredited by the ACGME, and Non-Standard Training (NST) programs, there must be a single program director (ACGME Common Program Requirements (CPR) 2.1; NST Recognition Requirements 1.3.). Program Directors have the authority and accountability for the overall program, including compliance with all applicable program requirements, as outlined in the ACGME CPRs (CPR 2.1.) for ACGME programs, or the UW GME Educational Standards for Non-ACGME Programs. Program Directors of NST programs, will be responsible for overseeing fellow supervision, education, and assessment at all participating sites of the fellowship program (NST Recognition Requirements 1.3.a.).

Program directors are expected to continue in their positions for a length of time adequate to maintain continuity of leadership and program stability (CPR 2.3.). It is the responsibility of UWSOM, as the sponsoring institution, in partnership with each of its ACGME-accredited programs, to ensure that program directors have support and dedicated time to effectively carry out educational, administrative, and leadership responsibilities (Institutional Requirements (IR) 2.2.a.). It is also the responsibility of the Designated Institutional Official (DIO) and the GME Committee (GMEC) to ensure that any new program director meets the required qualifications for this role. To ensure successful transitions in program directors, a collaborative process is thus required between department chairs, the Designated Institutional Official (DIO) and the GMEC.

4. Policy

The GMEC must review and approve the appointment of new program directors (IR 1.13.h; NST Recognition Requirements 1.4.b). To appoint a new program director to an existing program, or to appoint a program director to a program applying for ACGME accreditation or GMEC approval, the Department Chair proposes the change or appointment in advance of the proposed appointment start date. Support for the appointment by program faculty and trainees should be obtained prior to submitting the request to the GMEC. For ACGME programs, final approval of the program director resides with the Review Committee (CPR 2.2.a.)

Associate/Assistant Program Director: Approval of new associate/assistant program director appointments does not require GMEC approval. Programs should however notify the GME Office when a new associate/assistant program director has been appointed.

5. Procedure

A. ACGME programs

For ACGME programs, to initiate a new program director appointment, the Chair submits to the GME Office the proposed program director’s CV with a letter of request (using the Program Director Appointment Request Letter template) verifying the following information:

1. The program director will have the responsibility, authority, and accountability for: administration and operations; teaching and scholarly activity; resident recruitment and selection, evaluation, and promotion of residents, and disciplinary action; supervision of residents; and resident education in the context of patient care. (CPR 2.6.). Further, the program director has been delegated responsibility for and agrees to carry out the program director responsibilities as described in the CPRs (2.6.a–2.6.l).
2. The program director has been provided a written job description detailing the responsibilities of this position (see UW GME Program Director Job Description).
3. The program director meets the following qualification requirements:
4. Requisite specialty expertise, and/or qualifications acceptable to the relevant Review Committee, (CPR 2.5.);
5. Current certification in the specialty by a primary medical specialty board or specialty qualifications that are acceptable to the relevant Review Committee, (CPR 2.5.a.); and
6. Other required qualifications as specified by the appropriate Common Program Requirements set of standards and relevant Review Committee, if applicable (e.g., based at the primary training site).
7. Dedicated Time: The amount of dedicated time, defined by full time equivalent (FTE), that will be made available to the program director in order to support adequate administration of the program (CPR 2.4.). This amount must meet the required dedicated time specified by the relevant review committee. It is expected that this time will be partially utilized to complete all aspects of the New Program Director Orientation and participate in professional development activities including and Educator Development for GME Excellence​ (EDGE) offered by the UW GME Office, as well as other opportunities including School of Medicine faculty development workshops and the Teaching Scholars Program organized by the Department of Biomedical Informatics and Medical Education.
8. Funding Support: The funding support for the position of program director can include salary support, supplemental compensation, educational value units, or relief of time from other professional duties, as specified by the relevant Specialty Specific Requirements
9. Professional Development: A commitment of the department that the program director will be provided with funding for travel and participation in national meetings related to the position of program director. Specifically, program directors should be provided time and funding to attend the ACGME’s Introductory Course for New Program Directors, or an equivalent course for new program directors provided by the specialty’s program director organization, within the first two years of appointment. In additional, program directors are expected to participate in the ACGME’s Annual Educational Conference or national specialty society meetings for program directors at least once every three years.
10. Commitment to Academic Advancement: An assurance that the program director will be provided with sufficient mentorship and support to allow timely progression toward academic promotion, as well as support in evaluating and determining the programmatic role of more senior faculty, when the new program director is a junior faculty member. A program director who is a full-time clinical faculty member should be offered an opportunity to pivot to an appropriate academic track (e.g., clinician-educator, physician-scientist), and the ability to be promoted, acknowledging these new responsibilities.

B. Non-ACGME programs

For non-ACGME programs, department chairs must submit the proposed program director’s CV with an appointment letter using the Department Chair Letter of Support: Program Director Change Letter Template to the GME Office, verifying the following information:

1. The program director will have the necessary authority and accountability for the operation of the fellowship program. Further, the program director has been delegated and agrees to carry out the responsibilities of the position as outlined in the UW GME Educational Standards for Non-ACGME Programs.
2. Program director of NST program will be responsible for overseeing fellow supervision, education, and assessment at all participating sites of the fellowship program (NST Recognition Requirements 1.3).
3. Program director of NST program is a physician faculty member of the most closely related ACGME-accredited residency/fellowship program (NST Recognition Requirements 1.3).
4. Dedicated Time: The amount of dedicated time, defined by full time equivalent (FTE), that will be made available to the program director sufficient to support optimal performance in their role as Program Director^. The amount of dedicated time must meet FTE minimum requirements of any applicable accrediting bodies.
5. Resources: A commitment of the department that the program director will be provided with the necessary resources for professional development, academic advancement, adequate administrative support with a dedicated program administrator, and other resources necessary for the educational program.

6. Approval

If approved by the GMEC, the GME office will notify the new program director.

A. ACGME programs

• The GME Office will initiate a New Program Director Request in the Accreditation Data System (ADS) no more than 30 days prior to appointment date (for new programs, the approved program director will be entered into ADS upon initiation of the ACGME application for accreditation).
• Once this request has been initiated, an email will be sent to the new program director identified on the request form with instructions on how to complete the request. The email will include instructions to log into the ADS and will provide a username and password.
• The new program director will then be required to login and complete their professional information and an abbreviated CV, which will then be forwarded to the ACGME for approval.
• For some specialties, after this information is complete and submitted, the new program director will automatically be posted in ADS. For others, the request appears as “in progress”.
• Upon approval, the Review Committee may send a notification letter to the program director and DIO. If the program director does not meet Review Committee requirements, the Review Committee will notify the program director and DIO.

B. Updates to External Systems

For ACGME programs, requests to update new program directors with the National Resident Matching Program (NRMP), Electronic Residency Application Service (ERAS) or other systems will not be made until the new program director has been updated in ADS.

For non-ACGME programs the GME office will initiate the update to the new program director in the National Resident Matching Program (NRMP), MedHub Residency Management system and all other applicable systems no more than 30 days prior to appointment date.