Common Program Requirements

ACGME Program Requirements for

Graduate Medical Education

in Critical Care Medicine

ACGME-approved Focused Revision: February 7, 2022; effective July 1, 2022

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Contents

Introduction ................................................................................................................................. 3

Int.A. Preamble ................................................................................................................... 3

Int.B. Definition of Subspecialty ....................................................................................... 3

Int.C. Length of Educational Program .............................................................................. 4

I. Oversight ............................................................................................................................... 4

I.A. Sponsoring Institution .............................................................................................. 4

I.B. Participating Sites ..................................................................................................... 4

I.C. Recruitment ............................................................................................................... 6

I.D. Resources .................................................................................................................. 6

I.E. Other Learners and Other Care Providers .............................................................. 9

II. Personnel ............................................................................................................................... 9

II.A. Program Director ....................................................................................................... 9

II.B. Faculty ...................................................................................................................... 14

II.C. Program Coordinator .............................................................................................. 17

II.D. Other Program Personnel ....................................................................................... 18

III. Fellow Appointments .......................................................................................................... 19

III.A. Eligibility Criteria ..................................................................................................... 19

III.B. Number of Fellows .................................................................................................. 21

III.C. Fellow Transfers ...................................................................................................... 21

IV. Educational Program .......................................................................................................... 21

IV.A. Curriculum Components

........................................................................................ 21

IV.B. ACGME Competencies ........................................................................................... 22

IV.C. Curriculum Organization and Fellow Experiences .............................................. 28

IV.D. Scholarship .............................................................................................................. 30

V. Evaluation ............................................................................................................................ 32

V.A. Fellow Evaluation .................................................................................................... 32

V.B. Faculty Evaluation ................................................................................................... 35

V.C. Program Evaluation and Improvement ................................................................. 36

VI. The Learning and Working Environment .......................................................................... 40

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability ............ 41

VI.B. Professionalism ....................................................................................................... 46

VI.C. Well-Being ................................................................................................................ 48

VI.D. Fatigue Mitigation .................................................................................................... 51

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care ........................... 52

VI.F. Clinical Experience and Education ........................................................................ 53

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ACGME Program Requirements for Graduate Medical Education 1

in Critical Care Medicine 2

Common Program Requirements (Fellowship) are in BOLD 4

Where applicable, text in italics describes the underlying philosophy of the requirements in that 6

section. These philosophic statements are not program requirements and are therefore not 7

citable. 8

Background and Intent: These fellowship requirements reflect the fact that these

learners have already completed the first phase of graduate medical education. Thus,

the Common Program Requirements (Fellowship) are intended to explain the

differences.

Introduction 11

Int.A. Fellowship is advanced graduate medical education beyond a core 13

residency program for physicians who desire to enter more specialized 14

practice. Fellowship-trained physicians serve the public by providing 15

subspecialty care, which may also include core medical care, acting as a 16

community resource for expertise in their field, creating and integrating 17

new knowledge into practice, and educating future generations of 18

physicians. Graduate medical education values the strength that a diverse 19

group of physicians brings to medical care. 20

Fellows who have completed residency are able to practice independently 22

in their core specialty. The prior medical experience and expertise of 23

fellows distinguish them from physicians entering into residency training. 24

The fellow’s care of patients within the subspecialty is undertaken with 25

appropriate faculty supervision and conditional independence. Faculty 26

members serve as role models of excellence, compassion, 27

professionalism, and scholarship. The fellow develops deep medical 28

knowledge, patient care skills, and expertise applicable to their focused 29

area of practice. Fellowship is an intensive program of subspecialty clinical 30

and didactic education that focuses on the multidisciplinary care of 31

patients. Fellowship education is often physically, emotionally, and 32

intellectually demanding, and occurs in a variety of clinical learning 33

environments committed to graduate medical education and the well-being 34

of patients, residents, fellows, faculty members, students, and all members 35

of the health care team. 36

In addition to clinical education, many fellowship programs advance 38

fellows’ skills as physician-scientists. While the ability to create new 39

knowledge within medicine is not exclusive to fellowship-educated 40

physicians, the fellowship experience expands a physician’s abilities to 41

pursue hypothesis-driven scientific inquiry that results in contributions to 42

the medical literature and patient care. Beyond the clinical subspecialty 43

expertise achieved, fellows develop mentored relationships built on an 44

infrastructure that promotes collaborative research. 45

Int.B. Definition of Subspecialty 47

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Critical care medicine is the internal medicine subspecialty that focuses on the 48

diagnosis, management, and prevention of complications in patients who are 49

severely ill and who usually require intensive monitoring and/or organ system 50

support. 51

Int.C. Length of Educational Program 53

The educational program in critical care medicine must be 24 months in length. 55

(Core)*

I. Oversight 58

I.A. Sponsoring Institution 60

The Sponsoring Institution is the organization or entity that assumes the 62

ultimate financial and academic responsibility for a program of graduate 63

medical education consistent with the ACGME Institutional Requirements. 64

When the Sponsoring Institution is not a rotation site for the program, the 66

most commonly utilized site of clinical activity for the program is the 67

primary clinical site. 68

Background and Intent: Participating sites will reflect the health care needs of the

community and the educational needs of the fellows. A wide variety of organizations

may provide a robust educational experience and, thus, Sponsoring Institutions and

participating sites may encompass inpatient and outpatient settings including, but not

limited to a university, a medical school, a teaching hospital, a nursing home, a

school of public health, a health department, a public health agency, an organized

health care delivery system, a medical examiner’s office, an educational consortium, a

teaching health center, a physician group practice, federally qualified health center, or

an educational foundation.

I.A.1. The program must be sponsored by one ACGME-accredited 71

Sponsoring Institution.

(Core)*

I.B. Participating Sites 74

A participating site is an organization providing educational experiences or 76

educational assignments/rotations for fellows. 77

I.B.1. The program, with approval of its Sponsoring Institution, must 79

designate a primary clinical site.

(Core)

I.B.1.a) A critical care medicine fellowship must function as an integral 82

part of an ACGME-accredited residency in internal medicine.

(Core)

I.B.1.b) Located at the primary clinical site, there should be at least three 85

ACGME-accredited subspecialty programs from the following 86

disciplines: in cardiovascular disease, gastroenterology, infectious 87

diseases, nephrology, or pulmonary disease.

(Detail)

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I.B.1.c) The Sponsoring Institution must establish the critical care 90

medicine fellowship within a department of internal medicine or an 91

administrative unit whose primary mission is the advancement of 92

internal medicine subspecialty education and patient care.

(Detail)

I.B.1.d) The Sponsoring Institution must ensure that there is a reporting 95

relationship with the program director of the internal medicine 96

residency program to ensure compliance with ACGME 97

accreditation requirements.

(Core)

I.B.2. There must be a program letter of agreement (PLA) between the 100

program and each participating site that governs the relationship 101

between the program and the participating site providing a required 102

assignment.

(Core)

103

104

I.B.2.a) The PLA must: 105

106

I.B.2.a).(1) be renewed at least every 10 years; and,

(Core)

107

108

I.B.2.a).(2) be approved by the designated institutional official 109

(DIO).

(Core)

110

111

I.B.3. The program must monitor the clinical learning and working 112

environment at all participating sites.

(Core)

113

114

I.B.3.a) At each participating site there must be one faculty member, 115

designated by the program director, who is accountable for 116

fellow education for that site, in collaboration with the 117

program director.

(Core)

118

119

Background and Intent: While all fellowship programs must be sponsored by a single

ACGME-accredited Sponsoring Institution, many programs will utilize other clinical

settings to provide required or elective training experiences. At times it is appropriate

to utilize community sites that are not owned by or affiliated with the Sponsoring

Institution. Some of these sites may be remote for geographic, transportation, or

communication issues. When utilizing such sites, the program must designate a

faculty member responsible for ensuring the quality of the educational experience. In

some circumstances, the person charged with this responsibility may not be physically

present at the site, but remains responsible for fellow education occurring at the site.

The requirements under I.B.3. are intended to ensure that this will be the case.

Suggested elements to be considered in PLAs will be found in the ACGME Program

Director’s Guide to the Common Program Requirements. These include:

• Identifying the faculty members who will assume educational and supervisory

responsibility for fellows

• Specifying the responsibilities for teaching, supervision, and formal evaluation

of fellows

• Specifying the duration and content of the educational experience

• Stating the policies and procedures that will govern fellow education during the

assignment

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120

I.B.4. The program director must submit any additions or deletions of 121

participating sites routinely providing an educational experience, 122

required for all fellows, of one month full time equivalent (FTE) or 123

more through the ACGME’s Accreditation Data System (ADS).

(Core)

124

125

I.C. The program, in partnership with its Sponsoring Institution, must engage in 126

practices that focus on mission-driven, ongoing, systematic recruitment 127

and retention of a diverse and inclusive workforce of residents (if present), 128

fellows, faculty members, senior administrative staff members, and other 129

relevant members of its academic community.

(Core)

130

131

Background and Intent: It is expected that the Sponsoring Institution has, and programs

implement, policies and procedures related to recruitment and retention of minorities

underrepresented in medicine and medical leadership in accordance with the

Sponsoring Institution’s mission and aims. The program’s annual evaluation must

include an assessment of the program’s efforts to recruit and retain a diverse workforce,

as noted in V.C.1.c).(5).(c).

132

I.D. Resources 133

134

I.D.1. The program, in partnership with its Sponsoring Institution, must 135

ensure the availability of adequate resources for fellow education. 136

(Core)

137

138

I.D.1.a) Space and Equipment 139

140

There must be space and equipment for the program, including 141

meeting rooms, examination rooms, computers, visual and other 142

educational aids, and work/study space.

(Core)

143

144

I.D.1.b) Facilities 145

146

I.D.1.b).(1) Inpatient and outpatient systems must be in place to 147

prevent fellows from performing routine clerical functions, 148

such as scheduling tests and appointments, and retrieving 149

records and letters.

(Detail)

150

151

I.D.1.b).(2) The sponsoring institution must provide the broad range of 152

facilities and clinical support services required to provide 153

comprehensive care of adult patients.

(Core)

154

155

I.D.1.b).(3) Fellows must have access to a lounge facility during 156

assigned duty hours.

(Detail)

157

158

I.D.1.b).(4) When fellows are in the hospital, assigned night duty, or 159

called in from home, they must be provided with a secure 160

space for their belongings.

(Detail)

161

162

I.D.1.b).(5) There must be facilities to care for patients with acute 163

myocardial infarction, severe trauma, shock, recent open 164

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heart surgery, recent major thoracic or abdominal surgery, 165

and severe neurologic and neurosurgical conditions.

(Core)

166

167

I.D.1.c) Laboratory Services 168

169

The following must be available at the primary clinical site: 170

171

I.D.1.c).(1) a supporting laboratory that provides complete and prompt 172

laboratory evaluation;

(Core)

173

174

I.D.1.c).(2) timely bedside imaging services for patients in the critical 175

care units; and,

(Core)

176

177

I.D.1.c).(3) computed tomography (CT) imaging, including CT 178

angiography.

(Core)

179

180

I.D.1.d) Other Support Services 181

182

The following must be available: 183

184

I.D.1.d).(1) an active open heart surgery program;

(Core)

185

186

I.D.1.d).(2) an active emergency service;

(Core)

187

188

I.D.1.d).(3) post-operative care and respiratory care services;

(Core)

189

190

I.D.1.d).(4) nutritional support services;

(Core)

191

192

I.D.1.d).(5) equipment necessary to care for critically ill patients; and, 193

(Core)

194

195

I.D.1.d).(6) critical care unit(s) located in a designated area within the 196

hospital, and constructed and designed specifically for the 197

care of critically ill patients.

(Core)

198

199

I.D.1.d).(6).(a) Whether operating in separate locations or in 200

combined facilities, the program must provide the 201

equivalent of a medical intensive care unit (MICU), 202

a surgical intensive care unit (SICU), and a 203

coronary intensive care unit (CICU).

(Detail)

204

205

I.D.1.d).(6).(b) The MICU or its equivalent must be at the primary 206

clinical site, and should be the focus of a teaching 207

service.

(Core)

208

209

I.D.1.d).(7) Other services should be available, including 210

anesthesiology, laboratory medicine, and, radiology.

(Detail)

211

212

I.D.1.e) Medical Records 213

214

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Access to an electronic health record should be provided. In the 215

absence of an existing electronic health record, institutions must 216

demonstrate institutional commitment to its development and 217

progress toward its implementation.

(Core)

218

219

I.D.2. The program, in partnership with its Sponsoring Institution, must 220

ensure healthy and safe learning and working environments that 221

promote fellow well-being and provide for:

(Core)

222

223

I.D.2.a) access to food while on duty;

(Core)

224

225

I.D.2.b) safe, quiet, clean, and private sleep/rest facilities available 226

and accessible for fellows with proximity appropriate for safe 227

patient care;

(Core)

228

229

Background and Intent: Care of patients within a hospital or health system occurs

continually through the day and night. Such care requires that fellows function at

their peak abilities, which requires the work environment to provide them with the

ability to meet their basic needs within proximity of their clinical responsibilities.

Access to food and rest are examples of these basic needs, which must be met while

fellows are working. Fellows should have access to refrigeration where food may be

stored. Food should be available when fellows are required to be in the hospital

overnight. Rest facilities are necessary, even when overnight call is not required, to

accommodate the fatigued fellow.

230

I.D.2.c) clean and private facilities for lactation that have refrigeration 231

capabilities, with proximity appropriate for safe patient care; 232

(Core)

233

234

Background and Intent: Sites must provide private and clean locations where fellows

may lactate and store the milk within a refrigerator. These locations should be in close

proximity to clinical responsibilities. It would be helpful to have additional support

within these locations that may assist the fellow with the continued care of patients,

such as a computer and a phone. While space is important, the time required for

lactation is also critical for the well-being of the fellow and the fellow's family, as

outlined in VI.C.1.d).(1).

235

I.D.2.d) security and safety measures appropriate to the participating 236

site; and,

(Core)

237

238

I.D.2.e) accommodations for fellows with disabilities consistent with 239

the Sponsoring Institution’s policy.

(Core)

240

241

I.D.3. Fellows must have ready access to subspecialty-specific and other 242

appropriate reference material in print or electronic format. This 243

must include access to electronic medical literature databases with 244

full text capabilities.

(Core)

245

246

I.D.4. The program’s educational and clinical resources must be adequate 247

to support the number of fellows appointed to the program.

(Core)

248

249

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I.D.4.a) Patient Population 250

251

I.D.4.a).(1) The patient population must have a variety of clinical 252

problems and stages of diseases.

(Core)

253

254

I.D.4.a).(1).(a) Because critical care medicine is multidisciplinary in 255

nature, the program must provide opportunities to 256

manage adult patients with a wide variety of serious 257

illnesses and injuries requiring treatment in a critical 258

care setting.

(Detail)

259

260

I.D.4.a).(2) There must be patients of each gender, with a broad age 261

range, including geriatric patients.

(Core)

262

263

I.D.4.a).(3) A sufficient number of patients must be available to enable 264

each fellow to achieve the required educational outcomes. 265

(Core)

266

267

I.D.4.b) There must be an average daily census of at least five patients 268

per fellow during assignments to critical care units.

(Detail)

269

270

I.E. A fellowship program usually occurs in the context of many learners and 271

other care providers and limited clinical resources. It should be structured 272

to optimize education for all learners present. 273

274

I.E.1. Fellows should contribute to the education of residents in core 275

programs, if present.

(Core)

276

277

Background and Intent: The clinical learning environment has become increasingly

complex and often includes care providers, students, and post-graduate residents and

fellows from multiple disciplines. The presence of these practitioners and their learners

enriches the learning environment. Programs have a responsibility to monitor the learning

environment to ensure that fellows’ education is not compromised by the presence of

other providers and learners, and that fellows’ education does not compromise core

residents’ education.

278

II. Personnel 279

280

II.A. Program Director 281

282

II.A.1. There must be one faculty member appointed as program director 283

with authority and accountability for the overall program, including 284

compliance with all applicable program requirements.

(Core)

285

286

II.A.1.a) The Sponsoring Institution’s Graduate Medical Education 287

Committee (GMEC) must approve a change in program 288

director.

(Core)

289

290

II.A.1.b) Final approval of the program director resides with the 291

Review Committee.

(Core)

292

293

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Background and Intent: While the ACGME recognizes the value of input from numerous

individuals in the management of a fellowship, a single individual must be designated as

program director and have overall responsibility for the program. The program director’s

nomination is reviewed and approved by the GMEC. Final approval of the program

director resides with the applicable ACGME Review Committee.

294

II.A.2. The program director and, as applicable, the program’s leadership 295

team, must be provided with support adequate for administration of 296

the program based upon its size and configuration.

(Core)

297

298

II.A.2.a) At a minimum, the program director must be provided with the 299

salary support required to devote 20-50 percent FTE of non-

300

clinical time to the administration of the program.

(Core)

301

302

At a minimum, the program director must be provided with the 303

dedicated time and support specified below for administration of

304

the program:

(Core)

305

306

Number of Approved

Fellow Positions

Minimum Support

Required (FTE)

7-9

.25

10-12

13-15

.35

16-18

19-21

.45

>21

307

II.A.2.b) Programs must appoint at least one of the subspecialty-certified 308

core faculty members to be associate program director(s). The

309

associate program directors(s) must be provided with support

310

equal to a dedicated minimum time for administration of the

311

program as follows:

(Core)

312

313

Number of Approved

Fellow Positions

Minimum Support

Required (FTE)

7-9

.13

10-12

.14

13-15

.15

16-18

.16

19-21

.17

22-24

.18

25-27

.24

28-30

.30

314

Background and Intent: To achieve successful graduate medical education, individuals

serving as education and administrative leaders of fellowship programs, as well as those

significantly engaged in the education, supervision, evaluation, and mentoring of fellows,

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must have sufficient dedicated professional time to perform the vital activities required to

sustain an accredited program.

The ultimate outcome of graduate medical education is excellence in fellow education

and patient care.

The program director and, as applicable, the program leadership team, devote a portion

of their professional effort to the oversight and management of the fellowship program,

as defined in II.A.4.-II.A.4.a).(16). Both provision of support for the time required for the

leadership effort and flexibility regarding how this support is provided are important.

Programs, in partnership with their Sponsoring Institutions, may provide support for this

time in a variety of ways. Examples of support may include, but are not limited to, salary

support, supplemental compensation, educational value units, or relief of time from other

professional duties.

Program directors and, as applicable, members of the program leadership team, who are

new to the role may need to devote additional time to program oversight and

management initially as they learn and become proficient in administering the program. It

is suggested that during this initial period the support described above be increased as

needed.

315

Subspecialty-Specific Background and Intent: For instance, a program with an approved

complement of 12 fellows is required to have at least 30 percent FTE support for the Program

Director and at least 14 percent FTE support for the associate program director(s). Because an

associate program director is also a core faculty member, the minimum dedicated time

requirements for associate program directors are inclusive of core faculty activities. An additional

10 percent FTE for the core faculty position is not required. For example, if one core faculty

member is named the associate program director for a 12-fellow program, the required minimum

support for that position is 14 percent FTE. Further, the Review Committee allows the minimum

required FTE support to be shared among multiple associate program directors, as delegated by

and at the discretion of the program director.

II.A.3. Qualifications of the program director: 316

317

II.A.3.a) must include subspecialty expertise and qualifications 318

acceptable to the Review Committee; and,

(Core)

319

320

II.A.3.a).(1) The program director must have administrative experience 321

and at least three years of participation as an active faculty 322

member in an ACGME-accredited internal medicine 323

residency or critical care medicine fellowship.

(Core)

324

325

II.A.3.b) must include current certification in the subspecialty for 326

which they are the program director by the American Board 327

of Internal Medicine (ABIM) or by the American Osteopathic 328

Board of Internal Medicine (AOBIM), or subspecialty 329

qualifications that are acceptable to the Review Committee. 330

(Core)

331

332

II.A.3.b).(1) The Review Committee only accepts current ABIM or 333

AOBIM certification in critical care medicine.

(Core)

334

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335

II.A.4. Program Director Responsibilities 336

337

The program director must have responsibility, authority, and 338

accountability for: administration and operations; teaching and 339

scholarly activity; fellow recruitment and selection, evaluation, and 340

promotion of fellows, and disciplinary action; supervision of fellows; 341

and fellow education in the context of patient care.

(Core)

342

343

II.A.4.a) The program director must: 344

345

II.A.4.a).(1) be a role model of professionalism;

(Core)

346

347

Background and Intent: The program director, as the leader of the program, must serve

as a role model to fellows in addition to fulfilling the technical aspects of the role. As

fellows are expected to demonstrate compassion, integrity, and respect for others, they

must be able to look to the program director as an exemplar. It is of utmost importance,

therefore, that the program director model outstanding professionalism, high quality

patient care, educational excellence, and a scholarly approach to work. The program

director creates an environment where respectful discussion is welcome, with the goal

of continued improvement of the educational experience.

348

II.A.4.a).(2) design and conduct the program in a fashion 349

consistent with the needs of the community, the 350

mission(s) of the Sponsoring Institution, and the 351

mission(s) of the program;

(Core)

352

353

Background and Intent: The mission of institutions participating in graduate medical

education is to improve the health of the public. Each community has health needs that

vary based upon location and demographics. Programs must understand the social

determinants of health of the populations they serve and incorporate them in the design

and implementation of the program curriculum, with the ultimate goal of addressing

these needs and health disparities.

354

II.A.4.a).(3) administer and maintain a learning environment 355

conducive to educating the fellows in each of the 356

ACGME Competency domains;

(Core)

357

358

Background and Intent: The program director may establish a leadership team to assist

in the accomplishment of program goals. Fellowship programs can be highly complex.

In a complex organization the leader typically has the ability to delegate authority to

others, yet remains accountable. The leadership team may include physician and non-

physician personnel with varying levels of education, training, and experience.

359

II.A.4.a).(4) develop and oversee a process to evaluate candidates 360

prior to approval as program faculty members for 361

participation in the fellowship program education and 362

at least annually thereafter, as outlined in V.B.;

(Core)

363

364

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II.A.4.a).(5) have the authority to approve program faculty 365

members for participation in the fellowship program 366

education at all sites;

(Core)

367

368

II.A.4.a).(6) have the authority to remove program faculty 369

members from participation in the fellowship program 370

education at all sites;

(Core)

371

372

II.A.4.a).(7) have the authority to remove fellows from supervising 373

interactions and/or learning environments that do not 374

meet the standards of the program;

(Core)

375

376

Background and Intent: The program director has the responsibility to ensure that all

who educate fellows effectively role model the Core Competencies. Working with a

fellow is a privilege that is earned through effective teaching and professional role

modeling. This privilege may be removed by the program director when the standards

of the clinical learning environment are not met.

There may be faculty in a department who are not part of the educational program, and

the program director controls who is teaching the residents.

377

II.A.4.a).(8) submit accurate and complete information required 378

and requested by the DIO, GMEC, and ACGME;

(Core)

379

380

II.A.4.a).(9) provide applicants who are offered an interview with 381

information related to the applicant’s eligibility for the 382

relevant subspecialty board examination(s);

(Core)

383

384

II.A.4.a).(10) provide a learning and working environment in which 385

fellows have the opportunity to raise concerns and 386

provide feedback in a confidential manner as 387

appropriate, without fear of intimidation or retaliation; 388

(Core)

389

390

II.A.4.a).(11) ensure the program’s compliance with the Sponsoring 391

Institution’s policies and procedures related to 392

grievances and due process;

(Core)

393

394

II.A.4.a).(12) ensure the program’s compliance with the Sponsoring 395

Institution’s policies and procedures for due process 396

when action is taken to suspend or dismiss, not to 397

promote, or not to renew the appointment of a fellow; 398

(Core)

399

400

Background and Intent: A program does not operate independently of its Sponsoring

Institution. It is expected that the program director will be aware of the Sponsoring

Institution’s policies and procedures, and will ensure they are followed by the

program’s leadership, faculty members, support personnel, and fellows.

401

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II.A.4.a).(13) ensure the program’s compliance with the Sponsoring 402

Institution’s policies and procedures on employment 403

and non-discrimination;

(Core)

404

405

II.A.4.a).(13).(a) Fellows must not be required to sign a non-406

competition guarantee or restrictive covenant. 407

(Core)

408

409

II.A.4.a).(14) document verification of program completion for all 410

graduating fellows within 30 days;

(Core)

411

412

II.A.4.a).(15) provide verification of an individual fellow’s 413

completion upon the fellow’s request, within 30 days; 414

and,

(Core)

415

416

Background and Intent: Primary verification of graduate medical education is

important to credentialing of physicians for further training and practice. Such

verification must be accurate and timely. Sponsoring Institution and program policies

for record retention are important to facilitate timely documentation of fellows who

have previously completed the program. Fellows who leave the program prior to

completion also require timely documentation of their summative evaluation.

417

II.A.4.a).(16) obtain review and approval of the Sponsoring 418

Institution’s DIO before submitting information or 419

requests to the ACGME, as required in the Institutional 420

Requirements and outlined in the ACGME Program 421

Director’s Guide to the Common Program 422

Requirements.

(Core)

423

424

II.B. Faculty 425

426

Faculty members are a foundational element of graduate medical education 427

– faculty members teach fellows how to care for patients. Faculty members 428

provide an important bridge allowing fellows to grow and become practice 429

ready, ensuring that patients receive the highest quality of care. They are 430

role models for future generations of physicians by demonstrating 431

compassion, commitment to excellence in teaching and patient care, 432

professionalism, and a dedication to lifelong learning. Faculty members 433

experience the pride and joy of fostering the growth and development of 434

future colleagues. The care they provide is enhanced by the opportunity to 435

teach. By employing a scholarly approach to patient care, faculty members, 436

through the graduate medical education system, improve the health of the 437

individual and the population. 438

439

Faculty members ensure that patients receive the level of care expected 440

from a specialist in the field. They recognize and respond to the needs of 441

the patients, fellows, community, and institution. Faculty members provide 442

appropriate levels of supervision to promote patient safety. Faculty 443

members create an effective learning environment by acting in a 444

professional manner and attending to the well-being of the fellows and 445

themselves. 446

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447

Background and Intent: “Faculty” refers to the entire teaching force responsible for

educating fellows. The term “faculty,” including “core faculty,” does not imply or

require an academic appointment.

448

II.B.1. For each participating site, there must be a sufficient number of 449

faculty members with competence to instruct and supervise all 450

fellows at that location.

(Core)

451

452

II.B.2. Faculty members must: 453

454

II.B.2.a) be role models of professionalism;

(Core)

455

456

II.B.2.b) demonstrate commitment to the delivery of safe, quality, 457

cost-effective, patient-centered care;

(Core)

458

459

Background and Intent: Patients have the right to expect quality, cost-effective care

with patient safety at its core. The foundation for meeting this expectation is formed

during residency and fellowship. Faculty members model these goals and continually

strive for improvement in care and cost, embracing a commitment to the patient and

the community they serve.

460

II.B.2.c) demonstrate a strong interest in the education of fellows;

(Core)

461

462

II.B.2.d) devote sufficient time to the educational program to fulfill 463

their supervisory and teaching responsibilities;

(Core)

464

465

II.B.2.e) administer and maintain an educational environment 466

conducive to educating fellows;

(Core)

467

468

II.B.2.f) regularly participate in organized clinical discussions, 469

rounds, journal clubs, and conferences; and,

(Core)

470

471

II.B.2.g) pursue faculty development designed to enhance their skills 472

at least annually.

(Core)

473

474

Background and Intent: Faculty development is intended to describe structured

programming developed for the purpose of enhancing transference of knowledge,

skill, and behavior from the educator to the learner. Faculty development may occur in

a variety of configurations (lecture, workshop, etc.) using internal and/or external

resources. Programming is typically needs-based (individual or group) and may be

specific to the institution or the program. Faculty development programming is to be

reported for the fellowship program faculty in the aggregate.

475

II.B.3. Faculty Qualifications 476

477

II.B.3.a) Faculty members must have appropriate qualifications in 478

their field and hold appropriate institutional appointments. 479

(Core)

480

481

Critical Care Medicine Tracked Changes Copy

II.B.3.b) Subspecialty physician faculty members must: 482

483

II.B.3.b).(1) have current certification in the subspecialty by the 484

American Board of Internal Medicine or the American 485

Osteopathic Board of Internal Medicine, or possess 486

qualifications judged acceptable to the Review 487

Committee.

(Core)

488

489

II.B.3.c) Any non-physician faculty members who participate in 490

fellowship program education must be approved by the 491

program director.

(Core)

492

493

Background and Intent: The provision of optimal and safe patient care requires a team

approach. The education of fellows by non-physician educators enables the fellows to

better manage patient care and provides valuable advancement of the fellows’

knowledge. Furthermore, other individuals contribute to the education of the fellow in

the basic science of the subspecialty or in research methodology. If the program

director determines that the contribution of a non-physician individual is significant to

the education of the fellow, the program director may designate the individual as a

program faculty member or a program core faculty member.

494

II.B.3.d) Any other specialty physician faculty members must have 495

current certification in their specialty by the appropriate 496

American Board of Medical Specialties (ABMS) member 497

board or American Osteopathic Association (AOA) certifying 498

board, or possess qualifications judged acceptable to the 499

Review Committee.

(Core)

500

501

II.B.3.d).(1) ABIM- or AOBIM-certified clinical faculty members in 502

cardiology, gastroenterology, hematology, infectious 503

disease, nephrology, oncology, and pulmonary disease, 504

must participate in the program.

(Core)

505

506

II.B.3.d).(2) Faculty from anesthesiology, cardiovascular surgery, 507

emergency medicine, neurology, neurosurgery, obstetrics 508

and gynecology, orthopaedic surgery, surgery, thoracic 509

surgery, urology, and vascular surgery should be available 510

to participate in the education of fellows.

(Core)

511

512

II.B.4. Core Faculty 513

514

Core faculty members must have a significant role in the education 515

and supervision of fellows and must devote a significant portion of 516

their entire effort to fellow education and/or administration, and 517

must, as a component of their activities, teach, evaluate, and provide 518

formative feedback to fellows.

(Core)

519

520

Background and Intent: Core faculty members are critical to the success of fellow

education. They support the program leadership in developing, implementing, and

assessing curriculum, mentoring fellows, and assessing fellows’ progress toward

achievement of competence in and the independent practice of the specialty. Core

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faculty members should be selected for their broad knowledge of and involvement in

the program, permitting them to effectively evaluate the program. Core faculty

members may also be selected for their specific expertise and unique contribution to

the program. Core faculty members are engaged in a broad range of activities, which

may vary across programs and specialties. Core faculty members provide clinical

teaching and supervision of fellows, and also participate in non-clinical activities

related to fellow education and program administration. Examples of these non-clinical

activities include, but are not limited to, interviewing and selecting fellow applicants,

providing didactic instruction, mentoring fellows, simulation exercises, completing the

annual ACGME Faculty Survey, and participating on the program’s Clinical

Competency Committee, Program Evaluation Committee, and other GME committees.

521

II.B.4.a) Core faculty members must be designated by the program 522

director.

(Core)

523

524

II.B.4.b) Core faculty members must complete the annual ACGME 525

Faculty Survey.

(Core)

526

527

II.B.4.c) In addition to the program director, there must be at least two core 528

faculty members certified in critical care medicine by the ABIM or 529

the AOBIM.

(Core)

530

531

II.B.4.d) In programs approved for more than three fellows, there must be 532

at least one core faculty member certified in critical care medicine 533

by the ABIM or the AOBIM for every 1.5 fellows.

(Core)

534

535

II.B.4.e) At a minimum, the required core faculty members, in aggregate 536

and excluding members of the program leadership, must be

537

provided with support equal to an average dedicated minimum of

538

.1 FTE for educational and administrative responsibilities that do

539

not involve direct patient care.

(Core)

540

541

Specialty Background and Intent: The program must have a minimum number of ABIM- or

AOBIM-certified endocrinology, diabetes, and metabolism faculty members who devote

significant time to teaching, supervising, and advising residents, and working closely with the

program director. One way the endocrinology, diabetes, and metabolism-certified faculty

members can demonstrate they are devoting a significant portion of their effort to resident

education is by dedicating an average of 10 hours per week to the program.

542

Subspecialty-Specific Background and Intent: For instance, a program with an approved

complement of 12 fellows is required to have a minimum of eight ABIM- or AOBIM-subspecialty-

certified faculty members and an FTE of 10 percent each. Because an associate program director

is also a core faculty member, the minimum dedicated time requirements for associate program

directors are inclusive of core faculty activities. An additional 10 percent FTE for the core faculty

position is not required. For example, if one core faculty member is named the associate program

director for a 12-fellow program, the required minimum support for that position is 14 percent

FTE.

II.C. Program Coordinator 543

544

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II.C.1. There must be a program coordinator.

(Core)

545

546

II.C.2. The program coordinator must be provided with support adequate 547

for administration of the program based upon its size and 548

configuration.

(Core)

549

550

II.C.2.a) At a minimum, the program coordinator must be provided with the 551

dedicated time and support specified below for administration of

552

the program. Additional administrative support must be provided

553

based on the program size as follows:

(Core)

554

555

Number of Approved

Fellow Positions

Minimum FTE Required

for Coordinator Support

Additional Aggregate FTE

Required for Administration

of the Program

1-3

4-6

7-9

.38

10-12

.44

13-15

.50

16-18

.56

19-21

.62

22-24

.68

25-27

.74

28-30

.80

556

Background and Intent: The requirement does not address the source of funding required

to provide the specified salary support.

Each program requires a lead administrative person, frequently referred to as a program

coordinator, administrator, or as otherwise titled by the institution. This person will

frequently manage the day-to-day operations of the program and serve as an important

liaison and facilitator between the learners, faculty and other staff members, and the

ACGME. Individuals serving in this role are recognized as program coordinators by the

ACGME.

The program coordinator is a key member of the leadership team and is critical to the

success of the program. As such, the program coordinator must possess skills in

leadership and personnel management appropriate to the complexity of the program.

Program coordinators are expected to develop in-depth knowledge of the ACGME and

Program Requirements, including policies and procedures. Program coordinators assist

the program director in meeting accreditation requirements, educational programming,

and support of fellows.

Programs, in partnership with their Sponsoring Institutions, should encourage the

professional development of their program coordinators and avail them of opportunities

for both professional and personal growth. Programs with fewer fellows may not require a

full-time coordinator; one coordinator may support more than one program.

557

II.D. Other Program Personnel 558

559

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The program, in partnership with its Sponsoring Institution, must jointly 560

ensure the availability of necessary personnel for the effective 561

administration of the program.

(Core)

562

563

Background and Intent: Multiple personnel may be required to effectively administer a

program. These may include staff members with clerical skills, project managers,

education experts, and staff members to maintain electronic communication for the

program. These personnel may support more than one program in more than one

discipline.

564

II.D.1. There must be services available from other health care professionals, 565

including dietitians, language interpreters, nurses, occupational 566

therapists, physical therapists, and social workers.

(Detail)

567

568

II.D.2. Personnel must include nurses and technicians who are skilled in critical 569

care instrumentation, respiratory function, and laboratory medicine.

(Detail)

570

571

II.D.3. There must be appropriate and timely consultation from other specialties. 572

(Detail)

573

574

III. Fellow Appointments 575

576

III.A. Eligibility Criteria 577

578

III.A.1. Eligibility Requirements – Fellowship Programs 579

580

All required clinical education for entry into ACGME-accredited 581

fellowship programs must be completed in an ACGME-accredited 582

residency program, an AOA-approved residency program, a 583

program with ACGME International (ACGME-I) Advanced Specialty 584

Accreditation, or a Royal College of Physicians and Surgeons of 585

Canada (RCPSC)-accredited or College of Family Physicians of 586

Canada (CFPC)-accredited residency program located in Canada. 587

(Core)

588

589

Background and Intent: Eligibility for ABMS or AOA Board certification may not be

satisfied by fellowship training. Applicants must be notified of this at the time of

application, as required in II.A.4.a).(9).

590

III.A.1.a) Fellowship programs must receive verification of each 591

entering fellow’s level of competence in the required field, 592

upon matriculation, using ACGME, ACGME-I, or CanMEDS 593

Milestones evaluations from the core residency program.

(Core)

594

595

III.A.1.b) Prerequisite Postgraduate Clinical Education 596

597

III.A.1.b).(1) To be eligible for appointment at the F1 level, fellows 598

should have completed an ACGME-, AOA-, ACGME-I, or 599

RCPSC-accredited internal medicine or emergency 600

medicine program.

(Core)

601

602

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III.A.1.b).(2) To be eligible for appointment at the F2 level, fellows must 603

have completed a two- or three-year ACGME-, AOA-, 604

ACGME-I, or RCPSC-accredited internal medicine 605

subspecialty fellowship.

(Core)

606

607

III.A.1.b).(3) Fellows from ACGME-, AOA-, ACGME-I, or RCPSC-608

accredited emergency medicine programs should have 609

completed at least six months of direct patient care 610

experience in internal medicine, of which at least three 611

months must have been in a medical intensive care unit. 612

(Core)

613

614

III.A.1.b).(4) Fellows from non-ACGME-, AOA, ACGME-I, or RCPSC-615

accredited internal medicine or emergency medicine 616

programs must have completed at least three years of 617

internal medicine education prior to starting the fellowship. 618

(Core)

619

620

III.A.1.c) Fellow Eligibility Exception 621

622

The Review Committee for Internal Medicine will allow the 623

following exception to the fellowship eligibility requirements: 624

625

III.A.1.c).(1) An ACGME-accredited fellowship program may accept 626

an exceptionally qualified international graduate 627

applicant who does not satisfy the eligibility 628

requirements listed in III.A.1., but who does meet all of 629

the following additional qualifications and conditions: 630

(Core)

631

632

III.A.1.c).(1).(a) evaluation by the program director and 633

fellowship selection committee of the 634

applicant’s suitability to enter the program, 635

based on prior training and review of the 636

summative evaluations of training in the core 637

specialty; and,

(Core)

638

639

III.A.1.c).(1).(b) review and approval of the applicant’s 640

exceptional qualifications by the GMEC; and, 641

(Core)

642

643

III.A.1.c).(1).(c) verification of Educational Commission for 644

Foreign Medical Graduates (ECFMG) 645

certification.

(Core)

646

647

III.A.1.c).(2) Applicants accepted through this exception must have 648

an evaluation of their performance by the Clinical 649

Competency Committee within 12 weeks of 650

matriculation.

(Core)

651

652

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Background and Intent: An exceptionally qualified international graduate applicant has

(1) completed a residency program in the core specialty outside the continental United

States that was not accredited by the ACGME, AOA, ACGME-I, RCPSC or CFPC, and

(2) demonstrated clinical excellence, in comparison to peers, throughout training.

Additional evidence of exceptional qualifications is required, which may include one of

the following: (a) participation in additional clinical or research training in the specialty

or subspecialty; (b) demonstrated scholarship in the specialty or subspecialty; and/or

these positions must be informed of the fact that their training may not lead to

certification by ABMS member boards or AOA certifying boards.

In recognition of the diversity of medical education and training around the world, this

early evaluation of clinical competence required for these applicants ensures they can

provide quality and safe patient care. Any gaps in competence should be addressed

as per policies for fellows already established by the program in partnership with the

Sponsoring Institution.

653

III.B. The program director must not appoint more fellows than approved by the 654

Review Committee.

(Core)

655

656

III.B.1. All complement increases must be approved by the Review 657

Committee.

(Core)

658

659

III.C. Fellow Transfers 660

661

The program must obtain verification of previous educational experiences 662

and a summative competency-based performance evaluation prior to 663

acceptance of a transferring fellow, and Milestones evaluations upon 664

matriculation.

(Core)

665

666

IV. Educational Program 667

668

The ACGME accreditation system is designed to encourage excellence and 669

innovation in graduate medical education regardless of the organizational 670

affiliation, size, or location of the program. 671

672

The educational program must support the development of knowledgeable, skillful 673

physicians who provide compassionate care. 674

675

In addition, the program is expected to define its specific program aims consistent 676

with the overall mission of its Sponsoring Institution, the needs of the community 677

it serves and that its graduates will serve, and the distinctive capabilities of 678

physicians it intends to graduate. While programs must demonstrate substantial 679

compliance with the Common and subspecialty-specific Program Requirements, it 680

is recognized that within this framework, programs may place different emphasis 681

on research, leadership, public health, etc. It is expected that the program aims 682

will reflect the nuanced program-specific goals for it and its graduates; for 683

example, it is expected that a program aiming to prepare physician-scientists will 684

have a different curriculum from one focusing on community health. 685

686

IV.A. The curriculum must contain the following educational components:

(Core)

687

Critical Care Medicine Tracked Changes Copy

688

IV.A.1. a set of program aims consistent with the Sponsoring Institution’s 689

mission, the needs of the community it serves, and the desired 690

distinctive capabilities of its graduates;

(Core)

691

692

IV.A.1.a) The program’s aims must be made available to program 693

applicants, fellows, and faculty members.

(Core)

694

695

IV.A.2. competency-based goals and objectives for each educational 696

experience designed to promote progress on a trajectory to 697

autonomous practice in their subspecialty. These must be 698

distributed, reviewed, and available to fellows and faculty members; 699

(Core)

700

701

IV.A.3. delineation of fellow responsibilities for patient care, progressive 702

responsibility for patient management, and graded supervision in 703

their subspecialty;

(Core)

704

705

Background and Intent: These responsibilities may generally be described by PGY

level and specifically by Milestones progress as determined by the Clinical

Competency Committee. This approach encourages the transition to competency-

based education. An advanced learner may be granted more responsibility

independent of PGY level and a learner needing more time to accomplish a certain

task may do so in a focused rather than global manner.

706

IV.A.4. structured educational activities beyond direct patient care; and, 707

(Core)

708

709

Background and Intent: Patient care-related educational activities, such as morbidity

and mortality conferences, tumor boards, surgical planning conferences, case

discussions, etc., allow fellows to gain medical knowledge directly applicable to the

patients they serve. Programs should define those educational activities in which

fellows are expected to participate and for which time is protected. Further

specification can be found in IV.C.

710

IV.A.5. advancement of fellows’ knowledge of ethical principles 711

foundational to medical professionalism.

(Core)

712

713

IV.B. ACGME Competencies 714

715

Background and Intent: The Competencies provide a conceptual framework describing

the required domains for a trusted physician to enter autonomous practice. These

Competencies are core to the practice of all physicians, although the specifics are

further defined by each subspecialty. The developmental trajectories in each of the

Competencies are articulated through the Milestones for each subspecialty. The focus

in fellowship is on subspecialty-specific patient care and medical knowledge, as well

as refining the other competencies acquired in residency.

716

IV.B.1. The program must integrate the following ACGME Competencies 717

into the curriculum:

(Core)

718

Critical Care Medicine Tracked Changes Copy

719

IV.B.1.a) Professionalism 720

721

Fellows must demonstrate a commitment to professionalism 722

and an adherence to ethical principles.

(Core)

723

724

IV.B.1.b) Patient Care and Procedural Skills 725

726

Background and Intent: Quality patient care is safe, effective, timely, efficient, patient-

centered, equitable, and designed to improve population health, while reducing per

capita costs. (See the Institute of Medicine [IOM]’s Crossing the Quality Chasm: A New

Health System for the 21st Century, 2001 and

Berwick D, Nolan T, Whittington J. The

Triple Aim: care, cost, and quality. Health Affairs. 2008; 27(3):759-769.). In addition, there

should be a focus on improving the clinician’s well-being as a means to improve patient

care and reduce burnout among residents, fellows, and practicing physicians.

These organizing principles inform the Common Program Requirements across all

Competency domains. Specific content is determined by the Review Committees with

input from the appropriate professional societies, certifying boards, and the community.

727

IV.B.1.b).(1) Fellows must be able to provide patient care that is 728

compassionate, appropriate, and effective for the 729

treatment of health problems and the promotion of 730

health.

(Core)

731

732

IV.B.1.b).(1).(a) Fellows must demonstrate competence in the 733

practice of health promotion, disease prevention, 734

diagnosis, care, and treatment of patients of each 735

gender, from adolescence to old age, during health 736

and all stages of illness; and,

(Core)

737

738

IV.B.1.b).(1).(b) Fellows must demonstrate competence in the 739

prevention, evaluation, and management of 740

patients with: 741

742

IV.B.1.b).(1).(b).(i) acute lung injury, including radiation, 743

inhalation, and trauma;

(Core)

744

745

IV.B.1.b).(1).(b).(ii) acute metabolic disturbances, including 746

overdosages and intoxication syndromes; 747

(Core)

748

749

IV.B.1.b).(1).(b).(iii) anaphylaxis and acute allergic reactions in 750

the critical care unit;

(Core)

751

752

IV.B.1.b).(1).(b).(iv) cardiovascular diseases in the critical care 753

unit;

(Core)

754

755

IV.B.1.b).(1).(b).(v) circulatory failure;

(Core)

756

757

IV.B.1.b).(1).(b).(vi) end-of-life issues and palliative care;

(Core)

758

Critical Care Medicine Tracked Changes Copy

759

IV.B.1.b).(1).(b).(vii) hypertensive emergencies;

(Core)

760

761

IV.B.1.b).(1).(b).(viii) immunosuppressed conditions in the critical 762

care unit;

(Core)

763

764

IV.B.1.b).(1).(b).(ix) metabolic, nutritional, and endocrine effects 765

of critical illness, hematologic and 766

coagulation disorders associated with 767

critical illness;

(Core)

768

769

IV.B.1.b).(1).(b).(x) multi-organ system failure;

(Core)

770

771

IV.B.1.b).(1).(b).(xi) perioperative critically ill patients,

(Core)

772

773

IV.B.1.b).(1).(b).(xi).(a) including hemodynamic and 774

ventilatory support;

(Detail)

775

776

IV.B.1.b).(1).(b).(xii) renal disorders in the critical care unit,

(Core)

777

778

IV.B.1.b).(1).(b).(xii).(a) including electrolyte and acid-base 779

disturbance and acute renal failure; 780

(Detail)

781

782

IV.B.1.b).(1).(b).(xiii) respiratory failure,

(Core)

783

784

IV.B.1.b).(1).(b).(xiii).(a) including acute respiratory distress 785

syndrome, acute and chronic 786

respiratory failure in obstructive lung 787

diseases, and neuromuscular 788

respiratory drive disorders;

(Detail)

789

790

IV.B.1.b).(1).(b).(xiv) sepsis and sepsis syndrome;

(Core)

791

792

IV.B.1.b).(1).(b).(xv) severe organ dysfunction resulting in critical 793

illness,

(Core)

794

795

IV.B.1.b).(1).(b).(xv).(a) including disorders of the 796

gastrointestinal, neurologic, 797

endocrine, hematologic, 798

musculoskeletal, and immune 799

systems, as well as infections and 800

malignancies; and,

(Detail)

801

802

IV.B.1.b).(1).(b).(xv).(b) shock syndromes.

(Core)

803

804

IV.B.1.b).(2) Fellows must be able to perform all medical, 805

diagnostic, and surgical procedures considered 806

essential for the area of practice.

(Core)

807

808

Critical Care Medicine Tracked Changes Copy

IV.B.1.b).(2).(a) Fellows must demonstrate competence in 809

interpreting data derived from various bedside 810

devices commonly employed to monitor patients; 811

and,

(Core)

812

813

IV.B.1.b).(2).(b) Fellows must demonstrate competence in 814

procedural and technical skills, including: 815

816

IV.B.1.b).(2).(b).(i) airway management;

(Core)

817

818

IV.B.1.b).(2).(b).(ii) the use of a variety of positive pressure 819

ventilatory modes, including:

(Core)

820

821

IV.B.1.b).(2).(b).(ii).(a) initiation and maintenance of, and 822

weaning off of, ventilatory support; 823

(Detail)

824

825

IV.B.1.b).(2).(b).(ii).(b) respiratory care techniques; and, 826

(Detail)

827

828

IV.B.1.b).(2).(b).(ii).(c) withdrawal of mechanical ventilatory 829

support.

(Detail)

830

831

IV.B.1.b).(2).(b).(iii) the use of reservoir masks and continuous 832

positive airway pressure masks for delivery 833

of supplemental oxygen, humidifiers, 834

nebulizers, and incentive spirometry;

(Core)

835

836

IV.B.1.b).(2).(b).(iv) therapeutic flexible fiber-optic bronchoscopy 837

procedures limited to indications for 838

therapeutic removal of airway secretions, 839

diagnostic aspiration of airway secretions or 840

lavaged fluid, or airway management

(Core)

841

842

IV.B.1.b).(2).(b).(v) diagnostic and therapeutic procedures, 843

including paracentesis, lumbar puncture, 844

thoracentesis, endotracheal intubation, and 845

related procedures;

(Core)

846

847

IV.B.1.b).(2).(b).(vi) use of chest tubes and drainage systems; 848

(Core)

849

850

IV.B.1.b).(2).(b).(vii) operation of bedside hemodynamic 851

monitoring systems;

(Core)

852

853

IV.B.1.b).(2).(b).(viii) emergency cardioversion;

(Core)

854

855

IV.B.1.b).(2).(b).(ix) interpretation of intracranial pressure 856

monitoring;

(Core)

857

858

IV.B.1.b).(2).(b).(x) nutritional support;

(Core)

859

Critical Care Medicine Tracked Changes Copy

860

IV.B.1.b).(2).(b).(xi) use of ultrasound techniques to perform 861

thoracentesis and place intravascular and 862

intracavitary tubes and catheters; and,

(Core)

863

864

IV.B.1.b).(2).(b).(xii) use of transcutaneous pacemakers.

(Core)

865

866

IV.B.1.c) Medical Knowledge 867

868

Fellows must demonstrate knowledge of established and 869

evolving biomedical, clinical, epidemiological and social-870

behavioral sciences, as well as the application of this 871

knowledge to patient care.

(Core)

872

873

IV.B.1.c).(1) Fellows must demonstrate knowledge of the scientific 874

method of problem solving and evidence-based decision 875

making;

(Core)

876

877

IV.B.1.c).(2) Fellows must demonstrate knowledge of indications, 878

contraindications, limitations, complications, techniques, 879

and interpretation of results of those diagnostic and 880

therapeutic procedures integral to the discipline, including 881

the appropriate indication for and use of screening 882

tests/procedures:

(Core)

883

884

IV.B.1.c).(2).(a) pericardiocentesis;

(Core)

885

886

IV.B.1.c).(2).(b) placement of percutaneous tracheostomies;

(Core)

887

888

IV.B.1.c).(2).(c) imaging techniques commonly employed in the 889

evaluation of patients with critical illness, including 890

the use of ultrasound;

(Core)

891

892

IV.B.1.c).(2).(d) screening tests and procedures; and,

(Core)

893

894

IV.B.1.c).(2).(e) renal replacement therapy.

(Core)

895

896

IV.B.1.c).(3) Fellows must demonstrate knowledge of the indications, 897

contraindications, and complications of placement of 898

arterial, central venous, and pulmonary artery balloon 899

flotation catheters.

(Core)

900

901

IV.B.1.c).(4) Fellows must demonstrate knowledge of: 902

903

IV.B.1.c).(4).(a) the basic sciences, with particular emphasis on 904

biochemistry and physiology, including cell and 905

molecular biology and immunology, as they relate 906

to critical care medicine;

(Core)

907

908

IV.B.1.c).(4).(b) the ethical, economic and legal aspects of critical 909

illness;

(Core)

910

Critical Care Medicine Tracked Changes Copy

911

IV.B.1.c).(4).(c) the psychosocial and emotional effects of critical 912

illness on patients and their families;

(Core)

913

914

IV.B.1.c).(4).(d) the recognition and management of the critically ill 915

from disasters including,

(Core)

916

917

IV.B.1.c).(4).(d).(i) those caused by chemical and biological 918

agents inhalation, and trauma;

(Detail)

919

920

IV.B.1.c).(4).(e) the use of paralytic agents and sedative and 921

analgesic drugs in the critical care unit;

(Core)

922

923

IV.B.1.c).(4).(f) detection and prevention of iatrogenic and 924

nosocomial problems in critical care medicine; and,

925

(Core)

926

927

IV.B.1.c).(4).(g) monitoring and supervising special services, 928

including:

(Core)

929

930

IV.B.1.c).(4).(g).(i) respiratory care units,

(Detail)

931

932

IV.B.1.c).(4).(g).(ii) respiratory care techniques and services; 933

and,

(Detail)

934

935

IV.B.1.c).(4).(g).(iii) pharmacokinetics, pharmacodynamics, and 936

drug metabolism and excretion in critical 937

illness.

(Detail)

938

939

IV.B.1.d) Practice-based Learning and Improvement 940

941

Fellows must demonstrate the ability to investigate and 942

evaluate their care of patients, to appraise and assimilate 943

scientific evidence, and to continuously improve patient care 944

based on constant self-evaluation and lifelong learning.

(Core)

945

946

Background and Intent: Practice-based learning and improvement is one of the

defining characteristics of being a physician. It is the ability to investigate and

evaluate the care of patients, to appraise and assimilate scientific evidence, and to

continuously improve patient care based on constant self-evaluation and lifelong

learning.

The intention of this Competency is to help a fellow refine the habits of mind required

to continuously pursue quality improvement, well past the completion of fellowship.

947

IV.B.1.e) Interpersonal and Communication Skills 948

949

Fellows must demonstrate interpersonal and communication 950

skills that result in the effective exchange of information and 951

collaboration with patients, their families, and health 952

professionals.

(Core)

953

Critical Care Medicine Tracked Changes Copy

954

IV.B.1.f) Systems-based Practice 955

956

Fellows must demonstrate an awareness of and 957

responsiveness to the larger context and system of health 958

care, including the social determinants of health, as well as 959

the ability to call effectively on other resources to provide 960

optimal health care.

(Core)

961

962

IV.C. Curriculum Organization and Fellow Experiences 963

964

IV.C.1. The curriculum must be structured to optimize fellow educational 965

experiences, the length of these experiences, and supervisory 966

continuity.

(Core)

967

968

IV.C.1.a) Assignment of rotations must be structured to minimize the 969

frequency of rotational transitions, and rotations must be of 970

sufficient length to provide a quality educational experience, 971

defined by continuity of patient care, ongoing supervision, 972

longitudinal relationships with faculty members, and meaningful 973

assessment and feedback.

(Core)

974

975

IV.C.1.b) Clinical experiences should be structured to facilitate learning in a 976

manner that allows fellows to function as part of an effective 977

interprofessional team that works together towards the shared 978

goals of patient safety and quality improvement.

(Core)

979

980

IV.C.2. The program must provide instruction and experience in pain 981

management if applicable for the subspecialty, including recognition 982

of the signs of addiction.

(Core)

983

984

IV.C.3. A minimum of 12 months must be devoted to clinical experiences.

(Core)

985

986

IV.C.3.a) At least six months must be devoted to the care of critically ill 987

medical patients (i.e., MICU/CICU or equivalent).

(Core)

988

989

IV.C.3.a).(1) This required MICU/CICU experience may be reduced up 990

to three months by equivalent (month for month) ICU 991

experience completed during a previous two- to three-year 992

ACGME-, AOA, or RCPSC-accredited internal medicine 993

subspecialty fellowship.

(Detail)

994

995

IV.C.3.b) At least three months must be devoted to the care of critically ill 996

non-medical patients.

(Core)

997

998

IV.C.3.b).(1) This experience should consist of at least one month of 999

direct patient care activity, with the remainder being fulfilled 1000

with either consultative activities or with direct care of such 1001

patients.

(Detail)

1002

1003

IV.C.4. Fellows entering at the F1 level who have completed an ACGME, AOA-, 1004

Critical Care Medicine Tracked Changes Copy

ACGME-I-, or RCPSC-accredited emergency medicine program, but have 1005

not completed the prerequisite clinical experiences in internal medicine 1006

described in Section III.A.1.b).(3), must complete these experiences 1007

during the beginning of the F1 year prior to being allowed to supervise 1008

any internal medicine residents.

(Core)

1009

1010

IV.C.4.a) Any clinical experiences done to fulfill the prerequisite clinical 1011

experiences in internal medicine described in Section III.A.1.b).(3) 1012

will not count toward the 12 months of minimum required clinical 1013

experiences in critical care medicine.

(Core)

1014

1015

IV.C.5. Twelve additional months must be devoted to appropriate elective 1016

experiences or scholarly activity.

(Core)

1017

1018

IV.C.5.a) Fellows who have completed a previous two- to three-year 1019

ACGME-, AOA, ACGME-I, or RCPSC-accredited internal 1020

medicine subspecialty fellowship will automatically satisfy this 1021

requirement.

(Detail)

1022

1023

IV.C.6. Fellows must participate in training using simulation.

(Detail)

1024

1025

IV.C.7. Fellows must be informed of the clinical outcomes of their patients who 1026

are discharged from the critical care units.

(Detail)

1027

1028

IV.C.8. Fellows must have clinical experience in the evaluation and management 1029

of patients: 1030

1031

IV.C.8.a) with trauma;

(Core)

1032

1033

IV.C.8.b) with neurosurgical emergencies;

(Core)

1034

1035

IV.C.8.c) with critical obstetric and gynecologic disorders; and,

(Core)

1036

1037

IV.C.8.d) after discharge from the critical care unit.

(Core)

1038

1039

IV.C.9. Procedures and Technical Skills 1040

1041

IV.C.9.a) Direct supervision of procedures performed by each fellow must 1042

occur until proficiency has been acquired and documented by the 1043

program director.

(Core)

1044

1045

IV.C.9.b) Faculty members must teach and supervise the fellows in the 1046

performance and interpretation of procedures. Procedures must 1047

be documented in each fellow's record, giving indications, 1048

outcomes, diagnoses, and supervisor(s).

(Core)

1049

1050

IV.C.9.c) It is suggested that fellows have clinical experience in the 1051

placement of percutaneous tracheostomies.

(Detail))

1052

1053

IV.C.9.d) Fellows must have experience in the role of critical care medicine 1054

consultant in the inpatient setting.

(Core)

1055

Critical Care Medicine Tracked Changes Copy

1056

IV.C.10. The core curriculum must include a didactic program based upon the core 1057

knowledge content in the subspecialty area.

(Core)

1058

1059

IV.C.10.a) The program must afford each fellow an opportunity to review 1060

topics covered in conferences that he or she was unable to attend. 1061

(Detail)

1062

1063

IV.C.10.b) Fellows must participate in clinical case conferences, journal 1064

clubs, research conferences, and morbidity and mortality or quality 1065

improvement conferences.

(Detail)

1066

1067

IV.C.10.c) All core conferences must have at least one faculty member 1068

present and must be scheduled as to ensure peer-peer and peer-1069

faculty interaction.

(Detail)

1070

1071

IV.C.11. Patient-based teaching must include direct interaction between fellows 1072

and faculty members, bedside teaching, discussion of pathophysiology, 1073

and the use of current evidence in diagnostic and therapeutic decisions. 1074

(Core)

1075

1076

The teaching must be: 1077

1078

IV.C.11.a) formally conducted on all inpatient, outpatient, and consultative 1079

services; and,

(Detail)

1080

1081

IV.C.11.b) conducted with a frequency and duration that ensures a 1082

meaningful and continuous teaching relationship between the 1083

assigned supervising faculty member(s) and fellows.

(Detail)

1084

1085

IV.C.12. Fellows must receive instruction in practice management relevant to 1086

critical care medicine.

(Detail)

1087

1088

IV.D. Scholarship 1089

1090

Medicine is both an art and a science. The physician is a humanistic 1091

scientist who cares for patients. This requires the ability to think critically, 1092

evaluate the literature, appropriately assimilate new knowledge, and 1093

practice lifelong learning. The program and faculty must create an 1094

environment that fosters the acquisition of such skills through fellow 1095

participation in scholarly activities as defined in the subspecialty-specific 1096

Program Requirements. Scholarly activities may include discovery, 1097

integration, application, and teaching. 1098

1099

The ACGME recognizes the diversity of fellowships and anticipates that 1100

programs prepare physicians for a variety of roles, including clinicians, 1101

scientists, and educators. It is expected that the program’s scholarship will 1102

reflect its mission(s) and aims, and the needs of the community it serves. 1103

For example, some programs may concentrate their scholarly activity on 1104

quality improvement, population health, and/or teaching, while other 1105

Critical Care Medicine Tracked Changes Copy

programs might choose to utilize more classic forms of biomedical 1106

research as the focus for scholarship. 1107

1108

IV.D.1. Program Responsibilities 1109

1110

IV.D.1.a) The program must demonstrate evidence of scholarly 1111

activities, consistent with its mission(s) and aims.

(Core)

1112

1113

IV.D.1.b) The program in partnership with its Sponsoring Institution, 1114

must allocate adequate resources to facilitate fellow and 1115

faculty involvement in scholarly activities.

(Core)

1116

1117

IV.D.2. Faculty Scholarly Activity 1118

1119

IV.D.2.a) Among their scholarly activity, programs must demonstrate 1120

accomplishments in at least three of the following domains: 1121

(Core)

1122

1123

• Research in basic science, education, translational 1124

science, patient care, or population health 1125

• Peer-reviewed grants 1126

• Quality improvement and/or patient safety initiatives 1127

• Systematic reviews, meta-analyses, review articles, 1128

chapters in medical textbooks, or case reports 1129

• Creation of curricula, evaluation tools, didactic 1130

educational activities, or electronic educational 1131

materials 1132

• Contribution to professional committees, educational 1133

organizations, or editorial boards 1134

• Innovations in education 1135

1136

IV.D.2.b) The program must demonstrate dissemination of scholarly 1137

activity within and external to the program by the following 1138

methods: 1139

1140

Background and Intent: For the purposes of education, metrics of scholarly activity

represent one of the surrogates for the program’s effectiveness in the creation of an

environment of inquiry that advances the fellows’ scholarly approach to patient care.

The Review Committee will evaluate the dissemination of scholarship for the program

as a whole, not for individual faculty members, for a five-year interval, for both core

and non-core faculty members, with the goal of assessing the effectiveness of the

creation of such an environment. The ACGME recognizes that there may be

differences in scholarship requirements between different specialties and between

residencies and fellowships in the same specialty.

1141

IV.D.2.b).(1) faculty participation in grand rounds, posters, 1142

workshops, quality improvement presentations, 1143

podium presentations, grant leadership, non-peer-1144

reviewed print/electronic resources, articles or 1145

publications, book chapters, textbooks, webinars, 1146

Critical Care Medicine Tracked Changes Copy

service on professional committees, or serving as a 1147

journal reviewer, journal editorial board member, or 1148

editor.

(Outcome)‡

1149

1150

IV.D.2.b).(1).(a) At least 50 percent of the core faculty members 1151

who are certified in critical care medicine by the 1152

ABIM or AOBIM (see Program Requirements 1153

II.B.4.c)-d) must annually engage in a variety of 1154

scholarly activities, as listed in Program 1155

Requirement IV.D.2.b).(1).

(Core)

1156

1157

IV.D.3. Fellow Scholarly Activity 1158

1159

IV.D.3.a) While in the program, at least 50 percent of a program’s fellows 1160

must engage in more than one of the following scholarly activities: 1161

participation in grand rounds, posters, workshops, quality 1162

improvement presentations, podium presentations, grant 1163

leadership, non-peer-reviewed print/electronic resources, articles 1164

or publications, book chapters, textbooks, webinars, service on 1165

professional committees, or serving as a journal reviewer, journal 1166

editorial board member, or editor.

(Outcome)

1167

1168

V. Evaluation 1169

1170

V.A. Fellow Evaluation 1171

1172

V.A.1. Feedback and Evaluation 1173

1174

Background and Intent: Feedback is ongoing information provided regarding aspects

of one’s performance, knowledge, or understanding. The faculty empower fellows to

provide much of that feedback themselves in a spirit of continuous learning and self-

reflection. Feedback from faculty members in the context of routine clinical care

should be frequent, and need not always be formally documented.

Formative and summative evaluation have distinct definitions. Formative evaluation is

monitoring fellow learning and providing ongoing feedback that can be used by fellows

to improve their learning in the context of provision of patient care or other educational

opportunities. More specifically, formative evaluations help:

• fellows identify their strengths and weaknesses and target areas that need work

• program directors and faculty members recognize where fellows are struggling

and address problems immediately

Summative evaluation is evaluating a fellow’s learning by comparing the fellows

against the goals and objectives of the rotation and program, respectively. Summative

evaluation is utilized to make decisions about promotion to the next level of training, or

program completion.

End-of-rotation and end-of-year evaluations have both summative and formative

components. Information from a summative evaluation can be used formatively when

fellows or faculty members use it to guide their efforts and activities in subsequent

rotations and to successfully complete the fellowship program.

Critical Care Medicine Tracked Changes Copy

Feedback, formative evaluation, and summative evaluation compare intentions with

accomplishments, enabling the transformation of a new specialist to one with growing

subspecialty expertise.

1175

V.A.1.a) Faculty members must directly observe, evaluate, and 1176

frequently provide feedback on fellow performance during 1177

each rotation or similar educational assignment.

(Core)

1178

1179

V.A.1.a).(1) The faculty must discuss this evaluation with each fellow at 1180

the completion of each assignment.

(Core)

1181

1182

V.A.1.a).(2) Assessment of procedural competence should include a 1183

formal evaluation process and not be based solely on a 1184

minimum number of procedures performed.

(Detail)

1185

1186

Background and Intent: Faculty members should provide feedback frequently

throughout the course of each rotation. Fellows require feedback from faculty

members to reinforce well-performed duties and tasks, as well as to correct

deficiencies. This feedback will allow for the development of the learner as they strive

to achieve the Milestones. More frequent feedback is strongly encouraged for fellows

who have deficiencies that may result in a poor final rotation evaluation.

1187

V.A.1.b) Evaluation must be documented at the completion of the 1188

assignment.

(Core)

1189

1190

V.A.1.b).(1) For block rotations of greater than three months in 1191

duration, evaluation must be documented at least 1192

every three months.

(Core)

1193

1194

V.A.1.b).(2) Longitudinal experiences such as continuity clinic in 1195

the context of other clinical responsibilities must be 1196

evaluated at least every three months and at 1197

completion.

(Core)

1198

1199

V.A.1.c) The program must provide an objective performance 1200

evaluation based on the Competencies and the subspecialty-1201

specific Milestones, and must:

(Core)

1202

1203

V.A.1.c).(1) use multiple evaluators (e.g., faculty members, peers, 1204

patients, self, and other professional staff members); 1205

and,

(Core)

1206

1207

V.A.1.c).(2) provide that information to the Clinical Competency 1208

Committee for its synthesis of progressive fellow 1209

performance and improvement toward unsupervised 1210

practice.

(Core)

1211

1212

Background and Intent: The trajectory to autonomous practice in a subspecialty is

documented by the subspecialty-specific Milestones evaluation during fellowship.

Critical Care Medicine Tracked Changes Copy

These Milestones detail the progress of a fellow in attaining skill in each competency

domain. It is expected that the most growth in fellowship education occurs in patient

care and medical knowledge, while the other four domains of competency must be

ensured in the context of the subspecialty. They are developed by a subspecialty

group and allow evaluation based on observable behaviors. The Milestones are

considered formative and should be used to identify learning needs. This may lead to

focused or general curricular revision in any given program or to individualized

learning plans for any specific fellow.

1213

V.A.1.d) The program director or their designee, with input from the 1214

Clinical Competency Committee, must: 1215

1216

V.A.1.d).(1) meet with and review with each fellow their 1217

documented semi-annual evaluation of performance, 1218

including progress along the subspecialty-specific 1219

Milestones.

(Core)

1220

1221

V.A.1.d).(2) assist fellows in developing individualized learning 1222

plans to capitalize on their strengths and identify areas 1223

for growth; and,

(Core)

1224

1225

V.A.1.d).(3) develop plans for fellows failing to progress, following 1226

institutional policies and procedures.

(Core)

1227

1228

Background and Intent: Learning is an active process that requires effort from the

teacher and the learner. Faculty members evaluate a fellow's performance at least at

the end of each rotation. The program director or their designee will review those

evaluations, including their progress on the Milestones, at a minimum of every six

months. Fellows should be encouraged to reflect upon the evaluation, using the

information to reinforce well-performed tasks or knowledge or to modify deficiencies in

knowledge or practice. Working together with the faculty members, fellows should

develop an individualized learning plan.

Fellows who are experiencing difficulties with achieving progress along the Milestones

may require intervention to address specific deficiencies. Such intervention,

documented in an individual remediation plan developed by the program director or a

faculty mentor and the fellow, will take a variety of forms based on the specific learning

needs of the fellow. However, the ACGME recognizes that there are situations which

require more significant intervention that may alter the time course of fellow

progression. To ensure due process, it is essential that the program director follow

institutional policies and procedures.

1229

V.A.1.e) At least annually, there must be a summative evaluation of 1230

each fellow that includes their readiness to progress to the 1231

next year of the program, if applicable.

(Core)

1232

1233

V.A.1.f) The evaluations of a fellow’s performance must be accessible 1234

for review by the fellow.

(Core)

1235

1236

V.A.2. Final Evaluation 1237

1238

Critical Care Medicine Tracked Changes Copy

V.A.2.a) The program director must provide a final evaluation for each 1239

fellow upon completion of the program.

(Core)

1240

1241

V.A.2.a).(1) The subspecialty-specific Milestones, and when 1242

applicable the subspecialty-specific Case Logs, must 1243

be used as tools to ensure fellows are able to engage 1244

in autonomous practice upon completion of the 1245

program.

(Core)

1246

1247

V.A.2.a).(2) The final evaluation must: 1248

1249

V.A.2.a).(2).(a) become part of the fellow’s permanent record 1250

maintained by the institution, and must be 1251

accessible for review by the fellow in 1252

accordance with institutional policy;

(Core)

1253

1254

V.A.2.a).(2).(b) verify that the fellow has demonstrated the 1255

knowledge, skills, and behaviors necessary to 1256

enter autonomous practice;

(Core)

1257

1258

V.A.2.a).(2).(c) consider recommendations from the Clinical 1259

Competency Committee; and,

(Core)

1260

1261

V.A.2.a).(2).(d) be shared with the fellow upon completion of 1262

the program.

(Core)

1263

1264

V.A.3. A Clinical Competency Committee must be appointed by the 1265

program director.

(Core)

1266

1267

V.A.3.a) At a minimum the Clinical Competency Committee must 1268

include three members, at least one of whom is a core faculty 1269

member. Members must be faculty members from the same 1270

program or other programs, or other health professionals 1271

who have extensive contact and experience with the 1272

program’s fellows.

(Core)

1273

1274

V.A.3.b) The Clinical Competency Committee must: 1275

1276

V.A.3.b).(1) review all fellow evaluations at least semi-annually; 1277

(Core)

1278

1279

V.A.3.b).(2) determine each fellow’s progress on achievement of 1280

the subspecialty-specific Milestones; and,

(Core)

1281

1282

V.A.3.b).(3) meet prior to the fellows’ semi-annual evaluations and 1283

advise the program director regarding each fellow’s 1284

progress.

(Core)

1285

1286

V.B. Faculty Evaluation 1287

1288

Critical Care Medicine Tracked Changes Copy

V.B.1. The program must have a process to evaluate each faculty 1289

member’s performance as it relates to the educational program at 1290

least annually.

(Core)

1291

1292

Background and Intent: The program director is responsible for the education program

and for whom delivers it. While the term faculty may be applied to physicians within a

given institution for other reasons, it is applied to fellowship program faculty members

only through approval by a program director. The development of the faculty improves

the education, clinical, and research aspects of a program. Faculty members have a

strong commitment to the fellow and desire to provide optimal education and work

opportunities. Faculty members must be provided feedback on their contribution to the

mission of the program. All faculty members who interact with fellows desire feedback

on their education, clinical care, and research. If a faculty member does not interact

with fellows, feedback is not required. With regard to the diverse operating

environments and configurations, the fellowship program director may need to work

with others to determine the effectiveness of the program’s faculty performance with

regard to their role in the educational program. All teaching faculty members should

have their educational efforts evaluated by the fellows in a confidential and

anonymous manner. Other aspects for the feedback may include research or clinical

productivity, review of patient outcomes, or peer review of scholarly activity. The

process should reflect the local environment and identify the necessary information.

The feedback from the various sources should be summarized and provided to the

faculty on an annual basis by a member of the leadership team of the program.

1293

V.B.1.a) This evaluation must include a review of the faculty member’s 1294

clinical teaching abilities, engagement with the educational 1295

program, participation in faculty development related to their 1296

skills as an educator, clinical performance, professionalism, 1297

and scholarly activities.

(Core)

1298

1299

V.B.1.b) This evaluation must include written, confidential evaluations 1300

by the fellows.

(Core)

1301

1302

V.B.2. Faculty members must receive feedback on their evaluations at least 1303

annually.

(Core)

1304

1305

V.B.3. Results of the faculty educational evaluations should be 1306

incorporated into program-wide faculty development plans.

(Core)

1307

1308

Background and Intent: The quality of the faculty’s teaching and clinical care is a

determinant of the quality of the program and the quality of the fellows’ future clinical

care. Therefore, the program has the responsibility to evaluate and improve the

program faculty members’ teaching, scholarship, professionalism, and quality care.

This section mandates annual review of the program’s faculty members for this

purpose, and can be used as input into the Annual Program Evaluation.

1309

V.C. Program Evaluation and Improvement 1310

1311

V.C.1. The program director must appoint the Program Evaluation 1312

Committee to conduct and document the Annual Program 1313

Critical Care Medicine Tracked Changes Copy

Evaluation as part of the program’s continuous improvement 1314

process.

(Core)

1315

1316

V.C.1.a) The Program Evaluation Committee must be composed of at 1317

least two program faculty members, at least one of whom is a 1318

core faculty member, and at least one fellow.

(Core)

1319

1320

V.C.1.b) Program Evaluation Committee responsibilities must include: 1321

1322

V.C.1.b).(1) acting as an advisor to the program director, through 1323

program oversight;

(Core)

1324

1325

V.C.1.b).(2) review of the program’s self-determined goals and 1326

progress toward meeting them;

(Core)

1327

1328

V.C.1.b).(3) guiding ongoing program improvement, including 1329

development of new goals, based upon outcomes; 1330

and,

(Core)

1331

1332

V.C.1.b).(4) review of the current operating environment to identify 1333

strengths, challenges, opportunities, and threats as 1334

related to the program’s mission and aims.

(Core)

1335

1336

Background and Intent: In order to achieve its mission and train quality physicians, a

program must evaluate its performance and plan for improvement in the Annual

Program Evaluation. Performance of fellows and faculty members is a reflection of

program quality, and can use metrics that reflect the goals that a program has set for

itself. The Program Evaluation Committee utilizes outcome parameters and other data

to assess the program’s progress toward achievement of its goals and aims.

1337

V.C.1.c) The Program Evaluation Committee should consider the 1338

following elements in its assessment of the program: 1339

1340

V.C.1.c).(1) curriculum;

(Core)

1341

1342

V.C.1.c).(2) outcomes from prior Annual Program Evaluation(s); 1343

(Core)

1344

1345

V.C.1.c).(3) ACGME letters of notification, including citations, 1346

Areas for Improvement, and comments;

(Core)

1347

1348

V.C.1.c).(4) quality and safety of patient care;

(Core)

1349

1350

V.C.1.c).(5) aggregate fellow and faculty: 1351

1352

V.C.1.c).(5).(a) well-being;

(Core)

1353

1354

V.C.1.c).(5).(b) recruitment and retention;

(Core)

1355

1356

V.C.1.c).(5).(c) workforce diversity;

(Core)

1357

1358

Critical Care Medicine Tracked Changes Copy

V.C.1.c).(5).(d) engagement in quality improvement and patient 1359

safety;

(Core)

1360

1361

V.C.1.c).(5).(e) scholarly activity;

(Core)

1362

1363

V.C.1.c).(5).(f) ACGME Resident/Fellow and Faculty Surveys 1364

(where applicable); and,

(Core)

1365

1366

V.C.1.c).(5).(g) written evaluations of the program.

(Core)

1367

1368

V.C.1.c).(6) aggregate fellow: 1369

1370

V.C.1.c).(6).(a) achievement of the Milestones;

(Core)

1371

1372

V.C.1.c).(6).(b) in-training examinations (where applicable); 1373

(Core)

1374

1375

V.C.1.c).(6).(c) board pass and certification rates; and,

(Core)

1376

1377

V.C.1.c).(6).(d) graduate performance.

(Core)

1378

1379

V.C.1.c).(7) aggregate faculty: 1380

1381

V.C.1.c).(7).(a) evaluation; and,

(Core)

1382

1383

V.C.1.c).(7).(b) professional development

(Core)

1384

1385

V.C.1.d) The Program Evaluation Committee must evaluate the 1386

program’s mission and aims, strengths, areas for 1387

improvement, and threats.

(Core)

1388

1389

V.C.1.e) The annual review, including the action plan, must: 1390

1391

V.C.1.e).(1) be distributed to and discussed with the members of 1392

the teaching faculty and the fellows; and,

(Core)

1393

1394

V.C.1.e).(2) be submitted to the DIO.

(Core)

1395

1396

V.C.2. The program must participate in a Self-Study prior to its 10-Year 1397

Accreditation Site Visit.

(Core)

1398

1399

V.C.2.a) A summary of the Self-Study must be submitted to the DIO. 1400

(Core)

1401

1402

Background and Intent: Outcomes of the documented Annual Program Evaluation can

be integrated into the 10-year Self-Study process. The Self-Study is an objective,

comprehensive evaluation of the fellowship program, with the aim of improving it.

Underlying the Self-Study is this longitudinal evaluation of the program and its

learning environment, facilitated through sequential Annual Program Evaluations that

focus on the required components, with an emphasis on program strengths and self-

identified areas for improvement. Details regarding the timing and expectations for the

Critical Care Medicine Tracked Changes Copy

Self-Study and the 10-Year Accreditation Site Visit are provided in the ACGME Manual

of Policies and Procedures. Additionally, a description of the Self-Study process, as

well as information on how to prepare for the 10-Year Accreditation Site Visit, is

available on the ACGME website.

1403

V.C.3. One goal of ACGME-accredited education is to educate physicians 1404

who seek and achieve board certification. One measure of the 1405

effectiveness of the educational program is the ultimate pass rate. 1406

1407

The program director should encourage all eligible program 1408

graduates to take the certifying examination offered by the 1409

applicable American Board of Medical Specialties (ABMS) member 1410

board or American Osteopathic Association (AOA) certifying board. 1411

1412

V.C.3.a) For subspecialties in which the ABMS member board and/or 1413

AOA certifying board offer(s) an annual written exam, in the 1414

preceding three years, the program’s aggregate pass rate of 1415

those taking the examination for the first time must be higher 1416

than the bottom fifth percentile of programs in that 1417

subspecialty.

(Outcome)

1418

1419

V.C.3.b) For subspecialties in which the ABMS member board and/or 1420

AOA certifying board offer(s) a biennial written exam, in the 1421

preceding six years, the program’s aggregate pass rate of 1422

those taking the examination for the first time must be higher 1423

than the bottom fifth percentile of programs in that 1424

subspecialty.

(Outcome)

1425

1426

V.C.3.c) For subspecialties in which the ABMS member board and/or 1427

AOA certifying board offer(s) an annual oral exam, in the 1428

preceding three years, the program’s aggregate pass rate of 1429

those taking the examination for the first time must be higher 1430

than the bottom fifth percentile of programs in that 1431

subspecialty.

(Outcome)

1432

1433

V.C.3.d) For subspecialties in which the ABMS member board and/or 1434

AOA certifying board offer(s) a biennial oral exam, in the 1435

preceding six years, the program’s aggregate pass rate of 1436

those taking the examination for the first time must be higher 1437

than the bottom fifth percentile of programs in that 1438

subspecialty.

(Outcome)

1439

1440

V.C.3.e) For each of the exams referenced in V.C.3.a)-d), any program 1441

whose graduates over the time period specified in the 1442

requirement have achieved an 80 percent pass rate will have 1443

met this requirement, no matter the percentile rank of the 1444

program for pass rate in that subspecialty.

(Outcome)

1445

1446

Background and Intent: Setting a single standard for pass rate that works across

subspecialties is not supportable based on the heterogeneity of the psychometrics of

different examinations. By using a percentile rank, the performance of the lower five

Critical Care Medicine Tracked Changes Copy

percent (fifth percentile) of programs can be identified and set on a path to curricular

and test preparation reform.

There are subspecialties where there is a very high board pass rate that could leave

successful programs in the bottom five percent (fifth percentile) despite admirable

performance. These high-performing programs should not be cited, and V.C.3.e) is

designed to address this.

1447

V.C.3.f) Programs must report, in ADS, board certification status 1448

annually for the cohort of board-eligible fellows that 1449

graduated seven years earlier.

(Core)

1450

1451

Background and Intent: It is essential that fellowship programs demonstrate

knowledge and skill transfer to their fellows. One measure of that is the qualifying or

initial certification exam pass rate. Another important parameter of the success of the

program is the ultimate board certification rate of its graduates. Graduates are eligible

for up to seven years from fellowship graduation for initial certification. The ACGME

will calculate a rolling three-year average of the ultimate board certification rate at

seven years post-graduation, and the Review Committees will monitor it.

The Review Committees will track the rolling seven-year certification rate as an

indicator of program quality. Programs are encouraged to monitor their graduates’

performance on board certification examinations.

In the future, the ACGME may establish parameters related to ultimate board

certification rates.

1452

VI. The Learning and Working Environment 1453

1454

Fellowship education must occur in the context of a learning and working 1455

environment that emphasizes the following principles: 1456

1457

• Excellence in the safety and quality of care rendered to patients by fellows 1458

today 1459

1460

• Excellence in the safety and quality of care rendered to patients by today’s 1461

fellows in their future practice 1462

1463

• Excellence in professionalism through faculty modeling of: 1464

1465

o the effacement of self-interest in a humanistic environment that supports 1466

the professional development of physicians 1467

1468

o the joy of curiosity, problem-solving, intellectual rigor, and discovery 1469

1470

• Commitment to the well-being of the students, residents, fellows, faculty 1471

members, and all members of the health care team 1472

1473

Background and Intent: The revised requirements are intended to provide greater

flexibility within an established framework, allowing programs and fellows more

Critical Care Medicine Tracked Changes Copy

discretion to structure clinical education in a way that best supports the above

principles of professional development. With this increased flexibility comes the

responsibility for programs and fellows to adhere to the 80-hour maximum weekly limit

(unless a rotation-specific exception is granted by a Review Committee), and to utilize

flexibility in a manner that optimizes patient safety, fellow education, and fellow well-

being. The requirements are intended to support the development of a sense of

professionalism by encouraging fellows to make decisions based on patient needs and

their own well-being, without fear of jeopard

izing their program’s accreditation status. In

addition, the proposed requirements eliminate the burdensome documentation

requirement for fellows to justify clinical and educational work hour variations.

Clinical and educational work hours represent only one part of the larger issue of

conditions of the learning and working environment, and Section VI has now been

expanded to include greater attention to patient safety and fellow and faculty member

well-being. The requirements are intended to support programs and fellows as they

strive for excellence, while also ensuring ethical, humanistic training. Ensuring that

flexibility is used in an appropriate manner is a shared responsibility of the program and

fellows. With this flexibility comes a responsibility for fellows and faculty members to

recognize the need to hand off care of a patient to another provider when a fellow is too

fatigued to provide safe, high quality care and for programs to ensure that fellows

remain within the 80-hour maximum weekly limit.

1474

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability 1475

1476

VI.A.1. Patient Safety and Quality Improvement 1477

1478

All physicians share responsibility for promoting patient safety and 1479

enhancing quality of patient care. Graduate medical education must 1480

prepare fellows to provide the highest level of clinical care with 1481

continuous focus on the safety, individual needs, and humanity of 1482

their patients. It is the right of each patient to be cared for by fellows 1483

who are appropriately supervised; possess the requisite knowledge, 1484

skills, and abilities; understand the limits of their knowledge and 1485

experience; and seek assistance as required to provide optimal 1486

patient care. 1487

1488

Fellows must demonstrate the ability to analyze the care they 1489

provide, understand their roles within health care teams, and play an 1490

active role in system improvement processes. Graduating fellows 1491

will apply these skills to critique their future unsupervised practice 1492

and effect quality improvement measures. 1493

1494

It is necessary for fellows and faculty members to consistently work 1495

in a well-coordinated manner with other health care professionals to 1496

achieve organizational patient safety goals. 1497

1498

VI.A.1.a) Patient Safety 1499

1500

VI.A.1.a).(1) Culture of Safety 1501

1502

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A culture of safety requires continuous identification 1503

of vulnerabilities and a willingness to transparently 1504

deal with them. An effective organization has formal 1505

mechanisms to assess the knowledge, skills, and 1506

attitudes of its personnel toward safety in order to 1507

identify areas for improvement. 1508

1509

VI.A.1.a).(1).(a) The program, its faculty, residents, and fellows 1510

must actively participate in patient safety 1511

systems and contribute to a culture of safety.

1512

(Core)

1513

1514

VI.A.1.a).(1).(b) The program must have a structure that 1515

promotes safe, interprofessional, team-based 1516

care.

(Core)

1517

1518

VI.A.1.a).(2) Education on Patient Safety 1519

1520

Programs must provide formal educational activities 1521

that promote patient safety-related goals, tools, and 1522

techniques.

(Core)

1523

1524

Background and Intent: Optimal patient safety occurs in the setting of a coordinated

interprofessional learning and working environment.

1525

VI.A.1.a).(3) Patient Safety Events 1526

1527

Reporting, investigation, and follow-up of adverse 1528

events, near misses, and unsafe conditions are pivotal 1529

mechanisms for improving patient safety, and are 1530

essential for the success of any patient safety 1531

program. Feedback and experiential learning are 1532

essential to developing true competence in the ability 1533

to identify causes and institute sustainable systems-1534

based changes to ameliorate patient safety 1535

vulnerabilities. 1536

1537

VI.A.1.a).(3).(a) Residents, fellows, faculty members, and other 1538

clinical staff members must: 1539

1540

VI.A.1.a).(3).(a).(i) know their responsibilities in reporting 1541

patient safety events at the clinical site; 1542

(Core)

1543

1544

VI.A.1.a).(3).(a).(ii) know how to report patient safety 1545

events, including near misses, at the 1546

clinical site; and,

(Core)

1547

1548

VI.A.1.a).(3).(a).(iii) be provided with summary information 1549

of their institution’s patient safety 1550

reports.

(Core)

1551

Critical Care Medicine Tracked Changes Copy

1552

VI.A.1.a).(3).(b) Fellows must participate as team members in 1553

real and/or simulated interprofessional clinical 1554

patient safety activities, such as root cause 1555

analyses or other activities that include 1556

analysis, as well as formulation and 1557

implementation of actions.

(Core)

1558

1559

VI.A.1.a).(4) Fellow Education and Experience in Disclosure of 1560

Adverse Events 1561

1562

Patient-centered care requires patients, and when 1563

appropriate families, to be apprised of clinical 1564

situations that affect them, including adverse events. 1565

This is an important skill for faculty physicians to 1566

model, and for fellows to develop and apply. 1567

1568

VI.A.1.a).(4).(a) All fellows must receive training in how to 1569

disclose adverse events to patients and 1570

families.

(Core)

1571

1572

VI.A.1.a).(4).(b) Fellows should have the opportunity to 1573

participate in the disclosure of patient safety 1574

events, real or simulated.

(Detail)†

1575

1576

VI.A.1.b) Quality Improvement 1577

1578

VI.A.1.b).(1) Education in Quality Improvement 1579

1580

A cohesive model of health care includes quality-1581

related goals, tools, and techniques that are necessary 1582

in order for health care professionals to achieve 1583

quality improvement goals. 1584

1585

VI.A.1.b).(1).(a) Fellows must receive training and experience in 1586

quality improvement processes, including an 1587

understanding of health care disparities.

(Core)

1588

1589

VI.A.1.b).(2) Quality Metrics 1590

1591

Access to data is essential to prioritizing activities for 1592

care improvement and evaluating success of 1593

improvement efforts. 1594

1595

VI.A.1.b).(2).(a) Fellows and faculty members must receive data 1596

on quality metrics and benchmarks related to 1597

their patient populations.

(Core)

1598

1599

VI.A.1.b).(3) Engagement in Quality Improvement Activities 1600

1601

Critical Care Medicine Tracked Changes Copy

Experiential learning is essential to developing the 1602

ability to identify and institute sustainable systems-1603

based changes to improve patient care. 1604

1605

VI.A.1.b).(3).(a) Fellows must have the opportunity to 1606

participate in interprofessional quality 1607

improvement activities.

(Core)

1608

1609

VI.A.1.b).(3).(a).(i) This should include activities aimed at 1610

reducing health care disparities.

(Detail)

1611

1612

VI.A.2. Supervision and Accountability 1613

1614

VI.A.2.a) Although the attending physician is ultimately responsible for 1615

the care of the patient, every physician shares in the 1616

responsibility and accountability for their efforts in the 1617

provision of care. Effective programs, in partnership with 1618

their Sponsoring Institutions, define, widely communicate, 1619

and monitor a structured chain of responsibility and 1620

accountability as it relates to the supervision of all patient 1621

care. 1622

1623

Supervision in the setting of graduate medical education 1624

provides safe and effective care to patients; ensures each 1625

fellow’s development of the skills, knowledge, and attitudes 1626

required to enter the unsupervised practice of medicine; and 1627

establishes a foundation for continued professional growth. 1628

1629

VI.A.2.a).(1) Each patient must have an identifiable and 1630

appropriately-credentialed and privileged attending 1631

physician (or licensed independent practitioner as 1632

specified by the applicable Review Committee) who is 1633

responsible and accountable for the patient’s care. 1634

(Core)

1635

1636

VI.A.2.a).(1).(a) This information must be available to fellows, 1637

faculty members, other members of the health 1638

care team, and patients.

(Core)

1639

1640

VI.A.2.a).(1).(b) Fellows and faculty members must inform each 1641

patient of their respective roles in that patient’s 1642

care when providing direct patient care.

(Core)

1643

1644

VI.A.2.b) Supervision may be exercised through a variety of methods. 1645

For many aspects of patient care, the supervising physician 1646

may be a more advanced fellow. Other portions of care 1647

provided by the fellow can be adequately supervised by the 1648

appropriate availability of the supervising faculty member or 1649

fellow, either on site or by means of telecommunication 1650

technology. Some activities require the physical presence of 1651

the supervising faculty member. In some circumstances, 1652

Critical Care Medicine Tracked Changes Copy

supervision may include post-hoc review of fellow-delivered 1653

care with feedback. 1654

1655

Background and Intent: Appropriate supervision is essential for patient safety and

high-quality teaching. Supervision is also contextual. There is tremendous diversity of

fellow patient interactions, education and training locations, and fellow skills and

abilities even at the same level of the educational program. The degree of supervision

is expected to evolve progressively as a fellow gains more experience, even with the

same patient condition or procedure. All fellows have a level of supervision

commensurate with their level of autonomy in practice; this level of supervision may

be enhanced based on factors such as patient safety, complexity, acuity, urgency, risk

of serious adverse events, or other pertinent variables.

1656

VI.A.2.b).(1) The program must demonstrate that the appropriate 1657

level of supervision in place for all fellows is based on 1658

each fellow’s level of training and ability, as well as 1659

patient complexity and acuity. Supervision may be 1660

exercised through a variety of methods, as appropriate 1661

to the situation.

(Core)

1662

1663

VI.A.2.b).(2) The program must define when physical presence of a 1664

supervising physician is required.

(Core)

1665

1666

VI.A.2.c) Levels of Supervision 1667

1668

To promote appropriate fellow supervision while providing 1669

for graded authority and responsibility, the program must use 1670

the following classification of supervision:

(Core)

1671

1672

VI.A.2.c).(1) Direct Supervision: 1673

1674

VI.A.2.c).(1).(a) the supervising physician is physically present 1675

with the fellow during the key portions of the 1676

patient interaction; or,

(Core)

1677

1678

VI.A.2.c).(1).(b) the supervising physician and/or patient is not 1679

physically present with the fellow and the 1680

supervising physician is concurrently 1681

monitoring the patient care through appropriate 1682

telecommunication technology.

(Core)

1683

1684

VI.A.2.c).(2) Indirect Supervision: the supervising physician is not 1685

providing physical or concurrent visual or audio 1686

supervision but is immediately available to the fellow 1687

for guidance and is available to provide appropriate 1688

direct supervision.

(Core)

1689

1690

VI.A.2.c).(3) Oversight – the supervising physician is available to 1691

provide review of procedures/encounters with 1692

feedback provided after care is delivered.

(Core)

1693

1694

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VI.A.2.d) The privilege of progressive authority and responsibility, 1695

conditional independence, and a supervisory role in patient 1696

care delegated to each fellow must be assigned by the 1697

program director and faculty members.

(Core)

1698

1699

VI.A.2.d).(1) The program director must evaluate each fellow’s 1700

abilities based on specific criteria, guided by the 1701

Milestones.

(Core)

1702

1703

VI.A.2.d).(2) Faculty members functioning as supervising 1704

physicians must delegate portions of care to fellows 1705

based on the needs of the patient and the skills of 1706

each fellow.

(Core)

1707

1708

VI.A.2.d).(3) Fellows should serve in a supervisory role to junior 1709

fellows and residents in recognition of their progress 1710

toward independence, based on the needs of each 1711

patient and the skills of the individual resident or 1712

fellow.

(Detail)

1713

1714

VI.A.2.e) Programs must set guidelines for circumstances and events 1715

in which fellows must communicate with the supervising 1716

faculty member(s).

(Core)

1717

1718

VI.A.2.e).(1) Each fellow must know the limits of their scope of 1719

authority, and the circumstances under which the 1720

fellow is permitted to act with conditional 1721

independence.

(Outcome)

1722

1723

Background and Intent: The ACGME Glossary of Terms defines conditional

independence as: Graded, progressive responsibility for patient care with defined

oversight.

1724

VI.A.2.f) Faculty supervision assignments must be of sufficient 1725

duration to assess the knowledge and skills of each fellow 1726

and to delegate to the fellow the appropriate level of patient 1727

care authority and responsibility.

(Core)

1728

1729

VI.B. Professionalism 1730

1731

VI.B.1. Programs, in partnership with their Sponsoring Institutions, must 1732

educate fellows and faculty members concerning the professional 1733

responsibilities of physicians, including their obligation to be 1734

appropriately rested and fit to provide the care required by their 1735

patients.

(Core)

1736

1737

VI.B.2. The learning objectives of the program must: 1738

1739

VI.B.2.a) be accomplished through an appropriate blend of supervised 1740

patient care responsibilities, clinical teaching, and didactic 1741

educational events;

(Core)

1742

Critical Care Medicine Tracked Changes Copy

1743

VI.B.2.b) be accomplished without excessive reliance on fellows to 1744

fulfill non-physician obligations; and,

(Core)

1745

1746

Background and Intent: Routine reliance on fellows to fulfill non-physician obligations

increases work compression for fellows and does not provide an optimal educational

experience. Non-physician obligations are those duties which in most institutions are

performed by nursing and allied health professionals, transport services, or clerical

staff. Examples of such obligations include transport of patients from the wards or units

for procedures elsewhere in the hospital; routine blood drawing for laboratory tests;

routine monitoring of patients when off the ward; and clerical duties, such as

scheduling. While it is understood that fellows may be expected to do any of these

things on occasion when the need arises, these activities should not be performed by

fellows routinely and must be kept to a minimum to optimize fellow education.

1747

VI.B.2.c) ensure manageable patient care responsibilities.

(Core)

1748

1749

Background and Intent: The Common Program Requirements do not define

“manageable patient care responsibilities” as this is variable by specialty and PGY

level. Review Committees will provide further detail regarding patient care

responsibilities in the applicable specialty-specific Program Requirements and

accompanying FAQs. However, all programs, regardless of specialty, should carefully

assess how the assignment of patient care responsibilities can affect work

compression.

1750

VI.B.3. The program director, in partnership with the Sponsoring Institution, 1751

must provide a culture of professionalism that supports patient 1752

safety and personal responsibility.

(Core)

1753

1754

VI.B.4. Fellows and faculty members must demonstrate an understanding 1755

of their personal role in the: 1756

1757

VI.B.4.a) provision of patient- and family-centered care;

(Outcome)

1758

1759

VI.B.4.b) safety and welfare of patients entrusted to their care, 1760

including the ability to report unsafe conditions and adverse 1761

events;

(Outcome)

1762

1763

Background and Intent: This requirement emphasizes that responsibility for reporting

unsafe conditions and adverse events is shared by all members of the team and is not

solely the responsibility of the fellow.

1764

VI.B.4.c) assurance of their fitness for work, including:

(Outcome)

1765

1766

Background and Intent: This requirement emphasizes the professional responsibility of

faculty members and fellows to arrive for work adequately rested and ready to care for

patients. It is also the responsibility of faculty members, fellows, and other members of

the care team to be observant, to intervene, and/or to escalate their concern about

fellow and faculty member fitness for work, depending on the situation, and in

accordance with institutional policies.

Critical Care Medicine Tracked Changes Copy

1767

VI.B.4.c).(1) management of their time before, during, and after 1768

clinical assignments; and,

(Outcome)

1769

1770

VI.B.4.c).(2) recognition of impairment, including from illness, 1771

fatigue, and substance use, in themselves, their peers, 1772

and other members of the health care team.

(Outcome)

1773

1774

VI.B.4.d) commitment to lifelong learning;

(Outcome)

1775

1776

VI.B.4.e) monitoring of their patient care performance improvement 1777

indicators; and,

(Outcome)

1778

1779

VI.B.4.f) accurate reporting of clinical and educational work hours, 1780

patient outcomes, and clinical experience data.

(Outcome)

1781

1782

VI.B.5. All fellows and faculty members must demonstrate responsiveness 1783

to patient needs that supersedes self-interest. This includes the 1784

recognition that under certain circumstances, the best interests of 1785

the patient may be served by transitioning that patient’s care to 1786

another qualified and rested provider.

(Outcome)

1787

1788

VI.B.6. Programs, in partnership with their Sponsoring Institutions, must 1789

provide a professional, equitable, respectful, and civil environment 1790

that is free from discrimination, sexual and other forms of 1791

harassment, mistreatment, abuse, or coercion of students, fellows, 1792

faculty, and staff.

(Core)

1793

1794

VI.B.7. Programs, in partnership with their Sponsoring Institutions, should 1795

have a process for education of fellows and faculty regarding 1796

unprofessional behavior and a confidential process for reporting, 1797

investigating, and addressing such concerns.

(Core)

1798

1799

VI.C. Well-Being 1800

1801

Psychological, emotional, and physical well-being are critical in the 1802

development of the competent, caring, and resilient physician and require 1803

proactive attention to life inside and outside of medicine. Well-being 1804

requires that physicians retain the joy in medicine while managing their 1805

own real-life stresses. Self-care and responsibility to support other 1806

members of the health care team are important components of 1807

professionalism; they are also skills that must be modeled, learned, and 1808

nurtured in the context of other aspects of fellowship training. 1809

1810

Fellows and faculty members are at risk for burnout and depression. 1811

Programs, in partnership with their Sponsoring Institutions, have the same 1812

responsibility to address well-being as other aspects of resident 1813

competence. Physicians and all members of the health care team share 1814

responsibility for the well-being of each other. For example, a culture which 1815

encourages covering for colleagues after an illness without the expectation 1816

of reciprocity reflects the ideal of professionalism. A positive culture in a 1817

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clinical learning environment models constructive behaviors, and prepares 1818

fellows with the skills and attitudes needed to thrive throughout their 1819

careers. 1820

1821

Background and Intent: The ACGME is committed to addressing physician well-being

for individuals and as it

relates to the learning and working environment. The creation of

a learning and working environment with a culture of respect and accountability for

physician well-being is crucial to physicians’ ability to deliver the safest, best possible

care to patients. The ACGME is leveraging its resources in four key areas to support the

ongoing focus on physician well-being: education, influence, research, and

collaboration. Information regarding the ACGME’s ongoing efforts in this area is

available on the ACGME website:

www.acgme.org/physicianwellbeing.

The ACGME also created a repository for well-being materials, assessments,

presentations, and more on the Well-Being Tools and Resources page

in Learn at

ACGME for programs seeking to develop or strengthen their own well-being initiatives.

There are many activities that programs can implement now to assess and support

physician well-being. These include the distribution and analysis of culture of safety

surveys, ensuring the availability of counseling services, and paying attention to the

safety of the entire health care team.

1822

VI.C.1. The responsibility of the program, in partnership with the 1823

Sponsoring Institution, to address well-being must include: 1824

1825

VI.C.1.a) efforts to enhance the meaning that each fellow finds in the 1826

experience of being a physician, including protecting time 1827

with patients, minimizing non-physician obligations, 1828

providing administrative support, promoting progressive 1829

autonomy and flexibility, and enhancing professional 1830

relationships;

(Core)

1831

1832

VI.C.1.b) attention to scheduling, work intensity, and work 1833

compression that impacts fellow well-being;

(Core)

1834

1835

VI.C.1.c) evaluating workplace safety data and addressing the safety of 1836

fellows and faculty members;

(Core)

1837

1838

Background and Intent: This requirement emphasizes the responsibility shared by the

Sponsoring Institution and its programs to gather information and utilize systems that

monitor and enhance fellow and faculty member safety, including physical safety.

Issues to be addressed include, but are not limited to, monitoring of workplace injuries,

physical or emotional violence, vehicle collisions, and emotional well-being after

adverse events.

1839

VI.C.1.d) policies and programs that encourage optimal fellow and 1840

faculty member well-being; and,

(Core)

1841

1842

Background and Intent: Well-being includes having time away from work to engage with

family and friends, as well as to attend to personal needs and to one’s own health,

including adequate rest, healthy diet, and regular exercise.

Critical Care Medicine Tracked Changes Copy

1843

VI.C.1.d).(1) Fellows must be given the opportunity to attend 1844

medical, mental health, and dental care appointments, 1845

including those scheduled during their working hours. 1846

(Core)

1847

1848

Background and Intent: The intent of this requirement is to ensure that fellows have the

opportunity to access medical and dental care, including mental health care, at times

that are appropriate to their individual circumstances. Fellows must be provided with

time away from the program as needed to access care, including appointments

scheduled during their working hours.

1849

VI.C.1.e) attention to fellow and faculty member burnout, depression, 1850

and substance use disorder. The program, in partnership with 1851

its Sponsoring Institution, must educate faculty members and 1852

fellows in identification of the symptoms of burnout, 1853

depression, and substance use disorder, including means to 1854

assist those who experience these conditions. Fellows and 1855

faculty members must also be educated to recognize those 1856

symptoms in themselves and how to seek appropriate care. 1857

The program, in partnership with its Sponsoring Institution, 1858

must:

(Core)

1859

1860

Background and Intent: Programs and Sponsoring Institutions are encouraged to review

materials in order to create systems for identification of burnout, depression, and

substance use disorder. Materials and more information are available in Learn at

ACGME (https://dl.acgme.org/pages/well-being-tools-resources).

1861

VI.C.1.e).(1) encourage fellows and faculty members to alert the 1862

program director or other designated personnel or 1863

programs when they are concerned that another 1864

fellow, resident, or faculty member may be displaying 1865

signs of burnout, depression, a substance use 1866

disorder, suicidal ideation, or potential for violence; 1867

(Core)

1868

1869

Background and Intent: Individuals experiencing burnout, depression, substance use

disorder, and/or suicidal ideation are often reluctant to reach out for help due to the

stigma associated with these conditions, and are concerned that seeking help may have

a negative impact on their career. Recognizing that physicians are at increased risk in

these areas, it is essential that fellows and faculty members are able to report their

concerns when another fellow or faculty member displays signs of any of these

conditions, so that the program director or other designated personnel, such as the

department chair, may assess the situation and intervene as necessary to facilitate

access to appropriate care. Fellows and faculty members must know which personnel,

in addition to the program director, have been designated with this responsibility; those

personnel and the program director should be familiar with the institution’s impaired

physician policy and any employee health, employee assistance, and/or wellness

programs within the institution. In cases of physician impairment, the program director

or designated personnel should follow the policies of their institution for reporting.

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1870

VI.C.1.e).(2) provide access to appropriate tools for self-screening; 1871

and,

(Core)

1872

1873

VI.C.1.e).(3) provide access to confidential, affordable mental 1874

health assessment, counseling, and treatment, 1875

including access to urgent and emergent care 24 1876

hours a day, seven days a week.

(Core)

1877

1878

Background and Intent: The intent of this requirement is to ensure that fellows have

immediate access at all times to a mental health professional (psychiatrist,

psychologist, Licensed Clinical Social Worker, Primary Mental Health Nurse

Practitioner, or Licensed Professional Counselor) for urgent or emergent mental health

issues. In-person, telemedicine, or telephonic means may be utilized to satisfy this

requirement. Care in the Emergency Department may be necessary in some cases, but

not as the primary or sole means to meet the requirement.

The reference to affordable counseling is intended to require that financial cost not be a

barrier to obtaining care.

1879

VI.C.2. There are circumstances in which fellows may be unable to attend 1880

work, including but not limited to fatigue, illness, family 1881

emergencies, and parental leave. Each program must allow an 1882

appropriate length of absence for fellows unable to perform their 1883

patient care responsibilities.

(Core)

1884

1885

VI.C.2.a) The program must have policies and procedures in place to 1886

ensure coverage of patient care.

(Core)

1887

1888

VI.C.2.b) These policies must be implemented without fear of negative 1889

consequences for the fellow who is or was unable to provide 1890

the clinical work.

(Core)

1891

1892

Background and Intent: Fellows may need to extend their length of training depending

on length of absence and specialty board eligibility requirements. Teammates should

assist colleagues in need and equitably reintegrate them upon return.

1893

VI.D. Fatigue Mitigation 1894

1895

VI.D.1. Programs must: 1896

1897

VI.D.1.a) educate all faculty members and fellows to recognize the 1898

signs of fatigue and sleep deprivation;

(Core)

1899

1900

VI.D.1.b) educate all faculty members and fellows in alertness 1901

management and fatigue mitigation processes; and,

(Core)

1902

1903

VI.D.1.c) encourage fellows to use fatigue mitigation processes to 1904

manage the potential negative effects of fatigue on patient 1905

care and learning.

(Detail)

1906

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1907

Background and Intent: Providing medical care to patients is physically and mentally

demanding. Night shifts, even for those who have had enough rest, cause fatigue.

Experiencing fatigue in a supervised environment during training prepares fellows for

managing fatigue in practice. It is expected that programs adopt fatigue mitigation

processes and ensure that there are no negative consequences and/or stigma for using

fatigue mitigation strategies.

This requirement emphasizes the importance of adequate rest before and after clinical

responsibilities. Strategies that may be used include, but are not limited to, strategic

napping; the judicious use of caffeine; availability of other caregivers;

time management

to maximize sleep off-duty; learning to recognize the signs of fatigue, and self-

monitoring performance and/or asking others to monitor performance; remaining active

to promote alertness; maintaining a healthy diet; using relaxation techniques to fall

asleep; maintaining a consistent sleep routine; exercising regularly; increasing sleep

time before and after call; and ensuring sufficient sleep recovery periods.

1908

VI.D.2. Each program must ensure continuity of patient care, consistent 1909

with the program’s policies and procedures referenced in VI.C.2–1910

VI.C.2.b), in the event that a fellow may be unable to perform their 1911

patient care responsibilities due to excessive fatigue.

(Core)

1912

1913

VI.D.3. The program, in partnership with its Sponsoring Institution, must 1914

ensure adequate sleep facilities and safe transportation options for 1915

fellows who may be too fatigued to safely return home.

(Core)

1916

1917

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care 1918

1919

VI.E.1. Clinical Responsibilities 1920

1921

The clinical responsibilities for each fellow must be based on PGY 1922

level, patient safety, fellow ability, severity and complexity of patient 1923

illness/condition, and available support services.

(Core)

1924

1925

Background and Intent: The changing clinical care environment of medicine has meant

that work compression due to high complexity has increased stress on fellows. Faculty

members and program directors need to make sure fellows function in an environment

that has safe patient care and a sense of fellow well-being. Some Review Committees

have addressed this by setting limits on patient admissions, and it is an essential

responsibility of the program director to monitor fellow workload. Workload should be

distributed among the fellow team and interdisciplinary teams to minimize work

compression.

1926

VI.E.2. Teamwork 1927

1928

Fellows must care for patients in an environment that maximizes 1929

communication. This must include the opportunity to work as a 1930

member of effective interprofessional teams that are appropriate to 1931

the delivery of care in the subspecialty and larger health system. 1932

(Core)

1933

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1934

VI.E.3. Transitions of Care 1935

1936

VI.E.3.a) Programs must design clinical assignments to optimize 1937

transitions in patient care, including their safety, frequency, 1938

and structure.

(Core)

1939

1940

VI.E.3.b) Programs, in partnership with their Sponsoring Institutions, 1941

must ensure and monitor effective, structured hand-over 1942

processes to facilitate both continuity of care and patient 1943

safety.

(Core)

1944

1945

VI.E.3.c) Programs must ensure that fellows are competent in 1946

communicating with team members in the hand-over process. 1947

(Outcome)

1948

1949

VI.E.3.d) Programs and clinical sites must maintain and communicate 1950

schedules of attending physicians and fellows currently 1951

responsible for care.

(Core)

1952

1953

VI.E.3.e) Each program must ensure continuity of patient care, 1954

consistent with the program’s policies and procedures 1955

referenced in VI.C.2-VI.C.2.b), in the event that a fellow may 1956

be unable to perform their patient care responsibilities due to 1957

excessive fatigue or illness, or family emergency.

(Core)

1958

1959

VI.F. Clinical Experience and Education 1960

1961

Programs, in partnership with their Sponsoring Institutions, must design 1962

an effective program structure that is configured to provide fellows with 1963

educational and clinical experience opportunities, as well as reasonable 1964

opportunities for rest and personal activities. 1965

1966

Background and Intent: In the new requirements, the terms “clinical experience and

education,” “clinical and educational work,” and “clinical and educational work hours”

replace the terms “duty hours,” “duty periods,” and “duty.” These changes have been

made in response to concerns that the previous use of the term “duty” in reference to

number of hours worked may have led some to conclude that fellows’ duty to “clock

out” on time superseded their duty to their patients.

1967

VI.F.1. Maximum Hours of Clinical and Educational Work per Week 1968

1969

Clinical and educational work hours must be limited to no more than 1970

80 hours per week, averaged over a four-week period, inclusive of all 1971

in-house clinical and educational activities, clinical work done from 1972

home, and all moonlighting.

(Core)

1973

1974

Background and Intent: Programs and fellows have a shared responsibility to ensure

that the 80-hour maximum weekly limit is not exceeded. While the requirement has been

written with the intent of allowing fellows to remain beyond their scheduled work

Critical Care Medicine Tracked Changes Copy

periods to care for a patient or participate in an educational activity, these additional

hours must be accounted for in the allocated 80 hours when averaged over four weeks.

Scheduling

While the ACGME acknowledges that, on rare occasions, a fellow may work in excess of

80 hours in a given week, all programs and fellows utilizing this flexibility will be

required to adhere to the 80-hour maximum weekly limit when averaged over a four-

week period. Programs that regularly schedule fellows to work 80 hours per week and

still permit fellows to remain beyond their scheduled work period are likely to exceed

the 80-hour maximum, which would not be in substantial compliance with the

requirement. These programs should adjust schedules so that fellows are scheduled to

work fewer than 80 hours per week,

which would allow fellows to remain beyond their

scheduled work period when needed without violating the 80-hour requirement.

Programs may wish to consider using night float and/or making adjustments to the

frequency of in-house call to ensure compliance with the 80-hour maximum weekly limit.

Oversight

With increased flexibility introduced into the Requirements, programs permitting this

flexibility will need to account for the potential for fellows to remain beyond their

assigned work periods when developing schedules, to avoid exceeding the 80-hour

maximum weekly limit, averaged over four weeks. The ACGME Review Committees will

strictly monitor and enforce compliance with the 80-hour requirement. Where violations

of the 80-hour requirement are identified, programs will be subject to citation and at risk

for an adverse accreditation action.

Work from Home

While the requirement specifies that clinical work done from home must be counted

toward the 80-hour maximum weekly limit, the expectation remains that scheduling be

structured so that fellows are able to complete most work on site during scheduled

clinical work hours without requiring them to take work home. The new requirements

acknowledge the changing landscape of medicine, including electronic health records,

and the resulting increase in the amount of work fellows choose to do from home. The

requirement provides flexibility for fellows to do this while ensuring that the time spent

by fellows completing clinical work from home is accomplished within the 80-hour

weekly maximum. Types of work from home that must be counted include using an

electronic health record and taking calls from home. Reading done in preparation for the

following day’s cases, studying, and research done from home do not count toward the

80 hours. Fellow decisions to leave the hospital before their clinical work has been

completed and to finish that work later from home should be made in consultation with

the fellow’s supervisor. In such circumstances, fellows should be mindful of their

professional responsibility to complete work in a timely manner and to maintain patient

confidentiality.

During the public comment period many individuals raised questions and concerns

related to this change. Some questioned whether minute by minute tracking would be

required; in other words, if a fellow

spends three minutes on a phone call and then a few

hours later spends two minutes on another call, will the fellow need to report that time.

Others raised concerns related to the ability of programs and institutions to verify the

accuracy of the information reported by fellows. The new requirements are not an

attempt to micromanage this process. Fellows are to track the time they spend on

clinical work from home and to report that time to the program. Decisions regarding

Critical Care Medicine Tracked Changes Copy

whether to report infrequent phone calls of very short duration will be left to the

individual fellow. Programs will need to factor in time fellows are spending on clinical

work at home when schedules are developed to ensure that fellows are not working in

excess of 80 hours per week, averaged over four weeks. There is no requirement that

programs assume responsibility for documenting this time. Rather, the program’s

responsibility is ensuring that fellows report their time from home and that schedules

are structured to ensure that fellows are not working in excess of 80 hours per week,

averaged over four weeks.

1975

VI.F.2. Mandatory Time Free of Clinical Work and Education 1976

1977

VI.F.2.a) The program must design an effective program structure that 1978

is configured to provide fellows with educational 1979

opportunities, as well as reasonable opportunities for rest 1980

and personal well-being.

(Core)

1981

1982

VI.F.2.b) Fellows should have eight hours off between scheduled 1983

clinical work and education periods.

(Detail)

1984

1985

VI.F.2.b).(1) There may be circumstances when fellows choose to 1986

stay to care for their patients or return to the hospital 1987

with fewer than eight hours free of clinical experience 1988

and education. This must occur within the context of 1989

the 80-hour and the one-day-off-in-seven 1990

requirements.

(Detail)

1991

1992

Background and Intent: While it is expected that fellow schedules will be structured to

ensure that fellows are provided with a minimum of eight hours off between scheduled

work periods, it is recognized that fellows may choose to remain beyond their

scheduled time, or return to the clinical site during this time-off period, to care for a

patient. The requirement preserves the flexibility for fellows to make those choices. It is

also noted that the 80-hour weekly limit (averaged over four weeks) is a deterrent for

scheduling fewer than eight hours off between clinical and education work periods,

as it

would be difficult for a program to design a schedule that provides fewer than eight

hours off without violating the 80-hour rule.

1993

VI.F.2.c) Fellows must have at least 14 hours free of clinical work and 1994

education after 24 hours of in-house call.

(Core)

1995

1996

Background and Intent: Fellows have a responsibility to return to work rested, and thus

are expected to use this time away from work to get adequate rest. In support of this

goal, fellows are encouraged to prioritize sleep over other discretionary activities.

1997

VI.F.2.d) Fellows must be scheduled for a minimum of one day in 1998

seven free of clinical work and required education (when 1999

averaged over four weeks). At-home call cannot be assigned 2000

on these free days.

(Core)

2001

2002

Background and Intent: The requirement provides flexibility for programs to distribute

days off in a manner that meets program and fellow needs. It is strongly recommended

Critical Care Medicine Tracked Changes Copy

that fellows’ preference regarding how their days off are distributed be considered as

schedules are developed. It is desirable that days off be distributed throughout the

month, but some fellows may prefer to group their days off to have a “golden weekend,”

meaning a consecutive Saturday and Sunday free from work. The requirement for one

free day in seven should not be interpreted as precluding a golden weekend. Where

feasible, schedules may be designed to provide fellows with a weekend, or two

consecutive days, free of work. The applicable Review Committee will evaluate the

number of consecutive days of work and determine whether they meet educational

objectives. Programs are encouraged to distribute days off in a fashion that optimizes

fellow well-being, and educational and personal goals. It is noted that a day off is

defined in the ACGME Glossary of Terms as “one (1) continuous 24-hour period free

from all administrative, clinical, and educational activities.”

2003

VI.F.3. Maximum Clinical Work and Education Period Length 2004

2005

VI.F.3.a) Clinical and educational work periods for fellows must not 2006

exceed 24 hours of continuous scheduled clinical 2007

assignments.

(Core)

2008

2009

VI.F.3.a).(1) Up to four hours of additional time may be used for 2010

activities related to patient safety, such as providing 2011

effective transitions of care, and/or fellow education. 2012

(Core)

2013

2014

VI.F.3.a).(1).(a) Additional patient care responsibilities must not 2015

be assigned to a fellow during this time.

(Core)

2016

2017

Background and Intent: The additional time referenced in VI.F.3.a).(1) should not be

used for the care of new patients. It is essential that the fellow continue to function as a

member of the team in an environment where other members of the team can assess

fellow fatigue, and that supervision for post-call fellows is provided. This 24 hours and

up to an additional four hours must occur within the context of 80-hour weekly limit,

averaged over four weeks.

2018

VI.F.4. Clinical and Educational Work Hour Exceptions 2019

2020

VI.F.4.a) In rare circumstances, after handing off all other 2021

responsibilities, a fellow, on their own initiative, may elect to 2022

remain or return to the clinical site in the following 2023

circumstances: 2024

2025

VI.F.4.a).(1) to continue to provide care to a single severely ill or 2026

unstable patient;

(Detail)

2027

2028

VI.F.4.a).(2) humanistic attention to the needs of a patient or 2029

family; or,

(Detail)

2030

2031

VI.F.4.a).(3) to attend unique educational events.

(Detail)

2032

2033

Critical Care Medicine Tracked Changes Copy

VI.F.4.b) These additional hours of care or education will be counted 2034

toward the 80-hour weekly limit.

(Detail)

2035

2036

Background and Intent: This requirement is intended to provide fellows with some

control over their schedules by providing the flexibility to voluntarily remain beyond the

scheduled responsibilities under the circumstances described above. It is important to

note that a fellow may remain to attend a conference, or return for a conference later in

the day, only if the decision is made voluntarily. Fellows must not be required to stay.

Programs allowing fellows to remain or return beyond the scheduled work and clinical

education period must ensure that the decision to remain is initiated by the fellow and

that fellows are not coerced. This additional time must be counted toward the 80-hour

maximum weekly limit.

2037

VI.F.4.c) A Review Committee may grant rotation-specific exceptions 2038

for up to 10 percent or a maximum of 88 clinical and 2039

educational work hours to individual programs based on a 2040

sound educational rationale. 2041

2042

The Review Committee for Internal Medicine will not consider 2043

requests for exceptions to the 80-hour limit to the fellows’ work 2044

week. 2045

2046

VI.F.5. Moonlighting 2047

2048

VI.F.5.a) Moonlighting must not interfere with the ability of the fellow 2049

to achieve the goals and objectives of the educational 2050

program, and must not interfere with the fellow’s fitness for 2051

work nor compromise patient safety.

(Core)

2052

2053

VI.F.5.b) Time spent by fellows in internal and external moonlighting 2054

(as defined in the ACGME Glossary of Terms) must be 2055

counted toward the 80-hour maximum weekly limit.

(Core)

2056

2057

Background and Intent: For additional clarification of the expectations related to

moonlighting, please refer to the Common Program Requirement FAQs (available at

http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements).

2058

VI.F.6. In-House Night Float 2059

2060

Night float must occur within the context of the 80-hour and one-2061

day-off-in-seven requirements.

(Core)

2062

2063

Background and Intent: The requirement for no more than six consecutive nights of

night float was removed to provide programs with increased flexibility in scheduling.

2064

VI.F.7. Maximum In-House On-Call Frequency 2065

2066

Fellows must be scheduled for in-house call no more frequently than 2067

every third night (when averaged over a four-week period).

(Core)

2068

2069

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VI.F.7.a) Internal medicine fellowships must not average in-house call over 2070

a four-week period.

(Core)

2071

2072

VI.F.8. At-Home Call 2073

2074

VI.F.8.a) Time spent on patient care activities by fellows on at-home 2075

call must count toward the 80-hour maximum weekly limit. 2076

The frequency of at-home call is not subject to the every-2077

third-night limitation, but must satisfy the requirement for one 2078

day in seven free of clinical work and education, when 2079

averaged over four weeks.

(Core)

2080

2081

VI.F.8.a).(1) At-home call must not be so frequent or taxing as to 2082

preclude rest or reasonable personal time for each 2083

fellow.

(Core)

2084

2085

VI.F.8.b) Fellows are permitted to return to the hospital while on at-2086

home call to provide direct care for new or established 2087

patients. These hours of inpatient patient care must be 2088

included in the 80-hour maximum weekly limit.

(Detail)

2089

2090

Background and Intent: This requirement has been modified to specify that clinical work

done from home when a fellow is taking at-home call must count toward the 80-hour

maximum weekly limit. This change acknowledges the often significant amount of time

fellows devote to clinical activities when taking at-home call, and ensures that taking at-

home call does not result in fellows routinely working more than 80 hours per week. At-

home call activities that must be counted include responding to phone calls and other

forms of communication, as well as documentation, such as entering notes in an

electronic health record. Activities such as reading about the next day’s case, studying,

or research activities do not count toward the 80-hour weekly limit.

In their evaluation of fellowship programs, Review Committees will look at the overall

impact of at-home call on fellow rest and personal time.

2091

*** 2092

2093

*Core Requirements: Statements that define structure, resource, or process elements 2094

essential to every graduate medical educational program. 2095

2096

†

Detail Requirements: Statements that describe a specific structure, resource, or process, for 2097

achieving compliance with a Core Requirement. Programs and sponsoring institutions in 2098

substantial compliance with the Outcome Requirements may utilize alternative or innovative 2099

approaches to meet Core Requirements. 2100

2101

‡

Outcome Requirements: Statements that specify expected measurable or observable 2102

attributes (knowledge, abilities, skills, or attitudes) of residents or fellows at key stages of their 2103

graduate medical education. 2104

2105

Osteopathic Recognition 2106

For programs with or applying for Osteopathic Recognition, the Osteopathic Recognition 2107

Requirements also apply (www.acgme.org/OsteopathicRecognition

). 2108