Resident and Fellow Policy Manual

Appendix 1 - Probationary Status of a Residency Program:

When a residency Review Committee (RRC) of the ACGME places a residency program on probation after an unsatisfactory site visit the following will occur:

1. A copy of the notification from the RRC will be sent to the Office for Graduate Medical Education and will be presented at the next scheduled meeting of the Graduate Medical Education Committee (GMEC).  The Program Director should meet with the GMEC to discuss the issues involved.

2. If an appeal is lodged, a copy of the appeal materials will be sent to the Office for Graduate Medical Education and presented to the GMEC.

3. If, after the RRC has reviewed an appeal, the probationary status stands, the Program Director will develop and put into place a plan of correction.  The Program Director will present the plan of correction to the GMEC.

4. The GMEC will monitor the progress of the correction plan by whatever means it deems appropriate and at whatever frequency seems desirable.  In any case, review will take place before the next ACGME review of the program.

5. The GMEC will inform the Program Director in writing of its opinion of the progress of the correction plan, and make any suggestions for change to the Program Director.   The Program Director will make available to the site visitors all such internal documents during the program’s follow up ACGME site visit.

6. The Program Director will inform the program residents, the GMEC, and the Director of Residency Education of the outcome of the site visit in a timely fashion.  The outcome of the follow up site visit will determine if further action needs to be taken.

7. The Program Director may decide to call in a consultant to assist the program in addressing the citations and aiding the program in preparing for the next site visit.  The Program Director should correspond with hospital administration regarding the funding for a consultant.