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/policies/administrative/uwhc/department-specific/graduate-medical-education-gme/4311.policy

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UWHC,UWMF,

Policies,Administrative,UWHC,Department Specific,Graduate Medical Education (GME)

Resident Position Requests for New and Existing Programs (43.11)

Resident Position Requests for New and Existing Programs (43.11) - Policies, Administrative, UWHC, Department Specific, Graduate Medical Education (GME)

43.11




UWHC Departmental Policy
Category:
 UWHC only (Hospital Administrative-entity wide)  UWMF only (entity wide)
 UWHC Departmental (Graduate Medical Education)  UWMF Departmental (indicate name)
 UWHC and UWMF (shared)
Policy Title: Resident Position Requests for New and Existing Programs
Policy Number: 43.11
Effective Date: May 20, 2015
Chapter: Graduate Medical Education
Version: New
I. PURPOSE
The University of Wisconsin Hospital and Clinical (UWHC) is the sponsoring institution for more
than 60 graduate medical education (GME) programs that train more than 600 residents and fellows.
The UWHC federally funded cap is 336, however the hospital currently funds more than 390 of these
positions. The additional positions are funded from the William S. Middleton Veterans
Administration Hospital, Meriter Hospital, St. Mary’s Hospital, federal grants and individual
departments. As the UW Health enterprise continues to grow in size and complexity we can
reasonably expect that there will continue to be requests to increase the number of GME positions.
Traditionally, at UW Health the primary source of funding for GME has been the UWHC. In the
future we can anticipate the need to seek funding from all components of UW Health and other
sources if we expect to grow in size and scope. The Accreditation Council for Graduate Medical
Education (ACGME) grants authority to the UWHC Graduate Medical Education Committee
(GMEC) for establishing policies and procedures, regarding the quality of the education and the
clinical learning environment, for all residents and fellows in ACGME accredited programs. This
oversight responsibility includes approval of all proposed new positions but does not extend to
funding decisions.

II. PERSONS/PROGRAMS AFFECTED
This policy applies to all Graduate Medical Education (GME) programs sponsored by the University
of Wisconsin Hospital and Clinics (UWHC). This policy covers new position requests for existing
programs and for new programs. The term “resident” refers to residents and fellows.

III. POLICY
UWHC GME programs requesting new positions for new or existing programs must receive approval
from the GMEC. The UWHC leadership will make funding decisions with recommendations
provided by the Graduate Medical Education Committee Strategic Planning Subcommittee. It is
anticipated that the process for approval from both the institution and the ACGME, the final funding
decisions and actual hiring into new positions requires 12-18 months. It is strongly recommended that
Match deadlines, upcoming ACGME site visits, ACGME Residency Review Committee meeting
dates, hiring and funding timelines be considered in the timing of your request to the UWHC GMEC
for approval.

IV. PROCEDURE
A. Timeline Overview:



1. Month 1, Request submitted to GMEC
2. Month 2, GMEC votes on request based on educational merit
3. ACGME application may begin for those positions that do not require UWHC funding
4. September, GMEC Strategic Planning Subcommittee meets and prioritizes position requests
for UWHC funding and submits to UWHC CEO for approval
5. October - November, UWHC CEO notifies the GME Office of approved funding for new
positions
6. November, programs begin ACGME application
7. Time unknown, once ACGME approval and funding is secured recruitment may begin

B. GMEC Request for Approval: In order to be considered for additional positions for new or
existing programs, all required documentation below must be submitted to the GME Office at
least one month prior to the date of the UWHC GMEC meeting for which consideration is
requested. Additional information may be required. Current associated training programs (if
applicable) must be in good standing.
Required Documentation
Program Director Letter: The Program Director must provide a three-to-four page formal letter to
the UWHC GMEC requesting approval for a new position(s) that includes:
ξ Description of education requirements/opportunities prompting the request for the position
increase/new program and the associated academic rationale;
ξ The number of resident/fellow positions being requested;
ξ A detailed statement of impact on other GME programs, including core residency program if
applicable;
ξ ACGME clinical volume program requirements and current departmental/section clinical
experience data;
ξ Proposed faculty/resident ratios and ACGME requirements for ratios, if they exist;
ξ Space requirements/availability;
ξ Proposed Program Coordinator FTE and any other education administrative support;
ξ Funding source expectations, including affiliated hospital positions;
ξ A timeline for the expansion with approved funding amounts for each subsequent year until
the full complement has been reached;
ξ List of participating sites; and
ξ All citations listed in ACGME or UWHC GMEC reports of any associated programs must be
addressed.
Attachments:
ξ Separate written funding agreement(s) for any funding, other than UWHC, signed by the
Department Chair and any other funders (i.e., VA Chief);
ξ Information about the Program Director (i.e. an abbreviated current CV);
ξ Letter(s) of support from:
o Core Residency Program Director (if fellowship)
o Department Chair
o Program Directors of other partnering GME programs and those impacted by added
positions (if applicable); and
ξ Block schedule to be submitted in the ACGME ADS.

C. UWHC GMEC Meetings: The Program Director and the Core Residency Program Director (if
fellowship) must attend the UWHC GMEC meeting to present the initial new position request
(held the third Wednesday of each month). During that meeting the GMEC will discuss the
proposal and ask for any additional information needed to consider the educational merit of the
request. A vote will be taken once any additional information requested has been provided and



reviewed at a subsequent meeting. The presence of the Program Director is not needed at the
subsequent meeting unless s/he is specifically requested to attend by the GMEC. If approved and
no UWHC funding is required, the request moves to step E below ACGME Application
Preparation (step 6 in the timeline in IV, A).

D. GMEC Strategic Planning Subcommittee Review: The GMEC Strategic Planning
Subcommittee will meet once per year in September to prioritize all GMEC approved position
requests for the following fiscal year in which funding from the UWHC is requested. The GMEC
Strategic Planning Subcommittee will submit recommendations to the UWHC leadership for
funding approval.

E. ACGME Application Preparation and Submission: Once GMEC approval has been obtained
and funding has been secured, the GME Office will open an application in the ACGME ADS. An
email will be automatically generated to the Program Director with login information. The
program director will need to complete all parts of the common and specialty applications online.
Once the Program Director has a final application ready for submission s/he electronically
submits the application to the GME Office for approval. The GME Office, in conjunction with
the Program Review Subcommittee, will perform a brief review of the document to assure that it
is complete. If there are necessary edits the GME Office will re-open the application for the
program to edit. The GME Office is unable to edit the application. Once the GME Office has
approved the application the GME Office will electronically submit it to the ACGME and pay the
application fee.

F. Final Approvals: GMEC and ACGME approval as well as documentation of full funding for all
positions must be on file with the GME Office prior to commencing recruitment activities.

V. MODIFICATIONS
This policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not
made for the purpose of inducing any person to become or remain an employee of UWHC, and
should not be considered "promises" or as granting "property" rights. UWHC may add to, subtract
from and/or modify this policy at any time. Nothing contained in this policy impairs the right of a
non-represented employee or UWHC to terminate the employment relationship at-will. For
represented employees, who are not at-will employees, this policy does not supersede, limit nor grant
any rights beyond those provided by the applicable collective bargaining agreement.

VI. COORDINATION
Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Approval Committee: Graduate Medical Education Committee

SIGNED BY

Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Senior Medical Director for GME/Designated Institutional Official
Associate Dean for Graduate Medical Education

Revision Details:
Previous Revision Date: NA



Next Revision Due: May 20, 2018