Applies to: WSU College of Medicine Sponsored Residency and Fellowship Programs
Date: July 15, 2025
1.0 Policy Statement
It is the WSU College of Medicine policy to maintain and ensure support for its residents and fellows enrolled in its Graduate Medical Education (GME) programs in the event of program size reduction, program closure, or institutional closure.
2.0 Definitions
Accreditation Council for Graduate Medical Education (ACGME)
Accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of importance in graduate medical education.
Annual Program Evaluation (APE)
Written documentation of a formal, systematic evaluation of the curriculum and overall residency/fellowship program submitted, through the program via the Program Evaluation Committee (PEC), to the GMEC annually.
Designated Institutional Official (DIO)
The individual in a sponsoring institution who has the authority and responsibility for oversight and responsibility of all of the ACGME-accredited programs.
Primary Clinical Site
The hospital that is most commonly used in the residency/fellowship program is recognized as the primary clinical site.
Program Director
The one physician designated with authority and accountability for the operation of the residency/fellowship program; this person must be selected by the Designated Institutional Official and possess qualifications acceptable to the appropriate Residency Review Committee (RRC) of the ACGME.
Trainee
A physician in training at an ACGME accredited graduate medical education program, the term includes Interns, Residents, and Fellows or other trainee enrolled in an educational program whose education falls under the purview of the WSU Office of Graduate Medical Education.
Residency Review Committee (RRC)
The function of a Review Committee is to set accreditation standards and to provide a peer evaluation of residency programs and fellowships (or, in the case of the Institutional Review Committee, to set accreditation standards and to provide a peer evaluation of sponsoring institutions).
Special Review
The process in which the Sponsoring Institution demonstrates effective oversight of underperforming programs. The Special Review protocol establishes criteria for identifying underperformance resulting in a report that describes the quality improvement goals and corrective actions including GMEC monitoring of outcomes.
Sponsoring Institution
The organization (or entity) that assumes the ultimate financial and academic responsibility for a program of GME. The sponsoring institution has the primary purpose of providing educational programs and/or health care services (e.g., a university, a medical school, a hospital, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, a consortium, an educational foundation).
Withdrawal of Accreditation
A Review Committee determines that a program or sponsoring institution has failed to demonstrate substantial compliance with the requirements.
3.0 Responsibilities
DIO, GMEC
4.0 Procedures
WSU College of Medicine is committed to providing a high quality educational experience for all residents and fellows enrolled in College of Medicine sponsored GME programs.
Reduction in Trainee Complement
- Actions and procedures that may lead to reduction in GME Trainee complement include, but are not limited to:
- Voluntary reduction due to decreased financial or educational resources to support adequate training in the program;
- Non-voluntary reduction by the ACGMEResidentReviewCommittee (RRC) or other relevant accreditation bodies.
- When reduction in Trainee complement is deemed necessary, theGraduate Medical Education Committee(GMEC)and individual programs shall make every attempt to reduce the Trainee Complement gradually over a period of time.
Closure of a GME Program
- Actions and procedures that may lead to closure of a GME program include, but are not limited to:
- Failure of the training program to comply with the accreditation requirements bythe ACGME RRC or other relevant accreditation bodies;
- Voluntary withdrawal of accreditation of the GME program
- Failure of the training program to correct concerns and/or comply with recommendations of the GMEC based on the Annual ProgramEvaluation or SpecialReview conducted by the GMEC;
- Decreased financial or educational resources to support the training program;
- Reallocation of positions among other GME programs;
In the event that a program must reduce the size of or close the program due to an adverse action of the ACGME or involuntary loss of a training site, the Program Director must notify the GMEC, the Designated Institutional Official (DIO), and the program’s trainees within 15 days of receiving notification of the involuntary reduction or closure.
Programs that wish to voluntarily reduce the size of the program or to withdrawal accreditation must obtain prior approval for the reduction or closure from the DIO and GMEC before notifying the ACGME and the program’s trainees. When a GME program is deemed closed, the DIO will issue a letter of notification to the affiliate institution, the program, the applicable department chair, and/or its parent program when the program is a dependent subspecialty or sub-sub specialty program.
Should WSU College of Medicine as the Sponsoring Institution intend to reduce the size of or close one or more ACGME-accredited programs, the Dean or designee must inform the GMEC, DIO, programs, residents and fellows as soon as possible of the decision. In the event of a WSU GME program reduction or closure, or closure of the institution, WSU and the program will work collaboratively to ensure that residents/fellows currently enrolled in the program are able to complete their education within the program or will assist trainees in enrolling into another ACGME accredited program in which they may continue their education.
5.0 Related Policies
- GME Disasters Policy
- Special ReviewPolicy
7.0 Revision History
Original Approval: May 17, 2018
Revision Date Approval: July 15, 2025
Responsible Office: Designated Institutional Official; GME Office
Policy Contact: WSU College of Medicine Office of GME
Supersedes: N/A