No, but the program should internally track each actual assignment served by each resident/fellow (regardless of the number of days, weeks, or months of each assignment).

The block diagram is often confused with the resident/fellow rotation schedule. The block diagram is a map of the planned rotations (or other educational experiences) for all residents/fellows in a given post-graduate year. A rotation schedule depicts the actual sequence of rotations (or other educational experiences) for each individual resident/fellow. The ACGME requires programs to annually submit a block diagram but requests submission of rotation schedules only rarely and for very specific reasons. Refer to the Block Diagram section of the Residency Program Directors’ Guide or the Fellowship Program Director’s Guide for further clarification.

During the Annual Update, programs were able to explain how they were impacted by the COVID-19 (SARS-CoV-2) pandemic in the “Major Changes and Other Updates” as well as the “COVID 19 Pandemic Questions” section of the Accreditation Data System (ADS). Review Committees will determine how the disruptions in activities resulting from the pandemic will affect accreditation decisions in the specialty. Some Review Committees have included additional guidance on this topic in letters to the specialty communities, which can be accessed here.

For institutions in the Emergency Category, fellows will be allowed to act as attending physicians should the institution need them to meet patient care needs up to 20 percent of each academic year.

The fellowship program director and the designated institutional official (DIO) must approve any request for fellows to work as an attending physician in their primary specialty area.

The program director must maintain a record of the time fellows spend working as an attending physician in their primary specialty.

For institutions in the Non-Emergency Category, fellows may only act as an attending physician in their primary specialty in the subspecialties for which the Program Requirements permit this. These are listed below. Please consult the pertinent subspecialty’s Program Requirements to determine the time allowed for fellows to spend in their primary specialty.

• Adult Reconstructive Orthopaedic Surgery
• Clinical Informatics
• Complex Family Planning
• Craniofacial Plastic Surgery
• Emergency Medical Services
• Female Pelvic Medicine and Reconstructive Surgery
• Foot and Ankle Orthopaedic Surgery
• Gynecologic Oncology
• Hand Surgery
• Health Care Administration, Leadership and Management
• Maternal-Fetal Medicine
• Medical Toxicology
• Musculoskeletal Oncology
• Neurocritical Care
• Neurotology
• Orthopaedic Sports Medicine
• Orthopaedic Surgery of the Spine
• Orthopaedic Trauma
• Pediatric Dermatology
• Pediatric Orthopaedic Surgery
• Pediatric Otolaryngology
• Pediatric Urology
• Reproductive Endocrinology and Infertility
• Undersea and Hyperbaric Medicine

The Program Requirements for each of these subspecialties specify how much independent practice is permitted.

Reassignments can occur to other rotations or forms of clinical work with the approval of the program director and the DIO.

Prior to starting the reassignment, a resident/fellow must receive appropriate safety and clinical training for the new setting.

During such activity, the resident/fellow must have appropriate supervision at all times.

During such activity, the resident/fellow must adhere to work hour requirements.

The decision to graduate a resident/fellow is made by the program director, with input from the Clinical Competency Committee (CCC). Such decisions are based on that individual’s Milestones assessments, indicating the resident’s/fellow’s ability to perform the medical, diagnostic, and/or surgical care considered essential for the area of practice.

The determination of whether or not a resident/fellow can graduate as previously scheduled is the responsibility of the program director. As such, the determination can be made even if the curriculum as originally planned is not completed. However, an extension of the educational program may be necessary if the program director determines an individual has not demonstrated the competence necessary for autonomous practice and documentation of eligibility for the certifying or qualifying board examination.

Further guidance on assessing the competence of residents/fellows can be found in the ACGME’s Guidance Statement on Competency-Based Medical Education during COVID-19 Residency and Fellowship Disruptions.

Yes. The program director must still provide residents/fellows with semi-annual and summative evaluations. The program director must also provide a final evaluation for each graduating resident/fellow and attestation for future hospital privileges, licensure, and other purposes.

Further guidance on using the semi-annual evaluation and feedback to address gaps in learning experiences caused by COVID-19 can be found in the ACGME’s Guidance Statement on Competency-Based Medical Education during COVID-19 Residency and Fellowship Disruptions.

During the COVID-19 pandemic, at some institutions, clinical education experiences are not available or reduced for a period of time. This may include rotations, clinics or clinic visits, operations, and other procedures.

The program director will have to consider the circumstances and along with the Clinical Competency Committee (CCC), assess the readiness of each resident/fellow to progress to the next level of education or successfully complete the program. The ACGME’s Guidance Statement on Competency-Based Medical Education during COVID-19 Residency and Fellowship Disruptions recommends that before the mid-year semi-annual feedback, each residency and fellowship program’s CCC review the current status and progress of residents/fellows scheduled to graduate in June. By no later than December 31 of the graduation year, program leadership should assess the current state of progress in the program for each individual resident/fellow and then work with each resident/fellow not meeting particular milestones to create an individual learning plan (ILP) for the remaining time in the program. The ILP should include an identification of the remaining competency gaps. The individual and the program should have the opportunity to address those gaps with an increase of observations and feedback before the end of the academic year. (see ACGME Common Program Requirement V.A.1.d)).

Yes, the program must notify the Review Committee of the new site by adding it as a participating site in ADS. If it doesn’t meet the criteria for a participating site as noted below (Common Program Requirement 1.B.4.), it can be addressed in the Major Changes and Other Updates section in ADS.

Common Program Requirement I.B.4. states, “The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all residents, of one-month full time equivalent or more through the ACGME Accreditation Data System (ADS).”^(Core)

For required participating sites, the program must monitor the clinical and working environment (CPR I.B.3.) and identify a site director (CPR I.B.3.a)).

For each participating site, the residents who rotate there must know their responsibilities for reporting patient safety events and the method for reporting those events. (CPR VI.A.1.a).(3).(a)

Yes, there must be a PLA in place for this required experience. Common Program Requirement I.B.2. states, “There must be a PLA between the program and each participating site that governs the relationship between the program and the participating site providing a required assignment.”

The purpose of a PLA is to ensure that residents/fellows are provided with an appropriate educational experience and to protect them from undue service requirements that do not enrich their education. They also ensure an understanding of common expectations, the nature of the experience, and the responsibilities of the participating site.

No, a PLA is not required for a newly designated participating site that is owned and operated by the Sponsoring Institution.

Guidance for participating sites and PLAs is provided in the Program Directors’ Guide to the Common Program Requirements

If some of a program’s residents/fellows are assigned to work in another hospital as described in the question, that hospital would become a new participating site for the program. Each participating site must have a faculty member appointed by the program director as the site director who is accountable for resident/fellow education at that site, in collaboration with the program director. The program must monitor the clinical learning and working environment in that hospital, including resident/fellow work hours, resident/fellow supervision, and provisions for resident/fellow safety. If this site becomes one that routinely provides an educational experience required for all residents/fellows for one month or longer in duration, the program director will have to designate that hospital as an additional participating site in the program’s Accreditation Data System (ADS) record.

See Participating sites and PLAs in the Common Program Requirements:
I.B. Participating Sites to I.B.4.

Faculty members were able to provide direct supervision through telecommunications technology through the entire 2020-2021 academic year.

For the 2021-2022 academic year and beyond, each specialty Review Committee will choose whether to continue to allow for this type of direct supervision with telemedicine in other situations. This is spelled out in the applicable specialty- or subspecialty-specific Program Requirements.

There will be no change to existing requirements limiting residents to 80 hours per week or to any of the requirements in Section VI.F. of the Common Program Requirements. A strong evidence base has been established demonstrating that adherence to these requirements increases resident safety and well-being.

These dimensions are especially important in the care of patients in the current environment.

Yes. If a resident/fellow is participating in required learning activities, the time spent in these activities counts towards work hours, regardless of the setting. If a resident/fellow is studying independently, the time spent in this activity would not be reported as work hours.

Programs will not be required to complete a Self-Study until further notice and program Self-Study dates have been updated to “postponed” in ADS. Institutional Self-Studies will proceed according to the Institutional Review Committee’s announced plan. At this time, the program Self-Study is not connected to the Institutional Self-Study. Visit the program Self-Study web page for additional information.

Yes. The deferral does not prohibit program Self-Study activities. The ACGME encourages programs to incorporate the Self-Study into their Annual Program Evaluation process and track ongoing progress and program improvements as outlined in the Common Program Requirements. Click here for guidance on performing the program Self-Study.

The ACGME has not yet determined when it will reschedule the postponed Self-Study activities. In ADS, the Self-Study due date will appear as “postponed.”

Yes, remotely. In the future, it is likely that site visits will be performed both remotely and in-person.

The CLER Program is currently conducting a specially designed CLER site visit to understand the impact of COVID-19 on the clinical learning environment. These site visits are being conducted remotely for a random sample of 300 Sponsoring Institutions (stratified by census region and number of ACGME-accredited core programs). The protocol duration is approximately one year—anticipated to conclude in early 2022. The CLER Program plans to resume in-person site visits in 2022 (Protocol 4). More information will be forthcoming in 2022.

As stated in another FAQ, assignments and reassignments of residents/fellows to other rotations or forms of clinical work can occur at the direction and approval of the program director and the DIO. Such assignments would occur depending on local circumstances to address care and support needs, likely as a result of the COVID-19 crisis. Per the ACGME’s guidance on this subject, prior to starting such an assignment, residents/fellows must receive appropriate safety and clinical training specific to the assignment and setting, and during the assignment, they must have appropriate supervision at all times and must adhere to work hour requirements. As an accreditor, the ACGME cannot and does not intervene in disputes between individual residents/fellows and their programs, but the ACGME has established and reiterated these requirements to convey clearly that these must be followed to protect patients, residents/fellows, and supervising physicians, as well as the education of the residents/fellows. Violation of these requirements can result in negative consequences for all involved, including at the accreditation level at the time of the program’s next review.

The ACGME does not determine when a resident/fellow graduates from a program. The program director, with input from the CCC, must decide whether a resident/fellow has the knowledge, skills, and behaviors necessary to enter autonomous practice and is ready for graduation. In making that determination, the program director has a significant responsibility to both the public and to the resident/fellow. If the resident/fellow disagrees, that decision can be appealed following program and institutional policies.

Resident/fellow vacation time is dictated by the policies of the Sponsoring Institution, consistent with applicable laws, and is addressed in the contract/agreement of appointment. A decision to ask a resident/fellow to give up or postpone vacation would need to be consistent with institutional policy and with the terms of the contract/agreement of appointment.

The ACGME has no requirement regarding residents/fellows taking or passing licensure examinations (i.e., USMLE or COMLEX-USA), except for residents in transitional year programs, who must take USMLE Step 3 or COMLEX-USA Level 3 prior to completion of the program. The ACGME does not specify criteria for the determination of the readiness of a resident/fellow to progress to the next year of the program or to complete the program. Those determinations are made by the program director with input from the Clinical Competency Committee.

As always, requests for temporary complement increases should be submitted to the accreditation team for consideration by the Review Committee.