INSTITUTIONAL POLICY FOR PROGRAM DOCUMENTATION OF POLICIES AND PROCEDURES (BLUEBOOKS)
PREAMBLE
In order for the Graduate Medical Education Committee (GMEC) to carry out the responsibilities noted in the Institutional Requirements and the Institutional Policy for the Responsibilities of the Graduate Medical Education Committee, each residency program must be able to provide documentation that indicates that the program is in substantial compliance with both Institutional and Program Requirements and other institutional policies.
Documentation in the Policies and Procedures Binders (Bluebooks) will allow the GMEC to assure that appropriate policies are established and implemented, and that specified activities are appropriately monitored. The policies and monitoring functions include, but are not limited to:
- Assuring that program directors establish and maintain proper oversight and liaison with appropriate personnel of the other participating institutions.
- Assuring that each program’s curriculum provides the core curriculum components
- Assuring that each residency program establishes and implements formal written criteria and processes for the selection, evaluation, promotion, and dismissal of residents in compliance with both the Institutional and relevant Program Requirements.
- Monitoring of the programs in establishing an appropriate work environment and the duty hours of residents.
- Assuring that each program implements the terms and conditions in the “Resident Physician Conditions of Employment Agreement.”
- Monitoring the instruction of residents in quality assurance and their participation in quality assurance activities.
- Assuring that programs are in substantial compliance with ACGME Policies and Procedures.
- Assuring that interinstitutional agreements for major participating institutions and letters of agreement for all rotations to outside facilities meet the ACGME’s Institutional Requirements.
- Assuring that programs are providing residents with the opportunity to:
- a. Develop a personal program of learning to foster continued professional growth with guidance from the teaching staff;
- b. Participate in safe, effective and compassionate patient care, under c. supervision, commensurate with their level of advancement and responsibilities;
- c. Participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents and students;
- d. Participate, as appropriate, in institutional programs and medical staff activities and adhere to established practices, procedures, and policies of the institution;
- e. Have appropriate representation on institutional committees and councils whose actions affect their education and/or patient care; and,
- f. Submit to the program director, at least annually, confidential written evaluation of the faculty and of the educational experience.
- Providing sufficient institutional oversight to ensure adequate supervision of residents.
The Policies and Procedures Binders also enhance program director awareness of Institutional Requirements and Institutional Policies that directly affect their programs.
POLICY
The GMEC has determined that each program must develop a policies and procedures document that is arranged in a consistent format. The Chair of the GMEC shall provide the format and excerpts from the relevant Institutional and Program Requirements. Each program must complete the Policies and Procedures Binder (Bluebook) by inserting appropriate documents as requested in the instructions. The Policies and Procedures Binders will be essential in the process of
- Internal reviews of the residency programs
- Annual program reviews by the GMEC.
- Institutional Review by the ACGME.
Adopted August 2000, Reviewed July 2002, Reviewed August 2004
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