1. The Associate Medical Director/Director of Medical Education shall serve as Chair of the committee
2. The Administrative Director of Medical Education
3. The program directors for Internal Medicine, Pediatrics, General Surgery, Psychiatry, Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, Radiology, Family Medicine, Neurology, Pathology and Orthopaedic Surgery
4. At least two residents. Peer-selected representatives of the organized housestaff elected by the housestaff
5. A representative of Hospital Administration
6. A representative of the Medical School

1. Establishing and implementing policies that affect all residency programs regarding the quality of education and the work environment for the residents in each program with the recognition that the Memorandum of Understanding (MOU) between the County of Los Angeles and the Joint Council of Interns and Residents/Committee of Interns and Residents governs salaries, benefits and many aspects of working conditions.
2. Establishing and maintaining oversight and liaison with all program directors. (See Institutional Policy for Graduate Medical Education Committee Oversight Of And Liaison With Program Directors)
3. Assuring that program directors establish and maintain proper oversight and liaison with appropriate personnel of the other participating institutions. (See Institutional Policy for Graduate Medical Education Committee Oversight Of And Liaison With Program Directors)
4. Conducting regular reviews of all GME programs to assess compliance with institutional and program requirements. Reviews will be conducted between the ACGME program surveys according to specifications listed in the current Institutional Requirements. (See Institutional Policy and Protocol for Internal Review of Residency Programs)
5. Assuring that each program’s curriculum provides: (See Institutional Policy for Residency Program Core Curriculum Requirement)
• a. A regular review of ethical, socioeconomic, medical/legal and cost containment issues that affect GME and medical practice;
• b. An appropriate introduction to communication skills;
• c. An appropriate introduction to research design, statistics and critical review of the literature necessary for acquiring skills for lifelong learning;
• d. Appropriate resident participation in departmental scholarly activity as set forth in the applicable program requirements;
6. Providing an appropriate educational program on physician impairment, including substance abuse.
7. 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. (See Institutional Policy for the Application, Eligibility, Selection and Appointment of Resident Physicians, Institutional Policy for the Evaluation and Promotion of Residents and Institutional Policy for Grievance Procedures, Due process and Disciplinary actions, including Dismissal, Affecting Resident Physicians)
8. Assuring an educational environment in which residents may raise and resolve issues without fear of intimidation or retaliation. (See Institutional Policy for Grievance Procedures, Due Process and Disciplinary Actions, Including Dismissal, Affecting Resident Physicians) This includes:
• a. Provision of an organizational system for residents to communicate and exchange information on their working environment and their educational programs. This may be accomplished through a resident organization or other forums in which to address resident issues.
• b. A process by which individual residents can address concerns in a confidential and protected manner.
• c. Establishment and implementation of fair institutional policies and procedures for academic or other disciplinary actions taken against residents.
• d. Establishment and implementation of fair institutional policies and procedures for adjudication of resident complaints and grievances related to actions that could result in dismissal or could significantly threaten a resident's intended career development.
9. Collecting of intra-institutional information and making recommendations on the appropriate funding for resident positions, including benefits and support services County MOU specifies funding, benefits and support services for most residents.
10. Monitoring of the programs in establishing an appropriate work environment and the duty hours of residents. (See Institutional Policy for Resident Duty Hours and Working Conditions)
11. Assuring that each program implements the terms and conditions in the “Resident Physician Conditions of Employment Agreement.”
12. Assuring JCAHO accreditation for sponsoring and participating institutions.
13. Monitoring the instruction of residents in quality assurance and their participation in quality assurance activities and monitoring the autopsy rates and compliance with the policy regarding autopsies. (See Institutional Policy for Quality Assurance/Quality Improvement Education for Residents).
14. Assuring that programs are in substantial compliance with ACGME Policies and Procedures. The ACGME Manual of Policies and Procedures for Graduate Medical Education Review Committees may be accessed on the internet at www.acgme.org.
15. A periodic review of the ACGME’s Institutional Requirements, policies and procedures, especially those that govern administrative withdrawal of accreditation.
16. Assuring that inter-institutional agreements for major participating institutions and letters of agreement for all rotations to outside facilities meet the ACGME’s Institutional Requirements II.B.
17. 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 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 experiences.
18. Providing sufficient institutional oversight to ensure adequate supervision of residents. Residents must be supervised by teaching staff in such a way that the residents assume progressively increasing responsibility according to their level of education, ability, and experience. (See Institutional Policy for Resident Supervision)
19. The GMEC must review before submission to ACGME the following requests or material:
• a. all applications for ACGME accreditation of new programs and subspecialties;
• b. changes in resident complement;
• c. major changes in program structure or length of training;
• d. additions and deletions of participating institutions used in a program;
• e. appointments of new program directors;
• f. progress reports requested by any Review Committee;
• g. responses to all proposed adverse actions;
• h. requests for increases or any change in resident duty hours;
• i. requests for "inactive status" or to reactivate a program;
• j. voluntary withdrawals of ACGME-accredited programs;
• k. requests for an appeal of an adverse action; and,
• l. appeal presentations to a Board of Appeal or the ACGME.

Adopted Aug. 2000, Reviewed July 2002, Reviewed Aug. 2004, Revised Mar. 2005

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