Sponsoring Institution GME Policies

For program level policies please refer to your specific Residency/Fellowship policies and procedures.

ACGME: Scope includes Accreditation Council for Graduate Medical Education (ACGME)-
accredited programs and trainees
Non-ACGME: Scope may include all non-ACGME accredited programs and
Program Policy Required: Programs are required to develop and maintain a program-specific
policy as outlined in the institutional policy. These policies must be made available to
program trainees and faculty, and shared with the GME Office through their protected
folders in OneDrive and through New Innovations. Recommended program policies are
noted with an ‘R’.

Policy	Revised	ACGME	Sponsoring Institution	Program Specific Policy Required	Summary
Academic and Non Academic Grievances	7.1.2023	X		X	This policy describes the grievance process that is able to ensure that the trainee receives due process if an action is taken that could potentially affect their status within the program and could be reportable to future employers. This process offers a fair process for the trainee while maintaining patient safety, quality.
Citation Response	7.1.2023		X		This policy describes the internal process for monitoring citation responses to the ACGME with sponsoring institution oversight.
CLER Subcommittee	7.1.2023		X		This policy describes the CLER Subcommittees’ responsibility to the GMEC, to the sponsoring institution and sponsored programs.
External Resident Transfer	7.1.2023	X			This policy describes the process for residents external to the OSU/OMECO GME programs to assure that documents are appropriately reviewed and financial responsibilities are appropriately adjusted.
Internal Resident Transfer	7.1.2023	X			This policy describes the process for residents internal to the OSU/OMECO GME programs to assure that documents are appropriately reviewed and financial responsibilities are appropriately adjusted.
GMEC Fees	7.1.2023		X		This policy describes the process for routine GMEC fees that are paid by the sponsoring institution and additional fees that are incurred by the sponsored program.
Moonlighting	7.1.2023	X		X	This policy describes voluntary work experiences that are external to what is required by their training program.
OR Subcommittee	7.1.2023		X		This policy describes the Osteopathic Recognition Subcommittees’ responsibility to the GMEC, to the sponsoring institution and sponsored programs.
Fitness for Duty	7.1.2023		X		This policy describes processes for evaluation that all trainees are fit for responsibilities and tasks as described by the training program and are to the best of the sponsored program’s ability free from concerns from harming others and themselves.
Impaired Physician	7.1.2023	X			Address issues related with impairment in trainees to help protect the physician as well as protect patients simultaneously.
Participating Site Disciplinary Action	7.1.2023		X		This policy provides basic rules as it relates to disciplinary action taken by participating sites based on trainee performance.
Sexual Harassment and other Discriminatory Practices	7.1.2023	X			This policy requires all sponsored programs com comply with Oklahoma Law and prohibits discrimination on the basis of race, color, religion, sex, national origin, age, genetic information or disability unless the disability causes undue hardship on the basic operations of the program.
Professional Liability and Health and Disability Insurance	7.1.2023	X			This policy requires all sponsored programs under OSU/OMECO to provide professional liability, health and disability insurance to trainees.
Leave of Absences	7.1.2023	X		X	This policy addresses all resident leave provisions and policies regarding resident leave, as required by the ACGME.
Parental Leave Policy	7.1.2023	X		X	This policy addresses the parental leave provisions and policies regarding resident parental leave, as required by the ACGME.
Closures and Reductions	7.1.2023	X			Outlines the process for OSU/OMECO as it relates to closure or reductions in any of the sponsored programs, closure or loss of accreditation of the institution. This provides guidance for the trainees in the program and works towards mitigating the stress that comes along with finding an alternative training program to complete their educational curriculum.
Resident and Faculty Well Being	7.1.2023	X		X	Well-being of trainees and faculty is a priority of the sponsoring institution. The SI provides a basic overview and minimal requirements that should be instituted at the level of the sponsored program. Key elements of identifying individuals that are suffering from burnout or excessive fatigue and provides resources and infrastructure to support these individuals.
Agreement of Appointment	7.1.2023	X		X	Outlines requirements for appointment to a OSU/OMECO sponsored program, including eligibility and completion of credentialing requirements, appointment duration and approved compensation.
Disabilities and Accommodations	7.1.2023	X			This policy requires all sponsored programs com comply with Oklahoma Law and prohibits discrimination on the basis of race, color, religion, sex, national origin, age, genetic information or disability unless the disability causes undue hardship on the basic operations of the program.
Disaster	7.1.2023	X			Defines the responsibility of the institution to address and support programs and trainees in the event of an unpredicted event that results in substantial disruption in patient care and education.
Interaction with Vendors	7.1.2023	X			The purpose of this policy is to ensure that educational activities at OSU/OMECO sponsored programs are not compromised by industry influence.
Non-Compete	7.1.2023	X		X	Describes the prevention of requiring any trainee to sign a non-compete.
Professionalism	7.1.2023	X		X	Outlines expectations of all residents under OSU/OMECO and its respective sponsored programs as it relates to professionalism.
Promotion and Reappointment	7.1.2023	X		X	Outlines the terms and conditions of resident and fellow promotion and reappointment. This outlines fundamental components required for progression through the educational pathway. In addition, it also separates promotion and reappointment does not require promotion. At minimum these criteria must be met in addition to program specific requirements.
Recruitment	7.1.2023	X		X	This policy is designed to support fair and consistent consideration for all OSU/OMECO sponsored programs and decision making for all applicants to ACGME accredited programs. This outlines eligibility exceptions and requirements for use of the national matching/application services.
International Rotations	7.1.2023		X		Describes the process for sponsored programs to provide international rotations for trainees within their program.
New Program Development	7.1.2023	X			Describes the process for new program development under OSU/OMECO.
Program Evaluation	7.1.2023	X			Establishes the GME expectations of all sponsored programs and highlights the importance of the PEC (Program Evaluation Committee) and their function and purpose. It also highlights the importance of faculty evaluation as a key component of program health.
Resident Evaluations	7.1.2023	X			Establishes the GME expectations of all sponsored programs and highlights the importance of the CCC (Clinical Competency Committee) and their function and purpose. In addition, it provides recommendations as it relates to collaboration with respective state boards, future employers and credentialing committees and the sponsored programs responsibilities.
PLA’s	7.1.2023	X			To define the requirements for Sponsoring Institution’s (SI) program letters of agreement and its Accreditation Council for Graduate Medical Education (ACGME) sponsored residency/fellowship programs.
Match outside NRMP	7.1.2023		X		To achieve this, the Sponsoring Institution GME office will provide oversight of hiring applicants outside of the Match or SOAP. Approval from the sponsoring institution GME office must be granted before a verbal or written offer is extended to the applicant as described in the policy for Internal or External Resident Transfer.
Program Director and Coordinator Protected Time	7.1.2023	X			Describes the expectations of all program directors and program coordinators at all OSU/OMECO sponsored programs as it relates to administrative time to maintain integrity of the program.
Resident and Clinical Work Hours	7.1.2023	X		X	The purpose of this policy is to ensure effective oversight of institutional and program level compliance with ACGME clinical an educational work hour requirements.
Supervision	7.1.2023	X		X	The purpose of this policy is to define minimum requirements for communication and monitoring of residency supervision. This does include limited information as it relates to overarching supervision principles as it relates to direct and indirect supervision (including availability and telecommunication). This further specifies supervision of invasive procedures.
Special Review	7.1.2023	X			Programs determined by the GMEC as underperforming may be required to undergo a special review to identify areas of improvement and advocate for learners and faculty of the program.
Licensing	7.1.2023		X		Residents must hold an active Oklahoma provider license starting their PGY II year.
Policy on Policies	8.22.2023		X		This policy describes the development and maintenance of policies that are implemented by the sponsoring institution. It also allows programs to see which programs are ACGME institutional required, Sponsoring Institution required or sponsored program required.
Special Review Subcommittee	8.22.2023		X		This policy describes the Special Review Subcommittees' responsibility to the GMEC, to the sponsoring institution and sponsored programs.