Graduate Medical Education Policy for
Roles and Responsibilities of Program Directors
Policy Number: 27
Date Issued: 08/1999
Prior Revision Date:10/2010
  Date Revised:


To ensure compliance with the ACGME institutional/common and program specific requirements.

SCOPE The policy applies to all ACGME accredited programs sponsored by Texas Health Presbyterian Hospital Dallas (THD).

1. Each PAH GME program will have a single program director with authority and accountability for the operation of the program.

2. PAH GMEC must approve any change in program directors. After approval, the program director must submit this change to the ACGME via the Accreditation Data System (ADS).

3. The program director may not appoint more residents than approved by the Review Committee, unless otherwise stated in the specialty-specific requirements and as approved in advance by the PAH GMEC. The program's educational resources must be adequate to support the number of residents appointed to the program.

4. Each program director will be accountable for the following:

The oversight and organization of the activities of the educational program in all institutions that participate in the program to ensure the quality of didactic and clinical education. The program director must administer and maintain an educational environment conducive to education the residents in each of the ACGME competency areas.

The Program Director will establish a single Residency Site Coordinator (RSC) for each participating site. In the capacity of RSC, he/she will report to the Program Director. The RSC will be accountable for resident education, training, and monitoring of supervision of residents at the site, consistent with the goals and objectives of the training program. The RSC will be responsible for insuring adherence to all GME policies and procedures for residents at the site.

Approve the selection of program faculty as appropriate.

Evaluate program faculty and approve the continued participation of faculty based on evaluation.

Monitor resident supervision at all participating sites.

Prepare and submit all information required and requested by the ACGME, including but not limited to the program information forms and annual program resident updates to the ADS, and ensure that the information submitted is accurate and complete.

Provide each resident with the documented semiannual evaluation of performance with feedback.

Ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and as implemented by PAH.

Provide timely verification of residency education for all residents, including those who leave the program prior to completion and summarize performance evaluations for such residents.

Before accepting a resident who is transferring from another program, the program director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident.

Implement PAH GMEC policies and procedures consistent with the institutional and program requirements for resident duty hours and the working environment, including moonlighting, and, to that end, the program director must:

  • Distribute these policies and procedures to the residents and faculty;
  • Monitor resident duty hours, according to PAH GMEC policies, with the frequency sufficient to ensure compliance with ACGME requirements;
  • Adjust schedules as necessary to mitigate excessive service demands and/or fatigue; and
  • If applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive demands and/or fatigue.

Monitor the need for and ensure the provision of back up support systems and when patient care responsibilities are unusually difficult or prolonged.

Comply with PAH GMEC written policies and procedures, including those specified in the Institutional Requirements, for selection, eligibility, evaluation and promotion of residents, disciplinary action, and supervision of residents.

Monitor resident stress, including mental or emotional conditions inhibiting performance or learning, and drug or alcohol-related dysfunction. Both the program director and faculty should be sensitive to the need for timely provision of confidential counseling and psychological support services to residents. Situations that demand excessive service or that consistently produce undesirable stress on situations that demand excessive service or that consistently produce undesirable stress on residents are to be limited. 


Medical Director, Graduate Medical Education

Chief Medical Officer