Program Standards

Program Content:  There must be a written program description, provided to trainees and to applicants (i.e., those invited to interview), that defines:

• Program description and duration (ACGME programs should refer to the ACGME Common Program Requirements and all programs to either the ACGME curriculum template or the non-ACGME curriculum template)
• Specific goals and objectives for each educational experience and longitudinal assignment (clinical and research). Proposed ACGME programs should incorporate specialty-specific ACGME requirements
• Clinical rotations and other types of clinical activities; approximate time devoted to each (e.g., 1/2-day per week continuity clinic, research electives, rotations in other specialties and/or at other institutions)
• Scope of training including target volume for procedures, if applicable
• Didactics - Schedule, format and content of didactic activities that are specific to the training program
• Responsibilities of the trainees, including on-call responsibilities and any responsibilities to cross-cover private patients; whether or not a fellow will have admitting and billing privileges, etc.
• Details regarding supervision
• Description of research opportunities, if applicable
• Vacation time
• Evaluation:
  • Multi-source evaluation of trainees: All proposed programs should review the Mass General Brigham policies on trainee multi-source evaluations
  • The GME office offers the following PEC-approved evaluation templates that may be utilized by both ACGME and non-ACGME programs: competency-based multi-source evaluation of trainees (evaluation by faculty, patients, peers, other healthcare professionals and self-assessment); trainee evaluation of faculty; annual evaluation of program by faculty; and annual evaluation of program by trainee
  • Programs applying for ACGME accreditation should review specific specialty ACGME evaluation requirements

Written contract: The standard Mass General Brigham contract can be amended as necessary to reflect specifics of the program (alternative contracts can be drafted and used if approved by the Mass General Brigham Office of the General Counsel). A contract should be signed by each trainee each year. A copy of the contract should be provided to applicants no later than the time that they are offered a position.

Leadership: A single program director must be responsible for the overall quality of the educational experience. The program director must devote sufficient time to the program and be given sufficient authority to ensure that the program goals are achieved.

Program Size: For non-ACGME programs, the number of fellows must not exceed the capacity of the faculty to provide appropriate supervision and excellent teaching, and must not dilute the volume of clinical experience necessary for training.

Selection process: There must be an explicit (written) selection process that details the prerequisites, the parameters on which candidates will be judged and the overall timetable for applications and decision making.

Evaluation and Feedback: The program director should ensure that teaching faculty evaluate the trainees in writing (at least 4 times a year) and provide frequent, timely, verbal feedback. The program director should keep a file of written evaluations on each trainee and should meet with each fellow/trainee twice a year to provide formal feedback, career counseling and obtain feedback from the trainee. Fellows should be asked to complete written surveys about the program and the faculty.

Affiliation agreements must be in writing wherever reimbursement is expected for outside rotations.

Program environment and working conditions: The program director must ensure that the educational process is not undermined by excessive service requirements and that appropriate back-up and supervision are provided at all times.

This page was reviewed 3/31/21.