ACGME Program Requirements for Graduate Medical Education in Emergency Medicine

ACGME Program Requirements for Graduate Medical Education in ACGME approved: September 30, 2012; effective: July 1, 2013 Revised Common Program Requirements effective: July 1, 2015 Revised Common Program Requirements effective: July 1, 2016

ACGME Program Requirements for Graduate Medical Education in Common Program Requirements are in BOLD Introduction Int.A. Residency is an essential dimension of the transformation of the medical student to the independent practitioner along the continuum of medical education. It is physically, emotionally, and intellectually demanding, and requires longitudinally-concentrated effort on the part of the resident. The specialty education of physicians to practice independently is experiential, and necessarily occurs within the context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the resident physician to assume personal responsibility for the care of individual patients. For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions. As residents gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence. This concept--graded and progressive responsibility--is one of the core tenets of American graduate medical education. Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring each resident s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth. Int.B. Residencies in emergency medicine prepare physicians for the practice of emergency medicine. These programs must teach the fundamental skills, knowledge, and humanistic qualities that constitute the foundations of emergency medicine practice. These programs provide progressive responsibility for and experience in these areas to enable effective management of clinical problems. Residents must have the opportunity, under the guidance and supervision of a qualified faculty member, to develop a satisfactory level of clinical maturity, judgment, and technical skill. On completion of the program, residents should be capable of practicing emergency medicine, able to incorporate new skills and knowledge during their careers, and able to monitor their own physical and mental well-being. Int.C. Residency programs in emergency medicine are configured in 36-month and 48- month formats, and must include a minimum of 36 months of clinical education. (Core) * Int.D. Programs utilizing the 48-month format must ensure that all of the clinical, educational, and milestone elements contained in these Program Requirements are met, and must provide additional in-depth experience in areas related to emergency medicine, such as medical education, clinical- or laboratory-based research, or global health. An educational justification describing the additional 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 1 of 35

I. Institutions educational goals and outcomes to be achieved by residents in the incremental 12 months of education must be submitted to the Review Committee prior to implementation, and at each subsequent accreditation review of residency programs of 48 months duration. (Detail) I.A. Sponsoring Institution One sponsoring institution must assume ultimate responsibility for the program, as described in the Institutional Requirements, and this responsibility extends to resident assignments at all participating sites. (Core)* The sponsoring institution and the program must ensure that the program director has sufficient protected time and financial support for his or her educational and administrative responsibilities to the program. (Core) I.A.1. I.A.1.a) I.A.1.b) I.A.1.c) I.A.1.c).(1) I.B. I.B.1. The sponsoring institution and participating sites must: Participating Sites provide salary support or protected time for the program director; (Detail) provide salary support or protected time for each associate program director; and, (Detail) provide salary support or protected time for all core physician faculty members. (Detail) Core physician faculty members must not be required to generate clinical or other income to support reduced clinical hours. (Detail) There must be a program letter of agreement (PLA) between the program and each participating site providing a required assignment. The PLA must be renewed at least every five years. (Core) The PLA should: I.B.1.a) I.B.1.b) I.B.1.c) identify the faculty who will assume both educational and supervisory responsibilities for residents; (Detail) specify their responsibilities for teaching, supervision, and formal evaluation of residents, as specified later in this document; (Detail) specify the duration and content of the educational experience; and, (Detail) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 2 of 35

I.B.1.d) I.B.2. I.B.3. I.B.4. I.B.4.a) I.B.5. I.B.6. I.B.7. state the policies and procedures that will govern resident education during the assignment. (Detail) The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all residents, of one month full time equivalent (FTE) or more through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System (ADS). (Core) The program should be based at the primary clinical site. (Core) Programs using multiple participating sites must ensure the provision of a unified educational experience for the residents. (Core) Each participating site must offer significant educational opportunities to the overall program. (Core) Required rotations to participating sites that are geographically distant from the sponsoring institution must offer educational opportunities unavailable locally that significantly augment residents overall educational experience. (Detail) The program must be affiliated with a medical school and must have a written letter of understanding which documents the duties and responsibilities of both the medical school and the residency program. (Core) The sponsoring institution for emergency medicine education must have a major educational commitment as evidenced by training programs in other major specialties. The program must demonstrate the availability of educational resources in other specialties for the training of the emergency medicine residents. (Core) II. II.A. II.A.1. Program Personnel and Resources Program Director There must be a single program director with authority and accountability for the operation of the program. The sponsoring institution s GMEC must approve a change in program director. (Core) II.A.1.a) II.A.2. II.A.3. II.A.3.a) The program director must submit this change to the ACGME via the ADS. (Core) The program director should continue in his or her position for a length of time adequate to maintain continuity of leadership and program stability. (Detail) Qualifications of the program director must include: requisite specialty expertise and documented educational 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 3 of 35

and administrative experience acceptable to the Review Committee; (Core) II.A.3.b) II.A.3.c) II.A.3.d) II.A.4. current certification in the specialty by the American Board of, or specialty qualifications that are acceptable to the Review Committee; (Core) current medical licensure and appropriate medical staff appointment; and, (Core) at least three years experience as a core faculty member in an ACGME-accredited emergency medicine program. (Detail) The program director must administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas. (Core) The program director must: II.A.4.a) II.A.4.a).(1) oversee and ensure the quality of didactic and clinical education in all sites that participate in the program; (Core) The program director must be clinically active in emergency medicine. (Core) II.A.4.a).(1).(a) The program director must not work more than 20 hours per week clinically, on average, or 960 clinical hours per year. (Core) II.A.4.b) II.A.4.c) II.A.4.d) II.A.4.e) II.A.4.f) II.A.4.g) II.A.4.g).(1) II.A.4.h) approve a local director at each participating site who is accountable for resident education; (Core) approve the selection of program faculty as appropriate; (Core) evaluate program faculty; (Core) approve the continued participation of program faculty based on evaluation; (Core) monitor resident supervision at all participating sites; (Core) prepare and submit all information required and requested by the ACGME. (Core) This includes but is not limited to the program application forms and annual program updates to the ADS, and ensure that the information submitted is accurate and complete. (Core) ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 4 of 35

implemented by the sponsoring institution; (Detail) II.A.4.i) II.A.4.j) provide verification of residency education for all residents, including those who leave the program prior to completion; (Detail) implement policies and procedures consistent with the institutional and program requirements for resident duty hours and the working environment, including moonlighting, (Core) and, to that end, must: II.A.4.j).(1) II.A.4.j).(2) II.A.4.j).(3) II.A.4.j).(4) II.A.4.k) II.A.4.l) II.A.4.m) II.A.4.n) II.A.4.n).(1) II.A.4.n).(2) II.A.4.n).(3) distribute these policies and procedures to the residents and faculty; (Detail) monitor resident duty hours, according to sponsoring institutional policies, with a frequency sufficient to ensure compliance with ACGME requirements; (Core) adjust schedules as necessary to mitigate excessive service demands and/or fatigue; and, (Detail) if applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue. (Detail) monitor the need for and ensure the provision of back up support systems when patient care responsibilities are unusually difficult or prolonged; (Detail) comply with the sponsoring institution s written policies and procedures, including those specified in the Institutional Requirements, for selection, evaluation and promotion of residents, disciplinary action, and supervision of residents; (Detail) be familiar with and comply with ACGME and Review Committee policies and procedures as outlined in the ACGME Manual of Policies and Procedures; (Detail) obtain review and approval of the sponsoring institution s GMEC/DIO before submitting information or requests to the ACGME, including: (Core) all applications for ACGME accreditation of new programs; (Detail) changes in resident complement; (Detail) major changes in program structure or length of 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 5 of 35

training; (Detail) II.A.4.n).(4) II.A.4.n).(5) II.A.4.n).(6) II.A.4.n).(7) II.A.4.n).(8) II.A.4.o) II.A.4.o).(1) II.A.4.o).(2) II.A.5. II.A.5.a) II.A.5.a).(1) II.A.5.a).(2) II.A.5.a).(3) II.A.5.b) II.A.5.c) II.B. II.B.1. Faculty progress reports requested by the Review Committee; (Detail) requests for increases or any change to resident duty hours; (Detail) voluntary withdrawals of ACGME-accredited programs; (Detail) requests for appeal of an adverse action; and, (Detail) appeal presentations to a Board of Appeal or the ACGME. (Detail) obtain DIO review and co-signature on all program application forms, as well as any correspondence or document submitted to the ACGME that addresses: (Detail) program citations, and/or, (Detail) request for changes in the program that would have significant impact, including financial, on the program or institution. (Detail) Assistant or Associate Program Directors At a minimum, there must be assistant or associate program directors (APDs) at resident complements according to the following parameters: (Core) programs with 18-35 residents must have at least one APD; (Core) programs with 36-53 residents must have at least two APDs; and, (Core) programs with 54 or more residents must have at least three APDs. (Core) The APD must be clinically active in emergency medicine. (Core) APDs must not average more than 24 clinical hours per week, or 1152 clinical hours per year. (Core) At each participating site, there must be a sufficient number of faculty with documented qualifications to instruct and supervise all residents at that location. (Core) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 6 of 35

The faculty must: II.B.1.a) II.B.1.b) II.B.2. II.B.2.a) II.B.3. II.B.4. II.B.5. II.B.5.a) II.B.5.b) II.B.5.b).(1) II.B.5.b).(2) II.B.5.b).(3) II.B.5.b).(4) II.B.5.c) II.B.6. devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities; and to demonstrate a strong interest in the education of residents, and (Core) administer and maintain an educational environment conducive to educating residents in each of the ACGME competency areas. (Core) The physician faculty must have current certification in the specialty by the American Board of, or possess qualifications judged acceptable to the Review Committee. (Core) Core physician faculty members should have appropriate faculty appointments in the medical school. (Detail) The physician faculty must possess current medical licensure and appropriate medical staff appointment. (Core) The nonphysician faculty must have appropriate qualifications in their field and hold appropriate institutional appointments. (Core) The faculty must establish and maintain an environment of inquiry and scholarship with an active research component. (Core) The faculty must regularly participate in organized clinical discussions, rounds, journal clubs, and conferences. (Detail) Some members of the faculty should also demonstrate scholarship by one or more of the following: peer-reviewed funding; (Detail) publication of original research or review articles in peer reviewed journals, or chapters in textbooks; (Detail) publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings; or, (Detail) participation in national committees or educational organizations. (Detail) Faculty should encourage and support residents in scholarly activities. (Core) There must be a minimum of one core physician faculty member for every three residents in the program. (Core) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 7 of 35

II.B.6.a) Core physician faculty members must be members of the program faculty, must be clinically active and teach, and devote the majority of their professional efforts to the program. (Core) II.B.6.b) Core physician faculty members must not average more than 28 clinical hours per week, or 1344 clinical hours per year. (Core) II.B.6.c) II.B.6.d) II.B.6.d).(1) II.B.6.d).(1).(a) II.B.7. II.B.8. II.C. Core physician faculty members must include the program director and the chair/chief of emergency medicine. (Core) All core physician faculty members must be involved in scholarly activity. (Core) At minimum, each individual core physician faculty member must produce at least one piece of scholarly activity per year (averaged over the past five years). (Detail) At minimum, this must include one scientific peerreviewed publication for every five core physician faculty members per year (averaged over the previous five-year period). (Detail) All faculty members should participate in faculty development programs. (Core) A faculty staffing ratio of 4.0 patients per faculty hour or less must be maintained in order to ensure adequate clinical instruction and supervision, as well as efficient, high quality clinical operations. (Core) Other Program Personnel The institution and the program must jointly ensure the availability of all necessary professional, technical, and clerical personnel for the effective administration of the program. (Core) II.C.1. II.C.1.a) II.C.1.b) II.C.1.c) At a minimum, there must be at least one program coordinator dedicated solely to the residency program administration and additional support personnel at resident complements according to the following parameters: (Core) programs with fewer than 31 residents must have at least one FTE program coordinator; (Core) programs with 31-45 residents must have at least 1.5 FTE support personnel including at least one FTE program coordinator; (Core) programs with 46-60 or more residents must have at least 2.0 FTE support personnel including at least one FTE program coordinator; (Core) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 8 of 35

II.C.1.d) II.C.1.e) programs with 61-75 or more residents must have at least 2.5 FTE support personnel including at least one FTE program coordinator; and, (Core) programs with 76 or more residents must have at least 3.0 FTE support personnel including at least one FTE program coordinator. (Core) II.D. Resources The institution and the program must jointly ensure the availability of adequate resources for resident education, as defined in the specialty program requirements. (Core) II.D.1. II.D.1.a) II.D.1.b) II.D.1.c) II.D.1.d) II.D.1.e) II.D.1.f) II.D.1.g) II.D.1.h) II.D.2. II.D.3. II.D.4. II.D.4.a) At every site in which the emergency department provides resident education, the following must be provided: (Detail) adequate space for patient care; (Detail) space for clinical support services; (Detail) diagnostic imaging completed and results available on a timely basis, especially those required on a STAT basis; (Detail) laboratory studies completed and results available on a timely basis, especially those required on a STAT basis; (Detail) office space for core physician faculty members, and residents; (Detail) instructional space; (Detail) information systems; and, (Detail) appropriate security services and systems to ensure a safe working environment. (Detail) Clinical support services must include nursing, clerical, intravenous, electrocardiogram (EKG), respiratory therapy, messenger/transporter, and phlebotomy, and must be available on a 24-hour basis. (Detail) Office space for program coordinators and additional support personnel must be provided at the primary clinical site. (Detail) Each clinical site must provide timely consultation from services based on a patient s acuity. (Detail) If any clinical services are not available for consultation or admission, each clinical site must have a written protocol for provision of these services elsewhere. (Detail) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 9 of 35

II.D.4.b) II.D.5. II.D.6. II.D.6.a) II.D.6.b) II.D.7. II.E. Each clinical site must ensure timely consultation decisions by a provider from admitting and consulting services with decision making authority. (Detail) The patient population must include patients of all ages and genders as well as patients with a wide variety of clinical problems. (Core) The primary clinical site to which residents rotate must have at least 30,000 emergency department visits annually. (Core) The primary clinical site should have a significant number of critically-ill or critically injured patients constituting at least three percent or 1200 (whichever is greater) of the emergency department patients per year. (Detail) All other emergency departments to which residents rotate for four months or longer should each have at least 30,000 emergency department visits annually. (Detail) Residents must be provided with prompt, reliable systems for communication and interaction with supervisory physicians. (Core) Medical Information Access Residents must have ready access to specialty-specific and other appropriate reference material in print or electronic format. Electronic medical literature databases with search capabilities should be available. (Detail) III. III.A. Resident Appointments Eligibility Criteria The program director must comply with the criteria for resident eligibility as specified in the Institutional Requirements. (Core) III.A.1. III.A.1.a) III.A.1.b) Eligibility Requirements Residency Programs All prerequisite post-graduate clinical education required for initial entry or transfer into ACGME-accredited residency programs must be completed in ACGME-accredited residency programs, or in Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency programs located in Canada. Residency programs must receive verification of each applicant s level of competency in the required clinical field using ACGME or CanMEDS Milestones assessments from the prior training program. (Core) A physician who has completed a residency program that was not accredited by ACGME, RCPSC, or CFPC may enter 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 10 of 35

an ACGME-accredited residency program in the same specialty at the PGY-1 level and, at the discretion of the program director at the ACGME-accredited program may be advanced to the PGY-2 level based on ACGME Milestones assessments at the ACGME-accredited program. This provision applies only to entry into residency in those specialties for which an initial clinical year is not required for entry. (Core) III.A.1.c) III.A.1.d) III.A.2. A Review Committee may grant the exception to the eligibility requirements specified in Section III.A.2.b) for residency programs that require completion of a prerequisite residency program prior to admission. (Core) Review Committees will grant no other exceptions to these eligibility requirements for residency education. (Core) Eligibility Requirements Fellowship Programs All required clinical education for entry into ACGME-accredited fellowship programs must be completed in an ACGME-accredited residency program, or in an RCPSC-accredited or CFPC- accredited residency program located in Canada. (Core) III.A.2.a) III.A.2.b) Fellowship programs must receive verification of each entering fellow s level of competency in the required field using ACGME or CanMEDS Milestones assessments from the core residency program. (Core) Fellow Eligibility Exception A Review Committee may grant the following exception to the fellowship eligibility requirements: An ACGME-accredited fellowship program may accept an exceptionally qualified applicant**, who does not satisfy the eligibility requirements listed in Sections III.A.2. and III.A.2.a), but who does meet all of the following additional qualifications and conditions: (Core) III.A.2.b).(1) III.A.2.b).(2) Assessment by the program director and fellowship selection committee of the applicant s suitability to enter the program, based on prior training and review of the summative evaluations of training in the core specialty; and (Core) Review and approval of the applicant s exceptional qualifications by the GMEC or a subcommittee of the GMEC; and (Core) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 11 of 35

III.A.2.b).(3) III.A.2.b).(4) III.A.2.b).(5) III.A.2.b).(5).(a) Satisfactory completion of the United States Medical Licensing Examination (USMLE) Steps 1, 2, and, if the applicant is eligible, 3, and; (Core) For an international graduate, verification of Educational Commission for Foreign Medical Graduates (ECFMG) certification; and, (Core) Applicants accepted by this exception must complete fellowship Milestones evaluation (for the purposes of establishment of baseline performance by the Clinical Competency Committee), conducted by the receiving fellowship program within six weeks of matriculation. This evaluation may be waived for an applicant who has completed an ACGME International-accredited residency based on the applicant s Milestones evaluation conducted at the conclusion of the residency program. (Core) If the trainee does not meet the expected level of Milestones competency following entry into the fellowship program, the trainee must undergo a period of remediation, overseen by the Clinical Competency Committee and monitored by the GMEC or a subcommittee of the GMEC. This period of remediation must not count toward time in fellowship training. (Core) ** An exceptionally qualified applicant has (1) completed a non-acgme-accredited residency program in the core specialty, and (2) demonstrated clinical excellence, in comparison to peers, throughout training. Additional evidence of exceptional qualifications is required, which may include one of the following: (a) participation in additional clinical or research training in the specialty or subspecialty; (b) demonstrated scholarship in the specialty or subspecialty; (c) demonstrated leadership during or after residency training; (d) completion of an ACGME-Internationalaccredited residency program. III.B. Number of Residents The program s educational resources must be adequate to support the number of residents appointed to the program. (Core) III.B.1. III.B.2. The program director may not appoint more residents than approved by the Review Committee, unless otherwise stated in the specialty-specific requirements. (Core) There should be a minimum of six residents per year in the program. (Detail) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 12 of 35

III.C. III.C.1. III.C.1.a) III.C.2. III.D. Resident Transfers 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. (Detail) For information concerning the transfer of residents between emergency medicine residencies with differing educational formats and advanced placement credit for education in other specialties, contact the American Board of prior to the resident entering the program. A program director must provide timely verification of residency education and summative performance evaluations for residents who may leave the program prior to completion. (Detail) Appointment of Fellows and Other Learners The presence of other learners (including, but not limited to, residents from other specialties, subspecialty fellows, PhD students, and nurse practitioners) in the program must not interfere with the appointed residents education. (Core) III.D.1. IV. IV.A. IV.A.1. IV.A.2. IV.A.3. Educational Program The program director must report the presence of other learners to the DIO and GMEC in accordance with sponsoring institution guidelines. (Detail) The curriculum must contain the following educational components: Overall educational goals for the program, which the program must make available to residents and faculty; (Core) Competency-based goals and objectives for each assignment at each educational level, which the program must distribute to residents and faculty at least annually, in either written or electronic form; (Core) Regularly scheduled didactic sessions; (Core) IV.A.3.a) IV.A.3.a).(1) IV.A.3.a).(2) Didactic experiences must include administrative seminars, journal review, presentations based on the defined curriculum, morbidity and mortality conferences, and research seminars. (Detail) These didactic experiences should include joint conferences co-sponsored with other disciplines. (Detail) Educational methods should include problem-based 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 13 of 35

learning, evidence-based learning, and computer-based instruction. (Detail) IV.A.3.b) IV.A.3.c) The majority of didactic experiences must occur at the primary clinical site. (Detail) There must be an average of at least five hours per week of planned didactic experiences developed by the program s faculty members. (Core) IV.A.3.c).(1) Individualized interactive instruction must not exceed 20 percent of the planned didactic experiences. (Detail) IV.A.3.c).(2) IV.A.3.c).(3) IV.A.3.c).(4) IV.A.3.c).(5) IV.A.3.c).(6) IV.A.4. IV.A.5. All planned didactic experiences must be supervised by core physician faculty members. (Core) Each core physician faculty member must attend, on average per year, at least 20 percent of planned didactic experiences. (Core) Emergency medicine faculty members must present at least 50 percent of resident conferences. (Core) Residents must actively participate, on average, in at least 70 percent of the planned didactic experiences offered. (Core) All planned didactic experiences must have an evaluative component to measure resident participation and educational effectiveness. (Detail) Delineation of resident responsibilities for patient care, progressive responsibility for patient management, and supervision of residents over the continuum of the program; and, (Core) ACGME Competencies The program must integrate the following ACGME competencies into the curriculum: (Core) IV.A.5.a) IV.A.5.a).(1) Patient Care and Procedural Skills Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents: (Outcome) must demonstrate proficiency in: (Outcome) IV.A.5.a).(1).(a) synthesizes essential data necessary for the correct management of a patient with multiple 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 14 of 35

chronic medical problems and, when appropriate, comparing with a prior medical record and identifying significant differences between the current presentation and past presentations; (Outcome) IV.A.5.a).(1).(b) IV.A.5.a).(1).(c) IV.A.5.a).(1).(d) IV.A.5.a).(1).(e) IV.A.5.a).(1).(f) IV.A.5.a).(1).(g) IV.A.5.a).(1).(h) IV.A.5.a).(1).(i) IV.A.5.a).(1).(j) IV.A.5.a).(1).(k) generating an appropriate differential diagnosis; (Outcome) applying the results of diagnostic testing based on the probability of disease and the likelihood of test results altering management; (Outcome) narrowing and prioritizing the list of weighted differential diagnoses to determine appropriate management based on all of the available data; (Outcome) implementing an effective patient management plan; (Outcome) selecting and prescribing appropriate pharmaceutical agents based upon relevant considerations, such as: allergies; clinical guidelines; intended effect; financial considerations; institutional policies; mechanism of action; patient preferences; possible adverse effects; and potential drug-food and drug-drug interactions; and effectively combining agents and monitoring and intervening in the advent of adverse effects in the emergency department; (Outcome) progressing along a continuum of managing a single patient, to managing multiple patients and resources within the emergency department; (Outcome) providing health care services aimed at preventing health problems or maintaining health; (Outcome) working with health care professionals to provide patient-focused care; (Outcome) identifying life-threatening conditions and the most likely diagnosis, synthesizing acquired patient data, and identifying how and when to access current medical information; (Outcome) establishing and implementing a comprehensive disposition plan that uses appropriate consultation resources, patient education regarding diagnosis, treatment plan, medications, and time and location 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 15 of 35

specific disposition instructions; and, (Outcome) IV.A.5.a).(1).(l) IV.A.5.a).(2) IV.A.5.a).(2).(a) IV.A.5.a).(2).(a).(i) IV.A.5.a).(2).(a).(ii) IV.A.5.a).(2).(a).(iii) IV.A.5.a).(2).(a).(iv) IV.A.5.a).(2).(a).(v) IV.A.5.a).(2).(b) re-evaluating patients undergoing emergency department observation (and monitoring) and using appropriate data and resources, and, determining the differential diagnosis, treatment plan, and disposition. (Outcome) Residents must be able to competently perform all medical, diagnostic and surgical procedures considered essential for the area of practice. Residents: (Outcome) must demonstrate proficiency in: (Outcome) performing diagnostic and therapeutic procedures and emergency stabilization; (Outcome) managing critically-ill and injured patients who present to the emergency department, prioritizing critical initial stabilization action, mobilizing hospital support services in the resuscitation of critically-ill or injured patients and reassessing after a stabilizing intervention; (Outcome) properly sequencing critical actions for patient care and generating a differential diagnosis for an undifferentiated patient; (Outcome) mobilizing and managing necessary personnel and other hospital resources to meet critical needs of multiple patients; and, (Outcome) performing invasive procedures, monitoring unstable patients, and directing major resuscitations of all types on all age groups. (Outcome) must perform indicated procedures on all appropriate patients, including those who are uncooperative, at the extremes of age, hemodynamically unstable and who have multiple co-morbidities, poorly defined anatomy, high risk for pain or procedural complications, or require sedation, take steps to avoid potential complications; and recognize the outcome and/or complications resulting from the procedures; (Outcome) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 16 of 35

IV.A.5.a).(2).(c) IV.A.5.a).(2).(c).(i) IV.A.5.a).(2).(c).(ii) IV.A.5.a).(2).(c).(iii) IV.A.5.a).(2).(c).(iii).(a) IV.A.5.a).(2).(c).(iv) IV.A.5.a).(2).(c).(v) IV.A.5.a).(2).(c).(vi) IV.A.5.a).(2).(c).(vii) IV.A.5.a).(2).(c).(viii) IV.A.5.a).(2).(c).(viii).(a) IV.A.5.a).(2).(c).(ix) IV.A.5.a).(2).(c).(ix).(a) IV.A.5.a).(2).(c).(x) must demonstrate competence in performing the following key index procedures: (Outcome) adult medical resuscitation; (Outcome) adult trauma resuscitation; (Outcome) anesthesia and pain management; (Outcome) Residents must provide safe acute pain management, anesthesia, and procedural sedation to patients of all ages regardless of the clinical situation. (Outcome) cardiac pacing; (Outcome) chest tubes; (Outcome) cricothyrotomy; (Outcome) dislocation reduction; (Outcome) emergency department bedside ultrasound; (Outcome) Residents must use ultrasound for the bedside diagnostic evaluation of emergency medical conditions and diagnoses, resuscitation of the acutely ill or injured patient, and procedural guidance. (Outcome) intubations; (Outcome) Residents must perform airway management on all appropriate patients, including those who are uncooperative, at the extremes of age, hemodynamically unstable and who have multiple co-morbidities, poorly-defined anatomy, high risk for pain or procedural complications, or require sedation); take steps to avoid potential complications; and recognize the outcome and/or complications resulting from the procedures. (Outcome) lumbar puncture; (Outcome) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 17 of 35

IV.A.5.a).(2).(c).(xi) IV.A.5.a).(2).(c).(xii) IV.A.5.a).(2).(c).(xiii) IV.A.5.a).(2).(c).(xiv) IV.A.5.a).(2).(c).(xv) IV.A.5.a).(2).(c).(xvi) IV.A.5.a).(2).(c).(xvi).(a) IV.A.5.a).(2).(c).(xvii) IV.A.5.a).(2).(c).(xvii).(a) pediatric medical resuscitation; (Outcome) pediatric trauma resuscitation; (Outcome) pericardiocentesis; (Outcome) procedural sedation; (Outcome) vaginal delivery; (Outcome) vascular access; and, (Outcome) Residents must successfully obtain vascular access in patients of all ages regardless of the clinical situation. (Outcome) wound management. (Outcome) Residents must assess and appropriately manage wounds in patients of all ages regardless of the clinical situation. (Outcome) IV.A.5.b) Medical Knowledge Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and socialbehavioral sciences, as well as the application of this knowledge to patient care. Residents: (Outcome) IV.A.5.b).(1) IV.A.5.b).(2) IV.A.5.c) must demonstrate appropriate medical knowledge in the care of emergency medicine patients; and, (Outcome) must demonstrate knowledge of the scientific method of problem solving, evidence-based decision making, a commitment to lifelong learning, and an attitude of caring derived from humanistic and professional values. (Outcome) Practice-based Learning and Improvement Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. (Outcome) Residents are expected to develop skills and habits to be able to meet the following goals: 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 18 of 35

IV.A.5.c).(1) IV.A.5.c).(2) IV.A.5.c).(3) IV.A.5.c).(4) IV.A.5.c).(5) IV.A.5.c).(6) IV.A.5.c).(7) IV.A.5.c).(8) IV.A.5.c).(9) IV.A.5.c).(10) IV.A.5.c).(11) IV.A.5.c).(12) IV.A.5.d) identify strengths, deficiencies, and limits in one s knowledge and expertise; (Outcome) set learning and improvement goals; (Outcome) identify and perform appropriate learning activities; (Outcome) systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement; (Outcome) incorporate formative evaluation feedback into daily practice; (Outcome) locate, appraise, and assimilate evidence from scientific studies related to their patients health problems; (Outcome) use information technology to optimize learning; (Outcome) participate in the education of patients, families, students, residents and other health professionals; (Outcome) apply knowledge of study design and statistical methods to critically appraise the medical literature; (Outcome) use information technology to improve patient care; (Outcome) evaluate teaching effectiveness; and, (Outcome) teach different audiences using appropriate strategies based on targeted learning objectives. (Outcome) Interpersonal and Communication Skills Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. (Outcome) Residents are expected to: IV.A.5.d).(1) IV.A.5.d).(2) communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds; (Outcome) communicate effectively with physicians, other health professionals, and health related agencies; (Outcome) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 19 of 35

IV.A.5.d).(3) IV.A.5.d).(4) IV.A.5.d).(5) IV.A.5.d).(6) IV.A.5.d).(6).(a) IV.A.5.d).(6).(b) IV.A.5.d).(6).(c) IV.A.5.d).(7) IV.A.5.e) work effectively as a member or leader of a health care team or other professional group; (Outcome) act in a consultative role to other physicians and health professionals; (Outcome) maintain comprehensive, timely, and legible medical records, if applicable; (Outcome) communicate sensitive issues or unexpected outcomes, including: (Outcome) diagnostic findings; (Outcome) end-of-life issues and death; and, (Outcome) medical errors. (Outcome) lead patient care teams, ensuring effective communication and mutual respect among team members. (Outcome) Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. (Outcome) Residents are expected to demonstrate: IV.A.5.e).(1) IV.A.5.e).(2) IV.A.5.e).(3) IV.A.5.e).(4) IV.A.5.e).(5) IV.A.5.f) compassion, integrity, and respect for others; (Outcome) responsiveness to patient needs that supersedes selfinterest; (Outcome) respect for patient privacy and autonomy; (Outcome) accountability to patients, society and the profession; and, (Outcome) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. (Outcome) Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 20 of 35

(Outcome) Residents are expected to: IV.A.5.f).(1) IV.A.5.f).(2) IV.A.5.f).(3) IV.A.5.f).(4) IV.A.5.f).(5) IV.A.5.f).(6) IV.A.5.f).(7) IV.A.5.f).(8) IV.A.6. IV.A.6.a) IV.A.6.a).(1) IV.A.6.a).(1).(a) IV.A.6.a).(2) IV.A.6.a).(2).(a) IV.A.6.a).(2).(b) work effectively in various health care delivery settings and systems relevant to their clinical specialty; (Outcome) coordinate patient care within the health care system relevant to their clinical specialty; (Outcome) incorporate considerations of cost awareness and risk-benefit analysis in patient and/or populationbased care as appropriate; (Outcome) advocate for quality patient care and optimal patient care systems; (Outcome) work in interprofessional teams to enhance patient safety and improve patient care quality; (Outcome) participate in identifying system errors and implementing potential systems solutions; (Outcome) participate in performance improvement to optimize selflearning, emergency department function, and patient safety; and, (Outcome) use technology to accomplish and document safe health care delivery. (Outcome) Curriculum Organization and Resident Experiences The curriculum must include: four months of dedicated critical care experiences, including critical care of infants and children; (Core) At least two months of these experiences must be at the PGY-2 level or above. (Detail) five FTE months, or 20 percent of all emergency department encounters, dedicated to the care of pediatric patients less than 18 years of age in the pediatric emergency department or other pediatric settings; (Core) At least 50 percent of the five months should be in an emergency setting. (Detail) This experience should include the critical care of infants and children. (Detail) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 21 of 35

IV.A.6.a).(3) IV.A.6.a).(4) IV.A.6.a).(4).(a) IV.A.6.a).(4).(a).(i) IV.A.6.b) IV.A.6.b).(1) IV.A.6.b).(2) IV.A.6.c) IV.A.6.c).(1) IV.A.6.c).(2) IV.A.6.c).(3) IV.A.6.d) at least 0.5 months in obstetrics, or 10 low-risk normal spontaneous vaginal deliveries; and, (Core) at least 60 percent of each resident s clinical experience, including experiences dedicated to the care of pediatric patients less than 18 years of age in the pediatric emergency department, must take place in the emergency department under the supervision of emergency medicine faculty members. (Core) Residents should treat a significant number of critically-ill or critically injured patients at participating sites. (Core) These patients should be those admitted to intensive care units, operative care, or the morgue following treatment in the emergency department. (Detail) Each resident must maintain, in an accurate and timely manner, a record of all major resuscitations and procedures performed throughout the entire educational program. (Core) The record must document each procedure type, adult or pediatric patient, and circumstances of each procedure (live or simulation). (Detail) Only one resident must be credited with the direction of each resuscitation and the performance of each procedure. (Detail) Residents must have experience in emergency medical services (EMS), emergency preparedness, and disaster management. (Detail) EMS experiences must include ground unit runs and should include direct medical command. (Detail) This should include participation in multi-casualty incident drills. (Detail) If programs require residents to ride in air ambulance units, the residents must be notified of this requirement and associated liabilities during the resident recruitment process. (Detail) Residents should have experience teaching out-of-hospital emergency personnel. (Detail) IV.B. Residents Scholarly Activities 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 22 of 35

IV.B.1. IV.B.2. IV.B.3. The curriculum must advance residents knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. (Core) Residents should participate in scholarly activity. (Core) The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities. (Detail) V. Evaluation V.A. V.A.1. V.A.1.a) V.A.1.a).(1) Resident Evaluation The program director must appoint the Clinical Competency Committee. (Core) At a minimum the Clinical Competency Committee must be composed of three members of the program faculty. (Core) The program director may appoint additional members of the Clinical Competency Committee. V.A.1.a).(1).(a) V.A.1.a).(1).(b) V.A.1.b) V.A.1.b).(1) V.A.1.b).(1).(a) V.A.1.b).(1).(b) V.A.1.b).(1).(c) These additional members must be physician faculty members from the same program or other programs, or other health professionals who have extensive contact and experience with the program s residents in patient care and other health care settings. (Core) Chief residents who have completed core residency programs in their specialty and are eligible for specialty board certification may be members of the Clinical Competency Committee. (Core) There must be a written description of the responsibilities of the Clinical Competency Committee. (Core) The Clinical Competency Committee should: review all resident evaluations semi-annually; (Core) prepare and ensure the reporting of Milestones evaluations of each resident semi-annually to ACGME; and, (Core) advise the program director regarding resident progress, including promotion, remediation, and dismissal. (Detail) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 23 of 35

V.A.2. V.A.2.a) V.A.2.b) V.A.2.b).(1) V.A.2.b).(2) V.A.2.b).(3) V.A.2.b).(4) V.A.2.b).(4).(a) V.A.2.c) V.A.2.d) V.A.2.e) V.A.2.e).(1) V.A.3. V.A.3.a) Formative Evaluation The faculty must evaluate resident performance in a timely manner during each rotation or similar educational assignment, and document this evaluation at completion of the assignment. (Core) The program must: provide objective assessments of competence in patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice based on the specialty-specific Milestones; (Core) use multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff); (Detail) document progressive resident performance improvement appropriate to educational level; and, (Core) provide each resident with documented semiannual evaluation of performance with feedback. (Core) The program director must verify each resident s records of major resuscitations and procedures as part of the semiannual evaluation. (Core) The evaluations of resident performance must be accessible for review by the resident, in accordance with institutional policy. (Detail) At least annually, each resident s competency in procedures and resuscitations must be formally evaluated by the program director. (Core) A plan to remedy deficiencies must be in writing and on file. (Detail) Summative Evaluation Progress and improvement must be monitored at a minimum of every three months if a resident has been identified as needing a remediation plan. (Detail) The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. (Core) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 24 of 35

V.A.3.b) The program director must provide a summative evaluation for each resident upon completion of the program. (Core) This evaluation must: V.A.3.b).(1) V.A.3.b).(2) V.A.3.b).(3) become part of the resident s permanent record maintained by the institution, and must be accessible for review by the resident in accordance with institutional policy; (Detail) document the resident s performance during the final period of education; and, (Detail) verify that the resident has demonstrated sufficient competence to enter practice without direct supervision. (Detail) V.B. V.B.1. V.B.2. V.B.2.a) V.B.3. V.B.4. V.C. V.C.1. V.C.1.a) V.C.1.a).(1) V.C.1.a).(2) Faculty Evaluation At least annually, the program must evaluate faculty performance as it relates to the educational program. (Core) These evaluations should include a review of the faculty s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities. (Detail) Faculty member evaluations must also include administrative and interpersonal skills, quality of feedback and mentoring for residents, and participation in and contributions to resident conferences. (Detail) This evaluation must include at least annual written confidential evaluations by the residents. (Detail) A summary of the evaluations should be communicated in writing to each faculty member. (Detail) Program Evaluation and Improvement The program director must appoint the Program Evaluation Committee (PEC). (Core) The Program Evaluation Committee: must be composed of at least two program faculty members and should include at least one resident; (Core) must have a written description of its responsibilities; and, (Core) 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 25 of 35