GME Policies



Review the glossary here

Policies and Procedures

1. Institutional Statement of Commitment to Graduate Medical Education
Houston Methodist Hospital is committed to training tomorrow’s physicians in a system of medicine that emphasizes its foundation of core values. [Read more]

2. Composition and Responsibilities of GME Committee
The Graduate Medical Education Committee supervises, coordinates, reviews, and assures the quality of education in all ACGME-accredited graduate medical education programs, which includes residents at all levels of training. [Read more]

3. Resident Eligibility, Selection, and Appointment
This procedure sets forth the requirements for residents to participate in ACGME-accredited or Texas Medical Board-approved programs at Houston Methodist Hospital. [Read more]

4. Residents with Visas
Every non-citizen applicant selected for appointment must have permanent resident status or a J-1 or H-1B visa as a condition of appointment to a resident position at Houston Methodist. [Read more]

5. Responsibilities of Residents
A program of GME must provide residents with an extensive experience in the art and science of medicine. The resident’s responsibilities can be described with the context of the ACGME General Competencies and other program obligations. [Read more]

6. Promotion and Reappointment
Processes for residents who make satisfactory progress in achieving a Program’s standards for each year of training must be applied uniformly and fairly. [Read more]

7. Paid Time Off and Other Leaves of Absence
All residents are eligible for paid time off. Like other Houston Methodist employees, residents are eligible for bereavement, family medical leave, and other leaves of absence. [Read more]

8. Supervision of Residents
Residents must be given graded levels of responsibility so that they can mature into their roles as judgmentally sound, technically skilled, and independently functioning credentialed health care providers. [Read more]

9. Accommodation of Residents with Disabilities
An applicant or a resident in a program of GME may request reasonable accommodation for a disability. [Read more] [ADA Form]

10. Adverse Academic Actions
Processes for residents who fail to make satisfactory progress in achieving program standards must be applied uniformly and fairly. Adverse academic actions include probation, nonrenewal or non-reappointment, suspension, and termination. [Read more] [AAA Process] [Letter for Remediation] [Struggling Learner Assessment]

11. Nonacademic Grievance
Houston Methodist is committed to providing a work environment that is conducive to the learning activities of residents. Residents are encouraged to bring concerns or complaints about work-related conditions to the attention of their Program Directors. A resident can also confidentially bring a nonacademic grievance, concern, or dispute to the DIO (Designated Institutional Official). [Read more]

12. Resident Evaluation
Each residency program must use the goals and objectives of its educational framework to construct an evaluation system that defines the knowledge, skills, professional behavior, and experiences expected of residents. [Read more]

13. Resident Duty Hours and Working Environment
Residency training programs must comply with the requirements established by the ACGME concerning duty hours in July 2011. Duty hour assignments must also recognize that faculty and residents collectively have responsibility for the safety and welfare of their patients. [Read more]

14. Resident Moonlighting
The GME Committee and Houston Methodist-sponsored programs take seriously the responsibility of ensuring a quality learning environment for residents. Because of these concerns, moonlighting is, in general, discouraged for residents in ACGME-accredited programs sponsored by Houston Methodist. [Read more] [Moonlighting Form]

15. Residency Closure or Reduction
As a Sponsoring Institution of GME programs, Houston Methodist Hospital has a procedure to address a reduction in size or closure of a residency training program. [Read more]

16. Clinical Rotations
Houston Methodist Hospital has established eligibility requirements for “elective” clinical rotations by residents in ACGME-accredited programs. The availability of an educational experience for a non-Houston Methodist resident is at the discretion of each individual training program. [Read more]

17. Clinical Observerships
Standards and requirements determined by The Joint Commission and Houston Methodist Hospital establish the process for accepting learners from non-HMH training programs for a clinical experience at Houston Methodist Hospital. An observership is a voluntary experience without patient contact that does not constitute medical education, graduate medical education, continuing medical education, or training leading to licensure or board certification. More information on this process can be obtained by visiting Houston Methodist Hospital Education Institute.  

18. Responsibilities of Program Directors
The Program Director, with the assistance of faculty, is responsible for developing and implementing the academic and clinical program of education for residents. [Read more]

19. Compensation and Benefits for Unfunded Resident Positions
All residents in Houston Methodist-sponsored GME programs must have appropriate compensation and benefits. Infrequently, a program may appoint a Resident for whom no funded position exists within Houston Methodist. [Read more]

20. Internal Reviews
The GME Committee must conduct an internal review of each Houston Methodist-sponsored program to assess the program’s compliance with the ACGME Institutional, common program, and program-specific requirements. [Read more] [Action Plan]

21. Approval of New Programs
To establish a new residency training program at Houston Methodist Hospital, the faculty of that program must prepare a proposal and subject the proposal to an internal review and review of the GME Committee. [Read more] [New ACGME Program Form] [Non ACGME Form] [Letter of Financial Support]

22. Applicant Information
Applicants for residency positions through the “Match” must be given complete and accurate information regarding the policies and procedures governing the prospective training programs. [Read more] [Acknowledgement Statement with Virtual Attestment] [Non-Match or Transfer Applicant Form]

23. Special Electives
Special Electives should be conducted in an ACGME-accredited Program and count toward residency requirements and, if applicable, specialty board requirements. [Read more] [Global Health Rotations]

24. Interactions between Residents and GME Programs with Industry
Residents should be made aware of medical industry's current methods of promotions and potential conflicts of interest that can result from the gifting process. [Read more]

25. Disasters and other Events Interrupting Patient Care and Training
 This written procedure addresses administrative support if a disaster or other event interrupts patient care and the training of residents. It supplements the internal procedure on Employee Safety and Responsibility during Severe Weather and Emergencies and the emergency management plan established by each department. [Read more]

26. Prescription Writing by Residents
 Residents are restricted to the supervised practice of medicine that is part of and approved by a Program of GME. Other policies and regulations may apply to prescription writing by Residents, including but not limited to the use of the Institutional DEA number. [Read more]

27. Transitions of Care
 A transition of care is the movement patients make between healthcare practitioners and settings. [Read more]

28. Annual Program Review
 The Accreditation Council for Graduate Medical Education (ACGME) has expectations for each ACGME-accredited Program’s evaluation in the Next Accreditation System. [Read more]

29. Appointment of New Program Director
 Appointment process of a new program director. [Read more] [Sample Letter]

30. Passage of Medical Licensing Exam (USMLE)
 The United States Medical Licensing Exam (USMLE) assesses a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care. [Read more]

31. Residents on Research/Academic Leave
Residents in certain programs may be allowed to take extended time off from their clinical activities to participate in research activities, administrative/leadership activities, or other activities that will help them in their medical careers. [Read more]

32. Code of Professional Conduct for Faculty
 Houston Methodist Hospital is committed to providing unparalleled quality, safety, service, and medical education training of both graduate and undergraduate learners. This commitment also extends to ensuring that the educational environment is one in which faculty teachers and clinical supervisors display professionalism and respect for all learners. [Read more]


33. Medical Student Rotations
 The Texas Medical Board (TMB) has separate and distinct guidelines governing the supervision and rotation of medical students who are enrolled at a Texas medical school as a full-time or visiting student and those who are enrolled in institutions outside of the State of Texas. [Read more]

34. Educational Resources Devoted to Clinical Informatics
 It is the policy of the Houston Methodist GME Committee that appropriate and fair processes govern the allocation of resources to GME programs in which there is a similarity or overlap of the educational mission. [Read more]

35. Educational Leave and Reimbursement Process
 All Houston Methodist Residents are eligible for Educational Leave to present at professional meetings or to attend meetings of professional organizations in which the Resident occupies a position as an officer or representative in an official capacity. [Read More] [Pre-Travel Authorization Form]

36. Graduation Certificates
 The generation of certificates of training for graduation from or completion of a Houston Methodist ACGME or GMEC approved training experience in a residency or fellowship program is centralized through the GME Office. [Read more]

37. Fitness for Duty Evaluation

      Houston Methodist and its Programs of GME are committed to promoting a safe and healthy environment for its Residents.. [Read more]

38. Approval of Complement Increase 

      Each GME program should be aware of the resident complement limits as identified on their most recent accreditation/approval letter and must be in compliance with that complement.  [Read more] [Form to Request a Complement Increase] [Letter of Financial Support]

39. Fellow Billing

       Residents and Fellows in ACGME programs are not eligible to bill for any patient care services that they provide.  Such services are billed under the name of the attending physician.  Medicare rules allow for fellows who are not in approved programs, as defined below, to bill for services in there own name. Houston Methodist Medical Staff Bylaws have been adapted to allow these fellows in non-ACGME programs to bill provided they meet all applicable credentialing criteria for their core specialty and would be eligible to bill under Medicare billing rules.  [Read more]


40. GME Training Record Retention

       Records documenting resident performance must be maintained accurately.  The records must also be current and in accordance with Accreditation Council for Graduate Medical Education (ACGME) and relevant Residency Review Committee (RRC) regulations. [Read more]