Medical school produces a doctor. GME produces a specialist who can practice without supervision.

• Residency comes first. It trains a physician in a core specialty such as pediatrics, surgery, or psychiatry, usually over three to seven years.
• Fellowship follows residency and trains a subspecialist, such as a pediatric gastroenterologist or a pediatric anesthesiologist.
• Trainee is the umbrella word for residents and fellows. They are employees and learners at the same time, which explains much of GME's complexity.

13,762 accredited programs and 167,083 active residents and fellows in academic year 2024-2025 (ACGME, January 2026).

Three forces shape nearly everything: accreditation (the ACGME sets and enforces standards), certification (specialty boards decide who may sit for board exams), and funding (Medicare and other federal sources pay for much of the training).

One accountable physician leads each program. The Sponsoring Institution answers for all of them.

At the program

• Program Director (PD) Required The single physician accountable for education, evaluation, and compliance. The PD signs each trainee's final evaluation, which verifies readiness for autonomous practice.
• Associate Program Director (APD). Supports the PD. Some specialties require APDs by program size; others leave it local.
• Core faculty. Faculty with a significant teaching and evaluation role, listed in the ACGME's Accreditation Data System (ADS). Many specialties set minimum numbers.
• Site director Required A faculty member accountable for trainee education at each participating site outside the primary hospital.
• Program Administrator. The professional who runs program operations: recruitment, onboarding, evaluations, ADS, committee support, and compliance records. Current ACGME requirements use the title "program coordinator," and specialty requirements set minimum dedicated time for the role. Changing The proposed 2028 requirements rename the role "GME administrative professional" and revise the dedicated-time language.
• Chief residents or chief fellows. Trainee leaders. Usually a local role rather than an ACGME requirement.

At the institution

• Designated Institutional Official (DIO) Required The one person with authority and responsibility for oversight of every ACGME program at the Sponsoring Institution. The DIO approves key submissions, agreements, and program changes.
• GME office. The central team that supports the DIO and the programs. Size and structure are local.
• Graduate Medical Education Committee (GMEC). The oversight committee. See the committees section.
• Governing body Required Senior institutional leadership, which receives GME reports and holds final responsibility.

The ACGME accredits. The boards certify. The Match places trainees. Federal programs pay.

Professional community: program director associations such as APPD and AHME, and administrator networks such as FULGME. Membership is optional, but these groups share tools, benchmarks, and early warnings about requirement changes.

Accreditation is continuous. The ACGME reviews every program's data every year.

Three layers of requirements

1. Institutional Requirements (IRs) apply to the Sponsoring Institution: the DIO, the GMEC, institutional policies, and oversight of all programs.
2. Common Program Requirements (CPRs) apply to every program. Separate versions exist for residency, fellowship, one-year fellowship, and post-doctoral education.
3. Specialty-specific Program Requirements come from each Review Committee. They add detail and can be stricter than the CPRs.

Today each requirement carries a Core, Detail, or Outcome label. Programs in substantial compliance with Outcome requirements may use alternative approaches to meet Core requirements. Changing The proposed 2028 requirements drop those labels entirely.

What the ACGME reviews each year

• ADS Annual Update. Faculty, trainees, participating sites, scholarly activity, and responses to prior citations. The window usually falls in summer.
• Resident/Fellow and Faculty Surveys. Anonymous annual surveys on supervision, work hours, and the learning environment.
• Milestones. Competency ratings reported for every trainee, typically November to mid-January and April to mid-June.
• Case Logs in specialties that require them, and outcomes such as board pass rates and attrition.

The Review Committee screens these data. Most programs pass quietly. Concerning data can bring a request for information, a site visit, or a status change.

Accreditation statuses

New programs begin at Initial Accreditation and earn Continued Accreditation through a later review, usually with a site visit. Continued Accreditation without Outcomes applies to programs too new to have graduate data. Warning statuses exist at both stages, Probationary Accreditation follows, and Withdrawal of Accreditation is the worst outcome. Decisions and citations arrive in a Letter of Notification (LON).

• Citation. A finding of noncompliance with a specific requirement. The program responds in writing in ADS, usually in the next Annual Update.
• Area for Improvement (AFI). A concern that is not yet a citation. No written response is required, but an ignored AFI is how programs earn citations.

Site visits

• Application visits for new programs and institutions, plus focused or full visits when data raise concerns.
• Program 10-year site visits ended in October 2023. Since July 1, 2025, the ACGME no longer monitors the program Self-Study requirement, and enforcement of CPR 5.5.h was suspended February 9, 2026.
• Sponsoring Institution 10-year site visits continue. The institutional Self-Study is likewise no longer monitored.

ACGME Accreditation Field Representatives conduct every visit. Prepare all year: current documents, clean ADS data, and trainees and faculty who can describe how the program really works.

Changes that need approval first

Permanent complement increases need prior Review Committee approval. Program director changes and new participating sites go through GMEC review and DIO approval, then ADS. Check the specialty requirements and your GMEC process before promising anyone a new position or rotation.

The GMEC oversees the institution. The CCC judges each trainee. The PEC judges each program.

Minutes are accreditation evidence. Write them to show what the committee reviewed, decided, and assigned.

Graduate Medical Education Committee (GMEC) Required

• Voting members (institutions with more than one program): the DIO, a representative sample of program directors (at least two), at least two peer-selected trainees, and a quality improvement or patient safety officer or designee.
• Frequency: at least once every quarter during each academic year.
• Work: oversees every program's status and data, approves program director appointments, complement changes, and participating site changes, approves institutional GME policies, and monitors the learning and working environment.
• Subcommittees are local. The GMEC keeps responsibility and must document its own review and approval.

Annual Institutional Review (AIR) Required

The GMEC reviews institutional performance indicators each year and sets action plans. The DIO submits a written executive summary to the governing body.

Special Review Required

When a program shows signs of underperformance, the GMEC runs a Special Review with a report, required improvements, and monitoring. Changing The proposed Institutional Requirements convert the Special Review protocol into a Special Review policy and add a six-month deadline for the report.

Clinical Competency Committee (CCC) Required

• Members: appointed by the PD; at least three program faculty members, at least one of them core faculty.
• Work: reviews every trainee's evaluations at least twice a year, determines Milestones ratings, and advises the PD on promotion, remediation, and graduation readiness.
• Limit: the CCC advises. The PD decides.

Program Evaluation Committee (PEC) Required

• Members: appointed by the PD; at least two program faculty (one core) and at least one trainee.
• Work: runs the Annual Program Evaluation (APE). The PEC reviews program data and the prior action plan, then writes a new one. The APE and action plan must be distributed to and discussed with trainees and teaching faculty, and submitted to the DIO.
• Why it matters: the APE feeds the ADS Annual Update and GMEC oversight. A thin APE weakens both.

Seven stages, each with a paper trail the program must be able to produce.

1. Recruitment. Programs post positions and review applications, mostly through ERAS. Most residencies and many fellowships fill through the NRMP Match, whose terms bind both sides. Residency Match Day falls in the third week of March. Follow ACGME eligibility rules for who may be appointed.
2. Appointment and onboarding. Signed agreement of appointment, verification of prior training, licensure or training permit, visa sponsorship when needed, credentialing, and orientation. Before accepting a transfer, the program must obtain verification of prior training and a summative competency-based evaluation.
3. Supervision and work hours Required No more than 80 hours a week averaged over four weeks. One day in seven free of clinical work and education, averaged over four weeks. No more than 24 hours of continuous scheduled clinical assignments, plus up to four hours for transitions. In-house call no more often than every third night, averaged over four weeks. Changing Work hours are under review in the 2026 CPR revision.
4. Evaluation. Faculty evaluate trainees after each rotation. Trainees evaluate faculty and rotations anonymously. The CCC reviews it all twice a year.
5. Remediation, when needed. Feedback and coaching first, then formal written plans. Follow institutional policy on academic actions and due process. Document behaviors and performance, not impressions.
6. Completion. The PD's final evaluation verifies that the trainee has demonstrated the knowledge, skills, and behaviors needed for autonomous practice.
7. After graduation. Graduates apply for board certification. Programs answer training verification requests long after graduation. Retention periods are local.

The ACGME also offers direct channels to anyone with a concern: a non-compliance report form and an Office of the Ombudsperson. Assume a real concern can reach the ACGME without passing through the program.

July 1 to June 30, and the same deadlines return every year.

NST lets an institution train J-1 physicians in subspecialties that have no ACGME accreditation and no ABMS certification.

• Who approves what. The ACGME's Institutional Review Committee grants NST Recognition to the Sponsoring Institution, never to an individual program. ECFMG sponsors each trainee's J-1 visa.
• Recognition comes first. Since July 1, 2023, ECFMG creates NST appointment profiles only at institutions holding ACGME NST Recognition, and each NST program must be entered in ADS.
• Accredited subspecialties do not qualify. If ACGME accreditation exists for the subspecialty, an unaccredited program in that field cannot use the NST pathway.
• Requirements. The NST Recognition Requirements make the institution responsible for each NST program and trainee, for assessing the impact on related accredited programs, and for J-1 regulatory compliance.
• Oversight is institutional. The GMEC and GME office oversee NST programs alongside accredited ones. How closely NST programs mirror ACGME processes beyond the requirements is local.

Non-accredited fellowships that sponsor no J-1 trainees fall outside ACGME oversight entirely. Their standards are local.

Medicare pays the most, and a cap set in 1997 limits how many trainees it funds at each hospital.

• Direct GME (DGME). Medicare payments for direct training costs: trainee salaries and benefits, faculty supervision, program administration.
• Indirect Medical Education (IME). Add-on payments for the higher patient care costs of teaching hospitals.
• The cap. The Balanced Budget Act of 1997 fixed each hospital's Medicare-funded resident count at its 1996 level. Hospitals may train above the cap, but Medicare pays nothing extra for those positions.
• New slots. Section 126 of the Consolidated Appropriations Act, 2021 created 1,000 new Medicare-funded positions, released at up to 200 a year from fiscal year 2023. CMS opened the fifth and final round in January 2026.
• Children's hospitals. Freestanding children's hospitals treat few Medicare patients, so HRSA's CHGME program fills part of the gap through annual appropriations: $367.3 million in formula payments to 59 hospitals in fiscal year 2025.
• Other sources. Medicaid (varies by state), the Department of Veterans Affairs, HRSA's Teaching Health Center program, and institutional funds. Positions above the cap need one of these.

Funding decisions belong to finance and GME leadership. Program staff should know which positions are funded, by what source, and what the institution expects before a complement change reaches the GMEC.

The Common Program Requirements are in their once-a-decade rewrite. The proposed residency version takes effect July 1, 2028.

• CPR major revision Changing Proposed Residency and Post-Doctoral versions were posted for comment on September 8, 2026. Comments close October 22, 2026. The proposal cuts the requirement count by about 43 percent and renames the program coordinator role "GME administrative professional."
• Fellowship versions follow. The Fellowship and One-Year Fellowship versions are expected for public comment in early 2027, with the same tentative July 1, 2028 effective date. Fellowships follow current requirements until then.
• Institutional Requirements Changing A proposed revision was posted March 16, 2026, comments closed April 25, 2026, and the proposed effective date is July 1, 2027.
• Suspended enforcement. On February 9, 2026, the ACGME suspended enforcement of nine Common Program Requirements pending the revision, including the 10-year PLA renewal rule and the Self-Study. Suspended is not deleted. Many institutions keep some as local practice.
• CLER has ended. The Clinical Learning Environment Review program concluded in fall 2025. Older guidance that references CLER visits is out of date.
• Data moved. The 2024-2025 Data Resource Book is the last static edition. Public GME data now live in ACGME Cloud Analytics.
• Next national meeting. The 2027 ACGME Annual Educational Conference runs February 25 to 27, 2027, in San Antonio, Texas.

What to do now: read the proposed requirements with your GMEC, send comments through your institution or professional association, and flag any rule your programs would need time to meet by 2028.

Most accreditation problems start as small documentation gaps that nobody owned.

1. Read the requirement, not the summary. Pull the current Common, specialty, and Institutional Requirements from the ACGME website and check the version date.
2. Know required from local. Before you tell anyone "ACGME requires it," find the requirement number. If you cannot, it is probably institutional policy.
3. Treat ADS as a legal record. Everything in it should match your source documents.
4. Write minutes that prove the work. What the committee reviewed, what it decided, who owns each action, and when it is due.
5. Keep agreements current. Every participating site providing a required assignment needs a current program letter of agreement approved by the DIO.
6. Close the loop on every citation and AFI. Assign an owner, fix the root cause, keep the evidence.
7. Watch the survey results. Review Committees see them every year. Act on a weak area before it repeats.
8. Route program changes through the GMEC first. New sites, PD changes, and complement changes need approval before they happen.
9. Document remediation factually. Describe behaviors and performance, cite the evaluation evidence, and follow due-process policy exactly.
10. Prepare all year. A program that can produce its documents on any given Tuesday never needs a site-visit scramble.

• AAMCAssociation of American Medical Colleges
• ABMSAmerican Board of Medical Specialties
• ABPAmerican Board of Pediatrics
• ACGMEAccreditation Council for Graduate Medical Education
• ADSAccreditation Data System
• AFIArea for Improvement
• AIRAnnual Institutional Review
• AOAAmerican Osteopathic Association
• APDAssociate Program Director
• APEAnnual Program Evaluation
• APPDAssociation of Pediatric Program Directors
• C-TAGMECertified Training Administrator of GME
• CCCClinical Competency Committee
• CHGMEChildren's Hospitals GME Payment Program
• CLERClinical Learning Environment Review (ended 2025)
• CMSCenters for Medicare & Medicaid Services
• CPRCommon Program Requirements
• DGMEDirect Graduate Medical Education payments
• DIODesignated Institutional Official

• ECFMGEducational Commission for Foreign Medical Graduates
• ERASElectronic Residency Application Service
• FTEFull-time equivalent
• GMECGraduate Medical Education Committee
• HRSAHealth Resources and Services Administration
• IMEIndirect Medical Education payments
• IRInstitutional Requirements
• IRCInstitutional Review Committee
• J-1Exchange visitor visa used by many international trainees
• LONLetter of Notification
• NRMPNational Resident Matching Program
• NSTNon-standard training
• PDProgram Director
• PECProgram Evaluation Committee
• PGYPostgraduate year (PGY-1 is the first year after medical school)
• PLAProgram letter of agreement
• RCReview Committee
• SISponsoring Institution

• ACGME Common Program Requirements (Residency), 2026, with February 9, 2026 interim revision
• ACGME Institutional Requirements, 2026
• ACGME Manual of Policies and Procedures
• Proposed Common Program Requirements (Residency), posted September 8, 2026
• CPR major revision impact statement, 2026
• Institutional Requirements impact statement, 2026
• List of Suspended Common Program Requirements, February 2026
• ACGME e-Communication, September 22, 2025 (Self-Study no longer monitored)
• ACGME e-Communication, November 6, 2023 (program 10-year site visits discontinued)
• ACGME e-Communication, September 8, 2026
• ACGME NST Recognition
• ACGME CLER Program History
• ACGME 2024-2025 statistics release
• ACGME Milestones FAQ
• ECFMG sponsorship types
• NRMP Match Week
• HRSA CHGME Payment Program
• CMS Direct Graduate Medical Education
• GAO-26-107686, new Medicare-funded residency positions
• AAMC, final round of Section 126 distributions
• TAGME 2025 Initial Certification Guide
• JGME, the CPR major revision process