Criteria for Excellence | Chapter 2A: Residency faculty and staffing
Build the faculty, leadership and administrative team your residency needs to succeed.
Authors: Louis Sanner, MD; Judith Pauwels, MD; Bill Gillanders, MD; Diana Heiman, MD and Elissa Palmer, MD
The people who perform teaching, administrative, and clinical roles are the heart of any residency program. Recruitment, development, and retention of high-quality individuals in these roles are some of the most critical determinants of the health of the residency program as a whole. Programs of excellence strongly support their faculty and staff by delineating appropriate job roles and facilitating ongoing development. In addition, they regularly evaluate faculty and staff to ascertain that the program is meeting or
exceeding performance benchmarks, and they assess retention and well-being within the program.
Plan program director and core faculty staffing
The 2024 Accreditation Council for Graduate Medical Education (ACGME) Family Medicine Program Requirements (FM-PR) changed the required time allocations for clinical and administrative work for the program director (PD), dropped the associate PD requirement, and added required core faculty positions based on parameters defined in the 2023 ACGME Common Program Requirements. All family medicine residencies were expected to be in substantial compliance by July 1, 2024. The Program Requirements, the embedded clarifying statements of intent, and the separate Family Medicine FAQ documents must be reviewed in order to understand these changes in their entirety. The scope of the changes cannot be appreciated without reviewing all three sources of information.
The ACGME definition for the program director position specifically requires all PDs to have salary support of at least 0.2 full-time equivalent (FTE) for nonclinical administrative time, exclusive of resident clinical supervision (i.e., precepting) time. That percentage increases with the number of residents up to 0.5 FTE for programs with 11 or more residents. [See section II.A.2.a) of the ACGME FM-PR.] PDs must be engaged in ongoing clinical activity, although a required percentage of time is not specified. [See section II.A.3.c) of the ACGME FM-PR.]
Define the associate program director role
For programs with 16 or more residents, additional support for program leadership is required, ranging from 0.1 FTE for programs with 16 to 20 residents up to a maximum of 1.3 FTE for programs with 76 to 80 residents. Program leadership FTE may be added to the PD’s support or divided among the PD and one or more associate PDs. [See section II.A.2.a) of the ACGME FM-PR.] Note that the new requirements do not state that programs must have an associate PD. However, Residency Program Solutions (RPS) strongly urges all programs to have an associate PD. At minimum, the associate PD provides clear leadership in the absence of the PD, assists with leadership development, and aids in leadership succession planning. Associate PDs are often assigned critical roles, such as committee chair, clinic medical director, or hospital teaching service director.
Protect time for core faculty academic and administrative work
The 2024 ACGME Family Medicine Program Requirements do not specifically define administrative FTE for core faculty members. Instead, they state that core faculty in programs with 13 residents or more should devote a minimum of 60% of their time to the program and core faculty in programs with 12 residents or fewer should devote a minimum of 40% of their time, exclusive of direct patient care. This time definition includes both administrative time and clinical precepting time. However, the ACGME clearly recognizes the need for protected administrative time in the Background and Intent section regarding core faculty, which states, “Core faculty members are engaged in a broad range of activities, which may vary across programs and specialties. Core
faculty members provide clinical teaching and supervision of residents and also participate in non-clinical activities related to resident education and program administration. Examples of these non-clinical activities include, but are not limited to, interviewing and selecting resident applicants, providing didactic instruction, mentoring residents, simulation exercises, completing the annual ACGME Faculty Survey, and participating on the program’s Clinical Competency Committee, Program Evaluation Committee, and other GME committees.”2 [See section II.B.4.a) of the ACGME FMPR.] Additional administrative program activities include evaluation, recruitment,
scholarly activity, faculty development, resident/fellow engagement, and administrative documentation. These activities also include organizing the curriculum and the schedule, advising and counseling residents, participating in discussions, attending meetings, and planning for the future.
RPS believes it is essential for every PD, associate PD, and core faculty member to have specific nonclinical time for academic and administrative work. For clarity, RPS recommends that programs of excellence define three categories of work time in faculty contracts and/or position descriptions. Note that “academic salary support” is needed for category #3 below since there is no clinical income associated with these important residency tasks:
Time for direct care of patients assigned to the faculty member (billable)
Time for precepting or clinical resident supervision (also billable)
Nonclinical administrative time, distinct from clinical revenue-generating
time, that includes time devoted to program administration and scholarly activities
Balance clinical, teaching and administrative responsibilities
Balancing faculty responsibilities and time allocation can be one of the most difficult challenges for residency leadership. In addition to educational expectations for teaching, mentoring, educational improvement, scholarship, and faculty development, there may be intense expectations for clinical care within the practice and the sponsoring institution. Programs of excellence work to ensure that faculty members’ clinical responsibilities are balanced with the necessary administrative, teaching, and scholarly demands. In programs of excellence, the PDs and Designated Institutional Officials (DIOs) negotiate an appropriate balance of these different responsibilities with hospitals and sponsoring institutions.
Determine core faculty staffing by residency program size
Table 1: Recommended additional core faculty relative to size of program
| Progam size | ||||||||
| Core faculty (in addition to PD)* |
6 FTE (2-2-2) |
9 FTE (3-3-3) |
12 FTE (4-4-4) |
15 FTE (5-5-5) |
18 FTE (6-6-6) |
21 FTE (7-7-7) |
24 FTE (8-8-8) |
More than 24 FTE |
| ACGME Requirements |
1 | 2 | 2 | 3 | 4 | 5 | 6 | 1 per 4 residents |
| Program of Excellence** |
2 | 3 | 3 | 4 | 5 | 6 | 7 | Same as ACGME minimums |
Plan time allocations for residency leadership and faculty
Table 2: Essential core program time allocations
| Program Director | Minimum Required by ACGME |
Maximum Allowed by ACGME |
Minimum Recommended by RPS |
Maximum Recommended by RPS |
| Patient care without residentsa |
Some to role model |
Not specified | 10% | 30% |
| Precepting (direct resident supervision) in clinic and hospitalb |
20% to 50%, depending on program size |
Not specified | 10% | 30% |
| Administrative/ Academicc |
50%d | 80% | ||
| Core Faculty Physicians |
Minimum Required by ACGME |
Maximum Allowed by ACGME |
Minimum Recommended by RPS |
Maximum Recommended by RPS |
| Patient care without residentse |
Not specified | 40% to 60% | 20% | 40% |
| Precepting (direct resident supervision) in clinic and hospitalf |
40% for programs ≤12 residents 60% for programs ≥13 residentsg |
Not specified | 20% | 40% |
| Administrative/Aca demic |
10% to 20%, depending on program size |
50% | ||
| Associate Program Director(s) |
Minimum Required by ACGME |
Maximum Allowed by ACGME |
Minimum Recommended by RPS |
Maximum Recommended by RPS |
| Patient care without residentse |
Not specified | Not specified | 20% | 40% |
| Precepting (direct resident supervision) in clinic and hospitalf |
Not specified | Not specified | 20% | 40% |
| Administrative/Aca demic |
30% to 40%, depending on program sizeh |
50% |
Table 3: ACGME requirements for program leadership FTE
family medicine program leadership.
| Number of Approved Resident Positions |
Minimum Support Required (FTE) for Program Director |
Additional Minimum Support Required (FTE) for Program Leadership |
| 1-6 | 20% | N/A |
| 7-10 | 40% | N/A |
| 11-15 | 50% | N/A |
| 16-20 | 50% | 10% |
| 21-25 | 50% | 20% |
| 26-30 | 50% | 30% |
| 31-35 | 50% | 40% |
| 36-40 | 50% | 50% |
| 41-45 | 50% | 60% |
| 46-50 | 50% | 70% |
| 51-55 | 50% | 80% |
| 56-60 | 50% | 90% |
| 61-65 | 50% | 100% |
| 66-70 | 50% | 110% |
| 71-75 | 50% | 120% |
| 76-80 | 50% | 130% |
Table 4: Number of associate PDs and leadership time allocation
| Program size | |||||||||
| APDs: | 6 FTE (2-2-2) |
12 FTE (4-4-4) |
18 FTE (6-6-6) |
24 FTE (8-8-8) |
30 FTE (10-10-10) |
36 FTE (12-12-12) |
42 FTE (14-14-14) |
48 FTE (16-16-16) |
More than 48 FTE |
| Program of excellence number of APDs |
1 | 1 | 2 | 2 | 2 | 2 | 3 | 3 | ≥3 |
| Program of excellence leadership time, plus core faculty time per APD** |
30% (10% leader, plus 20% core) |
30% (10% leader, plus 20% core) |
30% (10% leader, plus 20% core) |
30% (10% leader, plus 20% core) |
35% (15% leader, plus 20% core) |
40% (20% leader, plus 20% core) |
40% (20% leader, plus 20% core) |
40% (20% leader, plus 20% core) |
40% (20% leader, plus 20% core) |
Define residency leadership roles and responsibilities
Table 2 shows specific RPS recommendations for PD, associate PD, and core faculty positions, with precepting time—a billable activity—distinguished from other academic/administrative work. The ACGME Family Medicine Program Requirements do not specify a minimum percentage of time that the PD and core faculty should spend precepting and/or in direct patient care. However, RPS has established minimum thresholds for these activities so programs of excellence can ensure that PDs and core faculty are active practice partners and role models for residents. Even while meeting the administrative/academic program requirements, PDs and core faculty must remain visible and participatory in core resident experiences.
One of the PD’s key administrative responsibilities is to ensure that administrative/academic time is not consumed with “catch-up” clinical work, such as managing the clinical desktop or completing medical records. Similarly, the PD should ensure that faculty members are adequately protected during precepting so they can focus on resident teaching and supervision duties and do not need to use precepting time to catch up on administrative work or other clinical work.
Recommendations for dedicated academic and administrative time present a clear dilemma for many programs, specifically related to having an adequate number of core faculty members available to precept. In addition, the most common root cause for faculty burnout and failure to meet Program of Excellence benchmarks is having an inadequate number of faculty members. Therefore, RPS recommendations for adequate core faculty size (Table 1) exceed the ACGME’s minimum standard. Sponsoring institutions and programs must arrange appropriate support to meet these recommendations.
Plan staffing and leadership for rural track programs
The definitions and funding rules for rural residencies have evolved over several decades. There are free-standing rural residencies, pathways within residencies that emphasize rural training, and one- to two-month rural rotations in otherwise urban residency programs. Rural training programs are one common type of rural residency, and specific rules govern Centers for Medicare & Medicaid (CMS) funding for these programs. Rural training programs were “rebranded” as Rural Track Programs (RTPs) by the Consolidated Appropriations Act, 2021, which removed the requirement for separate accreditation. CMS considers a new residency program or an expansion of an existing residency an RTP if greater than 50% of the residents’ training time is spent in a CMS-defined rural area. Currently, CMS defines “rural” as any U.S. location that is not in a metropolitan Core Based Statistical Area (CBSA).3
Inpatient prospective payment system (IPPS) hospital claims for RTP residents qualify for additional Medicare graduate medical education (GME) payments above the hospital’s cap and result in a specific “RTP cap exception” segregated cap after the program is five years old. The RTP-specific cap can only be used for RTP residents. The rules are complex, and an increasing number of urban-located teaching hospitals are being reclassified as “rural,” primarily by becoming rural referral centers. Currently, most residents and fellows in the United States are training at urban-located rural referral centers. RPS strongly encourages programs and communities planning a new RTP to have a detailed discussion with an RPS consultant to clarify the funding options, particularly if a rural referral center hospital may be involved.
The ACGME has adopted the CMS definition for RTPs and has an evolving process for designating new programs or expansions as RTPs. An excellent family medicine RTP—whether separately accredited or not—should have a close relationship with a “core” urban residency. The program should expect assistance with many aspects of running the RTP, including resident recruitment, evaluation, curriculum, maintenance of accreditation, faculty development, and leadership mentoring. An excellent family medicine RTP can then assign less leadership involvement, staff support, and faculty academic time than would be required for a stand-alone program. Recommended staffing levels are as shown in Table 1.
Define DIO responsibilities for single-program sponsors
In single-program institutions, having the program director serve as DIO raises concerning conflicts of interest. The DIO and Graduate Medical Education Committee (GMEC) must review and sign off on a residency program’s Annual Program Evaluation. This requirement is intended to ensure internal input on the evaluation, in addition to the PD’s input. All AGCME and Review Committee for Family Medicine responses to concerns, warnings, and citations must be reviewed and approved by the DIO, who serves as a “second set of eyes” for these responses. Additionally, in most institutions, the DIO is part of the appellate process for adverse resident personnel decisions (e.g., probation, termination). The PD obviously cannot fill an appellate role in the grievance process. (See the Institutional Engagement chapter for additional information.)
For single-site sponsoring institutions, programs of excellence provide 0.1 FTE for the DIO, with an additional 0.1 FTE if the DIO is also the chair of the institution's GMEC, which is often the case.
Build your residency administrative team
High-functioning residency programs have a sufficient number of staff members with appropriate job descriptions to help carry out the residency’s academic and administrative functions. This is particularly true because of the increasing complexity of resident evaluation requirements and the need to support faculty and resident scholarship.
The Family Medicine Program Requirements mandate that residency programs must have a program coordinator who is given dedicated time and support for administration of the program (Table 5). [See section II.C.1. of the ACGME FM-PR.] Programs of excellence will have at least a full 1.0 FTE in this position. The program coordinator is an essential part of the residency and must have a job description that entitles them to exempt (managerial) status in the sponsoring organization. This person shares major responsibility for the day-to-day operation of the program, including recruitment, human resources administration, and external compliance and reporting. In programs of excellence, the coordinator job will be sufficiently demanding to warrant a separate clinical practice manager role, so combining these roles is not recommended. The program coordinator should report directly to the PD.
Table 5. ACGME Dedicated Administrative Time and Support for Program
Coordinator
| Number of Approved Resident Positions |
Minimum FTE Required for Coordinator Support | Minimum Additional Aggregate FTE Required for Administration of the Program |
| 1-6 | 50% | N/A |
| 7-12 | 70% | N/A |
| 13-20 | 90% | N/A |
| 21-30 | 100% | N/A |
| 31-45 | 100% | 25% |
| 46 or more | 100% | 50% |
RPS recommends the following FTE minimums for coordinator support in a program of excellence:
- 1 to 6 approved resident positions: 0.5/1.0 FTE (Note: For 12 RTPs with strong support from the main program, 0.5 FTE may be sufficient to manage the program. For standalone RTPs, a 1.0 FTE minimum is needed.)
- 7 to 12 approved resident positions: 1.0 FTE
- 13 to 20 approved resident positions: 2.0 FTE
- 21 to 30 approved resident positions: 3.0 FTE
- 31 or more approved resident positions: 4.0 FTE
In addition to a program coordinator, all programs need administrative assistance to support residents and faculty. Duties may include staffing the required Program Evaluation Committee (PEC), the Clinical Competency Committee (CCC), and faculty meetings; coordinating the curriculum, portfolios, and evaluations; and supporting core faculty in their administrative/academic duties. Administrative assistant positions should report to the program coordinator and PD. RPS recommends the following administrative assistant staffing levels relative to program size:
- 12 to 20 total residents: 2.0 administrative assistant FTE
- 21 to 30 total residents: 3.0 or more administrative assistant FTE
- 31 or more total residents: 4.0 or more administrative assistant FTE
Additional administrative assistants may be needed if the program is responsible for helping with non-program functions (e.g., managing medical student, fellowship, or allied health professional training programs), as often occurs with single-site sponsors.
The Family Medicine Program Requirements state the following with regard to other personnel required to effectively administer a residency program: “These may include staff members with clerical skills, project managers, education experts, and staff members to maintain electronic communication for the program. These personnel may support more than one program in more than one discipline.”2
In particular, additional academic support personnel are necessary to fulfill requirements for scholarly productivity. At a minimum, these individuals need basic skills in information retrieval and display. In many organizations, job titles such as analyst are applicable, but individuals with other terminal degrees (e.g., Master of Public Health [MPH]) should be considered. Specific additional training in project management and continuous quality improvement (CQI) is helpful. In larger, multi-residency environments, this expertise can be shared among several residencies coordinated by the GMEC. Scholarly productivity requirements are the same for single programs, making it essential for these programs to have qualified staff to support scholarship.
References
- Kozakowski SM, Eiff MP, Green LA, et al. Five key leadership actions needed to redesign family medicine residencies. J Grad Med Educ. 2015;7(2):187-191.
- Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine. 2023. Accessed January 24, 2024.
- U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Condition of participation: status and location. 42 CFR §485.610. Accessed February 24, 2023..www.ecfr.io/Title-42/ Section-485.610