Sponsoring Institution-Based Fellowships: Health Care Administration, Leadership, and Management

The Accreditation Council for Graduate Medical Education (ACGME) recently began to provide accreditation for Sponsoring Institution (SI)-based programs in health care administration, leadership, and management (HALM). ACGME-accredited HALM fellowships contribute to the preparation of a competent physician executive workforce by establishing a formal pathway for health systems-based education that directly relates to physicians’ administrative, managerial, and leadership roles. Ideal candidates for HALM fellowships are physicians seeking structured learning and experience in becoming health care leaders, such as medical directors of inpatient or outpatient health care service lines, chief quality or patient safety officers, chief medical officers, physician practice plan executives, or hospital or health system chief executive officers. The SI-based HALM fellowship is designed so that physicians can gain executive leadership experience with increasing responsibility for patient care and health system leadership and operations (Box).

A growing body of evidence demonstrates that skilled physician executives make positive contributions to various aspects of patient care, including patient safety, health care quality, care management, and systems of care.^1,2  The ACGME’s Clinical Learning Environment Review program has identified substantial opportunities to focus on the patient safety and quality improvement activities of health care organizations within graduate medical education (GME) programs.³  SI-based fellowships in HALM will respond to health system needs by preparing physicians to oversee and enhance the care provided to patients and populations. As they learn to manage care at the organizational level, HALM fellows will gain experience in leading systematic efforts to achieve health equity goals, such as improving health care accessibility and availability, enhancing structural competency in health care settings, eliminating disparities in health care processes and outcomes, and addressing social drivers of health.

HALM fellowship programs will be expected to include experiential and didactic education that integrates medical knowledge with health systems science, allowing fellows to develop their ability to manage patient care operations safely across medical specialties and health care professions. Consistent with the Quadruple Aim,^4,5  SI-based fellowships in HALM will be expected to follow an approach to health care quality and safety that optimizes the improvement of population health, health care consumer experience, and the well-being of health professionals while reducing health care costs.

The HALM program requirements are designed so that physicians can attain competencies in essential aspects related to the administration of complex health care organizations. Under faculty supervision, fellows will be expected to obtain practical experience working with individuals and business units that have broad responsibility for health care, workforce, and public safety in health care settings. Accredited HALM programs may provide fellows with opportunities to develop skills in a range of participating sites that may include, but are not limited to, for-profit and not-for-profit hospitals, community-based centers, and government-operated facilities. Core and elective rotation experiences are expected to be structured in a format that allows for customization based on individualized learning goals.

By combining immersive rotations with longitudinal projects, mentorship, and a structured curriculum, fellowship programs must seek to educate physicians to ensure their competency in leading changes to health care delivery through the effective administration and management of health systems. Under ACGME program requirements for HALM, executive leadership must sign a letter of commitment for the resources needed for fellow education in various health system areas and must provide fellows with workspace in proximity to the offices of the executive team during their fellowship.

Physicians are eligible for recruitment and appointment to a HALM program if they have successfully completed any ACGME-accredited residency program. Fellowship programs will have a duration of 2 years, with a 1-year format available to fellows who hold a relevant master’s degree (eg, master’s in business administration [MBA], medical management [MMM], or health service administration [MHSA or MHA]). HALM program directors design educational and scholarly activities that develop fellows’ practical skills and facilitate the achievement of organizational goals.

Programs are expected to provide didactic education in HALM that is complementary to fellows’ courses of experiential learning. While many educational experiences in the fellowship will require the physical presence of faculty members and fellows, each fellowship program will determine appropriate and effective uses of distance education. Fellows’ engagement in scholarly activity is part of fellowship program design, and fellows will be required to complete at least one capstone project that includes the fellow’s leadership role in managing an organization-wide, interprofessional project as well as identification and implementation of health system improvements.

The program requirements provide accredited programs with the flexibility to meet some standards for experiential and didactic education through fellows’ participation in degree- or certificate-granting activities. In determining the potential role for degree-granting programs (eg, MBA, MHA, MMM) in fellowship programs, SIs should consider the time and cost of obtaining a degree, the rigidity or flexibility of curriculum, the opportunity cost to experiential learning, the difficulty of completing a master’s degree in a 1-year fellowship format, and the variability of focus on physician learning in master’s degree programs. With respect to certificate-granting programs, HALM programs should consider the potential for standardization of program structure; consistency with core knowledge, skills, attitudes, and exposures of the fellowship; and the enhancement of scholarly activity. The integration of degree- or certificate-granting activities with the fellowship program may be facilitated by institutional partnerships with other organizations (eg, business schools).

As standardized GME programs, the fellowships are anticipated to become part of an essential pathway for the promotion and retention of a workforce of US physician leaders over time. While focused on physician leadership, fellowships will offer multidisciplinary education that is aligned with emerging models of interprofessional health care leadership competencies. The fellowship will be designed to facilitate organizations’ development of leadership teams that share a common approach to effective and efficient health systems management.

HALM program requirements facilitate opportunities for fellows to pursue ongoing clinical practice in their specialty or subspecialty while completing the program. Although outside the scope of the fellowship, fellows’ direct provision of care to individual patients may facilitate their continued professional development as physician leaders. This practice opportunity also may serve as a source to generate clinical revenue that may facilitate institutional support for the fellowship. The requirements require time spent in independent practice to not exceed 50% of fellows’ time if they are completing the fellowship in the 24-month format, and 25% if they are completing the 12-month format.

The Institutional Review Committee (IRC) considers new applications for HALM fellowship program accreditation⁶  on a regular basis, and the first 2 HALM fellowship programs (at Cleveland Clinic Foundation and Icahn School of Medicine at Mount Sinai) achieved Initial Accreditation in 2023. This year, the American Board of Medical Specialties (ABMS) approved HALM as a subspecialty,⁷  and HALM fellowship graduates with ABMS member board certification in most specialties will be able to apply for the new HALM certificate. The ACGME SI team looks forward to supporting the IRC and the community of HALM program directors, faculty members, and fellows in shared learning about HALM as fellowship accreditation matures.

The authors acknowledge the commitment of many dedicated experts, volunteers, and staff members who have contributed to the development and implementation of health care administration, leadership, and management accreditation.