Preventing Today's GME Disasters: Lessons Learned From a Failed Contract Renewal

The rapidly changing health care delivery system exposes vulnerabilities in graduate medical education (GME) that must be understood and addressed. Hospital and provider group mergers and acquisitions that involve changes in leadership and GME program faculty can alter institutional cultures and disrupt patient care and education. In the most egregious cases, loss of program accreditation can occur.

We experienced a “disaster” when a contract dispute with our emergency medicine (EM) staffing group culminated in nonrenewal. This group provided the faculty for our EM residency program, and the nonrenewal resulted in a complete and abrupt change in the educational leadership and faculty for the program. As a result, the accreditation of our long-standing EM program was withdrawn, and the sponsoring institution (SI) was given Probationary Accreditation status.

This experience and the lessons we learned led to a revision of our GME Disaster or Interruption in Patient Care Policy, a comprehensive restructuring of our institutional contracting process, and the linking of the policy and the contracting process that we hope will prevent a similar situation in the future (provided as online supplemental material).

Summa Health sponsors 19 GME programs, 15 of which are Accreditation Council for Graduate Medical Education (ACGME) accredited residency and fellowship programs. Most of the educational and clinical services for these programs are provided by Summa Health's employed physician group. However, our EM services are provided by a contracted third-party vendor. These services include the staffing of our 5 emergency departments and, from 1982 to 2017, providing faculty for our EM residency program.

This clinical and educational arrangement was successful for 36 years. However, in December 2016, various factors led to an inability to reach mutually agreeable contract terms. Thus, the contract expired at midnight on December 31, 2016, and a new contracted EM management company assumed patient care at our 5 emergency departments and provided the educational leadership and faculty for our EM residency program on January 1, 2017.

Looking to our GME Disaster Policy for guidance, we realized it was inadequate. The policy did not help us prevent such a disaster, nor did it help us mitigate the damage created by such a disaster. Accreditation of our EM program was withdrawn July 1, 2017, and the SI was placed on probation. Ultimately, the accreditation status of the SI was changed to Continued Accreditation in October 2017.

The 2 significant policy and process changes that were made as a result of this crisis were an overhauled institutional contracting process and a revised GME Disaster Policy.

Across the institution, every contract now has an accountable owner who is charged with oversight of the renewal process. The vice president of medical education/designated institutional official (DIO) is the accountable owner for contracts that have significant influence on the education of our trainees (ie, groups that serve as residency and fellowship faculty and those providing significant education and clinical supervision of trainees). In addition, the timeline for the renewal process has been revised, allowing all parties the time necessary to consider the contract terms, evaluate the services provided, reach new terms, and, if unable to reach agreement, to make alternative plans to minimize any impact on education.

The changes in our GME Disaster Policy were guided by 2 questions:

1. What steps could we have taken to prevent the potential loss of accreditation due to business contracting?

2. How could we have mitigated the negative impact on our learners if we were unable to prevent this contract-related disaster?

Our first step in the revision process was to clarify our definition of a disaster. This became “an event or set of events that either prevents or significantly disrupts the system's ability to provide resident education in one or more of its GME programs.” The ACGME Policy and Procedures to Address Extraordinary Circumstances (Section 21.00) defines extraordinary circumstances as “abrupt hospital closures, natural disasters, or a catastrophic loss of funding.”¹  We now add “catastrophic loss of faculty” to this definition. Responsibilities of the GME Committee (GMEC) members were also clarified so that individuals understood that all GMEC members had the “authority and responsibility” to call an emergency GMEC meeting to discuss a potential impending disaster. Next, the procedure outlining the disaster action steps was made explicit. A significant addition was the Prevention section, which links the GME Disaster Policy to our new contracting process. That renewal process begins at least 12 months prior to the renewal date, and if mutually agreeable terms have not been met at the 6-month mark, the GME Disaster Policy is enacted. Lastly, we cataloged all clinical and education service agreements and contracts that involved third-party groups. Each quarter, the DIO reviews the status of each agreement at a GMEC meeting to provide the committee oversight of this aspect of the learning environment.

Our revised GME Disaster Policy was called to action on October 13, 2017, when a fire occurred at one of our hospitals, the base site for 2 of our programs. A member of the GMEC called an emergency meeting to review the situation and discuss options for continuity of resident education if repairs took longer than expected. Per policy, an ad hoc GMEC Disaster Subcommittee was formed to oversee the process. The hospital was reopened 10 days later with minimal disruption to education, and our alternative plans, while outlined, never needed to be executed. The program directors reported increased comfort with handling the disruption, which they attributed to the active oversight of the GMEC.

Sponsoring institutions typically think of natural disasters that interrupt patient care and resident and fellow education; however, in today's health care environment, we are beginning to see business transactions interrupting the growth and development of young physicians. These interruptions can be relatively minor, as in a change in a participating site, or disastrous, as in the loss of a program's entire faculty. As institutions that sponsor GME, we must have policies and processes in place that prevent, or, at a minimum, mitigate the damage from educational disasters that occur as a result of such business transactions. We must maintain vigilance about monitoring this aspect of the learning environment just as we monitor work hours, wellness, care transitions, patient safety, care quality, and supervision. The GMEC must own its role in overseeing the clinical and learning environment, and the institutional leadership, starting with the governing body, must empower the GMEC in this role. This final point is one that cannot be overstated.

This experience underscores the role that the DIO should play as a leader in the SI. Strong consideration should be given to including the DIO as a member of the executive team. At a minimum, he or she must have direct and regular access to executive leadership.

In summary, a failed contract renewal exposed a vulnerability in our system that led to the loss of accreditation of our EM residency program. Our new GME Disaster Policy and contract renewal process give us the tools to avoid an educational disaster in the future and to mitigate damage if a business transaction involves GME. By sharing our lessons learned, we hope to help other SIs prepare for, and hopefully prevent, “disasters” they might face.