**3. Building the infrastructure**

#### **3.1 Institutional accreditation and sponsorship**

Per ACGME institutional requirements, "Residency and fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) must function under the ultimate authority and oversight of one Sponsoring Institution" [16]. The ACGME's designated institutional official (DIO) will need to gain initial support from senior leadership and the board of trustees to embark on a new endeavor of starting a residency program at the institution. This support will be integral in successfully establishing the pillars that allow for a sustainable educational vision for the health network.

Hospitals or other health-care entities that seek to start new residencies/fellows have one of two options for sponsorship. Those options include partnering with an existing entity [hospital, medical school, federally qualified health center (FQHC), consortium, etc.] that sponsors ACGME accredited programs, or becoming its own sponsoring institution. There are pros and cons to each approach.

One advantage to partnering with an existing sponsoring institution (SI) is that the new teaching site could start a new residency application process without having to first obtain the ACGME institutional accreditation. Prior to applying for a new residency, the ACGME requires that there is a sponsoring institution to ensure the provision of resources and to foster a healthy learning environment. The mechanics to do this are straightforward; an existing sponsor's program would identify the new teaching hospital as a "participating site." The existing sponsor's program initiates a program letter of agreement to govern the relationship between the two entities unless the new site is under the sponsor's existing governance structure. Residents from the existing sponsor could start rotating at the new participating site, or the new participating site could apply for new residency programs.

This leads to the second advantage of partnering with an existing SI which is that resident rotations to a new participating site gives clinicians and administrators insight into what to expect when they decide to start their own residency programs. Many administrators like the idea of recruiting, training, and retaining their own workforce; however, few are aware of the cost/benefit analysis of such a venture. Thus, gaining experience in training residents without being fully committed is beneficial to all stakeholders.

A third advantage of partnering with an existing SI is that such an academic partnership could lead to a clinical affiliation, especially if the participating site has a strong and robust clinical scope within that given specialty (e.g., orthopedic hospital) and/or provides the sponsor with access to a new patient population (e.g., rural hospital or FQHC). In return, the new participating site receives the sponsorship needed to apply for new residency programs.

One downside of partnering with an existing sponsoring institution is that it can be confusing to the internal and external stakeholders as to who has the "ultimate authority" and "oversight" of the program. Governance structures are different from organization to organization and lines of accountability can be misplaced, misunderstood, or mislabeled. As a result, the question of "who has ultimate authority" can turn a once visionary proposition into a bureaucratic quagmire, especially when there are changes in leadership, organizational objectives, and internal politics. Ambiguity around "ultimate authority" and "oversight" dissipates if a site decides to sponsor its own residency programs and, as it turns out, is one of the advantages of becoming your own sponsoring institution of GME.

Sponsoring institutions are ultimately responsible for ensuring the provision of support systems, resources, and administrative structures and to foster the clinical learning and working environment. The SI's execution of these responsibilities becomes essential when recruiting, training, and retaining the right residents for the community. The SI's governing body has ultimate responsibility for GME activities and must weigh the rewards and risks of sponsoring GME programs. The risks being that the sponsor provides the necessary financial support for the administrative, educational, and clinical resources, including personnel. For example, each sponsoring institution of GME must identify a designated institutional official (DIO) and provide them with sufficient resources, time, salary, and professional development to effectively execute their duties [16]. A sponsoring institution must also ensure compliance with all ACGME institutional requirements while fostering a healthy learning environment, all of which can be additional costs as compared to partnering with the existing sponsor of GME.

Essentially, the decision of whether to partner with an existing sponsor or become one on your own comes down to three factors (the three Fs): faculty, finance, and facilities. Sponsors of GME are required to provide residents a broad, diverse, and in-depth training experience regardless if they own or partner with facilities that provide the clinic scope needed to comply with residency program requirements. The key is that the sponsor has "ultimate authority" and "oversight." Although this can be obtained through affiliation agreements, it is challenging for a sponsor to enforce oversight when they lack control of the training sites. Sponsors of GME are also required to provide a sufficient number of faculties who are interested in, qualified to, and have the time for teaching and supervising residents. Lack of sufficient faculties can have serious consequences for a sponsor as demonstrated in the 2017 case when the emergency medicine residency at Summa Health lost their accreditation and the sponsor was placed on probation for not adequately negotiating for faculty coverage when replacing their ER contract with a new ER group [17]. Lastly, sponsors of GME need to ensure adequate financing of new programs either through grants, operations, or Medicare GME reimbursement, the latter having a unique set of challenges.

*Starting New Accreditation Council for Graduate Medical Education (ACGME) Residency... DOI: http://dx.doi.org/10.5772/intechopen.93617*

#### **3.2 Budget and funding**

A key factor to the success in the budgeting process takes in all start-up costs and projected operating expenses of the new residency program. The bulk of these costs and expenses include resident salaries, faculty stipends for teaching, and administrative personnel, which creates an efficient system of management and program organization. The budgeting process includes accounting for costs such as protected time for program leadership [program director (PD) and associate program director], core faculty, along with faculty stipends that foster continuing education and research. Gathering data from other residency programs which are already in operation can be invaluable in terms of budgeting and forecasting costs for a new residency program start-up. It is pivotal that when starting the new program, the faculty costs are as accurate as possible. This can be achieved by using a fair market value (FMV) estimation when assessing the physician compensation.

The financing of GME programs mainly includes reimbursement from the federal government via Medicare that will, in turn, help sustain a residency program in the long term. For instance, the size of the federal investment in GME—estimated at \$16 billion in 2015 [18], helps to spur the growth of maintenance and conception of residency programs. The reimbursement offered through Medicare can help create profitability of a new residency program. A hospital is categorized into a certain reimbursement rate based on the guidelines set by the Centers for Medicare and Medicaid Services due to location and other factors. "In general, Medicare direct GME payments are calculated by multiplying the hospital's updated Per Resident Amount (PRA) by the weighted number of Full-Time Equivalent (FTE) residents working in all areas of the hospital complex (and at non-provider sites, when applicable), and the hospital's ratio of Medicare inpatient days to total inpatient days" [19]. It is important to consider that if a resident were to spend time in two different hospitals, then each hospital would count the proportion of the FTE time spent at its facility for reimbursement.

To properly plan for the space and facilities needed for a new residency program, it is important to understand the inpatient and outpatient accreditation and certifying board requirements for training. Even if most residents spend the majority of their training within an inpatient setting, it is pivotal that a resident also trains in an outpatient setting due to the high probability that they will practice in an ambulatory and community-based setting [20]. The primary training site will need adequate facilities, patient volume, and faculty for resident education. Evaluating inpatient volume data and the case mix of the hospital ensures a quality and diverse mix of patient cases for residents. Also, analyzing the capacity and forecasted volumes for outpatient sites is critical to ensure ACGME compliance and quality of resident education.

Recently, St. Luke's Hospital - Anderson Campus in Bethlehem, Pennsylvania, built state-of-the-art facilities for new resident education. During this phase of starting up new residency programs, the GME senior leadership incorporated a fullstaffed GME administrative office with on-site private program director and faculty offices, research support resources, residency program coordinators (PCs), and additional conference rooms dedicated to education. The goal of this unique GME space design was to encourage interdisciplinary collaboration between different residency programs to create a dynamic and high-quality educational experience for residents. At the St. Luke's Anderson Campus, the collaborative model allows for more open-door discussions and sharing of ideas between program directors in specialties such as internal medicine, psychiatry, neurology, family medicine, dermatology, and emergency medicine. Additional education facilities include a full simulation center, skills lab, and standardized patient rooms for trainees to learn. Collaborative space design is also another way to model interprofessional collaboration behaviors for trainees.
