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Competencies, Essential Training, and Resources Viewed by Designated Institutional Officials as Important to the Position in Graduate Medical Education

Riesenberg, Lee Ann PhD; Rosenbaum, Paula F. PhD; Stick, Sheldon L. PhD

doi: 10.1097/01.ACM.0000222279.28824.f5
Residents’ Education

Purpose In 1998, the Accreditation Council for Graduate Medical Education (ACGME) added the stipulation that each institution providing graduate medical education (GME) have a Designated Institutional Official (DIO). The authors conducted this study via a cross-sectional survey designed to provide descriptive data on the beliefs held by DIOs regarding required competencies, training and experience, and desired resources for the position.

Method The authors collected data between January 2004 and May 2004 using a multistep process that included a prenotice letter; a survey, cover letter, and stamped return envelope; a thank you/reminder postcard; and a replacement survey with new cover letter and stamped return envelope. Data were summarized using descriptive statistics.

Results Completed surveys were received from 243 of 363 DIOs (66.9%). Eighty-two percent indicated that DIOs should have specified minimum experience or training requirements. Ten competency items were viewed as essential by greater than 50% of respondents, with five items endorsed by over 95% of respondents: professionalism, verbal communication skills, interpersonal skills, leadership skills, and written communications skills. The percentage of responding DIOs who indicated they would be very likely to use resources were as follows: templates for GME policies, contracts, and affiliation agreements (83.1%); DIO-specific training (58.0%); data on DIO demographics (53.9%); DIO job description templates (46.9%); a clear description of DIO versus program director responsibilities (46.1%); and a DIO certification program (32.1%).

Conclusions Designated Institutional Officials supported the idea that there should be minimum experience and requirements and demonstrated remarkable consistency in endorsing essential competencies for the position. DIOs, their respective institutions, the ACGME, and other GME organizations and associations may use the data from this study to develop the role further.

Dr. Riesenberg is director, Medical Education Research and Outcomes, Academic Affairs, Christiana Care Health System, Newark, Delaware.

Dr. Rosenbaum is assistant professor and epidemiologist, Center for Outcomes Research and Evaluation, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York.

Dr. Stick is professor, Educational Administration, University of Nebraska-Lincoln, Lincoln, Nebraska.

Correspondence should be addressed to Dr. Riesenberg, Director of Medical Education Research and Outcomes, Academic Affairs, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718; telephone: (302) 733-1078; e-mail: 〈〉.

In 1998, the Accreditation Council for Graduate Medical Education (ACGME) instituted the requirement that each institution providing graduate medical education (GME) have a Designated Institutional Official (DIO). The requirement stipulates that the DIO is to have the authority and the responsibility for oversight and administration of ACGME-accredited residency programs and is to ensure compliance with ACGME requirements.1 In a previously published report, we demonstrated wide variability in DIO characteristics, roles, and responsibilities.2 We found substantial differences in salaries, titles, reporting titles, responsibilities, time commitment, training, authority, and support for required DIO activities. In addition, 21% of DIOs reported they did not have adequate training for their DIO responsibilities. Even DIOs who believe they possess adequate training might not meet minimum requirements for training and experience or possess essential competencies for the position. To date, there is no resource available that identifies job requirements, professional competencies, or resources for DIOs. This report takes a step toward creating benchmark criteria.

Competencies can be defined as minimal knowledge, skills, attitudes, and behaviors required to perform a specific job. From January 1998 to February 1999, the ACGME went through a year-long review process to identify general competencies to be met through GME training.3 Six general competencies (patient care, medical knowledge, professionalism, systems-based practice, practice-based learning and improvement, and interpersonal and communication skills) were endorsed in February 1999. By July 2001, all ACGME Residency Review Committees and the Institutional Review Committee were to have minimum competency language incorporated into their respective requirements. Review for compliance with the six general competencies began in July 2002.

In recognition of the significance placed on competencies by the ACGME, it seems appropriate to identify essential competencies for individuals charged with the oversight and administration of ACGME-accredited residencies. This investigation identified the views of persons currently serving as DIOs with respect to the minimum training required for performing effectively in the role; the kinds of experience(s) deemed necessary for providing a professional base of knowledge that would enable appropriate job performance; the nature and degree of additional training viewed as beneficial for success as a DIO; professional competencies deemed essential to the position; institutional involvement in the form of committee service believed helpful; and resources considered necessary for implementing regulations and accomplishing the requisite tasks.

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Research design and study population.

This cross-sectional study included a self-administered survey mailed to all 363 DIOs listed by the ACGME in December 2003. The survey was designed to obtain descriptive data about DIOs and their work, so as to begin the process of structuring the DIO position and its associated responsibilities. In addition, these data could be used to develop DIO training materials to improve job performance. The study was reviewed and approved by the University of Nebraska-Lincoln institutional review board.

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Survey instrument.

Prior to initiation of the current study, the Association for Hospital Medical Education (AHME) sponsored a pilot survey to assess the importance of the DIO role in GME.4 The pilot survey included 16 primarily open-ended questions related to the DIO position. Surveys were completed and returned by 122 of 400 DIOs (30.5%) listed by the ACGME at the time. Using the open-ended responses obtained from the pilot study, a 97-item survey was designed consisting mostly of fixed choice questions. The new survey was reviewed for face and content validity by experts at the AHME and selected other medical education professionals. More detail about the methods can be obtained from our previous publication on the characteristics, roles, and responsibilities of the DIO.2

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Survey mailings.

For the current study, data were collected between January 2004 and May 2004. We first sent current DIOs a prenotice letter. A week later, we mailed a cover letter and survey with a self-addressed, stamped return envelope. Seven days later a thank you/reminder postcard was sent, followed in two weeks by a replacement survey with new cover letter and self-addressed, stamped return envelope, which we sent to those who had not yet responded.

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Development of competency items.

In order to determine possible DIO competencies, we conducted a content analysis of the open-ended responses to the pilot study questions related to DIOs’ roles and responsibilities. Our objective was to identify competencies deemed important by persons working in the position of DIO. For instance, we interpreted responses noting leadership or financial management as DIO roles as possibly important competencies. Subsequent to those analyses, we reviewed the six ACGME general competencies for possible additions.5 Medical knowledge, interpersonal skills, verbal communication skills, written communications skills, and professionalism were added from the full description of the ACGME general competencies. In this way, we generated a list of 13 DIO competencies. The list was reviewed by content experts and determined to be relevant and to have face validity. All competency items were grouped together on the current survey and scored using a three-point scale, where 1 = not essential, 2 = neutral, and 3 = essential.

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Data analysis.

We entered all data into SPSS® Version 11.5 statistical software (SPSS Inc., Chicago, IL) and analyzed it using descriptive statistics. We summarized categorical variables using frequencies and summarized scale responses with frequencies, means, and standard deviations (SDs).

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We received completed surveys from 243 of 363 DIOs (66.9%). Nearly three quarters of respondents were male and physicians, 91% reported being white, and 75% were over 50 years of age. Additional characteristics and roles and responsibilities of respondents can be found in our previous report.2

The majority of respondents (82.3%) indicated their belief that there should be minimum experience or training requirements for DIOs. As noted in Table 1, experience working in graduate medical education was identified as most important (65.5%). Approximately half of the respondents reported having specific additional training that helped them meet their DIO responsibilities. Of those 120 DIOs, a majority (80%) indicated that attendance at specific meetings, workshops, and conferences was especially helpful (see Table 2).

Table 1

Table 1

Table 2

Table 2

Most DIOs reported serving on important institutional committees (89.7%) other than the Graduate Medical Education Committee (GMEC). Of those respondents, the majority (91.3%) indicated such involvement seemed to help with accomplishing DIO responsibilities (see Table 3).

Table 3

Table 3

We introduced the idea of competencies with the following statement in the survey: “In light of the current focus on competencies, it is important to know what competencies you see as important for a successful DIO.” Over 95% of respondents selected five competency items as essential from the list of 13 that we provided: professionalism, verbal communication skills, interpersonal skills, leadership skills, and written communications skills (see Table 4). In addition, we gave respondents the option to add to our list in a comment section. We then reviewed all respondents’ comments on competencies for emerging themes; few respondents wrote in additional competencies, none of which was listed more than once. Several commented that the list seemed complete as presented.

Table 4

Table 4

The most frequent comments were: required competencies probably would vary according to an organization’s structure; having good support staff was essential if a DIO did not possess a particular competency; and a DIO must be viewed as a leader, expert, and role model. In addition, two respondents’ specific comments seemed noteworthy: “[a] DIO has to be a jack of all trades and a master of many” and “when you don’t know, know who [sic] to ask.”

We asked respondents about the likelihood of their using five specific resources (see Table 5). The majority (83.1%) indicated they would be very likely to use resources such as templates for GME policies, contracts, and affiliation agreements. Over 50% reported that they were very likely to attend DIO-specific training and would use data on DIO demographics. About one third of respondents (32.1%) indicated they would be very likely to attend a DIO certification program, but, of note, several wrote in that they would not like to see such a program mandated. Respondents listed no additional resources in the comments section.

Table 5

Table 5

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This cross-sectional survey of DIOs had a 66.9% return rate and likely is representative of the views held by current DIOs at the time the survey was completed. The survey responses identified and defined DIOs’ perceptions of minimum DIO experience and training requirements, additional training desired by persons fulfilling the role, committee service viewed as helpful for reinforcing and enhancing the image of an institution’s DIO, professional competencies believed to be essential for successful job performance, and resources DIOs were most likely to use and need for accomplishing their jobs as expected.

Our previous report revealed considerable variability in DIO salaries, titles, reporting titles, responsibilities, time commitment, training, authority, and support. That knowledge led us to conclude that the DIO position was underdeveloped and in need of immediate attention.2 The findings reported here can be used by institutions providing GME, by DIOs, and by other medical education leaders to make informed decisions about how better to develop the DIO position. It appears that DIOs would welcome some standardization of the position. Eighty-two percent of respondents agreed that there should be minimum experience and training requirements set for DIOs. This is especially striking since no respondent suggested that current DIOs should be exempt from the new criteria on the basis of their prior appointment to the position.

The 243 respondents evidenced remarkable agreement on the competencies they deemed essential to success as a DIO. Few wrote in additional competency items, none of these write-ins was listed more than once, and several respondents commented that the list we provided seemed complete. Consequently, it seems reasonable to conclude that the 13 items do cover the most important competencies. Only three of 13 competency items were viewed by less than 50% of respondents as essential: medical knowledge, visa knowledge (immigration requirements), and legal expertise. While just under half endorsed medical knowledge as an essential competency, 59% of all 243 respondents believed experience working in undergraduate or graduate medical education should be a minimum requirement for the position. It appears that experience in a medical education setting is relatively more important to DIOs than medical knowledge. Far fewer respondents endorsed visa knowledge and legal expertise as essential competencies. The justification for this could be that competent support staff can fulfill these responsibilities.

The remaining 10 competency items were viewed as essential by more than 50% of respondents, with five items endorsed by at least 97%: professionalism, verbal communication skills, interpersonal skills, leadership skills, and written communication skills. In addition, approximately one quarter of those listing especially helpful additional training wrote in leadership training, lending more support for the importance of leadership competence. The nature of such training was not addressed, but is a justifiable area for additional study.

Establishing benchmark professional training and experience for persons aspiring to and currently filling a DIO position should be done as soon as possible. The DIO holds a critically important position within ACGME-accredited GME programs. The 13 competencies should become aspects of specific job descriptions, both for persons currently in such roles and for efforts to recruit new DIOs. A final recommendation, and probably one of urgency, is that DIOs and their respective institutions should consider the competencies and minimum training and experience identified here as areas for continuous improvement and targeted training for existing DIOs.

In our previous publication, we noted that 72% of DIOs reported confusion and/or overlap between the DIO and program director roles within their institutions.2 In addition, we report here that nearly half of the respondents indicated they were very likely to use a clear description of DIO versus program director responsibilities. Together, this information supports the need for a clear delineation between the two positions. Doing so should improve operations of medical training programs, enhance the effectiveness of residency training programs, and provide assurances to the public and accrediting agencies that respective institutions are earnest in their commitment to ensuring high-quality physician training.

Residency Review Committees address basic minimum qualifications and responsibilities for program directors. The information that we gathered may be similarly useful to Institutional Review Committee members, particularly in their role of developing and revising institutional requirements, which include the DIO role. Further clarification within the institutional requirements would, in fact, help to distinguish and clarify the role of DIO from that of program director.

Almost half of respondents in this study answered affirmatively when asked if they had received additional training that had helped them meet their DIO responsibilities. Of those, 80% reported attendance at meetings, workshops, or conferences as beneficial. Since this was a write-in item, it is possible that more DIOs would have endorsed specific additional training had it been included in the list we provided. Future research should explore the development of such options and probably approach the task by using either a Delphi study or focus groups to discover the kinds of activities deemed especially useful.

We asked respondents if they served on important institutional committees (other than the Graduate Medical Education Committee) where their involvement helped with the DIO role, and, if so, to list these committees. A majority of respondents reported that service on institutional committees helped with their DIO role, but the list of committees generated was based on write-in responses. It is possible that more committee service would have been identified if the participants had been presented with a list of choices with accompanying explanations rather than an open-ended comment section. Future research could consider the types and nature of committee service and explore how such activities are viewed as enhancing DIOs’ performance.

Since our research demonstrated the DIO role was underdeveloped, and there were issues that diluted or interfered with DIO authority,2 carefully selected committee service may be a means to confront and mitigate such concerns. In addition to being an opportunity for accumulating personal service points, committee service would provide valuable face time for a DIO to explain his or her role and its importance to the institution with regard to ACGME accreditation. Moreover, committee service provides a forum for interacting with a broad spectrum of professionals. In addition, strategically selected committee service might provide a venue for educating others about the importance of medical education activities within the institution and for recruiting other professionals to provide input into GME activities. A final bonus derived from such exposure would be to facilitate the process of acquiring other professionals to serve on GME committees, subcommittees, task forces, and internal review and curriculum and evaluation development committees.

Fifty-eight percent of respondents indicated that they were very likely to attend DIO-specific training. In addition, respondents noted resources that could be developed to assist DIOs. These included GME-specific templates, such as policies, contracts, and affiliations agreements. Other resources deemed helpful by DIOs included job description templates and publication of DIO demographics, such as salaries, degrees, titles, and responsibilities. Organizations and associations interested in the success of GME could use this information to guide resource development.

We believe the generalizability of our study to the broader DIO population is strong, because two thirds of the DIOs we surveyed responded to our questionnaire. The integrity of responses is only as strong as the honesty of respondents; however, we assume that the DIOs who responded had a vested interest in the research findings and likely provided honest answers. In addition, we provided numerous opportunities within the survey instrument for respondents to make comments, thus concerns about the completeness of this survey are mitigated.

One possible limitation of this study is that some individuals identified by the ACGME as the DIO delegated responsibilities of their job to another individual. In spite of this, identified DIOs would have answered questions from their perspectives, which are valid study data. For this reason, we do not consider this a major limitation of the study.

In summary, this article describes minimum requirements, additional training desired, ancillary activities (committee service) viewed as helpful, competencies believed to be essential, and resources DIOs are likely to use. DIOs and their institutions, the ACGME, and other organizations invested in GME can use our findings to better develop the role with the ultimate goal of improving GME outcomes. Future research should assess the effect of efforts at DIO role development on important outcomes, which might include the success of the DIO as measured by internal markers, the accreditation status of programs under the oversight of the DIO, and DIO job satisfaction. The DIO holds an increasingly important position in GME. Better-prepared DIOs could provide the necessary leadership and direction for improving future physician education.

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The authors thank Guthrie/Robert Packer Hospital for partial funding in the form of author time (LR) and some supplies for this research, as well as all of the DIOs who completed the survey.

This Research Report is based in part on Riesenberg L. The characteristics of the designated institutional official position in graduate medical education [dissertation]. Lincoln, NE: University of Nebraska, 2004.

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1 Accreditation Council for Graduate Medical Education, Institutional Requirements 〈〉. Accessed 27 January 2006.
2 Riesenberg LA, Rosenbaum P, Stick SL. Characteristics, roles, and responsibilities of the designated institutional official (DIO) position in graduate medical education. Acad Med. 2006;81:8–16.
3 Accreditation Council for Graduate Medical Education Outcome Project, Frequently Asked Questions (FAQ) 〈〉. Accessed 27 January 2006.
4 Riesenberg L. Editor’s educational corner: Designated Institutional Official (DIO). AHME News. Summer 2001:2.
5 Accreditation Council for Graduate Medical Education, Outcomes Project, General Competencies, full version 〈〉. Accessed 27 January 2006.
© 2006 Association of American Medical Colleges