Promotion in Place (PIP) Pilot

A Competency-Based, Time-Variable Model for General Surgery

The Promotion in Place (PIP) Pilot is a national initiative designed to enhance autonomy in residency training and strengthen readiness for independent practice.

Developed through the Blue Ribbon Committee II and endorsed by the ACS, ABS, ACGME, ASA, and APDS, PIP is a specific approach to competency-based, time-variable (CB-TV) surgical education where qualifying residents voluntarily graduate residency early into a period of “sheltered independent” autonomous practice within their department until what would have been their regularly scheduled graduation date.

Promotion in Place is a step toward a future in which surgical training length aligns with demonstrated competency. The pilot will evaluate feasibility, acceptability, patient safety, trainee wellness, competency achievement, and other key outcomes.

Promotion in Place has been piloted in other specialties including Pathology, Plastic Surgery, and OBGYN.

What Is Promotion in Place?

PIP allows qualified senior residents who are deemed competent and practice-ready to voluntarily graduate early and enter a 6-month period of sheltered independence (PIP-SI).

During this period, the individual becomes:

Board-admissible
A fully credentialed attending with billing privileges
Independent from the ACGME training program and no longer listed in ADS

The PIP-SI attending practices within their home institution until what would have been their standard graduation date, gaining authentic attending-level, autonomous experience in a familiar environment with trusted mentors.

Participation is voluntary. All residents in participating programs are assessed using the same competency standards and may be considered for PIP-SI.

How Readiness Is Determined

Practice readiness is determined by the program’s Clinical Competency Committee (CCC) using established competency metrics, including:

ABS case log minimums
ATLS, FLS, and FES certification
Passing the General Surgery Qualifying Exam
Meeting ACGME Milestones standards*
Being deemed practice-ready for all EPAs**
Multisource feedback assessing professionalism, communication, teamwork, and other core competencies

All ABS and ACGME requirements must be completed prior to early graduation.

* Achievement of Milestone levels per PIP guidelines.

**EPAs with fewer than 0.5% of collected assessments are exempted.

Residents who do not meet readiness criteria for early graduation continue in the standard program. Residents who qualify may choose to accept or decline early graduation.

Pilot Timeline

The first PIP-SI cohort will begin in January 2028. Key milestones include:

Expectations of Participating Programs

Participating programs must:

Maintain a robust, competency-based assessment process
Ensure CCC readiness for high-stakes graduation decisions
Complete institutional and regulatory steps for PIP-SI attendings (state license, credentialing, payor enrollment, malpractice coverage)
Design an individualized PIP-SI experience centered on core general surgery practice and enhanced autonomy

PIP-SI attendings undergo the same FPPE monitoring as other new attendings and must remain at their training institution through the standard graduation date for board certification.

Community Building

We are building a community to go through this pilot together. We are looking for your expertise to contribute and understand how PIP will work across programs and institutions. Even if you cannot participate in year one, we welcome interested participants to be part of ongoing discussions throughout the pilot. Email PIP@facs.org to be added to the list.

Read PIP FAQ