Internal Reviews Policy 2016-11-16T12:17:11+00:00

Internal Reviews

PREAMBLE

The Institutional Requirements of the Accreditation Council for Graduate Medical Education (ACGME) require that the Graduate Medical Education Committee (GMEC) be responsible for the regular review of all of residency programs to assess their compliance with the both the Institutional Requirements and Program Requirements of the relevant ACGME review committees. This review must follow a written protocol approved by the GMEC.

POLICY AND PROTOCOL

  1. The Chair of the Graduate Medical Education Committee (GMEC) shall appoint ad hoc committees to conduct internal reviews for each residency program.
  2. The Chair of the GMEC shall designate the ad hoc committee chair.
  3. The composition of the ad hoc committee shall be as follows:
    1. At least one faculty member of the GMEC from departments unrelated to the program undergoing review
    2. At least one resident from departments unrelated to the program undergoing review
    3. One representative from Hospital Administration
    4. The Administrative Director of Medical Education
    5. One or more clinical (voluntary) faculty from departments unrelated to the program undergoing review
  4. The reviews shall be conducted at approximately the midpoint between ACGME program surveys.
  5. The ad hoc committee shall utilize the following materials and data –
    1. Institutional and relevant Program Requirements for the specialties and subspecialties of the ACGME RRC’s from the Essentials of Accredited Residency Programs that are in effect at the time of the review.
    2. Letters of notification from previous ACGME reviews and the program’s response, if any.
    3. Reports from previous internal reviews and the program’s responses to the reviews, if any.
    4. Program letters of agreement for each rotation to sites other than the parent institution (ambulatory care sites and physicians’ offices are exempted unless otherwise stated in the Program Requirements).
    5. Interinstitutional agreements for each major participating institution.
    6. The program’s self-evaluation documents.
    7. The program’s policies and procedures binder (“Bluebook”) – The Bluebook will contain all items a. through f. in this section in addition to other data pertinent to the review.
    8. A completed Program Director’s Instructions and Questionnaire form.
    9. Interviews with the program director, faculty and residents, and others deemed appropriate by the ad hoc committee.
    10. The ad hoc committee may use written resident questionnaires to augment the resident interviews as deemed appropriate.
    11. ACGME WebADS data if available.
  6. The ad hoc committee shall produce a written report that addresses:
    1. The program’s compliance with Institutional and relevant Program Requirements for the specialties and subspecialties of the ACGME RRC’s from the Essentials of Accredited Residency Programs.
    2. The appropriateness of the program’s educational goals.
    3. The adequacy of available educational and financial resources to meet the educational objectives.
    4. The program’s effectiveness in addressing citations from previous ACGME letters of accreditation and previous internal reviews.
    5. Other issues identified that affect the quality of the program.
  7. The ad hoc committee report shall contain recommendations for addressing any concerns identified during the internal review.
  8. The ad hoc committee report shall recommend when a progress report from the program director, if required, should be received by the GMEC.
  9. The ad hoc committee’s report shall be presented to the GMEC for discussion and approval. The GMEC shall make the final determination of the need for a response from the program director. The GMEC shall also determine when the response or corrective action plan (CAP), if required, should be made.
  10. The CAP is then presented to GMEC for review and further recommendations if necessary before approval.

Adopted Oct. 2000; Reviewed July 2003; Revised in Jan. 2006

 

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