Internal Reviews are regular reviews of all Accreditation Council for Graduate Medical Education (ACGME) accredited programs, including subspecialty programs, performed by the sponsoring institution under the oversight of the Graduate Medical Education Committee (GMEC), to assess each program's compliance with the Institutional Requirements and the Program Requirements of the ACGME Residency Review Committees.
View Internal Review Policy
How are Reviews Coordinated?
Gay Meek in the GME Office serves as the Internal Review Coordinator and assists the ad hoc committee by facilitating communications between the committee and the program under review, reserving a meeting location, and disseminating forms and other information.
Who Conducts Reviews?
The review is conducted by a body designated by the GMEC including:
When are Reviews Conducted?
- Ad hoc committee chair (a Program Director) – appointed by the GMEC Chair
- One clinical faculty member from a department unrelated to the program undergoing review – selected by the ad hoc committee chair
- At least one resident from a department unrelated to the program undergoing review – selected by the ad hoc committee chair
- One representative from Hospital Administration
- The Administrative Director of Medical Education
Reviews are conducted at approximately the midpoint between the ACGME program surveys.
How long is the Review?
The meeting between the committee and the Program Director of the program being reviewed lasts approximately one hour and is followed by an additional hour in which the committee meets with the program’s housestaff.
What is Assessed During Reviews?
The Internal Review process assesses the residency program's compliance with each of the program standards and also appraises the following:
Materials and Data Used During Reviews
- Educational objectives of each program
- Adequacy of available educational and financial resources to meet these objectives
- Effectiveness of each program in meeting its objectives
- Effectiveness in addressing citations from previous ACGME letters of accreditation and previous internal reviews
- Use of dependable measures to assess residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice
- Effectiveness of each program in implementing a process that links educational outcomes with program improvement
Reports/Corrective Action Plans
- The program’s policies and procedures manual (Blue Book)
- The program’s objectives
- The ACGME notification letters and the program’s written responses
- The previous internal reviews and the program’s responses
- Institutional and Program Requirements for the specialties and subspecialties of the ACGME Residency Review Committees (RRCs) from the Essentials of Accredited Residency Programs
- Program Director's Instructions and Questionnaire Form
- Program letters of agreement for each rotation to sites other than the parent institution
- Inter-institutional agreements for each major participating institution
- The program’s self-evaluation documents
- Interviews with the program director, faculty and residents, and others deemed appropriate by the ad hoc committee
- The ad hoc committee may use written resident questionnaires to augment the resident interviews as deemed appropriate
- ACGME WebADS data if available
A written report of each internal review is presented to the GMEC for discussion and approval. Program Directors and Departmental Chairs receive copies of the final internal review report along with the GMEC's recommendation. 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), should be due. If required, the CAP is then presented to the GMEC for review and further recommendations before approval.
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