Harbor UCLA Medical Center Graduate Medical Education
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INSTITUTIONAL POLICY FOR ASSESSMENT OF COMPLIANCE WITH INSTITUTIONAL REQUIREMENTS


PREAMBLE
As an institution sponsoring programs in graduate medical education, the Harbor-UCLA Medical Center must be in substantial compliance with the Institutional Requirements of the Accreditation Council for Graduate Medical Education (ACGME). This policy is established with the goal of providing the Graduate Medical Education Committee (GMEC) with formal mechanisms for evaluating the institution’s compliance with the Institutional Requirements and identifying areas for improvement.


POLICY
The regular assessment of compliance with ACGME Institutional Requirements shall utilize the following:
  1. The compliance of individual programs with the major areas of the Institutional Requirements shall be assessed annually through the report to the GMEC and the Annual Report Form.
  2. The compliance of individual programs with the Institutional Requirements shall be assessed through a review of the individual program’s Policy and Procedures Binder at the regular internal review of the program.
  3. The compliance of individual programs and the institution with the Institutional Requirements shall be assessed by a periodic written survey of all residents in accredited residencies in the institution.

The written survey of the residents shall ensure the responding resident’s anonymity. It shall include all major aspects of the Institutional Requirements that directly affect residents. The data from the survey shall be compiled by the GMEC Chair and presented to the GMEC for review and for any action required to address identified deficiencies. As the GMEC gains experience with the survey mechanism, the survey form and procedures shall be modified to optimize the return rate and value of the data. The GMEC shall determine the frequency of the periodic written surveys of residents based on the data from the previous survey.

 

Adopted August 2000, Reviewed July 2002, Reviewed August 2004




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