Internal Review Protocol
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Internal Reviews of Graduate Medical Education Programs
Intent:
The Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirement requires a regular review of all residency programs to access their compliance with both the Institutional Requirements and the Program Requirements of the relevant ACGME Residency Review Committee (RRC).
Policy Statement:
The Graduate Medical Education Committee (GMEC) will appoint an Internal Review Subcommittee of the GMEC (IRS of the GMEC). This committee will perform a review of each program between RRC site visits in accordance with this written protocol.
Description:
- A subcommittee of the GMEC is appointed by the committee. The subcommittee will consist of GMEC members, residents from several residency programs, faculty members not on the GMEC committee, hospital administrators and the manager of GME. From time to time, other individuals may be appointed at the discretion of the Chair, GMEC. The committee will select a chair from among its members.
- The Chair of the subcommittee initiates the review process by sending a letter to the program director informing the director of the anticipated RRC site visit date and the upcoming institutional internal review process. Included with the letter are the following: Graduate Medical Education Information-Review and Accreditation of GME Programs, Essentials of Accredited Residencies in GME, Institutional Requirements, Common Program Requirements, Program Requirements, Last Letter of Accreditation from the ACGME, Last Internal Review Summary, Institutional Internal Review Protocol, ACGME Article-"Preparing for the ACGME Accreditation Site Visit", ACGME Outcome Project-General Competencies, ACGME Outcome Project-Toolbox of Assessment Methods, Sponsoring Institution's Internal Review Document, Institution's Core Competencies Checklist. The program director is requested to complete the Internal Review Document and Core Competencies Checklist and return it along with adequate supporting documentation to the Manager of Graduate Medical Education. In addition, a "GME Internal Review Resident Questionnaire" (Appendix A (pdf)) is sent to all residents in a program about to undergo an internal review. The questionnaire is totally anonymous, and provides a way for all residents in the program to express concerns in a confidential and protected manner.
- A program is selected for review half way between RRC site visits. Programs are also selected for review based on their last accreditation status. If a program receives an unfavorable status and/or has several citations, the program may be reviewed more frequently to review the program's progress in meeting the ACGME requirements.
- Upon receipt of the Program's completed "Internal Review Document and Core Competencies Checklist" and the supporting documentation in the Graduate Medical Education Office, the Manager of GME distributes the Program's documentation to each member of the subcommittee. In addition, to the Program's documentation, each member of the subcommittee is given:
- Institutional, Common Program Requirements, Program Requirements;
- Letters of accreditation from previous ACGME reviews, progress reports sent to the ACGME and all follow-up correspondence;
- Reports from previous internal reviews of the program; and
- Any pertinent program correspondence, which has transpired since the last RRC site visit.
- A meeting is arranged between members of the subcommittee not involved with the program being reviewed and the Program Director, faculty, and residents (peer selected from each level of training in the program). The subcommittee meets with the resident(s) without the program director being present to ensure confidentiality and free expression by the resident(s). The subcommittee may also interview individuals from outside the program if deemed appropriate.
- While assessing the residency program's compliance with each of the Institutional, Common Program Requirements, and Program Requirements, the subcommittee also appraises:
- The educational objectives of each program;
- The adequacy of available educational and financial resources to support the program;
- The effectiveness of each program in meeting its objectives; and
- The effectiveness in addressing citations from previous ACGME letters of accreditation and previous internal reviews.
- The 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 as defined in section II.B., and in the Program Requirements; and,
- The effectiveness of each program in implementing a process that links educational outcomes with program improvement.
- Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
- Demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and be able to apply this knowledge to patient care
- Utilize practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
- Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals
- Demonstrate professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
- Understand system-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value.
- Whether each program has defined, in accordance with the relevant Program Requirements, the specific knowledge, skills, and attitudes required and provides educational experiences for the residents to demonstrate competencies in the following areas: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice.
- Whether each program has developed specialty appropriate evaluation tools to ensure that the residents demonstrate competence in each of the six areas.
- Once #1 and #2 are in place for a period of time, whether the program has developed and utilized specialty appropriate and reliable outcome measures for each of the general competencies.
- Whether the program develops and implements a process that links these educational outcomes with program quality improvement and development.
- By interviewing residents in the program whether residents agree that the competencies are being systematically taught, how these competencies are evaluated and whether resident assessment of this process is in accordance with the descriptions provided by the program director.
- The Manager of GME prepares a report in accordance with the Institutional Requirements and forwards a draft copy to each member of the subcommittee. Each member is asked to review the document and return it with any noted comments to the GME office. Once all comments have been received, a final overview document is created and forwarded to the GMEC for approval. If it is found that the program needs to address issues identified during the internal review the program is request to address these issues in writing to the IRS of GMEC. All follow-up responses are reported to the GMEC.
- The summary and action of the GMEC is forwarded to the DIO, Senior Associate Dean for Education, departmental Chair, Program Director, Dean College of Medicine and to the CEO of the participating hospitals.
The six general competencies are defined by the ACGME as the ability to:
In order to demonstrate and assure each program's compliance with the ACGME Competencies, the Internal Review Subcommittee will specifically determine:
Last Review: Institutional Committee for Graduate Medical Education June 12, 2003
