Internal Reviews Protocol
Internal Review Process University of Utah Health Sciences Center 2009
An Internal Review sub-committee of the main Graduate Medical Education Committee volunteers, or is appointed, for each individual Internal Review. The sub-committee remains the same through the duration of a single Internal Review, but sub-committee composition may be slightly different for each subsequent Internal Review. Each sub-committee is composed of faculty members and residents from programs other than the one being reviewed, along with the DIO (who is also the Director of Graduate Medical Education), the Chair of the Graduate Medical Education Committee, and the Project Administrator for Graduate Medical Education. Thus, faculty, administration, and residents are represented on the Internal Review sub-committee.
Documentation from the program and GME office files used in the review include:
- The most recent ACGME letter of report
- The most recent previous internal review
- The most recent Program Information Form from previous site visit, updated to the midpoint of their cycle
- ACGME program requirements (both common and program-specific)
- Written educational goals and objectives for each rotation
- Current written copies of curriculum, including goals and objectives and ACGME’s general competencies
- Current written copies of evaluation forms, including evaluation of residents’ competence in ACGME’s general competencies:
- Faculty evaluating residents
- Residents evaluating faculty
- Residents evaluating program
- Any other evaluation tools or instruments designed to assess resident competence in the various areas (components of 360 degree evaluations)
- Evidence that there are regular evaluations of faculty, residents, and program
- Progress reports from previous review cycle requested by ACGME, if any
- Progress on general competencies in didactics, clinical experiences, and evaluation
- Evidence of the dependability of the program’s six competencies measures
- Work hours documentation
- Program web sites
- Annual resident survey, a confidential, web-based survey conducted by GME office
- Program policies, including work hours, moonlighting and supervision
- Information about local and national demand for program's graduates
- Boards pass rates
- Information about program funding
- Program letters of agreement for all sites
- Program letter of support
- Information about training in patient safety
- Information about training in sleep deprivation
- Recent ACGME surveys, if available
The internal review sub-committee reviews the previous ACGME letter of report and most recent previous internal review, noting the current status of any citations. Any progress report requested by ACGME is reviewed. All of the tools itemized above are used to assess the effectiveness of any progress or process the program has implemented. Interviews of the program director, the division chief or department chair, the faculty, and (peer-selected) residents are also tools used to appraise the effectiveness of progress.
Based on all the input from the Internal Review sub-committee, the Education Coordinator for Graduate Medical Education writes a draft internal review to present to the sub-committee. With the sub-committee’s input, a final draft is presented to the full GME Committee for comments and approval. After receiving the approval of the GME Committee, the internal review report is finalized and transmitted to the program director and program chair by the Director of GME (DIO).
When the internal review draft is presented to the GME Committee for approval, excessive concerns or failure to adequately respond to previous ACGME citations or concerns may prompt extensive discussion and follow-up actions. Follow-up actions may include the following:
- A request that the program director appear before the GME Committee with an action plan for improvement
- A request that the program director meet with the GME Executive Committee to discuss concerns and an action plan
- A meeting between the program director and the Chair of GMEC, including other key individuals such as the program chair, division chief, key faculty members, etc., who may be instrumental in bringing about a resolution of concerns
- A request that the program director submit a progress report to the DIO prior to sending to the RRC
- “Rounding” on the program by the DIO and Chair of the GMEC (in-person followup visit to check progress on deficiencies, typically six months after the internal review)
Since the ACGME now clearly states the date of a program's midpoint on the program's letter of report, and since it has very stringent requirements about performing the internal review at the midpoint, requests for extensions will not be entertained.
Note: Not all reviews will have all sections in the written report. Some of the above categories may be covered under Accreditation History, Faculty Comments, Resident Comments, Evaluation of Program, or Recommendations sections.
The Internal Review subcommittee will revise the draft report as necessary.
This report will be presented to the GME Committee for further comment and eventual approval.
The approved report will be sent to the program director by the Director of GME with recommendations and instructions for followup to correct deficiencies.
The program director responds and/or reports progress to the GME Committee, and the Director of GME (DIO) monitors the program's responses periodically.
