Internal Review Protocol
Graduate Medical Education Committee
University of Arkansas
for Medical Sciences College of Medicine
All accredited graduate medical education programs (residency and
fellowship) sponsored by the
of Arkansas for Medical
Sciences College of Medicine undergo an internal review as described in the
ACGME Institutional Requirements.
The internal review is conducted at approximately the midpoint of the
accreditation cycle as documented in the ACGME notification letter. The
mid-point is defined as the date in which the GME Committee reviews and
approves the internal review draft summary.
(Inst. Req. IV.A.2)
The internal review protocol described below is administered through
a series of template letters and reports.
Internal Review Panel
The GMEC Chair selects the Internal Review Panel for each program.
The panel includes: a Program Director (from a program not under
review), a faculty member of the GMEC, a resident member of the Resident
Council (also from a program not under review), an administrator (either the
Associate Dean for GME or GMEC Chair or a past GME Chair), the
Administrative Director for GME and the Educational Coordinator for Internal
Reviews. Other panel members may
be appointed at the discretion of the Chair.
The responsibilities of the panel are to review the Internal Review
Packet (described below), to conduct interviews with the Program Director,
the residents, the program coordinator and other faculty and staff members
of the department, provide a report to the GMEC, and a final report to the
program. (Inst. Req.
The Program Self-Study Questionnaire includes questions about the program
organization & administration, applicant pool, goals and objectives,
curriculum, general competencies, clinical care, research and scholarly
activity, evaluation, program’s improvement plan, supervision, duty hours,
work environment, professionalism and patient safety, transitions of care,
alertness management/fatigue mitigation, clinical responsibilities,
teamwork, previous ACGME & GMEC concerns, and departmental
self-study is sent to the Program Director approximately four months prior
to the internal review along with guidelines about the process for the
upcoming internal review. The
self-study, completed by the Program Director, is due approximately one
month prior to the internal review so that it can be distributed to the
Internal Review Panel.
The Resident Questionnaire includes questions about program organization &
administration, appointment to the program, educational and scholarly
components, duty hours, work environment, supervision, evaluations, support
services, professionalism and patient safety, transitions of care, alertness
management/fatigue mitigation, clinical responsibilities, teamwork, and
previous ACGME & GMEC concerns.
The resident member of the Internal Review panel meets with peer-selected
residents from each level of training in the program and completes the
Resident Questionnaire. This
meeting occurs about one month prior to the internal review meeting so that
all materials may be assembled for the Internal Review Panel.
The program coordinator of the program under review assists in
scheduling the resident meeting.
(Inst. Req. IV.A. 6)
Prior to the internal review, a faculty member of the Internal Review Panel
meets with key teaching faculty and staff of the program under review to
discuss goals and objectives of the program, research opportunities,
clinical and didactic teaching, evaluation and feedback, duty hour issues
and recommendations for improving the program.
The faculty member prepares a summary of the faculty interview.
The program coordinator of the program under review assists in
scheduling the faculty meeting.
(Inst. Req. IV.A. 6)
The Internal Review Packet is distributed to all internal reviewers
approximately two weeks prior to the internal review meeting.
The packet includes:
(Inst. Req. IV.A.5)
Requirements – Institutional and program
Last Internal Review Summary and progress report if applicable
Letters from the ACGME and progress report if applicable
Program Self-Study Questionnaire
Summary of interview with teaching faculty
Results of the last Annual GME Survey and work plan to correct
ratings if applicable
ACGME Survey results
Resident manual and website
Program letters of
goals and objectives
program-specific policies and procedures
Results of duty hour
The Internal Review Panel reviews the packet of information as described above,
completes an Internal Review Checklist, and meets with the program
director/coordinator to discuss the findings.
The internal review:
Assesses the program’s compliance with the program and institutional
Appraises the educational objectives of the program and the effectiveness in
Appraises the adequacy of available educational and financial resources.
Effectiveness in addressing areas of non-compliance and concerns in previous
ACGME accreditation letters of notification and previous internal reviews
Effectiveness in providing learning experiences that lead to achievement of
educational outcomes in the ACGME general competencies
Effectiveness in using evaluation tools and outcome measures to assess a
resident’s level of competence in each of the ACGME general competencies
Effectiveness in linking educational outcomes with program improvement
(Inst. Req. IV.A.4)
Following the meeting, the Chair of the Internal Review Panel, the
Administrative Director for GME, and the Educational Coordinator for Internal
Reviews prepare a draft Summary of Internal Review, which follows a standard
template including topics 1-7 above, and commendations and/or recommendations
for improvement. The draft summary is forwarded to the panel for their input.
If the program has no resident enrolled at the mid-point of the review cycle,
the Internal Review Summary will be annotated as provisional and awaiting
resident input. The resident
interview will occur within the second six month period of the resident’s first
year in the program. The Chair of
the internal review panel and the Administrative Director of GME will determine
whether the panel should be reconvened based on the results of the resident
interview. The Internal Review
Summary will be adjusted to document the resident interview.
If there are no pending actions on the internal review, the Final
Internal Review Summary is sent to the program and is maintained in the Dean’s
Office as part of the program’s record.
(Inst. Req. IV.A.3)
Internal Review Report
The report must contain the name of the program reviewed, the date of the
assigned midpoint and the status of the GMEC’s oversight at that midpoint, names
and titles of the internal review committee members, a brief description of how
the internal review process was conducted, sufficient documentation to
demonstrate a comprehensive review followed the protocol, and a list of the
citations and areas of non-compliance or any concerns or comments from the
previous ACGME accreditation letter of notification with a summary of how the
program and/or institution subsequently addressed each item.
IV.B.1) The Internal Review Subcommittee discusses/approves the draft
Summary of Internal Review. During
times of recess for the subcommittee the GME Executive Committee may
discuss/approve the summary. The
draft is sent to the Program Director, Department Chair and Program Coordinator.
The Program Director must acknowledge receipt of the summary and can
offer corrections or clarification.
Depending on the type and extent of the recommendations, a progress report may
be required from the Program Director. The progress report is reviewed by either
the internal review subcommittee or the GME Executive Committee.
When there are no pending actions on the internal review, the Final Internal
Review Summary is sent to the program and is maintained in the Dean’s Office as
part of the program’s record. The
Sponsoring Institution must submit the most recent internal review report for
each training program as a part of the Institutional Review Document (IRD).
(Inst. Req. IV.B.3)
(Inst. Req. IV.B.2)
In preparation for the ACGME site visit, the GME Office reviews and
critiques the Program Information Form (PIF) at least six weeks prior to the
external site visit.
The Program Director and the Associate Dean for GME receive the notification
letter which may include citations/concerns.
If applicable, the Program Director submits a work plan to the GMEC
to correct the citations. The
Internal Review Subcommittee reviews the work plan and determines if it is
acceptable or needs further modification. The internal review panel assists
with subsequent responses or interim reviews.
After receiving the final accreditation letter from the ACGME, the internal
review panel is notified including citations/commendations from the ACGME.
revision April 1997, revision August 2003, revision May 2006, reviewed October
2007, revised August 2011)