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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 University 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. IV.A.1)

Questionnaires/Interviews

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 policies/procedures.  This 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)

Internal Review

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)

  1. Requirements – Institutional and program

  2. Last Internal Review Summary and progress report if applicable

  3. Letters from the ACGME and progress report if applicable

  4. Program Self-Study Questionnaire

  5. Resident Questionnaire

  6. Summary of interview with teaching faculty

  7. Results of the last Annual GME Survey and work plan to correct ratings if applicable

  8. ACGME Survey results

  1.  Resident manual and website

  2. Program letters of agreement

  3. Written program goals and objectives

  4. Evaluation examples

  5. Required program-specific policies and procedures

  6. Results of duty hour monitoring

  7. Outcomes Project documentation

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:

  1. Assesses the program’s compliance with the program and institutional requirements

  2. Appraises the educational objectives of the program and the effectiveness in meeting them.

  3. Appraises the adequacy of available educational and financial resources.

  4. Effectiveness in addressing areas of non-compliance and concerns in previous ACGME accreditation letters of notification and previous internal reviews

  5. Effectiveness in providing learning experiences that lead to achievement of educational outcomes in the ACGME general competencies

  6. 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.  (Inst. Req. 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.  (Inst. Req. IV.B.2)

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)

Follow up (Inst. Req. IV.B.2)

  1. 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. 

  2. 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.

  3. After receiving the final accreditation letter from the ACGME, the internal review panel is notified including citations/commendations from the ACGME.

(Developed 1988; revision April 1997, revision August 2003, revision May 2006, reviewed October 2007, revised August 2011)

 

Last modified: 08/17/11

 

Office of Graduate Medical Education
University of Arkansas for Medical Sciences
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Little Rock, AR 72205

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