Resident and Fellow Policy Manual

Appendix 1 - Internal Reviews for Residencies and Fellowships:

The Internal Review is a process to comply with the ACGME Institutional Requirement, stating that the Graduate Medical Education Committee (GMEC) is responsible for regular review of all ACGME-accredited programs, including subspecialty programs.  These reviews are to assess the program's compliance with both the Institutional Requirements and the Program Requirements of the relevant ACGME Residency Review Committees.

The Office for Graduate Medical Education will coordinate the scheduling of these Internal Reviews.  The Review must be conducted and should be held mid-way between External ACGME Reviews.  The Review Committee must include Faculty, Residents, and Administrators from within the Institution but from programs other than the one being reviewed.  The Associate Dean for Graduate Medical Education will assign a Residency or Fellowship Program Director to chair the Internal Review Committee.  The Chair is required to bring a Resident/Fellow from his/her Program to be a member of the Committee.  The Associate Dean for Graduate Medical Education will appoint additional individuals to participate as members of the Committee as appropriate.

The Program will be asked to prepare documentation that follows a written protocol approved by the GME Committee.  An Instruction Guide has been prepared to facilitate the process and is available on the GME web site http://www.urmc.rochester.edu/smd/gme/directors/documents.cfm

(Program Directors and Coordinators/Important Documents).  Five copies of the completed internal review document must be returned to the GME Office at least two weeks before the review.

A guide has also been prepared for the Chair of the Review Committee.  This guide can also be found on the GME web site under Information for Program Directors / Coordinators.  The Review Committee will assess Residency Program's compliance with published ACGME Program requirements.  Focus will be placed on how the Program has addressed citations from both RRC letters and previous Internal Reviews.  The program's educational objectives, its effectiveness in meeting these objectives and the educational and financial resources available will also be evaluated.  The Committee will examine the program's use of dependable measures to assess Resident competency in key areas as defined by the ACGME program requirements.  Attention will also be paid to assessing the effectiveness of the Program in implementing a process linking educational outcomes with Program improvement. The Materials and Data for the Internal Review Committee to review must include the following:

• ACGME institutional, common, and program specific requirements
• Previous ACGME / RRC Letters of Accreditation
• Report from the previous Internal Review Committee
• Information submitted by the program per the institution's internal review manual
• Program policies regarding trainee selection, appoint/reappointment, promotion, dismissal, supervision, work hours, moonlighting, and evaluation
• Competency assessment; a listing of instruction and assessment methods used for each of the competencies
• Outcomes improvement; a description of the process used by the program to link educational outcomes with program improvement
• Privileging; a description of the process to determine the level of resident/fellow supervision needed for various patient conditions/procedures and how they are privileged to provide care under general or direct supervision
• Affiliation agreements; a current copy of any agreements with training sites outside of Strong Memorial Hospital should a program's residents/fellows spending time at a non-SMH facility
• ACGME Business Associate Agreements as required by HIPAA for all health care entities where residents/fellows have access to protected health information.
• The results summary of the resident survey from The GME Toolkit.  This applies to core programs with five or more trainees.

The Internal Review Committee must conduct interviews in the program and other individuals whose input would be helpful to the review as deemed appropriate by the Committee.

While assessing the Residency Program's compliance with each of the ACGME Program Requirements, the Review should also appraise the following:

• Documented evidence of a curriculum with goals and objectives.
• The effectiveness of the Program in meeting its objectives.
• Evidence of developing and using dependable measures to assess a Resident's competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practice as defined in the Institutional and Program Requirements.
• The effectiveness of the Program in implementing a process that links educational outcomes with program improvement.
• The adequacy of available educational and financial resources to support the program.
• The effectiveness of the Program in addressing citations from previous ACGME letters of accreditation and previous Internal Reviews.
• If applicable, the summarized results of the resident survey from E*value.

At the completion of the Review, the GME Office will generate a report and the Chair of the Review or the Associate Dean of GME will submit a written report of the Committee's findings to the GME Committee at one of its monthly meetings.  The report will include sufficient documentation or discussion of the Specialty's or Subspecialty's Program Requirements to demonstrate that a comprehensive review was conducted.  A copy of the final Review report will be sent to the Program Director, the Department Chair, the Senior Associate Dean for Medical Education, and the Dean of the School of Medicine and Dentistry. 

he Chair of the Internal Review Committee or the Associate Dean for Graduate Medical Education will present the review committee's findings to the GMEC at its next scheduled meeting.  The GME Committee will request Program Directors to provide, at 3, 6, 9 or 12 month intervals, updates to the GMEC regarding areas identified as requiring improvement.  A progress report will be submitted to the GMEC for review at the identified interval and a determination made regarding further follow up.  (See reporting grid.)

Revised  1/30/02, 2/3/02, 3/18/03, 1/04

Response to the Internal Review Letter of Report Form