Statement of Purpose

The Accreditation Council for Graduate Medical Education, in Section IV. of the Institutional Requirements, delineates the requirements for the regular review of all residency programs. The internal review is designed to assess the program compliance with the Institutional Requirements, the Common Program Requirements and the relevant specialty/subspecialty requirements of your RRC.

The Graduate Medical Education Office will be responsible for coordinating the internal review process. Each program will be reviewed between ACGME program surveys. Whenever possible, the internal review will be scheduled as close as possible to the midpoint between site visits.

The review panel will consist of the Designated Institutional Official or designee, one or more faculty physicians (program directors or faculty members) and a resident from a different training program.

All reviews will include meeting with the program director, department head, or their designees, teaching faculty (within and/or outside the program as determined by the GMEC), and residents in the program. It is the responsibility of the program director to ensure that the faculty and residents are available at the stipulated time.

When a program has no residents enrolled at the mid-point of the review cycle, the following circumstances apply:

1. The GMEC must demonstrate continued oversight of those programs through a modified internal review that ensures the program has maintained adequate faculty and staff resources, clinical volume, and other necessary curricular elements required to be in substantial compliance with the Institutional, Common and specialty-specific Program Requirements prior to the program enrolling a resident.
   
2. After enrolling a resident, an internal review must be completed within the second six-month period of the resident’s first year in the program.

The internal review process is designed as a constructive self-assessment function with the aim of developing positive recommendations for the improvement of the program! The review panel is meant to serve as fact finders, not judges. Attempts will be made to offer unbiased perspectives.
The review is designed to assess the programs’ compliance with the accreditation standards established by the relevant RRC. The review will focus on:

1. The educational objectives of each program.
   
2. The adequacy of available educational and financial resources to meet these objectives.
   
3. The effectiveness of each program in meeting its objectives.
   
4. The effectiveness in addressing citations from previous ACGME letters of accreditation and previous internal reviews.
   
5. Assurance that the 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 competency in the following areas: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and systems-based practice.
6. Evidence of the program’s use of evaluation tools to ensure that the residents demonstrate competence in each of the six areas.
   
7. Assurance of the program’s development and use of dependable outcome measures by the program for each of the general competencies.
   
8. The effectiveness of each program in implementing a process that links educational outcomes with program improvement.

Procedures

1. As soon as the ACGME Survey Letter is received, the GMEC will schedule a tentative date for the Internal Review based on the tentative date for the next RRC survey, and identify the review panel for each review.
   
2. The program director will submit 4 copies of the following to the GME Office at least 10 days prior to the review (for review panel and GME Office):
   1. A copy of the most recent RRC Accreditation Letter and all correspondence with the RRC. The program director must specifically respond to each citation explaining how it was addressed.
      
   2. A copy of the most recent internal review with an explanation of how each concern was addressed.A completed Internal Review Program Questionnaire.
      
   3. Most recent evaluation of the program by residents.
      
   4. A copy of all written goals and objectives for the training program.
      
   5. Special Provisions for all participating institutions.
      
   6. An example of the evaluation that residents complete on faculty members.
      
   7. An example of the evaluation form that residents complete about the educational program.
      
   8. A completed General Competencies Documentation form.
      
   9. Provide one copy of the completed Teaching Faculty Questionnaire (50% required).
   
   
3. The program director or designee should bring to the internal review session the following:
   1. The training program resident/fellow manual or handbook.
      
   2. Copies of all residency program policies (duty hours, leave of absence, moonlighting, quality assurance, resident selection and supervision).
      
   3. Several representative residents’ files with evaluations.
      
   4. Copy of all written goals and objectives for the training program based upon the competencies as specified in the Program Requirements.
      
   5. Copies of all recruiting materials.
   
   
4. The GME Office will distribute to all panel members the documents provided by the program to be reviewed along with the RRC Program Requirements at least 1 week prior to the review.
   
5. The review panel will meet in separate sessions with:
   1. The program director, department head or their designees.
      
   2. Key teaching faculty.
      
   3. Residents representing all levels of the training program. Whenever possible, the residents should be peer selected.
      
   4. Any additional individuals deemed necessary by the review team.
   
   
6. The Designated Institutional Official (or designee) and the Internal Review panel will submit a report to the program director and the GMEC summarizing the panel’s findings and perceived strengths and weaknesses of the program.
   
7. The GMEC will submit a follow up report of concerns to the program director and department head. The program director must submit a response to the GMEC within the specific time period noted by the review panel, addressing each concern raised and provide specific plans for correcting any problems noted.

Revised April 2007