Internal Reviews

Purpose:          

The Accreditation Council for Graduate Medical Education, in Section V. 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.

Policy:             

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.

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.

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