University of Pennsylvania Health System
Graduate Medical Education Committee
Protocol for Internal Residency Reviews

Introduction:

The Graduate Medical Education Committee (GMEC) is responsible for the development, implementation and oversight of the internal review process. This process must fully comply with all requirements as stipulated by the Accreditation Council for Graduate Medical Education (ACGME) Institutional Review Committee Standards as revised July 1, 2003.

All internal reviews of ACGME-accredited residency programs will involve a multi-step process designed to:

	1.		Ensure that all residency and fellowship training programs are conducted in accordance with program specific and institutional standards promulgated by the ACGME.
	2.		Establish mechanisms whereby GME staff may provide consultation and support to residency and/or fellowship training programs.
	3.		Establish equitable and uniform policies governing all training programs so that the overall GME environment within the health system promotes the educational needs of house staff.
	4.		Address any institutional support issues related to the responsibility of the health system in operating GME programs.

The Internal Review sub-committee of the GMEC will work closely with GME staff to actively coordinate our Internal Review process, with final responsibility and authority to rest with the GMEC concerning the outcomes of these reviews.

Procedures:

1.

Each internal review will be conducted by a designated internal review committee. The review committee will be chaired by a GMEC member and consist of representation as required by institutional standards (from ACGME Essentials of Accredited Residency Programs, i.e., administration, resident representation from another department, faculty, external representation where indicated).

2.

The review committee is charged with completing the internal review by the approximate midpoint between ACGME program reviews.

3.

The review committee will use the following materials in its  process: ACGME/RRC program standards (from ACGME Essentials of Accredited Residency Programs Institutional standards (from ACGME Essentials of Accredited Residency Programs) The most recent accreditation letters from previous ACGME program reviews The report from the most recent internal review by the GMEC

4.

The review committee will be informed by and examine closely: The results of a standardized questionnaire to residents/fellows currently enrolled in the program under review The results of a standardized questionnaire to the program director Both of these questionnaires address all program and institutional requirements put forth by the ACGME

5.

The review committee will assess the program’s compliance with each of the ACGME program standards as contained in the Essentials of Accredited Residency Programs.

	6.		The review committee will specifically assess the following: The educational objectives of each program The effectiveness of each program in meeting its objectives The adequacy of available educational and financial resources to support the program The effectiveness in addressing areas of noncompliance or concerns in previous ACGME accreditation letters and previous internal reviews Whether each 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 Evidence of the program’s use of evaluation tools to ensure that the residents demonstrate competence in each of the six areas The development and use of dependable outcome measures by the program for each of the general competencies The effectiveness of each program in implementing a process that links educational outcomes with program improvements

7.

The review committee will conduct an interview with residents/fellows currently enrolled in the program under review, wherein the committee examines all aspects of the program as stipulated above and gains feedback from the residents/fellows for this purpose.

8.

The review committee will conduct an interview with a representative of the teaching faculty, wherein the committee examines all aspects of the program as stipulated above and gains feedback from the faculty member for this purpose.

	9.		The review committee will conduct an interview with the program director, wherein the committee examines all aspects of the program as stipulated above and gains feedback from the program director for this purpose. During this interview, the program director is also presented with: A summary of the results of resident and faculty interviews Key findings and recommendations based on all data collected Expectations for the completion of the internal review process

10.

The review committee will prepare a final report containing: The name of the program being reviewed and the date of the review The names and titles of review committee members including residents A brief description of the review process including who was interviewed Documentation of discussion of the ACGME program requirements Documentation of the review process that demonstrates compliance with the internal review protocol A summary of all data and interviews A list of areas of noncompliance, concerns and/or comments from previous ACGME accreditation letters and how the program has responded A list of concerns identified as part of the most recent internal review and how the program has responded Specific recommendations on how the program can strengthen its current compliance with all RRC and IRC requirements.

11.

The review committee final report is sent to the program director, and s/he is given a specific charge to reply to areas of concern within thirty (30) days.

12.

The report and the program director’s response is submitted to the GMEC for review and discussion; the program director is invited to participate in the GMEC meeting where the internal review report is to be discussed.

13.

Final reports are maintained in the GME central office by the staff accreditation manager.

14.

The achievement of recommendations made by the GMEC as a result of the internal review process will be monitored proactively by the GMEC via the Internal Review sub-committee. An action plan that identifies how progress is being made by the program concerning previous RRC citations and/or recommendations from the internal review will be submitted periodically.