USF –
GRADUATE MEDICAL EDUCATION POLICY & PROCEDURE
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Title: Internal Review Process |
No.: GME-110 |
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Effective Date: 10/1/00 |
Revision Date: 1/17/01; 10/17/01, 3/20/02; 5/9/07 |
Distribution: All |
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Page: 1 of 4 |
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Policy Statement
Mid-cycle
internal review (approx. 6 month process)
It is the policy of the
Procedure
I. Application Process
On or about the
midcycle between external reviews, the office of Graduate Medical Education
will send notice to the Program Director and their respective chairperson
detailing the specific date and time
of the scheduled internal review and outlining the materials which must be
submitted no later than 10 business days prior to the review. The
Program Director will be allowed to reschedule this review date one time
without penalty. This
notice will be no less than six
three months in advance of the scheduled
review such that Program Directors have adequate time to prepare the materials
as listed below.
Application Materials will include the following.
1. Previous Program Information Form (PIF) with updates as appropriate. (Program Directors may elect to submit a new PIF eliminating the faculty calculations details).
2.
A Program Director Narrative Outline (A Strength, Weakness,
3. The previous letter of accreditation from the RRC and any correspondence to or from the RRC subsequent to that.
4. Competency Based Curriculum Worksheet
5. RRC Program Requirements Internal Review Form
6. The previous internal review report.
7. Completed Yearly Survey Checklist.
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Title: Internal Review Process |
No.: GME-110 |
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Page: 2 of 4 |
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These materials will be indexed and submitted (4 copies) to the GME Office no later than 10 business days prior to the scheduled site review.
During the internal site process, the ACGME general competencies will be assessed in the following manner:
1. The competency based curriculum worksheet will be completed by the Program Director as part of the application materials.
2. The completed worksheet will be reviewed during the site visit at which time various elements will be validated, clarified, and/or explored. Areas to be reviewed during the site visit will include the tools used to assess the six competencies as well as the effectiveness of the program in implementing a process that links the educational outcomes with the program’s own improvement.
3. The final program report will include an assessment, and recommendations as appropriate, as it pertains to the general competencies and the program’s compliance with it.
II. Site Visit
A Site Visit Team is defined as comprised at minimum of three individuals. These include an administrative representative as specified by the University, a faculty member, and a resident member, both of whom are NOT from the residency under review (see note below). This team is tasked with the responsibility of conducting onsite residency interviews, validating application and program-specific materials, and submitting a summary report to the Internal Program Review and Site Visits (IPRS) Committee of the GMEC. This team will be issued the completed application packet (see above) for review prior to the actual site visit. The team will conduct interviews with a representative sample (further defined as a minimum of one resident per class year but preferably two per class year) of the residents (with no faculty in attendance) and interviews with a representative sample of the faculty. The site visit team will then meet with the Program Director to answer any remaining questions and to review the materials they deem appropriate to verify primary documentation of compliance with the program-specific requirements. (Note: These documents will change from residency to residency and will follow the program-specific requirements.) Finally, the site visit team will meet in private, collectively come to consensus on the program status, and the site visit team leader (designated as the University administrative representative) will prepare and submit a summary report to the IPRS Committee at its subsequent meeting.
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Title: Internal Review Process |
No.: GME-110 |
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Page: 3 of 4 |
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The site visit team is comprised of the following members (at a minimum):
1. Administrative Reviewer: A University representative who will provide administrative review specifically looking for appropriate allocation of resources, including space, finances, and human resources. In addition, this individual will serve as the site visit team leader and will provide the written summary and will attend the corresponding IPRS committee meetings.
2. Faculty Reviewer: A faculty member will be designated from a sign-up list maintained by the GME Office of the University. This individual CANNOT be from the residency under review. In addition, this faculty member will designate a resident reviewer (usually a chief resident from the faculties program) to participate with the site visit team. This individual will not be responsible for attending subsequent IPRS meetings.
3. Resident Reviewer: A resident member (as determined by the Faculty Reviewer) or, if unavailable, a representative of the Housestaff Association, who will accompany their faculty and be an active participant in the review process. This individual will not be responsible for attending subsequent IPRS meetings.
NOTE: Application documentation must be available to the Site Visit Team as may be requested or required during a typical external site visit by the RRC. These could include things such as resident personnel files, conference attendance, and/or other areas as may be deemed appropriate by their specific RRC.
III. Internal Program Review Sub-Committee (IPRS) Review
A. With the completion of the site visit, the site visit team summary report will be brought to the next IPRS committee meeting for review. The program director will be invited to the meeting and can address any open issues as delineated in the site visit summary.
The site visit team summary report will also be made available to the Program Director within ten (10) business days following the site visit. A cover letter originating from the GME Office will notify the Program Director of their option to voluntarily attend the next IPRS committee meeting to address any items contained in the summary report.
B. Procedure
Open discussion will clarify any remaining issues that the IPRS Committee has as presented by the Site Visit Team Leader. The IPRS will make a final recommendation and submit a summary report to the Graduate Medical Education Council based on the findings and recommendations of the site visit
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Title: Internal Review Process |
No.: GME-110 |
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Page: 4 of 4 |
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team. Reports and recommendations to the GMEC from the IPRS could include, but would not be limited to:
- Acceptable program compliance with no significant areas of concern.
- Acceptable program compliance with focused areas of concern requiring no immediate response on the part of the program.
- Marginal program compliance requiring additional response by the program and potential for another follow-up internal review or mandatory progress report.
- Unacceptable program compliance requiring further action by the GMEC.
IV. Enforcement
If at any point throughout the scheduling process the Program fails to comply with the timeline as set forth above (without reasonable explanation) the program will be subjected to a five-hundred ($500.) dollar fine per occurrence, the Program Director and Chairman will be notified, and the program risks an unsatisfactory internal review which will be so disclosed at their next external review. Individual chairpersons at their discretion can implement additional enforcement procedures but in the event of repetitive infractions will be referred to the Graduate Medical Education Council and on to the Dean for final action.
APPROVED:
Associate Dean, Graduate Medical Education
Dean,
c:p&p\Internal
Review Process
Revised: IPRS 2-7-07 / GMEC 5-9-07