The internal review process is a key institutional oversight function delegated by the ACGME to the Graduate Medical Education Committee (GMEC). The purposes of the internal review are to: The internal review should be viewed as a positive intervention. Most importantly, the results of the internal review is considered confidential. At the time of an accreditation site visit, the ACGME staff is not privy to the content of the internal review summary, only that it was performed at approximately the mid-point of the program’s accreditation cycle. Why do you need an Internal Review?The ACGME requires all ACGME-approved programs to have gone through an internal review approximately mid-way through the ACGME approval cycle. Procedures for the Internal Review(Below is a description of the internal review process. To view the full protocol, please click here.) 1. Date and Time The GMEC is responsible for contacting you approximately mid-way through your ACGME approved cycle. You will be given about three different dates and times to choose from. Please respond promptly to these requests since these dates are being held by the internal review team. Since the internal review takes place in the program's department, it is the program director or coordinator's responsibility to coordinate a room. The room needs to hold the review team, faculty and housestaff. Click here to find out approximately when is your next internal review or site visit. 2. Review Team The review team shall consist of: · Senior Associate Dean for Graduate Medical Education/GMEC Chair
· Program Director (external to program being reviewed)
· resident physician (nominated by the external program director)
· senior level hospital administrator
· administrator, GME Office
3. Prior to the Review The program director will need to fill out the Internal Review Program Questionnaire and return it via email to the ACGME Coordinator, Tina K. Espina, at t-patricio@northwestern.edu, in the GME office, about 10 days prior to the review. The program director or coordinator will also need to pass out the Resident Questionnaire or Fellow Questionnaire to all housestaff in the program. They need to be collected and returned to Tina K. Espina in the GME office (645 N. Michigan Ave., Suite 1058-A) about 10 days prior to the review. A good way to keep their answers confidential is to 1) pass them out during a meeting and have them all collected in an envelope or 2) pass them out and have out a large manilla envelope so they can drop it off.
As part of the materials reveiwed we are now asking that each program provide a copy of all of their Program Letters of Agreement when you turn in your Internal Review Program Questionnaire. If you have any questions please feel free to contact Tina K. Espina at the GME office.
4. Materials Previewed by Review Team · Questionnaire from program director
· Collated results from resident/fellow questionnaires
· Previous ACGME accreditation letter & progress reports
· Current ACGME program & institutional requirements
· Previoius internal review report
· List of frequent citations from that RRC to all programs over the prior year (if available)
5. The Internal Review The review team will interview faculty members from the program (1 1/2hr), which requires a minimum of three faculty members including the program director. If the program director is not the departmental chair or division director, that individual should ideally be present.
The internal review team will also like to see examples of your resident/fellows folders, to include, all evaluations, case logs or any other necessary documentation specific to your specialty program requirements. The review team will then interview the housestaff (1 hr), which requires peer-selected residents/fellows from each level of training. However, it would be beneficial to have as many residents as possible, ideally all in the program. Information reviewed with faculty and residents: · History of the program
· Changes in the program since last review
· Previous ACGME citations and effectiveness of corrective measures
· Organization of the education curriculum, including educational objectives
· Research and scholarly environment
· Work environment, including duty hours and moonlighting policy
· Support and resources
· The methods for evaluating the faculty, the program, and the residents Specific assessment with regard to competencies: · Assess 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, professionalism, practice-based learning, and systems-based practice · Provide evidence of the program’s use of evaluation tools to ensure that the residents demonstrate competence in each of the six areas. · Appraise the development and use of dependable outcome measures by the program for each of the general competencies · Appraise the effectiveness of each program in implementing a process that links educational outcomes with program improvement
6. Summary Report A summary report will be drafted by the Senior Associate Dean for GME and circulated to the internal review team members and program director reviewed for review/editing. (It will be labeled "draft".) 7. GMEC Action The GMEC is responsible for directing all aspects of the internal Review Program, including: the timing and conduct of internal reviews to ensure at least one review for every program occurring at approximately mid-way through the ACGME approval cycle; review of internal review summary reports; ensuring follow-up from programs when areas needing improvement are identified; assessing the effectiveness of the internal review process for each program at the time of review of that program’s accreditation letter. The edited summary will be given to GMEC members at least 5 days prior to the meeting and the GMEC will recommend any corrective actions needed at the meeting. The recommendations and GMEC-approved summary report will be given to the program director and chair. The program is expected to reply promptly to any follow-up corrective actions and report back to the GMEC. | 
