GMEC Internal Review Policy and Procedure

1. The GMEC is a standing subcommittee of the Committee on Educational Policy (CEP). The function of the GMEC as defined by the CEP shall be to ensure that clinical graduate training programs meet institutional and national (including the Accreditation Council for Graduate Medical Education) performance standards. The GMEC assumes all functions as required by the ACGME.

    

   GME training program review will be scheduled by the GMEC for each accredited program mid-cycle between its ACGME site visits, or as otherwise needed. In programs with a longer 4-5 year review cycle, there may be leeway in that the review may be completed either three months prior to or three months post the actual mid-cycle date. In programs with shorter review cycles, there will less flexibility. If problems exist in scheduling internal reviews, the GMEC shall forward its concern to the GMEC-EC for resolution.

    

   Following ACGME review and RRC notification of the outcome of the review, the GMEC will invite the individual training program director to present a written report to the GMEC regarding any needed resolution to ACGME areas of concern. If the RRC specifies that the program director must forward a progress report or further information to the ACGME, the program director must present the documentation to the GMEC for approval and co-signature prior to forwarding to the RRC.

    

   The Graduate Medical Education Executive Committee will conduct an initial review of the Institutional Review Letter of Report and will bring its recommendation for action regarding any designated citations forward to the Graduate Medical Education Committee. The GMEC-EC and GMEC will continue to act upon IRC concern(s) until the issue is appropriately addressed and resolved.

    

   This information contained in this document provides a standardized guide for use during the GMEC internal review process. Internal review surveyors will be oriented to the review process by the Chair, GMEC or his/her designee.

    

   The ACGME sets forth the requirement for the regular review of all graduate medical education programs, pursuant to a written protocol, for the purpose of assessing compliance with both the Institutional Requirements and Program Requirements of the relevant ACGME Residency Review Committee. The review is to be conducted between the ACGME program surveys and should appraise the following:

   • The educational objectives of the program;
   • The effectiveness of the program in meeting its objectives;
   • The adequacy of available educational and financial resources support to support the program;
   • The effectiveness in addressing areas of non-compliance and concerns in previous ACGME letters of accreditation and previous internal reviews;
   • The effectiveness in defining, in accordance with the Program and Institutional Requirements, the specific knowledge, skills, attitudes, and educational experience required for the residents to achieve competence in the following: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and system-based practice. The program's curriculum should include goals and objectives based on the competencies because without them, effective evaluation tools cannot be constructed;
   • The effectiveness of the program in using dependable outcome measures developed for each of the 6 general competencies; and
   • The effectiveness of each program in implementing a process that links educational outcomes with program improvement.
   
   

   ACGME General Competencies and Outcomes Assessment:
   Please note: Internal reviews that are conducted after July 1, 2002 will provide an assessment of a program's progress in adding the ACGME general competencies to its curriculum, development of goals and objectives for teaching the competencies, and the types of evaluation tools that are being used. Evidence will be sought in the GMEC internal review report that the program is addressing these areas.
   
   Specifically, the internal review will 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 trainees to demonstrate competency in the following areas: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice.
   
   The internal review will provide evidence of the program's use of evaluation tools to ensure that the trainees demonstrate competence in each of the six areas.
   
   The internal review will appraise the development and use of dependable outcome measures by the program for each of the general competencies.
   
   And finally, the internal review will appraise the effectiveness of each program in implementing a process that links educational outcomes with program improvement.

   Documentation utilized in the GMEC internal review process includes:

   • ACGME Institutional and Program Requirements from the Essentials of Accredited Residency Programs;
   • Letters of accreditation (and related correspondence) from previous ACGME reviews;
   • Reports from previous internal reviews of the program;
   • Material provided by the training program director as noted in II.B. below; and
   • Interviews with the training program director, faculty and residents in the program and individuals outside the program as deemed appropriate by the GMEC. Interviews with the GME trainee(s), shall be separate from interview(s) held with the faculty and their comments will be anonymous.

   The review is written and includes mechanisms to correct any identified deficiencies.

    

2. Process

   1. A GMEC faculty member surveyor or a GMEC Program Director faculty member (team leader), the Associate Dean for GME/DIO who is a faculty member, a member of the house staff who may or may not be a member of the GMEC, and an administrator shall be selected by the Chair, GMEC (or his/her designee) to review a specific training program. None of those participating in the internal review on the GMEC Survey Team will be from the program that is being reviewed.

       

   2. The Training Program Director will be asked to provide a list of documents/materials to forward to the survey team prior to the review as well as other documents to have available during the review. This will reflect the specific Program Requirements for the program being reviewed.

      1. Evidence of the time the TPD devotes to the program per week throughout the year.
      2. The written learning objectives and expectations of the program outlining the educational goals and objectives of the program with respect to knowledge, skills and other attributes of trainees at each level of training and for each major rotation or other program assignment.
      3. Description of how the documentation in B.2. above is circulated to both the trainees and faculty members.
      4. Documentation of core competence process and tools utilized to evaluate competence. This includes:
         • Documented evidence of a written curriculum, complete with goals and objectives, that are used by the program for teaching the following six general competencies: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice;
         • Documented evidence of the evaluation tools used to evaluate resident competencies in the six areas based on the goals and objectives;
         • Provide evidence of developing or using dependable measures to access the trainees' competence in each of these areas. Note: Dependable measures may not be developed until the program has had an opportunity to evaluate its trainees over a period of time using various evaluation tools and analyzing the results; and
         • Provide evidence of a process developed to link educational outcomes with program improvement. Note: Evidence of program improvement may not be available at first until the program has had an opportunity to develop and analyze its outcome measures over a period of time.
      5. Written policies of the program that define the lines of responsibility and supervision for the care of patients in all settings, including all clinical sites for all members of the teaching teams and program staff.
      6. Evaluation Process and Evaluation Forms used for:
         • Evaluation of trainee by the faculty;
         • Evaluation of faculty by the trainee;
         • Evaluation of the rotation by trainee;
         • Evaluation of the program by the faculty and trainee(s);
         • Final Trainee Evaluation Required by specialty board; and
         • Evaluation of program graduates.
      7. Duty Hour Compliance
         • Departmental written duty hour policy;
         • Confirmation that the program is in compliance with the duty hour requirements;
         • Method (written policy) used by the program to monitor duty hour compliance;
         • Method (written policy) used by the program to monitor hours called in-house from home call;
         • Written program policy regarding monitoring resident fatigue;
         • Written program policy regarding systems to provide back-up support; and
         • Written moonlighting policy/procedure, monitoring plan, forms used.
      8. Documentation regarding the mechanisms used by the Program Director to maintain oversight with the faculty at affiliated institutions to assure proper supervision, hours and working conditions and safety for the trainees rotating to the offsite facility.
      9. Board certification exam success for past 5 years, number who have passed boards and number, if any, who have not passed boards.
      10. Curriculum, including block rotations or rotation schedule.
      11. Housestaff Handbook

   3. The Training Program Director, in conjunction with the Office of Graduate Medical Education, will be responsible for coordinating the schedules of faculty, housestaff and others, required to be in attendance during the internal review interview process.

       

   4. The Training Program Director will attend the meeting of the Graduate Medical Education Committee when the internal report is presented by the survey team to the GMEC.

       

   5. Format: Written report following the guidelines outlined within this document. A copy of the report will be sent to the program director in draft format for comment. The survey team?s written and oral report will be presented to the GMEC.

       

   6. Discussion and recommendations by GMEC.

       

   7. Minutes of the GMEC meeting with a copy of the written report and recommendations shall be sent to the Dean, School of Medicine and Chair, CEP. A copy of the final report shall be sent to the Training Program Director.

3. Resources available to the GMEC surveyors

   1. Program Information Forms (PIF) prepared for prior ACGME review.

       

   2. Relevant correspondence between the ACGME-RRC and the program director, following ACGME site visits.

       

   3. Prior GMEC internal review documentation.

       

   4. Information noted in II.B. above.

       

   5. Interviews with department chair, program director, members of the faculty, residents/fellows, graduates of the program and others as may be identified.

       

   6. Other documentation regarding the training program, e.g., financial support provided to the program, affiliation agreement documentation for the program, program policies regarding selection, evaluation, promotion and dismissal criteria, evidence of trainee attendance at the UCSDMC Resident Core Lecture Series, etc.

       

   7. Copy of the applicable Essentials of Accredited Residencies as published in the AMA Directory of Graduate Medical Education Programs
      • Applicable RRC Program Requirements
      • Institutional Requirements

4. Objectives of the review (format)
   In starting the review, the surveyors must first read the ACGME-RRC Program Requirements and the ACGME Institutional Requirements. Information is sought based upon the criteria defined in these two resources. Particular attention is paid to the responsibilities of the program director, to assure that all activities are completed and that written evidence is available.

   1. Define goals and objectives of the program

      1. Body of knowledge
      2. Skills
      3. Board eligibility
      4. Address whether the program has a predominantly clinical or research orientation
      5. Each program director must prepare a written statement outlining the educational goals of the program with respect to knowledge, skills and other attributes of trainees at each level of training and for each major rotation or other program assignment. This statement must be distributed to the trainees and members of the teaching staff.
         
         

         Attach a copy of the program's documentation to your report.

   2. Instructional plans to achieve goals and objectives

      1. Outline of educational format
      2. Clinical exposure
      3. Rotation assignments
      4. Teaching staff and qualifications
      5. Faculty supervision (written policies as mandated in the Program Requirements)

   3. Effectiveness in achieving program goals and objectives

      1. Resident/fellow evaluations by faculty - copy of form(s) used
      2. Evaluation of faculty by resident/fellow - copy of form(s) used
      3. Evaluation of the rotation by resident/fellow - copy of form(s) used
      4. Evaluation of the program by the faculty and trainees. Describe the process
      5. Board certification exam success - Identify whether it is tracked by the program, and the outcome.
      6. Address the career paths being followed by the program graduates
      7. As needed, address whether a summative evaluation is completed
      8. As needed, address tracking information from program graduates

   4. ACGME Clinical Competencies

      1. Verification of the existence of a curriculum with goals and objectives provided for several of the general competencies
      2. A summary or list of the types of evaluation tools used by the program for evaluating the competencies (see attached example)
      3. Comments on the program's status in the development and use of dependable measures to assess resident competency in the six areas.
      4. Comments on the program's status in developing a process that links educational outcomes with program improvement.
      5. Verification or confirmation from the trainees as to the existence of a curriculum with goals and objectives for teaching the competencies, their involvement in the curriculum, and the kinds of tools used by the program to evaluate them.

   5. Effectiveness in addressing citations/areas of concern from previous ACGME letters of accreditation and previous GMEC internal reviews.

      1. Identify each citation and how the program director has resolved the issue.

   6. Resource utilization

      1. Facilities
      2. Equipment
      3. Adequate patient population for training in all aspects of the program
      4. Faculty
      5. Financial support for the program and for trainees in the program
         • Hospital support toward operation of the program, e.g., staff, supplies, program director
         • Trainee salary/benefit support commensurate with UCSD published salary scales

   7. Appropriateness of number of trainees in program

       

   8. Provide a copy of written departmental policies regarding:
      • Trainee selection
      • Trainee evaluation
      • Trainee promotion
      • Trainee dismissal
      • Trainee supervision
   9. Adequacy of due process procedures
      • Promotions
      • Counseling
      • Remedial Training
      • Appeal mechanism for disciplinary action or termination
   10. Hours and working conditions
       Policy Effective July 1, 2003:
       • Maximum 80 hours/week over 4 weeks
       • 1 day off in 7 free of patient care averaged over 4 weeks
       • Call 1 in 3 averaged over 4 weeks
       • 24 hour limit on duty; 6 hour extension (total of 30 hours)
       • 10 hours minimum rest period between duty periods
       • Call from home-time called in "counts" toward weekly duty hours limit
       • Moonlighting at own institution "counts" toward weekly duty hours limit
       • Moonlighting anywhere to be approved and monitored by program director.
   11. Identify specific methods utilized by the program director to establish and maintain proper oversight of and liaison with appropriate personnel at affiliated institutions where trainees participate in offsite rotations. This should cover:
       • Supervision
       • Hours and working conditions
       • Housestaff safety

   12. Describe the mechanisms used to acquaint residents/fellows with the educational objectives of their departmental/division clerkship and their role in teaching, evaluating and dealing with the student in academic difficulty. If residents/fellows receive feedback on their teaching, please describe the process.

        

   13. Institutional Requirements

       1. Describe how the trainee curriculum provides (a) a regular review of ethical, socioeconomic, medical/legal, and cost containment issues that affect GME and medical practice, and (b) instruction in quality assurance/performance improvement and physician impairment.
       2. If the trainees attend the UCSD Resident Core Lecture Series review the summary of attendance provided to the program director following each lecture.
       3. Describe how the trainee curriculum provides an appropriate introduction to communications skills and to research design, statistics, and the critical review of the literature necessary for acquiring skills for lifelong learning.
       4. Does the program have in place program letters of agreement/educational memorandum of understanding identifying the points defined in the specialty specific program requirements for offsite rotations conducted in other affiliated institutions?
          
          Attach a copy of the documentation. (The GMEC has created template documents for use by our program directors for both community affiliated hospitals and for the VAMC.)
       
       
       5. Responsibilities of the affiliated institutions used in this program
          
          

          Does each affiliate assure:

          
          
          1. Resident access to adequate and appropriate food services 24 hours/day;
          2. Residents are provided with adequate and appropriate sleeping quarters;
          3. Residents are provided adequate patient support services such as intravenous, phlebotomy, and laboratory services; and messenger and transporter services;
          4. Residents are provided with appropriate and effective laboratory, pathology, and radiologic information systems;
          5. Residents are provided with a medical records system that is available at all times and that documents the course of each patient's illness; and
          6. Residents are provided with appropriate security and personal safety measures at all locations to include parking facilities, on-call quarters, hospital and institutional grounds, and related clinical facilities.

   14. Define program strengths

   15. Define program deficiencies

   16. Define the quality of this training program relative to others in the same field.

   17. State recommendations for improving the program.

Revision Reviewed/Approved by the Graduate Medical Education Executive Committee:
June 20, 2002, November 14, 2002, April 8, 2004, September 8, 2005