GME Internal Review Basics

1
GME Internal Review Basics

Heather A. Nichols Accreditation Manager Office
of Graduate Medical Education
2
Internal Review Basics

• What is an Internal Review (IR)?
• Why are IRs conducted?
• When are IRs held?
• How do you prepare?
• Where are IRs held?
• Who must attend?
• What occurs during a review?
• What occurs after a review?

3
What is an Internal Review (IR)?

• Assessment of a programs compliance with ACGME
  requirements
• Method to address program challenges
• Method to share best practices
• Two hour meeting with prep and follow up

4
Why are IRs conducted?

• Valuable preparation for a Site Visit
• ACGME Institutional Requirement
• Valuable preparation for a Site Visit
• ACGME Institutional Requirement
• Valuable preparation for a Site Visit
• ACGME Institutional Requirement
• Valuable preparation for a Site Visit
• ACGME Institutional Requirement
• Valuable preparation for a Site Visit
• ACGME Institutional Requirement

5
When are IRs held?

• ACGME Institutional Requirements Internal
  reviews must be in process and documented in the
  GMEC minutes by approximately the midpoint of the
  accreditation cycle. The accreditation cycle is
  calculated from the date of the meeting at which
  the final accreditation action was taken to the
  time of the next site visit. (IV.A.2)

6
DIO View of Internal Review Schedule in ADS
7
Where are IRs held?
8
How do you prepare?

• Select a date
• Complete Self Study document
• Read your Program Requirements
• Gather documents
• Submit materials
• Distribute binders

9
Who must attend?

• YOU
• Program director
• Key program faculty
• Department chair (optional)
• Peer selected residents from each PGY
• Internal Review Committee

10
Who serves on the Internal Review Committee?

• Associate Dean for GME, Robert Baron, MD
• Chair, Internal Review Committee, Claire Brett,
  MD
• GME Accreditation Manager, Heather Nichols
• GME Director, Amy Day
• Outside faculty member
• Outside resident/clinical fellow

11
What occurs during the review?

• Open discussion
• Review documents in binder
• Best practices
• Final 30 minutes of review is spent with the
  residents/clinical fellows

12
What occurs after the review?

• Internal Review Committee writes report
• Report sent to program with request for response
• Report presented to GME Executive Committee and
  GME Committee
• Programs response to report presented to GME
  Executive Committee and GME Committee
• NEW progress report
• ACGME/RRC reviews report and response at
  Institutional Review

13
Dates to Know and Remember

• Your mid cycle date
• Your approximate site visit date
• Institutional Review October 2010
• ACGME ADS Annual Update August 2009

14
Im here to help you with

• Anything ACGME related
• Site Visit and PIF preparation
• OGME PD Annual Report September 2009
• Program Letter of Agreement (PLA)
• AND Internal Reviews

15
Additional Accreditation Resources

• ACGME e-Communication
• ACGME ADS Video Tutorials
• ACGME program requirements
• Program Coordinators
• Claire Brett, MD, Vice Chair, Internal Review
  Committee
• ACGME Annual Conference, Nashville, TN March
  4-7, 2010

16
Heather NicholsAccreditation ManagerOffice of
GMEContact nicholsha_at_medsch.ucsf.edu