Graduate Medical Education

About Internal Reviews

Internal Reviews are regular reviews of all Accreditation Council for Graduate Medical Education (ACGME) accredited programs, including subspecialty programs, performed by the sponsoring institution under the oversight of the Graduate Medical Education Committee (GMEC), to assess each program's compliance with the Institutional Requirements and the Program Requirements of the ACGME Residency Review Committees.

Who Conducts Review?

The review is conducted by a body designated by the GMEC, and which includes at least one faculty member and at least one resident/fellow from within the Sponsoring Institution but not from within the program being reviewed. External reviewers may also be included on the review body as determined by the GMEC. Administrators from outside the program may also be included.

When are Reviews Conducted?

Reviews are conducted at approximately the midpoint between the ACGME accreditation cycles. 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.

When a program has no residents/fellows enrolled at the mid-point of the internal review, the following circumstances apply:

The GMEC must continue its oversight by performing a modified internal review that ensures the program has maintained adequate faculty and staff resources, clinical volume, and other necessary curricular elements required to be in substantial compliance with the Institutional, Common and specialty-specific Program Requirements prior to the program enrolling a resident/fellow.
After enrolling a resident/fellow, an internal review must be completed within the second six-month period of the
resident's/fellow's first year in the program.

What is Assessed During Reviews?

The Internal Review must assess:

Compliance with the Common, specialty/subspecialty specific Program, and Institutional Requirements;
Educational objectives and effectiveness of the program in meeting those objectives;
Educational and financial resources;
Effectiveness in addressing areas of non-compliance and concerns in previous ACGME accreditation letters of notification and previous internal reviews
Effectiveness of educational outcomes in the ACGME general competencies;
Effectiveness in using evaluation tools and outcome measures to assess a resident's/fellow's level of competence in each of the ACGME general competencies (patient care, medical knowledge, systems based practice, practice based learning and improvement, interpersonal skills and communication; professionalism);
Annual program improvement efforts in:
- Resident performance using aggregated resident data;
- Faculty development
- Graduate performance, including performance of program graduates on certification examination; and
- Program quality.

Materials and Data Used During Reviews

The ACGME Common, specialty/subspecialty-specific Program, and Institutional Requirements in effect at the time
of the review;
Accreditation letters of notification from previous ACGME reviews and progress reports sent to the respective RRC;
Reports from previous internal reviews of the program;
Previous annual program evaluations;
Results from internal or external resident surveys, if available;
Institutional and Program Requirements for the specialties and subspecialties of the ACGME Residency Review Committees (RRCs); and
Interviews with the program director, key faculty members, at least one peer-selected resident/fellow from each level of training in the program, and other individuals deemed appropriate by the Review Team or GMEC.

Process and Reports

Internal Review Report

The written report of the internal review for each program must contain, at a minimum:

Name of the program reviewed;
Date of the assigned midpoint and the status of the GMECs oversight of the internal review at that midpoint;
Names and titles of the internal review team members;
A brief description of how the internal review process was conducted, including the list of the groups/individuals
interviewed and the documents reviewed;
Sufficient documentation to demonstrate that a comprehensive review followed the GMECs internal review
protocol;
List of the citations and areas of non-compliance or any concerns or comments from the previous ACGME
accreditation letter of notification with a summary of how the program and/or institution subsequently addressed each
item.

The program director or his/her designee will be requested to attend an upcoming GMEC to present the findings of the internal review process.

Program Directors and Departmental Chairman receive copies of the final internal review report along with the GMEC's recommendation.

Progress Reports

The DIO and the GMEC must monitor the response by the program to actions recommended by the GMEC in the internal review
process. Progress reports will be requested periodically on behalf of the GMEC to areas of concern. The program director or his/her designee will be requested to attend an upcoming GMEC to present the findings of the most recent progress report provided.

This page was last updated on: May 27, 2008.