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:
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;
Graduate performance, including performance of program graduates on certification examination; and
Materials and Data Used During Reviews
Process and Reports
Internal Review Report
The written report of the internal review for each program must contain, at a minimum:
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.
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.