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INTERNAL RESIDENCY REVIEW

By Louise Perez,2014-11-25 10:56
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INTERNAL RESIDENCY REVIEW

    (Revision December 2009)

    INTERNAL RESIDENCY REVIEW

    Medical College of Georgia

    2009- 2010

I. PROCESS OVERVIEW

    1. The Graduate Medical Education Committee (GMEC) is responsible for the development,

    implementation and oversight of the internal review process.

    2. The GMEC must designate an internal review committee(s) to review each ACGME-accredited

    program in the Sponsoring Institution.

    3. The internal review committee will include faculty, residents, and administrators from within the

    institution but from GME programs other than the one that is being reviewed. There will be at a

    minimum a three-person team that will conduct the internal review sessions. There will be a physician

    team leader, a resident and an administrative person that is all external to the program and the

    department undergoing review but internal to the organization. External reviewers may also be

    included on the committee as determined by the GMEC.

    4. The review must follow a written protocol approved by the GMEC that incorporates, at a minimum,

    the requirements by the ACGME.

    5. Internal residency reviews (IRRs) will be conducted at approximately the midpoint between the

    ACGME program surveys. This midpoint information is now provided to us with the

    accreditation letter from the respective RRC.

    6. While assessing the residency program=s compliance with each of the program standards, the review

    should also appraise the following:

     a. the educational objectives of each program;

     b. the effectiveness of each program in meeting its objectives;

     c. the adequacy of available educational and financial resources to support the program;

     d. the effectiveness of each program in addressing areas of noncompliance and concerns in

    previous ACGME accreditation letters and previous internal reviews;

    e. the effectiveness of each program in defining, in accordance with the Program and

    Institutional Requirements (Section III.E), the specific knowledge, skills, attitudes, and

    educational experiences 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 systems-based

    practice;

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    f. the effectiveness of each program in using evaluation tools developed to assess a resident=s

    level of competence in each of the six general areas listed above;

    g. the effectiveness of each program in using dependable outcome measures developed for each

    of the six general competencies listed above; and,

    h. the effectiveness of each program in implementing a process that links educational outcomes

    with program improvement.

II. MATERIALS AND DATA

    1. The Institutional and Program Requirements for the specialties and subspecialties of the ACGME

    RRCs from the Essentials of Accredited Residency Programs;

    2. The accreditation letters from previous ACGME reviews and any progress reports or other

    communications sent to the RRC;

3. The reports from previous internal reviews of the program.

    4. Completion of a Program Information Form (PIF is highly encouraged for all programs undergoing an

    internal review. This activity permits the program director and the training program personnel to do

    a thorough, in-depth review of their training program. Completion of the PIF permits the IRR team to

    gain greater insights into the training program and its compliance with both common and program

    specialty specific training requirements.

     Note: There will be appropriate adjustments to the document review session in advance of the

    internal review based upon the detailed information in the completed PIF.

III. INTERNAL RESIDENCY REVIEW PROGRAM VISIT

    1. The IRR will follow the same format for program review as utilized by the RRC site visits. The initial

    interview will be with the program director and the program coordinator by the three member internal

    review team with all requested documents available for review (see attached checklist). The

    information requested on the document checklist should be available at the time of the initial visit. If

    the department chair or section chief is not the program director, a separate meeting can be arranged if

    desired by the department or section chief.

    2. The second and third interview sessions will include the faculty, peer-selected residents from each level

    of training in the program, and other individuals deemed appropriate by the IRR committee.

    3. In larger programs with greater than 10 faculty members, the review team will meet with at least four

    or five key faculty members as a group. In smaller programs, it is desirable that all faculty be present.

    4. The review team member desires to meet with a representative sampling of all year group residents.

    Their peers should select these residents. In smaller programs with fewer than 10 residents, it is

    desirable that as many residents as possible be present.

    5. The residents will be asked to complete the ACGME resident survey two weeks in advance of the IRR

    survey date for the program. The surveys will be done in an anonymous fashion. The results will be

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    reviewed by the Senior Associate Dean for Graduate Medical Education and will be tabulated and

    means determined for the survey results for each of the 30 questions on the survey. The resident

    survey results will be used as part of the IRR process in all three interviews on the day of the IRR and

    the results will become part of the official report for the survey.

IV: INTERNAL REVIEW REPORT

    1. There will be a written report of the internal review for each ACGME-accredited specialty and

    subspecialty program that contains, at a minimum, the following:

     a. the name of the program or subspecialty program reviewed and the date of the review;

     b. the names and titles of the internal review committee members to include the resident(s);

     c. a brief description of how the internal review process was carried out, including the list of the

    groups/individuals who were interviewed;

     d. sufficient documentation or discussion of the specialty's or the subspecialty's Program

    Requirements and the Institutional Requirements to demonstrate that a comprehensive review

    was conducted and was based on the GMEC's internal review protocol;

     e. a list of the areas of noncompliance or any concerns or comments from the previous ACGME

    accreditation letter with a summary of how the program and /or institution addressed each one.

    2. The report will be provided to the Internal Residency Review Committee for its review and approval

    of the findings and recommendations from the internal review team.

    3. The Internal Residency Review Committee will make recommendations to the GMEC regarding areas

    of concern related to the program’s compliance with RRC requirements.

V. GMEC ACTION

    1. The written report of each internal review report will then be presented to and reviewed by the GMEC.

    2. The GMEC findings and recommendations will be summarized in the Internal Residency Review Report.

     This report will reflect the area(s) of concern related to the program’s compliance with specific RRC

    requirements. The internal review citations will be monitored by the GMEC and DIO through the use

    of GMEC Action Plans for Program Quality Improvement addressing:

     a) Individual internal review citations with correction strategies

     b) Resources defined that are needed to correct the citation

     c) A timeline for the correction and

     d) The evaluation process to ensure the adequacy of the correction.

    3. The written Internal Residency Review Reports will be shown to the ACGME site visitor for the

    institutional review and will be included in the Institutional Review Document submitted to the IRC.

     NOTE: During the review of individual programs, these internal review reports will not be shown to

    the ACGME site visitor or specialist site visitors, who only will ascertain that an internal review was

    completed in the interval since the program's previous site visit. A copy of the cover sheet of the IRR

    report will be provided to the site visitor upon request by the site visitor.

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    INTERNAL RESIDENCY REVIEW

    DOCUMENT CHECKLIST

1. The accreditation letters from previous ACGME reviews.

    ; Response(s) to areas of concern on the last RRC site visit report

2. The reports from previous internal reviews of the program.

    ; Response to areas of concern on last Internal Review site visit.

3. Description of major changes in your program since your last review

    ; Changes in faculty since the last review

    ; Changes in resident complement since the last review.

    4. A copy of the most recent Annual Program Evaluation Report will be made available to the IRR team.

    5. A copy of the programs action plan (s) for the most recent internal review citations will be made

    available to the IRR Team.

    6. A written copy of the written curriculum with goals and objectives for the program

    ; goals and objectives for each separate resident rotation with designation of which

    competencies are addressed by the goal and objective and what measurement tool is

    used to measure the resident’s achievement of the competency

    7. Documentation that the faculty and residents have seen the written curriculum with its goals and

    objectives and have participated in its review and revision

    8. Descriptions of learning activities such as lectures, conferences, reading assignments, and educational

    materials with documentation of attendance by residents and faculty for:

    ; Core curriculum conferences

    ; Basic science conferences

    ; Research conferences

    ; Journal club

    ; CPC/Mortality and morbidity conferences

    ; Multidisciplinary conferences

9. Examples of rotation schedules for residents

    10. Evidence that the program goals and objectives of the program are used for teaching the six general

    competencies:

    ; Patient Care Skills

    ; Medical Knowledge

    ; Interpersonal and Communication Skills

    ; Professionalism

    ; Practice-based Learning

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    ; Systems-based Practice

    11. Provide the program evaluation plan that spells out how the program is currently or planning to

    evaluate the six competencies

    ; description of tools developed to evaluate resident competencies in the six areas

    above.

    ; Example(s) of changes in resident performance and changes in the training program

    based upon the above evaluation process

12. Examples of evaluation forms

    ; Written documentation of bi-annual resident summative evaluations by the program

    director

    ; Evaluations by faculty of residents at the end of rotations

    ; Resident evaluations of the faculty at least on an annual basis

    ; Documentation that resident evaluations have been shared with the faculty and an

    explanation of the format in which the information is shared with the faculty members

    by the program director, division chief, chair etc.

    ; Written evaluations of the faculty, and residents of the training program at least on an

    annual basis

    ; Summary evaluations of each resident who are graduating from the program written

    prior to their graduation with the program director attesting to their competence in

    each of the six areas to practice independently in their specialty

    11. Methods for keeping track of attendance of residents at conferences, meetings etc.

    12. Methods for documenting resident clinical experiences and how the program director knows they are

    accurate

    13. Documentation of resident and faculty attendance at conferences and journal clubs

    14. Please provide a list of the Program Director's research and scholarly activities (e.g., publications and

    presentations at regional, national or international meetings) for the last three years.

    15. Please attach a list of the key faculty member’s research and scholarly activities (e.g., publications and

    presentations at regional, national or international meetings) for the last three years.

    16. Program committee minutes and faculty meeting minutes with discussions of resident clinical

    competence and faculty meetings reviewing the program

    ; Documentation of attendance of faculty at the meetings.

    17. Written policies and procedures for the program and the institution including guidelines for the

    supervision of residents and the selection, evaluation, promotion, dismissal of residents and any

    relevant program specific policies.

    18. Information about any residents who have left the program prior to completion of training, including

    the reasons for leaving

    19. Affiliation agreements and rotation agreements for all training that the residents participate in during

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    their residency

20. Two current resident training files and two graduated resident files

    21. Duty hour’s policies and procedures monitoring duty hours by the training program

22. Copies of resident duty hour logs

    ; evidence of program director review of resident duty hours and action taken for excessive

    hours

23. Moonlighting policies and procedures for the program

    24. Specialty board first time taker board pass rates as a measure of program effectiveness

    25. Review of any requests for experimentation or innovative projects that may deviate from the

    institutional, common and/or specialty specific program requirements that must be approved

    by the GMEC before submission to a Residency Review Committee.

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    INTERVIEW QUESTIONS FOR

    INTERNAL RESIDENCY REVIEW

PROGRAM DIRECTOR QUESTION LIST

1. What are the strengths of this program?

2. What are the weaknesses of the program?

3. Has your program developed a curriculum, including goals and objectives that will produce residents

    educated in the following six general competency areas?

     Patient Care Skills

     Medical Knowledge

     Interpersonal and Communication Skills

     Professionalism

     Practice-based Learning

     Systems-based Practice

    4. Are you aware of specific measurement tools that have been developed by your program to

    evaluate the resident competencies in the areas listed above?

     Discuss examples of these measurement tools

5. Are there available resources available to achieve the goals and objectives of the training program?

6. Do residents evaluate faculty members?

7. How is the resident evaluation results communicated to you?

    8. How do you as a faculty member participate in the following activities:

    ; selection of residents

    ; evaluation of residents

    ; promotion of residents

    ; dismissal of residents

    9. How do you ensure that the residents do not have excessive duty hours?

10. Does your residency-training program provide education and procedures to handle the issue of resident

    stress and fatigue? What is your approach to recognition of excessive resident fatigue?

11. Do the residents moonlight in the training program?

12. How does the faculty supervise the residents in this program?

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    13. Do you believe the residents will pass the Boards when they finish the program?

14. What are the first time taker board pass rates for your program?

    15. Do residents participate in institutional activities and/or serve on institutional committees?

    16. Is there resident participation in formal quality-assurance programs within the training program, department and/or at an institutional level?

    17. Does the training program with the faculty and residents review patient complications and deaths?

18. What changes would you recommend for this program?

    19. Do you have any plans for experimentation or innovation projects where the project may

    deviate from the institutional, common and/or specialty specific program requirements?

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    INTERVIEW QUESTIONS FOR

    INTERNAL RESIDENCY REVIEW

FACULTY QUESTION LIST

1. What are the strengths of this program?

2. What are the weaknesses of the program?

3. Has your program developed a curriculum, including goals and objectives that will produce residents

    educated in the following six general competency areas?

     Patient Care Skills

     Medical Knowledge

     Interpersonal and Communication Skills

     Professionalism

     Practice-based Learning

     Systems-based Practice

    4. Are you aware of specific measurement tools that have been developed by your program to

    evaluate the resident competencies in the areas listed above?

     Discuss examples of these measurement tools

5. Are there available resources available to achieve the goals and objectives of the training program?

6. Do residents evaluate faculty members?

7. How is the resident evaluation results communicated to you?

    8. How do you as a faculty member participate in the following activities:

    ; selection of residents

    ; evaluation of residents

    ; promotion of residents

    ; dismissal of residents

    9. How do you ensure that the residents do not have excessive duty hours?

10. Does your residency-training program provide education and procedures to handle the issue of resident

    stress and fatigue? What is your approach to recognition of excessive resident fatigue?

11. Do the residents moonlight in the training program?

12. How does the faculty supervise the residents in this program?

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    13. Do you believe the residents will pass the Boards when they finish the program?

14. What are the first time taker board pass rates for your program?

    15. Do residents participate in institutional activities and/or serve on institutional committees?

    16. Is there resident participation in formal quality-assurance programs within the training program, department and/or at an institutional level?

    17. Does the training program with the faculty and residents review patient complications and deaths?

18. What changes would you recommend for this program?

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