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Internal Reviews

UCSF INTERNAL REVIEW PROTOCOL

(refer to Institutional Requirements, V. Internal Review)

A. The GMEC conducts Internal Reviews of ACGME programs mid-cycle of RRC visits. (V.A.1.c) Follow-up mini-reviews will be conducted as necessary pending outcome. In addition, an Internal Review may be requested by a Program Director as a more formal “consultation” in between the required Internal Reviews.

B. GMEC Internal Review Committee (V.A.1.a.):
1. Chair of Internal Review Committee, Claire Brett, M.D. (Vice Chair of GMEC) and/or Robert Baron, M.D. (Chair of GMEC)
2. Other faculty: Program Director of upcoming Internal Review or other Program Director from GMEC.
3. GMEC or Residents Council resident representative who is not a member of the program under review. Recruiting a resident from a program soon to undergo an Internal Review would be desirable.
4. GMEC Administrators, Lorenzo Woo (Director of GME Operations) and Heidy Garcia (Accreditation Manager)
5. Hospital administrator, as indicated
6. Occasionally, guest faculty and/or additional resident representative.

C. Program Internal Review panel composition (V.A.4)
1. Department Chair (optional)
2. Program Director
3. 1-2 faculty
4. Peer selected residents representing each level of training
5. Program coordinator/department administrator (optional)

D. GMEC Internal Review panel reviews the following:
1. Internal Review Self-Study
a. Educational Goals and Objectives of the Program for each rotation and each level of training (V.A.2.a.)
b. Effectiveness of meeting Educational Goals and Objectives (outcomes such as in-service exams, board exams, academic/private practice jobs of recent program graduates, as well as scholarly activity of faculty/residents, and resident evaluation of faculty/program). (V.A.2.b.)
c. Adequacy of available educational and financial resources (V.A.2.c)
d. Effectiveness of each program in addressing areas of noncompliance and concerns in previous ACGME accreditation letters and previous Internal Reviews (V.A.2.d)
e. Compliance with and effectiveness of incorporation of the six General Competencies (V.A.2.e,f,g,h)
f. Rotation sites and Letters of Agreement with Site Directors at affiliated institutions
g. Program or Departmental changes (faculty, curriculum, rotations, site, size, etc.) since prior Internal Review/Annual Update
h. List of trainees assigned to Departmental, Medical School, Hospital and University committees
i. Program’s policies for selection, evaluation, dismissal, promotion, grievance, well-being, supervision, duty hours, moonlighting
j. Quality Assurance process followed by the program
k. Systems for evaluation of trainees, faculty, program
l. Annual Program Director’s Update Report
m. Minutes of Faculty Teaching Committee meeting where resident outcomes were linked to program improvement
n. Duty Hours policy with a data collection methodology and Moonlighting Policy
o. Copy of signed resident contract letter
p. JCAHO Procedure Competencies and sample of trainee attestation statement
r. Current and projected program enrollment by trainee name and PGY level

2. Residents’ Survey (ACGME WebADs and Office of Graduate Medical Education)
3. Current RRC Program Requirements (V.A.3.a)
4. Current RRC Parent Program Requirements for subspecialty programs) (V.A.3.a)
5. Current ACGME Common Program Requirements (V.A.3.a) 6. Current ACGME Institutional Requirements (V.A.3.a)
7. Accreditation letters from previous ACGME reviews and progress reports sent to the RRC or other RRC Communications (V.A.3.b) 8. Reports from previous internal reviews of the program (V.A.3.c)

E. GMEC members of the panel meet with the residents without the faculty from the training program present.
The following are examples of some of the topics pursued with the trainees.
1. Systems available for confidential discussion of concerns
2. Duty Hours
3. Work environment
4. Evaluation processes
5. Education and research opportunities
6. Career development
7. Supervision
8. General Competencies

F. Panel submits written summary with follow-up plan and recommendations to Program Director.

G. Report submitted to GMEC for review and approval (V.B.2)

H. Final report from the Associate Dean (Chair, GMEC and DIO) to Program Director and Department Chair

I. Follow-up by GMEC and/or GMEC Executive Committee as necessary

Approved by GMEC on February 26, 2007

Prior revisions: March 1, 2005 November 15, 2004 October 13, 2003 March 17, 2003 January 14, 2002 November 18, 2001 January 12, 1999

Approved by GMEC on _______2/26/07
Revised 2/07

 

Internal Review Committee

Robert B. Baron, MD - Associate Dean & Chair, GMEC
Clair Brett, MD - Vice Chair, GMEC
Heidy Garcia - Accreditation Manager, GME
Lorenzo Woo, Director of Operations, GME
GME The Internal Committee must also incluse at least one Faculty Member and at least one Resident from within the sponsoring institution but not from within the GME Program being reviewed.

Program Links



Graduate Medical Education
500 Parnassus Avenue, MU 250 East
San Francisco, CA 94143-0474
Telephone: (415) 476-4562
Fax: (415) 502-4166
www.medschool.ucsf.edu/gme