Medical University of South Carolina College of Medicine Internal Reviews Statement of Policy:
To assess each ACGME accredited program (including subspecialty programs) and to demonstrate compliance with the ACGME Institutional, Common and Program Requirements. To conduct internal reviews of all ACGME-accredited residency/fellowship programs to assess whether each program has defined, in accordance with the relevant Program Requirements, the specific knowledge, skills and attitudes required, and provide educational experiences for the residents to demonstrate competency in the following areas: patient care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and systems-based practice. The internal review is to provide evidence of the program’s use of evaluation tools to ensure that the residents demonstrate competence in each of the six areas. The internal review is to appraise the development and use of dependable outcome measures by the program for each of the general competencies and to appraise the effectiveness of each program in implementing a process that links educational outcomes with program improvement. The internal review is to appraise the educational objectives of the program, the effectiveness and the adequacy of available educational and financial resources to meet these objectives, and the effectiveness in addressing any citations from previous ACGME letters of accreditation and previous internal reviews.
1. The GME Committee has appointed a subcommittee to conduct the internal reviews. The subcommittee is made up of a Chair (who is a Program Director from a program other than the one being reviewed), two Program Directors, one faculty member, a resident, and a hospital administrator. The committee is staffed by one member of the GME Office. All panel members are from programs other that the one being reviewed. An external reviewer may also be included on the committee as determined by the GMEC.
2. Internal reviews are conducted on all ACGME-accredited residency/fellowship programs. A scheduled review takes place at midpoint between ACGME site visits. All program are given notification of the internal review at least one year out and reminders are sent regularly starting two months prior to the actual internal review.
3. Program Directors are required to go to the ACGME website and print out the PIF for their program for completion.
4. Faculty members are given a questionnaire to complete and are returned with all PIF documents for review.
5. Residents are given a questionnaire to completer and are returned with all PIF documents for review.
6. Residents complete an interview survey.
7. The Committee reviews the completed Internal Residency Review Document (i.e. PIF, Faculty questionnaire results, resident questionnaire results, and summary of resident interview), letters of accreditation from previous ACGME reviews, reports, if any, sent to the ACGME from the program, the last Internal Review Report, if applicable and Program, Common and Institutional Requirements.
8. A meeting is held where the Internal Residency Review Committee interviews the Program Director, the residency coordinator, peer selected residents from each level of training, and any faculty or persons related to the program being reviewed, as needed.
9. During the internal review the panel will assess:
a. the educational objectives of the program; b. the effectiveness of the program in meeting is objectives; c. the adequacy of available educational and financial resources to support the program; d. the effectiveness of the program in addressing areas of noncompliance and concerns in previous ACGME accreditation letters and previous internal reviews; e. the effectiveness of the program in defining, in accordance with the Program and Institutional Requirements 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; f. the effectiveness of the 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 the of the 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.
10. Following the interviews, the Internal Residency Review Committee meets to consider their findings and prepares a written report. The original report is reviewed by the Internal Residency Review Committee and the Program Director for accuracy. The report must address strengths, weaknesses, concerns, opportunities as well as future goals, and mechanisms for follow-up.
11. The GME Committee reviews the report at its next regular meeting and makes recommendations for follow-up as appropriate. The GMEC votes on the report and either approves or disapproves.
12. Approximately six months after the internal review, a member of the Internal Residency Review Committee will meet with the program director and follow-up on the recommendations of the review panel. If any concerns were cited, the Program Director and the member of the Internal Residency Review Committee will work together to address and correct the concerns and will submit a report to the GME Committee. Approximately one month prior to the ACGME conducting their program survey, there will be a meeting to reassess the program and assure that concerns and issues have been addressed and corrected and the program is prepared for their site visit. The completed PIF will be reviewed at that time.
Materials and data used in the review process will include: a. Institutional and Program Requirements for the specialties
and subspecialties of the ACGME RRCs from the Essentials of Accredited
Residency Programs: b. Accreditation letters from previous ACGME reviews and progress reports
sent to the RRC, and, c. Reports from previous reviews of the program.
MEDICAL UNIVERSITY OF SOUTH CAROLINA Internal Residency Review Committee (IRRC) MEETING PROCEDURE - The IRRC members review the previous ACGME accreditation letter and any subsequent correspondence; focusing on responses to any citations.
- The Program Director presents an overview of the program, including any significant changes since the last ACGME/RRC review.
- The IRRC members review each of the ten (10) sections of the completed Internal Residency Review Document (IRRD) and the Faculty and Resident Surveys. Any questions or concerns raised by responses in the IRRD are posed by the IRRC members to the Program Director, two to three faculty members, program coordinator, chief resident and peer selected residents from each training year.
- The IRRC reviews areas of concern, requests any documents to be provided and makes specific recommendations to correct deficiencies and/or improve the overall quality of the program.
- The IRRC Coordinator gives a summary of the resident feedback.
MEDICAL UNIVERSITY OF SOUTH CAROLINA Composition of the Internal Residency Review Committee
CHAIR: Residency Program Director MEMBERS: Two Residency Program Directors; One - Two Faculty Members; Two Residents One Member of Hospital Administration STAFF: IRRC Coordinator from the GME Office
Internal Residency Review Committee GOALS AND OBJECTIVES
The College of Medicine at the Medical University of South Carolina has instituted a standing Internal Residency Review Committee to ensure all residency programs, including the subspecialtyprograms, are meeting and exceeding their educational commitment. The Goals of the Committee are to:
· Assess the educational goals and objectives of the programs linking the ACGME Six General Competencies; · Ensure the programs have the financial and educational resources to meet the program’s objectives; · Evaluate the effectiveness of the program in meeting its objectives;
· Prepare programs for their upcoming reviews by the ACGME;
· Review previous letters of accreditation by the ACGME;
· Provide support and recommendations to the programs through the evaluation process. INTERNAL REVIEW SCHEDULE
January - December 2008 (All Reviews are held at 4:00 pm)
Program Date Location
Addiction/Psych March 4, 2008 601 CSB Child/Adolescent Psych March 25, 2008 601 CSB CT Anesthesia June 3, 2008 601 CSB Dermatology July 22, 2008 601 CSB Anesthesia August 26, 2008 601 CSB Pediatric
Endocrinology September 16, 2008 601 CSB Clinical
Neurophysiology October 21, 2008 601 CSB
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