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, two residents, 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. The mid-point is set by the ACGME and in included in the notification letter. Dates for reviews are set in September/October for the following year. 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 and residents are given a survey questionnaire to complete and are returned with all PIF documents for review. In addition, residents complete an interview questionnaire. All completed surveys/interviews are included for review during the IRRC meeting. 5. The Committee reviews the completed Internal Residency Review Document (i.e. PIF, Faculty survey questionnaire results, resident interview 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, the most recent ACGME resident survey, the most recent annual program evaluation, affiliation agreements, and Program Common and Institutional Requirements. 6. 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 at least one faculty member or persons related to the program being reviewed, as needed. 7. 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.
8. The IRRC staff prepares a report following the meeting. 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. 9. 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.
Materials and data (known as the PIF Binder) 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. The most recent internal review d. Affiliation Agreements e. PIF document f. The most recent ACGME resident survey g. The most recent annual program evaluation h. Faculty survey i. Resident survey j. Resident survey
MEDICAL UNIVERSITY OF SOUTH CAROLINA Internal Residency Review Committee (IRRC) MEETING PROCEDURE - The PIF Binder is due to the GME Office two weeks prior to the scheduled review.
- Committee members review the information and mark any concerns or corrections needed.
- At the review, the Chair goes through the binder page by page, with committee members or program personnel, commenting on questions or concerns.
- Following the meeting, the IRRC staff member summarizes the meeting in a report. The committee members review the document and present it to the GMEC.
- The IRRC Coordinator gives a summary of the faculty and 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 subspecialty programs, 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. 2009 Internal Residency Review Schedule - Tuesday, November 10, 4 PM, 501 CH - Neurological Surgery - Tuesday, November 10, 5 PM, 501 CH - Orthopaedic Surgery |