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MUSC GME Resident Handbook

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Graduate Medical Education  2013-2014

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Resident Handbook Introduction

Letter of Commitment/
Accreditation Status Disclaimer

Administration & Governance - Graduate Medical Education Programs

Policies & Procedures

Salaries & Benefits

MUSC Policies

Appendix 1 - Resident Agreements (Medical and Dental)

Appendix 2 - Evaluation Forms

Appendix 3 - Forms

Appendix 4 - Scopes of Practice

Appendix 5 - Program Director/Program Coordinator Resources

 

Medical University of South Carolina
College of Medicine
Internal Reviews

AN UPDATE TO INTERNAL REVIEWS effective July, 2012

From the ACGME DIO News, June 2012 edition:

“What effect will the NAS have on internal reviews?
At present, most internal reviews should be continued until further guidance from the IRC. DIOs are not required to schedule internal reviews for “early adopter” specialties (emergency medicine, internal medicine, neurological surgery, Orthopaedics, pediatrics, diagnostic radiology, and urology) that have received notice of an extended date for program self-study visits. As the NAS emerges, the IRC anticipates that sponsoring institutions will increase emphasis on annual review of program outcomes and learning environments, instead of mid-cycle internal reviews. Therefore, we can anticipate a decreased emphasis on the midpoint as the only occasion for internal review. The functions accomplished by internal reviews are under discussion by the IRC to determine which quality improvement principles should be retained or expanded in the NAS.”

In seeking further clarification from the ACGME, the GME Office has word that early adopter sub-specialties are included in this policy.

Statement of Policy:

The College of Medicine at the Medical University of South Carolina has instituted a standing Internal Residency Review Committee (IRRC) to:

  • ensure all residency programs, including the subspecialty programs, are meeting and exceeding their educational commitment.
  • assess each ACGME accredited program (including subspecialty programs) and to demonstrate compliance with the ACGME Institutional, Common and Program Requirements. 

The Internal Review is 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. 
  • provide evidence of the program’s use of evaluation tools to ensure that the residents demonstrate competence in each of the six areas. 
  • 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. 
  • 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, a hospital administrator and a member of the GME Office.  All Committee members are from programs other than the one being reviewed.  During a review, the minimum number of reviewers, as defined by the ACGME to include at least one faculty member and at least one resident from within the Sponsoring Institution but not from within GME programs being reviewed, will be present.

2.  Internal reviews are conducted on all ACGME-accredited residency/fellowship programs.  A scheduled review takes place at mid-point 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 the fall for the following year and distributed to all known programs.  All programs are regularly notified of the review starting two months prior to the actual internal review.

a. If a program director wishes to have an additional review at some point during the accreditation cycle length, they may request one of the IRRC chair.   The chair may grant a full internal review, a modified review or a PIF review based on a number of factors (scheduling, time until site visit, citation progress, etc….)

3.  Faculty members and residents are given a survey questionnaire to complete and are returned with all Program Information Form (PIF) documents for review.  In addition, residents complete an interview questionnaire.  All completed surveys/interviews are included for review during the IRRC meeting.

4.  The IRRC uses a PIF Binder to include the information the ACGME requires.  The IRRC requires this information to be in a three ring binder.  When putting binders together, tab/label each section accordingly and place in the binders in the order listed below.  Please use double-sided copies.  

The tabs should be:

  • The previous internal review
  • ACGME letter/response letter (progress report)*  (*if response letter was required by the ACGME)
  • Citation Response and Summary
  • Affiliation agreements (if these are required as part of the program’s PIF, you may include them in the appropriate PIF section, rather than in a separate tab)
  • Specific program requirements
  • PIF document and required attachments
  • Evaluations
    • The most recent ACGME resident survey
    • The most recent annual program evaluation (APR). 
  • Faculty survey (no need to summarize)
  • Resident survey (no need to summarize)
  • Aggregate results of the resident interview

5.   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.  Program Directors of Specialty Programs are strongly encouraged to attend any sub-specialty reviews.

  • When a program has no residents enrolled at the mid-point of the review cycle, the following circumstances apply:
    • The GMEC must demonstrate continued oversight of those programs through a modified internal review that ensures the program has maintained adequate faculty and staff resources, clinical volume, and other necessary curricular elements required to be in substantial compliance with the Institutional, Common and specialty-specific Program Requirements prior to the program enrolling a resident.
      • After enrolling a resident, another internal review must be completed within the second six-month period of the resident’s first year in the program.

6.  The internal review should assess each program’s:

  • Compliance with the Common, specialty/subspecialty-specific Program, and Institutional Requirements;
  • Educational objectives and effectiveness 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 level of competence in each of the ACGME general competencies; and,
  • Annual program improvement efforts in:
         o   resident performance using aggregated resident data;
         o   faculty development;
         o   graduate performance including performance of program graduates on the certification examination; and,
         o   program quality. (see Common Program Requirements, V.C.)

7.  The following will be used for the 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.  The IRRC Coordinator gives a summary of the faculty and resident surveys/interviews.
  • 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 GMEC will vote to accept the report as is or with stipulations.  Following the GMEC, the IRRC staff member will contact the program and issue a final report.
    • The written report of the internal review for each program must contain, at a minimum:
      • The name of the program reviewed;
      • The date of the assigned midpoint and the status of the GMEC’s oversight of the internal review at that midpoint;
      • The names and titles of the internal review committee members;
      • A brief description of how the internal review process was conducted, including the list of the groups/individuals interviewed and the documents reviewed;
      • Sufficient documentation to demonstrate that a comprehensive review followed the GMEC’s internal review protocol;
      • A list of the citations and areas of non-compliance or any concerns or comments from the previous ACGME accreditation letter of notification with a summary of how the program and/or institution subsequently addressed each item.

8.  The DIO and the GMEC must monitor the response by the program to actions recommended by the GMEC in the internal review process.


2011 Internal Residency Review Schedule

All meetings are from 4-5 p.m. unless noted otherwise and held in the Radiology Department Conference Room, 2nd Floor CSB. ACGME numbers for the programs are listed.

  • August 2 - Surgical Critical Care
  • August 9 - Peds Rheumatology
  • October 4 - Clinical Neurophysiology
  • November 1 - Rheumatology
  • November 8 - Ophthalmology

2012 Internal Residency Review Schedule

All meetings are from 4-5 p.m. unless noted otherwise and held in the Radiology Department Conference Room, 2nd Floor CSB. ACGME numbers for the programs are listed.

Geriatric psychiatry [4074521035]
13-Mar-12
4:00 PM
Cytopathology [3074521012]
20-Mar-12
5:00 PM
Obstetrics and gynecology [2204521270]
20-Mar-12
4:00 PM
Cardiovascular disease [1414521129]
3-Apr-12
4:00 PM
Interventional cardiology [1524521087]
3-Apr-12
5:00 PM
Clinical cardiac electrophysiology [1544531099]
5-Apr-12
4:00 PM
Pulmonary disease and critical care medicine [1564521067]
5-Apr-12
5:00 PM
Vascular surgery - integrated [4514531010]
8-May-12
4:00 PM
Pediatric hematology/oncology [3274521068]
Sept. 4, 2012
5:00 PM
Hematology (Path) [3114521057]
Sept. 4,2012
4:00 PM
Psychiatry [4004521204]
Sept. 18, 2012
4:00 PM
Adult cardiothoracic anesthesiology [0414531020]
Sept. 18, 2012
5:00 PM
Gastroenterology [1444521107]
Oct. 9, 2012
4:00 PM
Infectious disease [1464521104]
Oct. 9, 2012
5:00 PM
Nephrology [1484521156]
Oct. 23, 2012
4:00 PM
Hematology and oncology [1554521063]
Oct. 23, 2012
5:00 PM
Internal medicine [1404521403]
Nov. 6, 2012
4:00 PM
Endocrinology, diabetes, and metabolism [1434521088]
Nov. 6, 2012
5:00 PM
Urology [4804521140]
Nov. 13, 2012
4:00 PM