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Ask the expert: What should be included in an internal review report?

Residency Program Connection, January 5, 2010

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The internal review report should reflect the ACGME requirements and the institution’s internal review protocol. As the case studies in this book illustrate, there are many ways to complete the report; however, the ACGME has specific criteria that must be in each report. These items are:

• The name of the program reviewed: The internal review report should include the official name of the residency program reviewed. This is especially important if the institution sponsors subspecialty programs with similar names.
• Assigned midpoint and status of the review: Completing the internal review on time—by the midpoint of the accreditation cycle—is essential to showing the ACGME that your institution’s GMEC is providing oversight to its programs. The GMEC meeting minutes must include a statement about any internal reviews in process, their status at the time, and, if possible, an anticipated completion date.
• Internal review committee members: Listing the names and titles of the committee members shows the ACGME that the committee included all of the members the accrediting organization requires to sit on internal review committees This also becomes a record of who participated in the review and contributed to the report.
• Internal review process summary: Internal review reports must include a description of how the committee conducted the review, the individuals interviewed, and the paper and electronic documents assessed. The report must also examine the significance, pertinence, and appropriateness of the items reviewed. The report should also provide an explanation of how the committee incorporated the information gleaned from interviews and documentation review into the report. Include a detailed assessment of the data, evaluation of its significance, and recommendations for the program. During an institutional review, the ACGME site visitor may review the internal review reports to make sure the reviews meet the ACGME requirements, as well as your institutional protocol. When the GMEC reviews each internal review report, it must confirm that the internal review was completed in accordance with its protocol. This is an important point to remember before the internal review committee is performing the review—the members must understand the protocol and their responsibilities.
• Citations, concerns, comments, and corrections: A main function of the internal review is tracking how programs correct citations and areas of concern identified during the previous ACGME site visit. It is fitting that the ACGME requires that the internal review report include a list of citations, areas of noncompliance, issues, or comments from the last ACGME accreditation notification letter of and a description of how the program dealt with each. Writing the summaries of how a program fixed citations and other issues is difficult if the program director did not keep proper documentation. Stress to program directors and administrators the importance of recording information about how they corrected or attempted to correct citations and problems. The internal review committee must also evaluate a program’s progress toward fixing the citations and concerns and give recommendations on how the program can make further improvements.

Today’s question and answer are adapted from Internal Review Made Simple by Robin E. Graham, MD, FACS, published by HCPro, Inc., Marblehead, MA.

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