Ask the expert: How does the GMEC determine when to conduct a training program's internal review?

Residency Program Insider, November 16, 2010

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The ACGME mandates in its Institutional Requirements that the internal review should be “in process” at the midpoint of a program’s accreditation cycle and documented in the GMEC minutes. Recording that the internal review is “in process” at the midpoint should indicate that the internal review committee is nearly finished with their review—not just beginning the process.

It can be challenging to determine the midpoint of an institution’s accreditation cycle, especially when additional information or updates are required, or an appeal is requested after an accreditation letter arrives. The ACGME Policies and Procedures, revised in February 2008, states that accreditation letters will include an approximate midcycle date that should serve as a guideline for the program and institution. If an appeal or update is approved by the chair of the RRC without a committee meeting, the program should confirm with the RRC that this additional time does not change the midpoint date.

The institution must track these dates and plan for the necessary internal reviews; the ACGME will not send a reminder. The graduate medical education office may use the date included in the accreditation letter to plan internal reviews. However, if the program has not had a site visit recently and doesn’t have a recommended internal review date, the institution can find out this information on WebADS for each of its training programs. The institution may track the programs by calendar, spreadsheet, or any other technique that works. The GMEC must evaluate the internal review process to determine how long the reviews take so it can ensure their timely completion. The GMEC also must notify the program and internal review committee members well enough in advance to allow the program to fully prepare all of the items the committee will review and ensure that all individuals required to participate in the internal review are available.

If a program has no residents at the time an internal review is due, the institution should perform a modified review prior to enrolling a resident in the program to ensure that the program still has the resources and clinical volume available to substantially comply with Institutional and Program Requirements. The GMEC must then perform a full internal review during the resident’s second six months of training.

This week’s question and answer are from Internal Review Made Simple.

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