Tip of the week: Document timing of the internal review

Residency Program Insider, January 11, 2011

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Correct timing of internal reviews is critical. Not having your reviews start on time is one of the most common citations the ACGME issues during program and institutional reviews. The current Institutional Requirements clearly state the GMEC must conclude and approve the internal review by the midpoint of the accreditation cycle, or the internal review must be “substantially in progress.” Your GMEC minutes must document that the internal reviews are in progress by the midpoint date. Ideally, the review should be so far along that the GMEC will approve the internal review report at the next meeting.

Do not make the mistake of thinking that simply documenting that an internal review is in progress means you have another three or four months to complete the review. Nothing results in a citation faster than completing an internal review well past the midpoint or completing one in the same year as the program’s site visit!

Once you know the midpoint date of the accreditation cycle, figure out how long it takes you to perform the internal review from start to finish. Then, go to the midpoint date, and count back as many months as it takes you to do the reviews. That is the date you should begin the internal review process.

This week's tip is from the Graduate Medical Education Handbook by Vicki Hamm.

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