Prepare for your Internal Review

Residency Program Insider, October 9, 2007

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The internal review (i.e., institutionally required mid-accreditation cycle review) is a superb opportunity to assess the quality of your program and prepare for the next site visit. Unlike the annual program review, which the residency review committee (RC) requires the program to conduct, the Accreditation Council for Graduate Medical Education (ACGME) requires your program's sponsoring institution, through its graduate medical education committee (GMEC), to develop a process and then conduct and document an internal review according to this process.


Internal reviews are a major function of the sponsoring institution. The importance of these reviews is perhaps best illustrated by their prominence in the ACGME requirements for sponsoring institutions.  Descriptions of and requirements for the internal review, account for four of the 16 pages of the Institutional Requirements. Internal reviews are one of the main functions of the GMEC, which is charged with developing, implementing, and overseeing the process.


A thorough and valid internal review is a "win-win" for your program and sponsoring institution. Conversely, if the review of your program is not done on time by the designated review team, including a complete assessment of all necessary elements, your program and the institution may be cited for this failure. Therefore, the program and the institution must be active partners when it comes time for the internal review.


In addition to participating in your own internal review, getting involved with the internal review of another program in your institution helps to keep nuances of various requirements fresh in your mind. Your ability to assess how another program meets requirements allows you to compare and contrast your own programmatic choices, and a great deal of active collaboration may ensue.   


Program directors should consult the ACGME's Institutional Requirements, posted on the ACGME's Web site (, to learn what is required of the institution and to review the details of this mid-cycle review process. They can also confirm with their DIO and GMEC that their own internal review process conforms to all of the requirements and their program's anticipated date for this review.


Editor's Note: The paragraphs above are excerpted from HCPro's recently published training resource for residency program directors and coordinators, Insider's Guide to the ACGME Site Visit, Second Edition, by Kathryn Andolsek, MD, MPH, and Shep Cohen.

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