Approved by the GMEC August, 1997.
Approved as amended, March, 2002
Approved as amended, January, 2005
The ACGME requires regular review of all residency programs to assess their
compliance with both the Institutional Requirements and Program Requirements
of the relevant ACGME Residency Review Committees. MSU/CHM assures that Internal
Reviews will be conducted at the mid-point between RRC visits. MSU/CHM assures
that the review will be conducted by the GMEC or a body designated by the
GMEC, and will include:
• Faculty
• Residents - peer selected
residents at each level of the residency will be included
•Administrators - both
within and outside the department in which the residency exists.
•External reviewers may
also be utilized as determined by the GMEC.
MSU/CHM will appraise the following in its Internal Review of residency programs:
•The extent to which
each program has defined, in accordance with the relevant Program Requirements,
the specific knowledge, skills and attitudes required to successfully complete
the program
•The extent to which
each program has 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
•Evidence of the program's
use of evaluation tools to ensure that the residents demonstrate competence
in each of the six areas listed above
• Evidence of the development
and use of dependable outcome measures by the program for each of the general
competencies
•The effectiveness of
each program in implementing a process that links educational outcomes with
program improvement
Materials and data to be used in the review process must include:
•Institutional and program
requirements from the Essentials of Accredited Residency Programs.
•Letters of Accreditation
from previous ACGME reviews.
•Reports from previous
internal reviews of the program.
•Interviews with Program
Director, faculty, and residents in the program, and individuals outside the
program deemed appropriate by the Committee.
• Note: The ACGME Outcomes
Project is now in Phase II. This requires that Program Directors provide for
Internal Reviews documentation that the program provides learning opportunities
in all six competency domains
• In addition, Program
Directors must also provide documentation that programs are implementing evaluation
processes as needed to obtain accurate resident performance data in all six
competency domains (see Attachment A)
•Finally, Program Directors
must provide documentation of aggregate resident performance data.
MSU/CHM will provide documentation of the review including:
•Description of mechanisms
or plans to correct identified deficiencies.
•Dates on which the GMEC
will review the document
•A succinct summary for
each review.