NAS Internal Review Protocol

Under the direction of the GMEC, the Office of Graduate Medical Education (OGME) schedules Internal Reviews of residency programs and subspecialty programs to occur as directed by the GMEC Program Oversight and Review Policy. OGME recommends a Chairperson and at least two other committee members (1 resident and/or 1 faculty) to serve on the Internal Review committee, in addition to an OGME staff person. Internal Review committee members will not be from the GMEC program being reviewed. Whenever possible, the committee will be from a different department than the GME program being reviewed.

OGME prepares a monitoring form and electronic surveys that go to the Program Director, Program Coordinator, Hospital Administrators, and Residents. Completed surveys are compiled by OGME.

Program Director submits the following materials to OGME:

  • All Assessment or Evaluation Tools
  • A completed Program Director's Survey
  • The most recent Annual Program Evaluation (APE) provided by the program (not pulled from New Innovations

OGME provides and collates all review information for members of the Internal Review committee, including:

  1. Completed Program Director’s Survey
  2. ACGME Letters and Reponses (only notification/citation/progress report letters) since the last Internal Review or Site Visit, whichever occurred last.
  3. Most recent Internal Review report
  4. WebADS sections
    • Response to Citations
    • Faculty roster
    • Faculty and resident scholarly activity
    • Case Reports (if applicable): a) National Percentile rankings for key indicators for graduates, b) RRC Defined index or key minimums for senior residents, c) Activity Report for current residents
  5. Most Recent SIU Resident End of Year Evaluations
  6. Duty Hour Compliance Report
  7. Most recent ACGME Resident Survey
  8. Most recent ACGME Faculty Survey
  9. Hospital Administrator Internal Review Survey Results
  10. Program Coordinator Internal Review Survey Results (optional)
  11. Resident/Fellow Internal Review Survey Results
  12. Most recent Special Review Report, if applicable

Once the documentation has been distributed to the review committee, OGME will work with the committee members and program being reviewed to schedule the following meetings:

  • Initial committee meeting;
  • Interviews with all available faculty (it is recommended that the department or division chair not be present in group faculty interviews and can be interviewed separately if the committee chooses);
  • Interviews with residents/fellows (whenever possible, all residents/fellows in a program will be interviewed), an OGME staff will attend this meeting to record information;
  • Interview with the director of the program being reviewed.

The Chair of the Internal Review committee will then draft an internal review report that includes, but is not limited to, an assessment of the program’s strengths, weaknesses, and opportunities; educational and financial resources; and recommendations for the program. If specific recommendations are made, time lines must be included. The Chair will send the report to committee members for review/ additions/ changes. This report will always be shared with the Director of the program being reviewed prior to presenting it to GMEC.

At the GMEC meeting in which the report is presented by the internal review committee, the Director of the program being reviewed will be available to answer any questions about the program that arise.

GMEC will decide to accept, modify, or refer back to the internal review committee their findings and recommendations.

If requested by GMEC, at follow up time the Program Director will respond in writing to GMEC regarding concerns noted on the report and will attend the GMEC meeting where the follow up is to be presented.

The GMEC will follow up on any unresolved issues identified by the internal review committee until resolved.

 Last Approval Date:  September 17, 2018

 Effective Date: September 17, 2018