Resident Program Internal Review Checklist



INTERNAL REVIEW PROCESS

1. Attached are the following documents:

Internal Review Self-Study

Last ACGME letter

Last Internal Review report

ACGME Institutional, Common and Specific Program Requirements (on the ACGME website, )

2. Please review each of these documents. The program director of the program being reviewed completes the self-study and submits it to the GME Coordinator in the House Staff office.

3. Upon receipt of the self-study, a panel will be selected to participate in the review.

4. A meeting is arranged by the GME Coordinator for the review.

1. The program director and coordinator must be available during the entire review process.

2. ALL residents/fellows should be made available to the review committee.

3. ALL faculty involved with the residency be made available to review committee.

4. ALL accompanying documents should be prepared and available to the review committee (See #9).

5. The review panel includes the chair (a program director), and a resident/fellow (from programs other than the one being reviewed), the DIO and the GME Coordinator. Other members may include faculty and program coordinator.

6. During the interview, the panel asks pertinent questions about the program based on the information and materials provided. (Sample questions are attached.)

7. Following the review, the chair of the panel completes a written report based on the findings of the panel. The original report is sent to Dr. Schiavone, Chair of the GMEC. The report must address strengths, weaknesses and concerns as well as recommendations and mechanisms for follow up. Additional copies of the report are sent to the program director of the program being reviewed and the GME Coordinator in the House Staff office. A summary of this report is also presented to the GME Committee at the next scheduled meeting.

Residency/Fellowship Program Internal Review Self-Study

Residency/Fellowship Program ________________________

Accreditation Status __________________________

Program Director ____________________________

Program Coordinator _________________________

Date Self-Study Completed ____________________

1. ACGME Citations:

Indicate how the program responded to any citations, concerns or comments from the last ACGME site visit.

2. Last Internal Review:

Indicate how the program responded to any recommendations from the last Institutional internal review.

3. Sponsoring Institution:

Are there sufficient faculty, financial resources, space, clinical and research facilities, and library materials to meet educational needs? (Describe how these needs are being met.)

4. Participating institutions:

a. List all participating institutions.

b. How does each rotation provide experiences not available at the sponsoring institution?

c. Are there current letters of agreement in place for each participating institution, which identify educational and supervisory responsibility, evaluation of residents, educational goals and objectives, period of assignment, policies and procedures to govern that assignment?

d. Are there sufficient faculty at each participating institution to assume educational and supervisory responsibility?

4. Resident/Fellow appointment:

a. How many residents/fellows are in the program?

b. How many are approved by ACGME (per year and total number)?

c. What are the funding sources?

d. How have graduates performed on board cert exams?

e. What are current graduates doing (additional study, private practice, academic setting, etc.)?

Number of Residents/Fellows in program:

PGY-1 |PGY-2 |PGY-3 |PGY-4 |PGY-5 |Fellow |Accredited Positions |Unaccredited Positions |UH Paid |Other Pay source | |

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5. Faculty:

a. What is the faculty to resident/fellow ratio?

b. Do the qualifications of the program director meet requirements of the RRC?

c. Is the program director board certified in the specialty/subspecialty?

d. Do all faculty participate in resident/fellow education? If not, what percentage are core faculty?

e. How do faculty provide adequate supervision?

f. What scholarly activities do faculty participate in?

6. Facilities and resources:

a. Describe the inpatient experiences.

b. Describe the outpatient experiences.

c. What are the support services that ensure excellence in patient care?

d. Is there a library and computer services available for resident research?

e. Is there space designated for the residents/fellows?

f. Are there on-call rooms available?

7. Educational Program:

a. Please provide a copy of the curriculum. Is the curriculum competency-based?

b. Are the residents/fellows and faculty provided a copy of the curriculum?

c. What are the goals and objectives of the program including rotations/blocks?

d. How does the program meet these objectives? (How do you know that the resident/fellow is actually learning?)

e. What scholarly activities are residents/fellows involved in?

f. Are duty hours set and maintained within the standards? How is this monitored?

g. Do residents/fellows moonlight? What is the dept. policy on moonlighting?

h. How does the program provide progressive education and responsibility for residents/fellows?

i. How does the program provide for residents/fellows teaching of other residents/fellows/medical students?

j. Describe the grievance and due process.

k. Describe the system used to monitor resident/fellow well-being.

l. Describe the professional/didactic activities offered by the program (i.e. educational conferences, journal club, grand rounds, etc.)

m. Is there documentation (i.e. procedure logs, attendance, meeting minutes, evaluations, etc.) to substantiate resident/fellow education and credentialing?

8. Evaluation:

a. Describe the methods used to assess resident/fellow performance.

b. Describe the tools used to assess the general competencies of patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism and system-based practice.

c. How often are residents/fellows evaluated?

d. Is there a final evaluation in place? Is it kept as part of the permanent file?

e. Describe the process used for residents/fellows to evaluate faculty and program.

f. Are these evaluations anonymous?

g. How are these assessments used to evaluate the educational effectiveness of the program?

9. Documentation:

Please have the following documentation available for the internal review panel.

a. Resident Case logs for each resident by year and by credentials

b. Evaluations of residents/fellows by faculty with summary of scores for each resident by year and whether they are above or below the metric score

c. Evaluations of the faculty and program by the residents/fellows

d. Minutes of Department Education Committee meetings indicating number of meetings per year (percentage that occur/are canceled)

e. Minutes of Educational Retreat

f. A competency-based written curriculum for residents/fellows including fatigue curriculum, wellness curriculum and “Residents as teachers” curriculum

g. Written goals and objectives for residents/fellows

h. Residents’ educational conference schedule and sign-in sheets with attendance percentages and resident numbers

i. Departmental on-call schedule

j. Letters of agreement with participating institutions

k. Department Resident/Fellow Manual

l. Policies on grievance and due process, duty hours and moonlighting

m. Resident files including portfolios with research activity and specific case outcomes/ performance (matrix)

n. Program Information Form (PIF)

SAMPLE INTERVIEW QUESTIONS

(For Residents/Fellows)

1. What do you see as the goals and objectives of this program? Are these goals being met? How do you participate in formulating the goals and objectives?

2. Are you given goals and objectives for each rotation or block? Are these being met?

3. Are you given a copy of the program’s curriculum?

4. Are there assessments in place for evaluating the general competencies of patient care, medical knowledge, interpersonal and communications skills, professionalism, practice-based learning and systems-based practice?

5. Are there sufficient resources and facilities available? If not, what could be improved?

6. Are rotations to affiliates important and pertinent to resident/fellow education?

7. Are you involved with research projects? Is there adequate time for research?

8. Are clinical and operative experiences adequate?

9. Are there regularly scheduled conferences? What percentage is cancelled?

10. Are there enough faculty to provide an adequate educational experience?

11. Are there enough faculty to provide sufficient supervision?

12. Are duty hours maintained within the required standards?

13. Do you evaluate the faculty? Are these evaluations anonymous?

14. Do you evaluate the program? Have these evaluations resulted in changes in the program?

15. What are the positives and negatives of the program?

SAMPLE INTERVIEW QUESTIONS

(For Faculty)

1. What are the goals and objectives of this program? Are these goals being met? How do you participate in formulating the goals and objectives?

2. Does the program have goals and objectives for each rotation or block?

3. Does the program have a written curriculum? How are you involved with writing the curriculum?

4. Are there assessments in place for evaluating the general competencies of patient care, medical knowledge, interpersonal and communications skills, professionalism, practice-based learning and systems-based practice?

5. Are there sufficient resources and facilities available?

6. What role do affiliate institutions play in the residents'/fellows’ education?

7. How do you participate in scholarly activity?

8. To what extent are residents/fellows involved in your patient management?

9. Are there regularly scheduled conferences? What percentage is cancelled?

10. Are there enough faculty to provide an adequate educational experience?

11. Are there enough faculty to provide sufficient supervision?

12. Are duty hours maintained within the required standards?

13. How often are residents/fellows evaluated?

14. Do residents/fellows evaluate the faculty and program?

15. What are the positives and negatives of the program?

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