As required by the Accreditation Council for Graduate Medical Education (ACGME), all graduate medical education training programs (residency and fellowship) at UTMS-H undergo a periodic internal review as described in the "Essentials of Accredited Residency Programs." The review is conducted under the guidance of the Internal Review Coordinator. The Internal Review Executive Committee (IREC), a subcommittee of the Graduate Medical Education Committee (GMEC) prepares and presents the Internal Review Report to the GMEC. The Graduate Medical Education Committee reviews the final report of each Internal Review and makes recommendations if indicated. Internal reviews should be conducted at approximately the mid point between ACGME site visits.

I. Internal Review Executive Committee

The Internal Review Executive Committee includes (a) at least two faculty members from the GME Committee, who may also be Program Directors, (b) at least two residents, (c) a Medical Educator from the Office of Educational Programs, and (d) a representative from the Office of Graduate Medical Education.

The responsibilities of the Committee are to prepare Internal Review Reports of all Residency and Fellowship Programs midpoint between RRC Site Visits in accordance with the ACGME Institutional Requirements.

For each Internal Review, the IREC appoints:

• faculty members outside of the committee and the program being reviewed to interview the Program Director and a representative number of faculty from the program,
• residents to interview a representative number of residents from each PGY level in the program being reviewed,
• and a coordinator to interview the Program Coordinator. If a coordinator is not available to interview, a GME representative will perform the interview.

The Interviewers are provided with an Interview Guide to follow for the interview, as well as a list of areas to explore more closely.

The Internal Review Documents (described below) will be available to the IREC and the Interviewers.

II. Internal Review Questionnaire

The Internal Review Questionnaire (IRQ) consists of various questions that the GMEC believes are important with regard to each Program. The questionnaire is formatted after the ACGME Common Program Requirements. This questionnaire is sent to the Program Director and he/she is given approximately three months to complete the questionnaire. The Program Director is also provided with guidelines for the upcoming internal review. The Program Director is asked to provide a list of all faculty members and residents from each level of training. The IREC will choose the faculty to be interviewed. Download the IRQ.

The Internal Review Documents will be available for all members of the Internal Review Executive Committee and the Interviewers. A document checklist can be downloaded here. The documents include the following:

1. Internal Review Protocal {Download}
2. Copy of the Essentials of Accredited Residencies in GME
3. ACGME Institutional Requirements Checklist
4. Questionaires: Faculty, Resident & Coordinator
5. Sample Internal Review Report
6. Current ACGME accreditation letter
7. ACGME Common & Individual Program Requirements
8. Last Internal Review Report
9. Completed Internal Review Questionaire (completed by Program Director) with the following attachments.

1. Letters of Agreement. (IRQ Section: I.B.3.)
2. Written Policy for Criteria and Processes for Eligibility, Selection, Evaluation, Promotion, Non-Renewal and Dismissal of Residents. (IRQ Section: II.A.) * Please note: It is not acceptable to refer to the Institutional Policy. Please include your program policy.
3. Program Policy concerning the effect of leaves of absence, for any reason, on satisfying the criteria for completion of the residency program. (IRQ Section: II.A.) *
4. Program Director’s CV. (IRQ Section: III.A.4.)
5. Block Schedule of Resident/Fellow Rotations. ** Example on Blackboard (IRQ Section: IV.A.1.)
6. Departmental Conference Block Schedule. ** (IRQ Section: IV.A.2.)
7. Departmental Conference List for the year. ** (IRQ Section: IV.A.2.)
8. Educational Goals and Objectives. (IRQ Section: IV.B.3.)
9. Tools used to evaluate Resident Competencies in the six areas. (IRQ Section: IV.B.6.)
10. Updated “General Competencies Assessment Addendum” from ACGME web site. Please contact GME Office to see if this is applicable to your program. (IRQ Section: IV.B.8.)
11. Program Policy governing Resident Duty Hours and On-call Schedules. (IRQ Section: IV.D.1.a.) *
12. Call Schedule. (2 months for each major rotation) (IRQ Section: IV.D.1.c.)
13. Program Policy for Grievance and Due Process (IRQ Section: IV.D.4.) * 14. Moonlighting Policy. (IRQ Section: IV.D.6.a.) *
15. Resident Evaluation Form. (IRQ Section: V.A.1.)
16. Example of a completed Summary Evaluation for a resident who has left the program. (IRQ Section: V.A.7.)
17. Faculty Evaluation Form. (IRQ Section: V.B.1.)
18. Rotation Evaluation Form. (IRQ Section: V.C.1.)
19. Program Evaluation Form. (IRQ Section: V.C.2.)
20. Residency/Fellowship Training Committee Meeting Minutes for the last year. ** (IRQ Section: V.C.3.)
21. A roster list of all faculty with contact information. (Indicate whether faculty is Full-Time/Part-Time/Voluntary.)
22. A roster list of all residents/fellows (in each year of the program) with pager numbers. Indicate the PEER SELECTED residents based on the requirements below:

a. At least 3 residents
b. At least 1 resident per PGY level
c. At least 20% of the residents

23. Resident/Fellow Program Manual (Not the GME Handbook)

The Internal Review Executive Committee reviews the IR Documents and assigns interviews with the Program Director, key faculty, residents,and coordinator to discuss the Program. Other individuals deemed appropriate by the Committee may also be interviewed. Discussions may include program innovations, changes that have been made based on the latest ACGME Residency Review Committee (RRC) recommendations, perceived problems related to the Program, and plans for corrections.

At the Internal Review Executive Committee meeting, the committee reviews and discusses all information pertinent to the Program including the Internal Review Resident Questionnaire and the IR Document List. The Internal Review Executive Committee assesses the following:

• compliance with ACGME Program and Institutional Requirements;
• the effectiveness of the Program in addressing previous ACGME citations or concerns, and/or previous GMEC concerns;
• the effectiveness of the Program in meeting its program goals and objectives;
• the adequacy of available educational and financial resources to support the Program;
• The effectiveness of the program in defining the specific knowledge, skills and attitudes required, and in providing educational experiences for the residents to demonstrate competency in the following areas: patient care skills, medical knowledge, interpersonal and communications skills, professionalism, practice-based learning, and systems-based practice;
• the program's use of evaluation tools to ensure that the residents demonstrate competence in each of the six areas;
• the development and use of dependable outcome measures by the program for each of the general competencies; and
• the effectiveness of the Program in implementing a process that links educational outcomes with program improvement.

The Internal Review Executive Committee also addresses the following topics assessed during the interview/survey process:

• the administration of the program;
• the quality of the educational program;
• resident participation in QA activity;
• supervision and duty hours;
• conferences and scholarly activity;
• resident, faculty and program evaluation;
• the adequacy of support services/facilities at affiliated hospitals;
• institutional support for the program;
• the quality of residents in the program; and
• strengths and weakness of the program.

IV. Internal Review Report

Based on the Interviewers’ reports, a designee of the Internal Review Executive Committee prepares a draft of the Internal Review Report (IRR). It is approved by the IREC and is sent to the Program Director and the Associate Dean for Educational Programs for review.

A designee of the Internal Review Executive Committee will present the IRR to the GMEC. The Program Director is invited to respond to the report and to attend the GMEC meeting when the report is formally presented and discussed. The Department Chair is also invited to the GMEC meeting.

A copy of the final report is sent to the Program Director, the Department Chair, and to the Dean of the Medical School.

A follow up written report may be requested by the GMEC to assure the program’s progress in complying with the Internal Review Executive Committee’s recommendations.

Jacqueline Brooks is the Internal Review Coordinator and will be happy to answer any questions related to the Internal Review Process.